From Silence to Voice

Nurses constitute the largest professional group in health services and yet are often the least visible in articulating health issues and even in speaking about their own practice. As a result, opinion is shaped by medical practitioners, policy makers and others who are assumed to speak for the entire heath sector. Bernice Buresh and Suzanne Gordon aim to change all that, and if enough nurses read their book they might well be successful. The authors are journalists who have studied nurses and nursing and who have considerable empathy for both. From silence to voice takes the aim of a well developed research tradition in nursing, articulating the practical knowledge of nursing, and turns it into a political program for the nursing profession. Nurses are encouraged in all spheres of their lives, to talk about what they do, to describe their role in health care, to speak with pride and confidence about their skills, knowledge, and the day to day reality of their work. The book is carefully argued and practical, from the tips about how to respond to dinner guests asides about nurses ("You're a nurse practitioner. So you're like a doctor?") to guidelines for media interviews and political campaigns. It is both a manifesto and a manual.

The book is divided into two main sections. The first section Silent no more focuses on the individual nurse, and how a general silence on nursing becomes and internalised part of nurses' identities. "Despite what nurses....say about wanting nursing to gain more recognition...nurses often seem as hesitant to tell their friends and relatives about their work as they are to tell the New York Times or the Globe and Mail." p. 4). This section leads readers from the experience of nurses in maintaining their silence to practical suggestions aimed at helping nurses speak about their practice in their day to day conversations with family and friends. By beginning in the private sphere the authors recognise that a personal sense of agency is a valuable forerunner to speaking in professional forums, to the media, and in planned political campaigns. Nurses will recognise themselves in the vignettes that illustrate this section. Nurse Marian Phipps who presented a compelling account of helping a dying patient but ended by minimising her role in preserving the patient's dignity, saying "I tend to pull back." Nurse Ruth Jones who managed a patient's chemotherapy and helped her end an abusive relationship, but credited everyone except herself with pivotal roles in the woman's care. Buresh and Gordon link this sort of professional reticence to the social position of nursing. Nurses who cannot claim a 'voice of agency' in these critical encounters with patients are hardly in a position to advocate, against the grain of media opinion, for greater recognition for the profession.

The second part of the book, Communicating with the public and the media, is a manual for activists. Nurses involved in professional organizations and in speaking in public forums will find a wealth of practical suggestions, from tips on how to prepare for interviews, what questions to ask before agreeing to speak, to detailed discussion of campaign strategies. Individual chapters explain the workings of the news media, how to construct effective liaisons with reporters, writing for newspapers, using publicists and appearing on television and radio. The chapter on promoting nursing research provides an informative discussion on how academic papers can be adapted for public consumption. The analysis of how medical journals have actively courted media attention is a superb illustration of how news doesn't just happen, it is constructed by those who know the media and who are prepared to actively promote their opinions.

Although Buresh and Gordon place their feminist cards on the table early in the book, they do not expect that adopting a feminist stance will provide a carte blanche argument for the stance they advocate for nursing. The book is neither doctrinaire nor dogmatic, yet it is forthright in its critique of patriarchal medicine. The authors argue that nursing, as a predominantly female profession, needs both to both advocate for the feminine values of nursing, and to avoid the demeaning and sexist practices inherent in healthcare and in media reporting of healthcare. They are critical of those feminists who belittle nursing as a basket case profession hopelessly mired in the subordination of women, arguing that to accept this position is to accept that traditional feminine values are of no great social consequence and need to be renounced in favour of more competitive masculine values. There is little time given to making such ideological points. Like the discipline it represents, this book is about practice.

If there is something I would like to have seen in the book it is some specific coverage of issues faced by mental health nurses. While everything in the book is as relevant to mental health as to other areas of nursing, there are particular perils for any health professionals who speak out on mental health issues. News media tend to draft health professionals' comments into a dominant discourse of dangerousness and stigma. Health professionals, nurses included, need to be particularly wary that they don't contribute to an exaggerated association between mental illness and dangerousness. In mental health, nurses may find it less easy to gain public support as they will face public opinion which is often misinformed on mental health issues. While the specific issues may be different, the principles of breaking silence are the same. Buresh and Gordon's suggestions of memorising a few 'bumper stickers' to ensure that a positive message is communicated, redirecting questions where they seem to be leading towards a negative portrayal of mental illness are as apposite here as they are in resisting negative stereotypes of nurses. Having a few vignettes available to illustrate points will be just as helpful as making principled arguments about patients' rights.

From silence to voice deserves the accolades it has won from nurses such as Patricia Benner. Nurses in every section of the workforce will find something to take from this book. Those involved in professional organisations and in campaigning for nursing issues will find From silence to voice an invaluable source book. It is also recommended to teachers in undergraduate and postgraduate education. Rather than simply exhort students to speak out, From silence to voice tells how to do it, in plain language, and with examples that will be familiar to most. Researchers will benefit from the discussion of reaching the public, rather than only the academic community, with their research. While the book is written for nurses, other health professionals and those working in health, social and community work and education will benefit from its practical advice. Journalism students will also learn from the experience of two veterans of their profession. The book has already spawned a website http://www.silencetovoice.com/ and seems destined to become a classic.

© 2003 Tony O'Brien

Tony O'Brien, Senior Lecturer, School of Nursing, University Auckland, New Zealand.