After reading this chapter, you should be able to:
Relevant Nursing Education Standards and Concepts to the Chapter Content
AACN Essentials Relevant Standard Domains and Values:Knowledge for Nursing Practice, Scholarship for the Nursing Discipline, Professionalism, Personal/Professional/Leadership Development Concepts:Clinical judgment communication, compassionate care, diversity/equity/inclusion, ethics, evidence-based practice, health policy (AACN, 2021)
National League for Nursing (NLN) Values Related to Standards:Culture of caring, diversity and inclusion, excellence, and integrity (NLN, 2021)
Chapter Outline
This text presents an introduction to the nursing profession and critical aspects of nursing care and the delivery of health care. To begin the journey to graduation, licensure, and then practice, it is important to understand several aspects of the nursing profession. What is professional nursing? How did it develop? What factors influence the view of the profession? This chapter addresses these questions.
From Past to Present: Nursing History
Nursing students need to learn about nursing history because this provides a framework for understanding how nursing is practiced today and the societal trends that shape the profession. The characteristics of nursing as a profession and what nurses currently do have their roots in the past, not only in the history of nursing but also in the history of health care and society in general. Today, health care is highly complex; diagnostic methods and therapies have been developed that offer many opportunities for prevention, treatment, and cures that did not exist even a few years ago. Understanding this development is part of this discussion; it helps us to appreciate the practice of nursing and may provide stimulus for changes in the future. “Nursing is conceptualized as a practice discipline with a mandate from society to enhance the health and well-being of humanity,” and this perspective continues to be relevant (Shaw, 1993, p. 1654). However, other perspectives of nursing, such as the past portrayal of nurses as handmaidens and assistants to physicians, have their roots in the profession's religious beginnings, but over time, this view of nurses changed. The following sections examine the story of nursing and explore how it developed as a profession.
History Surrounding the Development of Nursing as a Profession
When nursing history is described, distinct historical periods typically are discussed: early history (AD 1-500), the rise of Christianity and the Middle Ages (500-1500), the Renaissance (mid-1300s-1600s), and the Industrial Revolution (mid-1700s-mid-1800s). In addition, the historical perspective must consider the different regions and environments in which the historical events took place. Early history focuses on Africa, the Mediterranean, Asia, and the Middle East. The focus then turns to Europe, with the rise of Christianity and subsequent major changes that span several centuries. Nursing history expands as British colonists arrived in America, and a new country and environment helped to slowly develop the nursing profession, which at the time was not a profession. Throughout all these periods and locations, wars had an impact on nursing. Because of the varied places and time periods in which nursing practice has existed, major historical events, different cultures and languages, religions, varying views on what constitutes disease and illness, roles of women and introduction of men into nursing, political issues, location, and environment influenced the profession. Nursing probably existed for as long as humans have been ill; someone always took care of the sick. This does not mean that there was a formal nursing position as we know it today, but rather, in its early history, the nurse was a woman who cared for ill family members. This discussion begins with this group and then expands to the development and implementation of a formal nursing position, then later to multiple roles and different healthcare settings and recognition of nursing as a profession and changes in its image.
Early History
The early history of nursing focused on the Ancient Egyptians and Hebrews, Greeks, and Romans. During this time, communities often had women who assisted with childbearing as a form of nursing care, and some physicians had assistants. The Egyptians had physicians, and some sick people looking for magical answers would go to them or to priests or sorcerers. Hebrew (Jewish) physicians kept records and developed a hygiene code that examined issues, such as personal and community hygiene, contagion, disinfection, and preparation of food and water (Masters, 2018). This occurred at a time when hygiene was poor-a condition that continued for several centuries.
Disease and disability were viewed as curses and related to sins, which meant that afflicted persons had to change or follow the religious statutes (Bullough & Bullough, 2020). Greek mythology recognized health issues and physicians in its gods. Hippocrates, a Greek physician known as “the father of medicine,” contributed to health care by writing a medical textbook that was used for centuries. He also developed an approach to disease that would later be referred to as epidemiology and had a major impact on understanding infectious diseases, epidemics, and pandemics. Hippocrates wrote the Hippocratic Oath (Bullough & Bullough, 2020), which is still recited by new physicians and influenced the writing of the Nightingale Pledge for nurses. The Greeks viewed health as a balance between mind and body-a different perspective from earlier views of health that focused on curses and sins.
