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? Societys 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.
Nursings 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 agapethe 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.
Theres 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
Its 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 couldnt
do it unless you were truly linked to those who were suffering. And that
colors all of what she wrote.
Life wasnt 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 whats happened between then and now? Obviously weve 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
The original triadphysician, patient, nursewas viewed by
society through essentially the late 1980s as the primary drivers in caring.
Sicker and quicker is certainly the context now; its
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 challengingnot that its 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 weve never faced before. In 1980, about a quarter of
all nurses were under 30; now its 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 its 5 percent male and
not at all reflective of societys racial and ethnic diversity. The
supply of nurses is changing dramaticallynot increasingand
were 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 were 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 societys responsibility is to make sure nursings
context actually allows caring to take place. Weve gone through
a tremendous period of neglect. Working conditions are of tremendous concern.
Nursing, relative to other professions, has traditionally had low compensation;
it couldnt really depend, in the same way as other professions,
on society taking care of it. From 19922000, nursing
salaries have been flat. There has been no growth, and that certainly
doesnt 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 arent nursing services because,
in order to retain the nurses, cutbacks have to be made in other areas.
Its 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; thats
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
This essay was adapted from Salmons March 22 Great Teachers Lecture, The Profession of Nursing and the Contract to Care.