It seems a commonly received idea among men and even among women themselves that it requires nothing but a disappointment in love, the want of an object, a general disgust, or incapacity for other things, to turn a woman into a good nurse.
-- Florence Nightingale, 1859
Recent changes in the nation's health care delivery system have presented both opportunities and challenges for America's nurses. As one of the culture's most enduring and familiar images, "the nurse" is also one of the least well understood. The original "Lady with the Lamp," inspired by the work of Nightingale, has infused contemporary positive images with qualities associated with unselfish service to humanity. These images often compete with ones of passivity (the "handmaiden"); sexual promiscuity ("You're a nurse...You'll appreciate this joke"); and intellectual frailty ("I had no idea you needed to go to college to be a nurse!").
Observers of the profession have noted its ambiguous status, labeling it a "twilight case" (Flexner) and a semi-profession" (Etzioni). Nursing's own analysis has ranged from self-pity (How can we make people understand and appreciate us?) through blaming (Nursing cannot advance because of_________. Fill in the blank with the name of some external force, usually male.) to self-congratulation (If it weren't for nurses...). The good news is that as this century closes, unique opportunities exist for nursing to redefine itself for society in accordance with reality.
At all levels of practice, current opportunities for professional nurses demand sophisticated intellectual, technical and leadership skills. As the hospital is displaced as the dominant employer of entry level nurses, the degree of competence required for practice in the community and the home escalates. People are frequently discharged from hospital to home with complicated needs for care that cannot be immediately met by family members. In the community, the resurgence of communicable diseases (particularly tuberculosis, sexually transmitted diseases and HIV/AIDS) challenges the case finding, surveillance and care providing skills of community health nurses. At the same time, the drive to reduce costs associated with acute care has produced attempts to augment (and in many instances replace) professional nurses with unlicensed personnel hired and trained to perform certain custodial and technical functions required by very sick people. Nurses are challenged to train, delegate and supervise this new cadre of workers in environments where the values of the corporation compete with the profession's values of compassion and care.
These shifts in the practice environment for entry level nurses are both problematic and portentous. As they struggle to maintain their contract with society, nurses have the opportunity to resolve the century long debate over the appropriate level of education required for initial licensure. This licensure for professional nursing must be limited to those who have completed at minimum the baccalaureate degree. Both the profession and society will be better served if alternative routes to licensure are phased out.
At the advanced nursing practice level (nurse practitioners, nurse midwives, clinical nurse specialists), consensus has developed making the master's degree the appropriate minimum academic credential. The next step is to define the appropriate standards for specialty certification. As the profession struggles to remove the legal barriers to advanced practice (prescriptive authority, e.g.) it must seize the opportunity and confront the challenge to specify the clinical practice requirements for this certification. The public is well served by advanced practice nurses who possess master's degrees and appropriate certification, but the current crazy quilt of requirements surrounding certification must be unified. Without such standardization, the profession will perpetuate at the advanced practice level a debate synonymous with the one centered on entry level practice. If this occurs, neither the profession nor society will be well served.
Finally, nursing must intensify efforts to conduct and disseminate research findings that confirm the value of nursing care. In the current health care environment, this means fiscal, or economic value. Long socialized to leave matters of power and finance to others, the profession's small but well qualified cohort of researchers must find ways to transcend the apparent competition existing between the values of compassion and those of the corporation. Health care reform in general and managed care specifically, more than any other factor, has transformed work environments for nurses. If nursing is to retain its cherished values, nurses must prove the worth of those values in economic terms. Fortunately, the intellectual resources to accomplish this exist in the profession; however, they need to grow and strengthen.
As the nation experiences the massive shifts associated with health care reform, nurses, as the largest group of health care providers, are ready to help smooth the transitions. At all levels of practice, nurses will use their unique blend of skills to serve society. At the same time, the profession needs to take advantage of this time of disequilibrium to resolve its own nagging questions related to the credentials required to provide that service. In addition, it must enter and win the duel between its traditional values and those driving contemporary efforts to reshape the nation's health care delivery system. Failure to meet these challenges will result in damage to both the profession and the society it loves to serve.
As Francis Bacon said, "(S)he that will not apply new remedies must expect new evils."
Margaret Parsons is associate dean of the nursing school.