Throughout this period, the wounded and sick in the armies also required care. Generally, during this period-which represents thousands of years and involved several major cultures that rose and fell-nursing care was provided, but not nursing as it is thought of today. People took care of those who were sick and women during childbirth, representing an early nursing role.
Rise of Christianity and the Middle Ages
The rise of Christianity led to more structured nursing care, but it was still far from what we know today as professional nursing. Women continued to carry most of the burden of caring for the poor and the sick. The church set up a system for care that included the role of the deaconess, who provided care in homes. Women who served in these roles had to follow strict rules set by the church. This role eventually evolved into that of nuns, who began to live and work in convents, which was considered a safe place for women. The sick came to convents for nursing care and also received spiritual care (Wall, 2003). The establishment of convents and the nursing care provided there formed the seed for what, hundreds of years later, would become the Catholic hospital system that still exists today.
Men were also involved in nursing at this time. For example, men in the Crusades cared for the sick and injured. These men wore large red crosses on their uniforms to distinguish them from the fighting soldiers. The “red cross” later became the symbol for the International Committee of the Red Cross.
Altruism and connecting care to religion were major themes during this period. Even Florence Nightingale continued with these themes in developing her view of nursing. Disease was common and spread quickly, and medical care had little to offer in the way of prevention or cure. Institutions that were called “hospitals” were not like modern hospitals; they primarily served travelers and sometimes the sick (Kalisch & Kalisch, 1986, 2005).
The Protestant Reformation had a major impact on some of the care given to the sick and injured. The Catholic Church's loss of power in some areas resulted in the closing of hospitals, and some convents closed or moved. The hospitals that remained were no longer staffed by nuns but rather by women from the lower classes who often had major problems, such as alcoholism, or were former prostitutes. This is what Nightingale found when she entered nursing.
Renaissance and the Enlightenment
The Renaissance had a major impact on health and views of illness. This period was one of significant advancement in science, though by today's standards, it might be viewed as limited. These early discoveries led to advancements that had never been imagined. This is the period, spanning many years, of Columbus, the French and American Revolutions, and the increased importance of education. Leonardo da Vinci's drawings of human anatomy, which were done to help him understand the human body for his sculptures, provided details that had not been recognized before (Donahue, 1985). The 18th century was a period of many discoveries and changes (Masters, 2018; Dietz & Lehozky, 1968; Rosen, 1958), including the following:
Industrial Revolution
The Industrial Revolution brought changes in the workplace, but many were not positive from a health perspective. The crowded factories of this era were hazardous and served as breeding grounds for disease and the risk of accidents. People worked long hours and often under harsh conditions. This was a period of great exploitation of children, particularly those of the lower classes, who were forced to work at very young ages (Masters, 2018). No child labor laws existed, so preteen children often worked in factories alongside adults. Some children were forced to quit school to earn wages to help support their families. Cities were crowded and very dirty, with epidemics erupting about which little could be done. There were few public health laws and services to alleviate the causes. Some years later, we now include occupational health in our public and community health perspective.
Colonization of America and the Growth of Nursing in the United States
The initial experiences of nursing in the United States were not much different from those described in Britain and Europe. Nurses were often from the lower class and had limited or no training; hospitals were not used by the upper classes, as they stayed home for care, but rather by the lower classes and the poor. Hospitals were dirty and lacked formal care services.
Nursing in the United States moved forward, taking significant steps to improve nursing education and the profession of nursing. The first nursing schools-or, as they were called, “training schools”-were modeled after Nightingale's school in Britain. Some of the earlier schools were in Boston, New York, and Connecticut. The schools emphasized moral character and subservience, with efforts to move away from using lower-class women with dubious histories (Masters, 2018). Limitations regarding what women could do on their own continued to be a major problem-for example, women could not vote and had limited rights.
In the early 1900s, this situation began to change when women obtained the right to vote but only with great effort. The Nurses' Associated Alumnae, established in 1896, was renamed the American Nurses Association (ANA) in 1911. At the same time, the first nursing journal, the American Journal of Nursing (AJN), was created and sponsored by the ANA. The AJN was published until early 2006 when the ANA replaced it with American Nurse Today as its official journal. The AJN, the oldest U.S. nursing journal, still exists today but under the direction of a publisher not associated with ANA. Its content has always focused on issues facing nurses and their patients. Additional information about significant nursing professional activities is discussed in this chapter and other chapters throughout this text.
