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April 16, 2001

Nursing's contract to care

Marla Salmon is dean of the Nell Hodgson Woodruff School of Nursing

The notion of the social contract is an ancient one, reaching back to Greek and Roman writings. In the 1700s, Locke, Hobbes and Rousseau created a foundation for the notion of the social contract in the face of emerging ideas of democracy and the roles of individuals in society. Adam Smith was among the first to talk about professions and their responsibility to and for the public, to and for governance, and to and for the state.

What is the nature of the social contract between the professions and society? Society’s part is that it accords special status to those professions. In the community where I grew up, if you happened to be a physician, there was a good chance you would be on the school board or elected to public office; you were viewed as having the ability to do something “special” because of being a professional. There was a sacred trust that somehow professionals would seek to do good in the broader social context.

Society also affords the ability to self-regulate; professionals have a guild, an opportunity for self-determination of their own destiny. And there is also tangible support.

On the professions’ part, the notion is that professions will promote and protect the well-being of society over their own self-interest, and that expresses itself quite differently depending on the profession.

Nursing’s contract to care has origins that in part are similar to those of medicine; they too extend back to Greece and some are captured in the Hippocratic oath. But nursing has also been deeply influenced by religion, both in the Judeo-Christian tradition and beyond. The roots from Judaism and Christianity reflect agape—the notion of love for the stranger, that one provides care and service to a stranger and is obligated to do so, perhaps out of what one could call human decency. But there is also a responsibility to care.

There’s also a military tradition. For one reason, it was simple necessity; regimentation of and the tremendous need for caring in the military called for some ways of making uniform how people cared. The military also provided the beginnings of social recognition for nursing.

The Florence Nightingale legacy distills the contract to one of care. She provided an ethical base, as well as a belief that you had to be a moral person to do good works. She created a profession where individuals had to be selected on the basis of their moral character.

For Nightingale herself, there was a strong sense of calling. In her writings, there are at least two or three instances where she speaks of having literally heard the voice of God telling her to do good for society. At that point, she had not identified nursing as her method for doing good, but she was called, and out of that grew the social responsibility of nursing.

It’s critical to note that Nightingale lived the experience of the Crimean War, and that had a profound impact on her notion of how you care. You had to be embedded in the experience of caring; you couldn’t do it unless you were truly linked to those who were suffering. And that colors all of what she wrote.

Life wasn’t actually simpler then; it was just different. There was a romantic notion of nursing, along with trust and respect for the role, although not quite a certainty about what that role was. “Expert caretaker” was always one of those pieces that was hard for society to integrate into its notion of what nursing did. It was a proper option for women to work, so it took care of that problem of intelligent women who wanted to do something other than be at home.

So what’s happened between then and now? Obviously we’ve seen fundamental shifts in the health care system. It is now market-driven, and society is in the backdrop. Costs are increasingly constrained; for the first time ever, nurses are seen as a significant problem as well as part of the solution because they consume resources and need to be paid for.

The original triad—physician, patient, nurse—was viewed by society through essentially the late 1980s as the primary drivers in caring. “Sicker and quicker” is certainly the context now; it’s become a competition for nurses’ care between patients, physicians, staff, technology, administration, etc. Some people wonder whether “managed care” is an oxymoron.

To be sure, there are very exciting things about nursing: It has a strong base in scholarship; we have advanced the practice, clearly moving a great deal since our inception; there are new roles, opportunities and functions; and there are the continuing intrinsic rewards of caring, one of the great constants in nursing.

But there are barriers to expert caring and its rewards, and these are extremely challenging—not that it’s ever been easy. I want to focus on what we are facing as a society in the nursing supply shortage because it is, in some sense, an important question for all of us.

There are several factors: One is the aging of the nursing workforce, a phenomenon we’ve never faced before. In 1980, about a quarter of all nurses were under 30; now it’s less than 10 percent. Half of us were under 40 in 1980; not even a third of us are now.

Second is a failing demographic equation; at one point nursing was a profession of both men and women, but now it’s 5 percent male and not at all reflective of society’s racial and ethnic diversity. The supply of nurses is changing dramatically—not increasing—and we’re looking at knowledge and skill shortages.

And there is a lack of public awareness. During every other shortage, you would hear leaders in the health care industry talk about how their institutions were experiencing shortages. Because we’re competing now on the basis of quality of care, it is very dangerous for an administrator to say he or she does not have enough nurses.

Part of society’s responsibility is to make sure nursing’s context actually allows caring to take place. We’ve gone through a tremendous period of neglect. Working conditions are of tremendous concern. Nursing, relative to other professions, has traditionally had low compensation; it couldn’t really depend, in the same way as other professions, on society “taking care” of it. From 1992–2000, nursing salaries have been flat. There has been no growth, and that certainly doesn’t match up with the rest of society.

And while we have advanced our science and expertise, we are challenged to be able to use this in a context of care. In a clinical context, nurses are frequently providing services that aren’t nursing services because, in order to retain the nurses, cutbacks have to be made in other areas.

It’s quite evident to our students that there has been no real growth in scholarship funding or educational programs for decades. Society has acted in the past; the last time society took major action was during the second World War. Through the Cadet Nurse Corps, 186,000 nurses were produced in four years. It was a joint effort among government, industry and the health system. It was astounding because there was a galvanized concern not for nurses but for the importance of caring in society.

Nurses remain second only to clergy as the most trusted profession; society loves nurses and trusts them with their lives. But care is being neglected, and the context for care is being neglected. Nurses and nursing are only worthwhile and relevant if they have the capacity to care; that’s the fundamental clause of the contract. In and of itself, the profession does not matter except in its capacity to care.

What next? I hope this is the beginning of the conversation. Shakespeare said the past is prologue, and he also said the future is yours and mine to dispatch.

This essay was adapted from Salmon’s March 22 Great Teachers Lecture, “The Profession of Nursing and the Contract to Care.”


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