By J. M. Coetzee
Short fiction published in The New Yorker, June 27, 2005
Drawn from the novel Slow Man (September 2005)
Barbra said people who need people are the luckiest people in the world. And J. M. Coetzee's short story "The Blow" also seems to honor human co-dependence, showing how even severe breaks in our lives can lead to new and unexpected social bonds. A solitary older Australian despairs when his leg is amputated after a bicycle accident. Who should end up saving his life but his Croatian home care nurse, his "day help," who offers not just expert care but also someone for him to love and care for. The story, actually an excerpt from Coetzee's forthcoming novel Slow Man, is not without handmaiden elements. In some ways it presents nursing more as a vital craft, or perhaps a female art, than as a scientific profession. And it's not entirely clear where nursing stops and the patient's love for his nurse begins. Even so, the Nobel Prize-winning South African's story offers a compelling, nuanced vision of the power of nursing in rehabilitation, and the dynamics of the relationship between an isolated patient and his nurse.
A car hits Paul Rayment's bicycle and sends him to an Adelaide hospital, where he drifts in and out of consciousness. Paul's ex-wife has re-married, and no one visits. He interacts only with Dr. Hansen, the touchy-feely surgeon (!) who ultimately amputates his leg, and with a blandly kind nurse named Elaine, who inserts a catheter. From the start, the bitter patient rejects a prosthesis. Upon Paul's discharge to his apartment, a social worker arranges for a "day nurse." This is Sheena, whose "confident fatness," annoying habits and bizarrely inappropriate discussions of personal care (complete with baby talk about Paul's "willy") are less than endearing.
Paul's second long term day nurse is a different story. Marijana Jokic is a married, middle-aged Croatian immigrant of great competence, energy and skill. She can "intuit" how Paul's body feels and how he will respond. She has a cheerful yet respectful demeanor. Her regimen includes wound care, massage, cooking, cleaning, pushing Paul to exercise and use his crutches, and talking to him. They discuss their lives, sticking to the "impersonal personal" a man might discuss with a woman who "happens to be his nurse." Marijana expresses what appears to be an expert opinion on the quality of Paul's sutures ("Good surgeon...Good job."). She is decent about sensitive personal tasks. Paul reflects that this meeting of a man and woman "behind locked doors" might as well be a sex act, but it is in fact "nothing like that. It is just nursing, just care."
Paul does come to feel a physical attraction to Marijana, but more important is that her touch signals that she does not find his body distasteful. Instead, she is ready to transmit some of her own "ruddy good health." She is the "perfection of a certain feminine type," and Paul's admiration grows. As his leg heals and he gains strength, he finds that "all gloom is gone." Of course, her care is "not a cure, it is not done with love, it is probably no more than orthodox nursing practice...What love there is is all on his side." Paul is aware of his "absurd" situation, but he becomes desperate to "protect" Marijana and her children.
[Note: If you do not wish to know how the story ends, stop reading here.]
Marijana gives Paul no reason to think that she reciprocates his personal feelings. She does bring her motorcycle-riding teenage son Drago by to hear Paul's cautionary tale about the perils of two-wheeled transport. Paul's chief regret is not having had a child, particularly a son, and he is impressed with the respectful, savvy Drago. Later, Marijana, worried about her son's "wild friends," asks: "What you think of boarding school, Mr. Rayment?" Paul offers to loan her the money for such a school, and when she wonders why, he confesses that he loves her. Marijana is silent. She disappears for several days, then returns with a brochure for the school Drago favors, carefully noting that her husband, now "just autoworker," was in Croatia a respected antique repair technician. Paul reflects that he has become a "godfather," like the Holy Spirit, ghostly and "beyond anger and desire." Marijana tells him how happy he will make Drago, then asks: "And you? Leg is OK? No pain? You do your exercises?" Paul responds: "The leg is OK...No pain, no pain at all."
This is a story of the power of nursing. It's true that we don't know how much of Paul's recovery is due to Marijana's nursing, and how much to his growing love for her. And one of the last things nursing would seem to need is further association with on-the-job romance. But Marijana is not presented as a sex object, and the main thing Paul seems to have fallen in love with is her nursing. Perhaps love is a natural reaction to sustained, excellent nursing. In any case, the story is clear and specific about how critical Marijana's deft care is to Paul's recovery. As Coetzee notes, she does not treat Paul as an old fool, but simply as a man whose movements are restricted by injury. She is sensitive, both emotionally and physically. She knows about wounds and rehabilitation. Under her care, Paul gains independence and autonomy. By the end of the story, he has taken a solo trip to the library to learn about Croatia, survived for several days by himself in the apartment, and reported that he has "no pain at all."