Although some nurse leaders were ardent suffragists, Nightingale was not interested in these ideas, even though women in Britain did not have the right to vote. She felt that the focus should be on allowing (a permissive statement indicative of women's status) women to own property and then linking voting rights to this ownership right (Masters, 2018). There was, however, communication between U.S. and British nurses. They did not always agree on the approach to take on the road to professionalism, and nurses did not always agree on this issue within the United States. During times of war (American Revolution, Civil War, the Spanish-American War, World War I, World War II, Korean War, Vietnam War, and modern wars today), nurse leaders and practicing nurses who participated in healthcare services with the military helped nursing develop into a profession. The website Experiencing War: Women at War offers information about some of the nurses who served in these wars, providing nursing care leadership and further developing the nursing profession (Library of Congress, 2023).
In the 1930s, the Great Depression also had an impact on nursing. Throughout the country, unemployment increased, including the employment of private-duty nurses and the closing of some nursing schools due to lack of funding (Masters, 2018). As was true for many problems during the Depression, there was a greater need to assist those who needed help with limited resources, such as fewer student nurses to staff the hospitals. Consequently, nurses were hired, but at very low pay, to replace the students. Until that time, hospitals had depended on student nurses to staff hospitals, and nurses who had completed “training” (a term then used for nursing education) served as private-duty nurses in homes. Using students to staff hospitals continued until the university-based nursing effort grew. On one level, reducing the use of students in staff positions could be seen as an improvement in care and expansion in the nurse's role, but the obstacle of low pay was difficult to overcome, resulting in a long history of low pay scales for nurses.
In the 1940s and 1950s, other changes occurred in the U.S. healthcare system that had a direct impact on nursing. Certainly, scientific discoveries were changing care, but important health policy changes occurred as well, and as noted in this text, health policy impacts nursing and health care. For example, the Hill-Burton Act (1946) established federal funds to build more hospitals. Because of this building boom, at one point in the 1980s, there were too many hospital beds. In turn, many nurses lost their jobs in hospitals because their salaries represented the largest operating expense and there were not enough patients to fill the beds. There is some belief that this decision still affects fluctuating problems of nursing shortage either at the national level or in specific states and healthcare organizations (HCOs), though its scope has varied over the past few years. Some of the nurses who were laid off moved into new jobs or careers or left the workforce, and then when more nurses are needed, they are not available. The latter half of the 20th century represented a period of rapid change in healthcare reimbursement due to the growth of health insurance; greater attempts to manage care, particularly to reduce costs; and the establishment of Medicare and Medicaid to expand national government healthcare reimbursement managed by the Center for Medicare and Medicaid Services (CMS). Such rapid changes were repeated with the passage of the Patient Protection and Affordable Care Act of 2010 (ACA), and possible future changes to this law are unknown. During these times, typically, more nurses and other healthcare providers are needed. Chapter 8, “The Healthcare Delivery System: Focus on Acute Care,” discusses some of these issues in more detail. Chapter 5, “Health Policy and Political Action,” examines significant issues in current healthcare delivery. In addition, in 1922, 1946, and then in 2010, critical reports were published describing the status of nursing education, as discussed later in this text in content about nursing education leading to more recognition of the positive impact a well-educated workforce has on reducing mortality rates and medication errors and improving patient outcomes and quality care (American Association of Colleges of Nursing [AACN], 2023a).
This description of early nursing history includes little information about the role of men and minorities in nursing due to their limited involvement in the profession's early history. This lack of diversity-men and minorities-has been a long-term problem for the profession. Segregation and discrimination also existed in nursing, just as they did in the society at large. The National Association of Colored Graduate Nurses closed in 1951 when the ANA began to accept African American nurses as members, which represented an important change. Nevertheless, concern remains about the limited number of minorities in health care. The Sullivan Commission's report on health profession diversity, Missing Persons: Minorities in the Health Professions (L. Sullivan, 2004), is an important document offering a historical perspective and recommendations to improve diversity in the health professions. The AACN (2004) responded to this critical report by recommending the following actions: Healthcare professional schools should have diversity program managers and develop strategic diversity plans, provide support services for minority students, and assist 2-year nursing students with efforts to transition to baccalaureate degree programs. The AACN and other health profession organizations should guide schools to improve policies and cultural competence along with minority student recruitment and student funding. There also needs to be a greater governmental effort to provide funding and support.
