However, inexplicably, when we reach adult life and we study to become nurses, we are denied this very way of learning to care for others, which is so intimately linked to the world of feelings and to those who, in the past, looked after us. Our own personal history of caring is hereby ignored and substituted by imposed, rigid techniques, by isolated information and by repetition. As a result, we often end up learning about different ways of caring rather than about the sense of caring itself. Thus, if our experiences teach us how to care for others, then each and every one of our lives is, in itself, a history of caring.
Now, history reveals that we are what we are today because there is a history of caring in every one of us, and because those who preceded us left their own knowledge engraved in the tales that we long to hear once again and through which this knowledge was passed on to us. In fact, without these tales, we would have never known what and who came before us and, more importantly, who we are. He who grows up without tales lacks a story of his own and is, therefore, obliged to tell the lives of others. The most unfortunate life is the life of the exile, he who must leave his own world and become part of a different reality.
Where is our most recent history? We already know about the origins of the history of caring. According to Greek Mythology, Caring emerged from an argument between Jupiter and the Earth in order to give a name to a piece of clay shaped into a 'man', translated as 'humus', 'fertile land', (Leonardo Boff).1 Therefore, the evolution of caring from the Classic Era to the Modern Age has already been described. Then, why can we not find a way to describe our most recent history? I can think of several anecdotes which lead me to ask myself the same question.
From the beginning of democracy in Spain our profession has developed alongside women's position in productive society, as well as science and technology. Nursing became a university discipline in 1977. The new nursing syllabus already included modules such as Geriatrics, Service Management, Public Health and Professional Ethics. Interestingly, none of these modules where taught in any other Health Science degree at the time. Nursing was the first profession which attempted to design plans for the future society. However, no historical references were found of this piece of evidence. On the contrary, references were found about the creation of Medical Geriatrics as a university module, about the introduction of Medical Public Health instead of Preventative Medicine and about the substitution of Legal Medicine for Medical Ethics. In addition, Service Administration is nowadays taught in master courses of new creation, and so on. Unfortunately, so far, nursing has not been able to incorporate this knowledge into its own professional history, thus putting at risk the continuity to this project by future generations.
In addition, nurses promoted lifelong learning in hospitals since the 1980s. In the early 1990s, lifelong learning became generally accepted and allocated financial resources. However, paradoxically, nurses were left out of the funded plans.
From the beginning, nurses have worked for the incorporation of chronically ill patients and their families into Primary Care and for the establishment of community health care programmes as well as domiciliary attention and healthcare education. The number of nurses in Primary Care services used to be three times higher than physicians. However, nowadays, nurses have lost their position in community whilst GPs keep expanding their professional boundaries despite their traditional training in disease treating and health care prevention. According to several experts, the lack of nursing competencies in Primary Care is behind the general collapse of accident and emergency services in hospitals. In contrast, GPs keep trying to increase their numbers in order to further expand their boundaries.
Let's take a look at Europe, where there are 843 nurses per 100.000 inhabitants. In Spain, the average number of nurses per 100.000 inhabitants is 500. Spain has 40% fewer nurses looking after the same population than the European average. Only Italy, Greece and Portugal are below the Spanish average.2 In other words, the percent distribution of doctors and nurses in the European Union is as follows: 29.03% physicians; 70.97% nurses, whereas in Spain it is as follows: 45.58% physicians; 54.42% nurses.3 These data should make us reflect on the differences between the Spanish health system and other European countries' successful health care systems, such as Finland, Sweden, Denmark, Ireland, the United Kingdom and France. For instance, in Finland there are 2.181 nurses per 100.000 inhabitants; in France there are 646 nurses.
Even more surprising is the fact that no references were found about the history of nursing palliative care in Spain when, paradoxically, it was a nurse who first started to work on the philosophy of palliative care in the western world in the 1970s. I am talking about Cicely Saunders (1913-2005), who initiated the Hospice Movement in England which, during the 1970s, began to be known as palliative care. Unfortunately, there are scarce references to this topic made by nurses. Instead, most of the references found belong to SECPAL, the Spanish Society for Palliative Care, which is eminently medical. Nurses created their own, independent, scientific society, AEACPAL, the Spanish Nursing Association for Palliative Care, which does not appear in any of the Palliative Care documents edited by the Spanish Ministry of Health and other European scientific associations. Thus, was it not us, nurses, who were pioneers in the determination of the caring paradigm which became the starting point for the development of palliative care?
Moving on to another issue: the existing crisis in health care management. We, Spanish nurses, created in the 1980s a participation structure for health care management which has been admired and acknowledged in both Spain and Europe, as well as many Latin-American countries. I remember, for instance, the project developed by the Committee for the Evaluation of the National Health Service in April 1991, where the participation of nurses was acknowledged as an important step towards the modernisation of the Spanish NHS. However, due to different reasons, nurse managers are going through a complex identity crisis, both in the Spanish NHS and in Primary Care. For instance, the nursing profession itself is failing to recognise the importance of nursing management. In addition, few managerial positions are offered to nurses nowadays. Once again, the lack of a written history of nursing reveals professional weaknesses and places nursing in the invisible side of society.
We need to think about these issues and look inside our own history in order to understand our own difficulties. Often, we see our own limitations in whatever is empowering other professions and, subsequently, we try to imitate their ways of exerting their own power. However, we must not forget that imitating others' identities does not necessarily lead to strengthening our own professional identity as a source of power. Observing others' power often lures us to believe that this power emerges from 'being' in places and positions, such as nursing managerial boards as opposed to medical managerial boards. However, it can be suggested that power emerges from within ourselves. In other words, power emerges from one's own authority rather than, for instance, a highly regarded position in society. In order to improve our situation in society and in the NHS, nurses must learn to introduce their own professional essence in to both management and care through care systematisation and exportation and communication of professional experiences and scientific evidence. Social acknowledgement will emerge from investigation and knowledge generation. The history or nursing must be told by nurses. Nurses must investigate and learn from all those aspects of history which contribute to the completion and development of our profession. If we keep denying our past we put ourselves at risk of losing our professional identity and, therefore, become a group of exiles in others' personal territories. We must tell the untold history.
1. Boff L. El cuidado esencial.
Madrid: Editorial Trotta, 2002.