There are some problems with the way the story presents nursing care. Paul's repeated statements that Marijana seems able to "intuit" what is going on with his body, along with his suggestion that she embodies a "feminine" type, may suggest that nursing is an expression of some mysterious female spirituality, rather than a skilled modern profession. It's often said that nursing is an "art" as well as a science, but portrayals that emphasize only the "art" elements risk reinforcing familiar notions of the profession that are dangerously incomplete. Of course, it's entirely plausible that this is how a man like Paul would regard Marijana. And though he is not the narrator, the story is told entirely from his perspective; the reader learns nothing that he does not know. But the author might have told readers more about nursing in other ways, perhaps through comments by Marijana or the other nurses. Readers may not understand that Marijana has real technical skill, and that her practical ability is based on a professional model of care. The author might also have shared a bit more of the tenacity that is often required to push patients like Paul to gain strength and autonomy. Marijana seems to have simply willed his recovery. Or did she inspire him by her example? Perhaps it was just his love.
Likewise, Paul marvels that what Marijana does is so amazing even though it's "just nursing, just care." Yet what Marijana does goes beyond the common current understanding of "nursing." She cooks, cleans, and sews, actions that obviously do not require a nursing degree (we actually do not learn what level of nursing education Marijana has). We understand why a home care nurse might choose to spend paid time engaged in such tasks, which might otherwise be done by nursing assistants or workers with no health training at all, especially when conditions in many clinical settings today are abysmal. Moreover, in a larger sense nursing might be deemed to encompass most or all of the tasks Marijana performs, since they do affect Paul's physical and mental health. She hems his pants on one leg to just cover his stump, allowing him to incorporate his amputation into his new self-image. Her cleaning eliminates the filth that can breed illness. And her cooking provides the nutrition required for good health. Of course, today these tasks are more closely associated with homemaking than health care. But homemaking education figured prominently in Florence Nightingale's "Notes on Nursing: What It Is, And What It Is Not." Indeed, hospital patients today obviously need nutritious food and a hygienic atmosphere to get well. If a patient cannot provide the basics of good health for himself, nursing models call for his nurse to make sure he gets those basics, as the nurse educates and empowers the patient to survive on his own. However, while an informed observer could see Marijana's seemingly "domestic" tasks as part of a larger nursing process, without explanation many readers may assume that "nursing" requires little more scientific training and skill than "cooking" and "cleaning" do.
The hospital interactions are worse. Dr. Hansen appears to direct every important aspect of care, and he conducts all significant interactions with Paul, as if only physicians had serious health knowledge. Hansen even promises to help nurse Elaine in getting Paul up for a walk, an unusual thing for a surgeon to do, to say the least. Elaine's main role seems to be to reassure Paul that Dr. Hansen will soon come by to see him, a damaging, if common, misconception of hospital nursing. Elaine's only real independent action is the insertion of the catheter, which does little to convey the importance of post-op nursing. Of course, Paul has no great love for surgery either. He shows more bitterness about his lost leg than gratitude for his immediate survival.
If Sheena were the only nurse in the story, she might be a problem. But she seems to function more as a plausible counterweight to Marijana, making that portrayal more credible. In other words, nurses are like anyone else: some of them excel at their work, and some are like Sheena.
It would seem that the feelings Paul has for Marijana could easily develop in a home care setting. How should the nurse react to this kind of attention? Perhaps Marijana should have responded more directly to her patient's expression of love. But that's probably easier to say than to do, and in any case, perfect characters are not very persuasive. And what does the loan mean? Is it just another form of payment for her nursing services? It's possible to see it as a kind of compensation for society's failure to value nursing adequately, though nothing is really said in the story about Marijana's pay. Of course, nurses should not have to depend on discretionary windfalls. On the other hand, boarding school is not exactly a basic human right.
The story underlines the symbiosis in human society, including the unique relation between nurse and patient. Here a disconnecting interaction--a violent blow and critical injury that would seem to cut Paul off from society--ironically leads to his deeper reconnection with it. Now he has needs, and is needed. Perhaps Paul, as a "holy spirit" who has moved "beyond anger and desire," feels he has reached a kind of way station to the hereafter. Yet his relation with Marijana and Drago is very real. It's possible to see nursing itself as Paul's "prosthesis," but Marijana's work means more. It seems like a bridge between the accident and Paul's new life, between a past of solitude and regret and a future of renewal and integration. To paraphrase Madonna, nursing makes the people come together. And you can't ask more of a profession than that.
Review by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Reviewed July 29, 2005
The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.