These recommendations and efforts to improve the number of minorities in all health professions have had some impact on diversity in the profession, but more ongoing improvement is required. The need to make changes is recognized by the AACN Diversity, Equity, and Inclusion (DEI) initiative and the publication of a statement supporting greater integration of DEI in nursing education, practice, and research (AACN, 2023b). This topic also relates to the problems of health equity and disparities, as noted in other chapters, and it is associated with the major nursing report Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (National Academy of Medicine [NAM], 2021a). This report expanded on earlier nursing reports and added new information and recommendations focused on health equity, a growing need in healthcare delivery. Its recommendations for education, practice, the profession, and research are identified in Exhibit 1-1.
| Exhibit 1-1 Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity Recommendations |
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The need for greater diversity in nursing led to an increase in the number of men in nursing, but it still is not at the level it should be. Men served as nurses in the early history period, such as noted earlier in this chapter about the Crusades, and monks provided care in monasteries. After this period, however, men were not accepted as nurses because nursing was viewed as a woman's role. There were some men in nursing, though few, and some were well known, but perhaps not for their nursing, such as the poet Walt Whitman, who was a nurse in the Civil War (Kalisch & Kalisch, 1986). Early in the history of nursing schools in the United States, men were not accepted. This may have been influenced by the gender-segregated housing for nursing students and the model of apprenticeship that focused on women (Bullough, 2006). In part, this female dominance was also the result of nursing's religious roots, which promoted sisters/nuns as nurses. This made it difficult for men to come into the system and the culture.
After the major wars-such as World Wars I and II, the Korean War, and the Vietnam War-medics who were men came home and entered nursing programs, and they continue to do so. In 1940, the ANA recognized men by having a session on men in nursing at its annual convention. When schools of nursing began to transition to academic settings, more men applied to nursing programs. Men in nursing must contend with male-dominated medicine, which has influenced men to become nurses. There was a time when male nurses were also able to get commissions in the military when women could not, and this increased their numbers in the military (Bullough, 2006). These changes had an impact, but the increase in salaries and improvement in work conditions had the strongest effects on increasing the number of men in nursing.
Early in 2000, Boughn conducted a study to explore why women and men wanted to be nurses. The results of this study indicated that female and male participants did not differ in their desire to care for others (Boughn, 2001). Both groups had a strong interest in power and empowerment, but female students were more interested in using their power to empower others, whereas male students were more interested in empowering the profession. The most significant difference was found in the expectations of salary and working conditions, with men expecting more. Why would not both men and women expect higher salaries and better working conditions? Is this still part of the view of nursing and nurses from nursing's past? A survey of salaries in 2022, some years after the Bough study, indicated that there was a gender pay gap, and in some cases, it was significant (Vaughn, 2022). Some of the reasons for the gap are supported by the earlier study, such as men negotiating more for salaries, often working in higher-paying specialties, and for healthcare organizations that pay more. The following are recommendations to reduce the gender pay gap: All potential employees should negotiate for higher pay, ask for information about salaries and compare, include the gender pay gap in discussions with employer leaders and professional leaders, increase awareness of positions and specialties that offer higher pay, and focus on employers that value equity and transparency (Nurse.com, 2023; Vaughn, 2022).
Luther Christman, a well-known nurse leader for many years, retired at the age of 87, and, after retirement, he continued to be an active voice for the profession and for men in nursing until his death in 2011. According to E. Sullivan, Christman stated that “men in medicine were reluctant to give up power to women and, by the same token, women in nursing have fought to retain their power. Medicine, however, was forced to admit women after affirmative action legislation was enacted” (2002, p. 10). “Sadly,” Christman reported, “Nursing, with a majority of women, was not required to adhere to affirmative action policies” (E. Sullivan, 2002, p. 12). The organization for men in nursing, the American Assembly for Men in Nursing (AAMN), has focused on increasing gender diversity and supporting men who choose nursing as a career. Men are also members of other nursing organizations, but the AAMN is important for speaking out for men in nursing, impacting roles, policies, education, and so on (2023). In 2022, an estimated 13% of nurses were men compared to 1960, when 2% of nurses were men (U.S. Bureau of Labor Statistics, 2023; Munday, 2023). Though this represents an improvement, more needs to be done, such as more media coverage, which would be helpful in publicizing the role of men and minorities in nursing. Or, when photos are distributed to the media, photos should emphasize the diversity of the profession. We need to see more men in key nursing positions in practice, professional organizations, and academics. They should act as role models to attract more men into the profession. As commented earlier, men have represented a small percentage of the total number of registered nurses (RNs) living and working in the United States, although their numbers continue to grow (U.S. Bureau of Labor Statistics, 2023; Brusie, 2020).
Nurse Leaders: History in the Making
The best place to begin to gain a better understanding of nursing history is with a description of its leaders-that is, nurses who have made a difference in the development of the profession. Florence Nightingale is viewed as the “mother” of modern nursing throughout the world. Most nursing students at some point say the Nightingale Pledge, which helps all new nurses connect the past with the present. The Nightingale Pledge is found in Exhibit 1-2. It was composed to provide nurses with an oath similar to the physician's Hippocratic Oath. The oath was not written by Nightingale but emphasized her view of nursing, and it is easy to also see the influence of the culture at the time this was written.
| Exhibit 1-2 The Original Nightingale Pledge |
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| I solemnly pledge myself before God and in the presence of this assembly, to pass my life in purity and to practice my profession faithfully. I will abstain from whatever is deleterious and mischievous and will not take or knowingly administer any harmful drug. I will do all in my power to maintain and elevate the standard of my profession and will hold in confidence all personal matters committed to my keeping and all family affairs coming to my knowledge in the practice of my calling. With loyalty will I endeavor to aid the physician in his work and devote myself to the welfare of those committed to my care.Composed by Lystra Gretter in 1893 for the class graduating from Harper Hospital, Detroit, Michigan. |
Volumes have been written about Nightingale. She has become the almost perfect vision of a nurse; however, although Nightingale did much for nursing, many who came after her provided even greater direction for the profession, building on her contributions. Focusing on Nightingale helps to better understand where nursing began and the major changes that occurred in the profession and nursing leaders. In 1859, Nightingale wrote, “No man, not even a doctor, ever gives any other definition of what a nurse should be than this-‘devoted and obedient.' This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman” (Nightingale, 1992, p. 20). This quote clearly demonstrates that she was outspoken and held strong beliefs, though she lived during a time when this type of forthrightness from a woman was extraordinary.
Nightingale was British and lived and worked in London during the Victorian era and the Industrial Revolution. During this time, the role of women-especially women of the upper classes-was clearly defined and controlled. Women did not work outside the home and maintained a monitored social existence. Their purpose was to be a wife and a mother, two roles that Nightingale never assumed. The education of women was also limited. With the support of her father, Nightingale received some classical education, but there was never any expectation that she would “use” the education (Slater, 1994). “Nightingale grew up knowing what was expected of her life: Women of her class ran the home and supervised the servants. Although this was not her goal, the household management skills that she learned from her mother were put to good use when she entered the hospital environment. Because of her social standing, she was in the company of educated and influential men, and she learned the ‘art of influencing powerful men'” (Slater, 1994, p. 143). Nightingale applied this skill as she fought for reforms.
Nightingale held different views about the women of her time. She had “a strong conviction that women have the mental abilities to achieve whatever they wish to achieve: compose music, solve scientific problems, create social projects of great importance” (Chinn, 2001, p. 441). She felt that women should question their assigned roles, and she herself wanted to serve people. When she reached her 20s, Nightingale felt an increasing desire to help others and decided that she wanted to become a nurse. Nurses at that time came from the lower classes, and there was no training for this type of role. Her parents refused to support her goal, and because women were not free to make this type of decision by themselves, she was blocked. Nightingale became angry and then depressed. When her depression worsened, her parents finally relented and allowed her to attend nurses' training in Germany. This venture was kept a secret, and people she knew were told that she was away at a spa for 3 months' rest (Slater, 1994). Nightingale was also educated in math and science, which was unusual for this, but it would later lead her to use statistics to demonstrate the nurse's impact on health outcomes. Had it not been for her social standing and her ability to obtain some education, coupled with her friendship with Dr. Elizabeth Blackwell, a British physician, nurses might well have remained uneducated assistants to doctors, at least for a longer period than they did.
An important fact about Nightingale is that she was very religious-to the point that she felt God had called on her to help others (Woodham-Smith, 1951). She also felt that the body and mind were separate entities, but both needed to be considered from a health standpoint. This view later served as the basis of nursing's holistic view of health. Nightingale's convictions also influenced her views of nurses and nursing practice. She viewed patients as persons who were unable to help themselves or were dying, supporting her views by saying, “What nursing has to do … is to put the patient in the best condition for nature to act upon him” (Seymer, 1954, p. 13). Nightingale also recognized that a patient's health depends on environmental factors, such as light, noise, odors, and heat-something that we examine more closely today in nursing and in health care by using alternative and complementary methods, and these factors are even included in national initiatives, such as Healthy People 2030, discussed in this text. In her work during the Crimean War, she applied her beliefs about the body and mind by arranging activities for the soldiers, providing them with classes and books, and supporting their connection with home-an early version of what is now often called “holistic care.” Later, this focus on the total patient became an integral part of psychiatric-mental health nursing and then nursing in general. Nightingale's other interest-sanitary reform-also grew from her experience in the Crimean War. She also worked with influential men to make changes. Although she did not agree with some of the new science theories, she did support the value of education in improving social problems and believed that education should also include moral, physical, and practical aspects (Widerquist, 1997). Later, nurses based more of their interventions on science and evidence-based practice.
The many important discoveries noted earlier, such as the work done by Lister and Pasteur, had an impact on nursing over the long term and changed the sociopolitical climate of health care-for example, public health policy and services. Nightingale, however, did not agree with the new theory of contagion, but over time, the nursing profession accepted these new theories, which remain critical components of patient care today as recently experienced in the COVID-19 pandemic. Nightingale stressed, however, that the mind-body connection-putting patients in the best situation for healing-ultimately made the difference. Discovering methods for preventing disease and using this information in health promotion and disease prevention is an important part of nursing today. Public/community health is concerned with many of the same issues that led to critical new discoveries so many years ago, such as the contamination of food and water, preventing disease worldwide, and the impact of environment and climate on health, and today, due to these new views, there is a greater emphasis on population health.
During the Industrial Revolution, Nightingale and enlightened citizens tried to reform some of the working conditions that were influencing health and public problems. As Nightingale stated in her books Notes on Nursing and Notes on Hospitals (1859), “There are five essential points in securing the health of houses: pure air, pure water, efficient drainage, cleanliness, and light” (Gonzalo, 2023). She strongly supported more efforts to promote health and felt that this was more cost-effective than treating illness, which are important healthcare principles today. These ideas are good examples reflecting the influence of the society, environment, and culture in which a person lives and works on personal views and problems. For example, today, we see even greater emphasis on climate and environment, as will be discussed in later chapters.
Nightingale wrote four small books-or “treatises,” as they were called-thus starting the idea that nurses need to publish and share what they do and what they learn about patient care. The titles of the books were Notes on Matters Affecting the Health, Efficiency, and Hospital Administration of the British Army (1858a); Subsidiary Notes as to the Introduction of Female Nursing into Military Hospitals (1858b); Notes on Hospitals (1859); and Notes on Nursing (1859, republished in 1992). The first three focused on hospitals that she visited, including military hospitals (Slater, 1994). Nightingale collected a lot of data about illness. Her interest in healthcare data analysis helped to lay the groundwork for epidemiology, highlighting the importance of data in nursing, particularly in a public health context, and established an initial foundation for nursing research and evidence-based practice. These early initiatives also relate to the current quality improvement efforts requiring measurement and analysis of large quantities of data. An interesting fact is that Notes on Nursing was not written for nurses but rather for women who cared for ill family members in their homes. Even later in her nursing initiatives, Nightingale had not completely given up on the idea of care provided by women as a form of service to family and friends. This text was popular when it was published because, at the time, family members provided most of the nursing care and sought out guidance for these activities.
Nightingale's religious and upper-class background had a major impact on her important efforts to improve both nursing education and nursing practice in the hospital setting. Nurses were of the lower class; usually had no education; and often had alcohol disorders, engaged in sexual activities for pay, and had economic problems impacting where they lived and their basic needs, such as food, housing, and support. Nightingale led changes in who went into nursing. She believed that patients needed educated nurses to care for them, and she founded the first organized school of nursing. Nightingale's school, which opened in London in 1860, accepted women who were different from women typically involved in providing nursing care, as had been the case with previous generations of nurses. The students were not viewed as servants; their loyalty was to the school, not the hospital. This point is somewhat confusing and must be viewed from the perspective that important changes were made; however, these were not monumental changes but a beginning. For example, even in Nightingale's school, students were a part of the hospital; they staffed the hospital, represented free labor, and worked long hours. This approach developed into the diploma school model, which was considered an apprenticeship model. Today, diploma schools have less direct relationships with hospitals, and in some cases, they have transitioned to associate degree programs and, in other cases, baccalaureate degrees. There are fewer diploma schools of nursing today (see Chapter 3, “Nursing Education, Accreditation, and Regulation”).
Nightingale's students received some training, which had not been provided in an organized manner prior to her efforts. Her religious views also had an impact on the rigid educational system she proposed and implemented, expecting students to have high moral values. Training was based on an apprenticeship model and continued to be for some time in Britain, Europe, and the United States. The structure of hospital nursing was also very rigid, with a matron in charge. This rigidity persisted for decades.
Nurses in Britain began to recognize the need to band together, and they eventually formed the British Nurses Association. This organization soon focused on the issue of regulating nursing practice. Nightingale did not approve of efforts made to establish government registration (licensure) of nurses, mostly because she did not trust the leaders' goals (Freeman, 2007). There were no known nursing standards, so how one became a registered nurse was unclear. Many questions were raised regarding the definition of nursing: who should be registered, and who controlled nursing? Some critics agree that Nightingale did make changes, but the way she made the changes also had negative effects, including delaying the development of the profession (particularly her support of nurses' subordinate position to physicians), failing to encourage nursing education offered at a university level, and delaying licensure (Freeman, 2007). Despite these criticisms, Nightingale still holds an important place in nursing history as a major leader of the profession.
The vignettes in Exhibit 1-3 describe some of the contributions made by nursing leaders, emphasizing that Nightingale is not the only important nursing leader. People do not operate in a vacuum, and neither did the nurses highlighted in this exhibit. Many factors influence nurse leaders, such as the healthcare system, their communities, the society, their education, and the time in which they practice.
| Exhibit 1-3 A Glimpse into the Contributions of Nurses in the United States |
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| This list does not represent all the important nursing leaders but does provide examples of the broad range of their contributions and highlights specific achievements. These glimpses are written in the first person, but they are not direct quotes. |
| Dorothea Dix (1840-1841) |
| I traveled the state of Massachusetts to call attention to the present state of insane persons confined within this Commonwealth, in cages, stalls, pens! Chained, naked, beaten with rods, and lashed into obedience. Just by bettering the conditions for these persons, I showed that mental illnesses aren't all incurable. |
| Linda Richards (1869) |
| I was the first of five students to enroll in the New England Hospital for Women and Children and the first to graduate. Upon graduation, I was fortunate to obtain employment at the Bellevue Hospital in New York City. Here, I created the first written reporting system, charting and maintaining individual patient records. |
| Clara Barton (1881) |
| The need in America for an institution that is not selfish must originate in the recognition that some evil is adding to the sum of human suffering or diminishing the sum of happiness. Today, my efforts to organize such an institution have been successful: the National Society of the Red Cross. |
| Isabel Hampton Robb (1896) |
| In 1896, I organized the Nurses' Associated Alumnae of the United States and Canada and served as the first president. Later, this organization became the ANA. I also founded the American Society of Superintendents of Training Schools for Nurses, which later became the National League of Nursing Education (NLNE) and then changed its name to the National League for Nursing (NLN). Through these professional organizations, I was able to initiate many improvements in nursing education. |
| Sophia Palmer (1900) |
| I launched the American Journal of Nursing and served as editor-in-chief of the journal for 20 years. I believe my forceful editorials helped guide nursing thought and shape nursing practice and events. |
| Lavinia L. Dock (1907) |
| I became a staunch advocate of legislation to control nursing practice. Realizing the problems that students faced in studying drugs and solutions, I wrote one of the first nursing textbooks, Materia Medica for Nurses. I served as foreign editor of the American Journal of Nursing and coauthored the book The History of Nursing. |
| Martha Minerva Franklin (1908) |
| I actively campaigned for racial equality in nursing and guided 52 nurses to form the National Association of Colored Graduate Nurses. |
| Mary Mahoney (1909) |
| In 1908, the National Association of Colored Graduate Nurses was formed. As the first professional Black nurse, I gave the welcome address at the organization's first conference. |
| Mary Adelaide Nutting (1910) |
| I advocated for university education for nurses and developed the first program of this type. Upon accepting the chairmanship at the Department of Nursing Education at Teachers College, Columbia University, I became the first nurse to be appointed to a university professorship. |
| Lillian Wald (1918) |
| My goal was to ensure that women and children, immigrants and the poor, and members of all ethnic and religious groups would realize America's promise of life, liberty, and the pursuit of happiness. The Henry Street Settlement and the Visiting Nurse Service in New York City championed public health nursing, housing reform, suffrage, world peace, and the rights of women, children, immigrants, and working people. |
| Mary Breckenridge (1920) |
| Through my own personal tragedies, I realized that medical care for mothers and babies in rural America was needed. I started the Frontier Nursing Service in Kentucky. |
| Elizabeth Russell Belford, Mary Tolle Wright, Edith Moore Copeland, Dorothy Garrigus Adams, Ethel Palmer Clarke, Elizabeth McWilliams Miller, and Marie Hippensteel Lingeman (1922) |
| We were the founders of the Sigma Theta Tau International Honor Society of Nursing. Each of us provided insights that advanced nursing scholarship, leadership, research, and practice. |
| Susie Walking Bear Yellowtail (1930-1960) |
| I traveled for 30 years throughout North America, walking to reservations to improve health care and Indian health services. I established the Native ANA and received the President's Award for Outstanding Nursing Healthcare. |
| Virginia Avenel Henderson (1939) |
| I am referred to as “the first lady of nursing.” I think of myself as an author, an avid researcher, and a visionary. One of my greatest contributions to the nursing profession was revising Harmer's Textbook of the Principles and Practice of Nursing, which has been widely adopted by schools of nursing. |
| Lucile Petry Leone (1943) |
| As the founder of the U.S. Cadet Nurse Corps, I believe we succeeded because we had a salable package from the beginning. Women immediately liked the idea of being able to combine war service with professional education for the future. |
| Esther Lucille Brown (1946) |
| I issued a report titled Nursing for the Future. This report severely criticized the overall quality of nursing education. Thus, with my nursing education report, we began the long-discussed move to accreditation of nursing education programs. |
| Lydia Hall (1963-1969) |
| I established and directed the Loeb Center for Nursing and Rehabilitation at Montefiore Hospital in the Bronx, New York. Through my research in nursing and long-term care, I developed a theory (core, care, and cure) that the direct professional nurse-to-patient relationship is itself therapeutic and nursing care is the chief therapy for the chronically ill patient. |
| Martha Rogers (1963-1965) |
| I served as editor of the Journal of Nursing Science, focusing my attention on improving and expanding nursing education, developing the scientific basis of nursing practice through professional education, and differentiating between professional and technical careers in nursing. My book, An Introduction to the Theoretical Basis of Nursing (1970), marked the beginning of nursing's search for a theoretical base. Later, my work led to a greater emphasis on research and evidence-based practice. |
| Loretta Ford (1965) |
| I codeveloped the first nurse practitioner program in 1965 by integrating the traditional roles of the nurse with advanced medical training and the community outreach mission of a public health official. |
| Madeleine Leininger (1974) |
| I began, and continued to guide, nursing in the recognition that the cultural care needs of people in the world will be met by nurses prepared in transcultural nursing. |
| Florence Wald (1975) |
| I devoted my life to the compassionate care for the dying. I founded Hospice Incorporated in Connecticut, which is the model for hospice care in the United States and abroad. |
| Joann Ashley (1976) |
| I wrote Hospitals, Paternalism, and the Role of the Nurse during the height of the women's movement. My book created controversy with its pointed condemnation of sexism toward and exploitation of nurses by hospital administrators and physicians. |
| Luther Christman (1980) |
| As founder and dean of the Rush University College of Nursing, I was linked to the “Rush Model,” a unified approach to nursing education and practice that continues to set new standards of excellence. As Dean of Vanderbilt University's School of Nursing, I was the first to employ African American women as faculty at Vanderbilt University, and I became one of the founders of the National Male Nurses Association, now known as the American Assembly for Men in Nursing. |
| Hildegard E. Peplau (1997) |
| I became known as the “Nurse of the Century.” I was the first nurse to serve the ANA as executive director and later as president, and I served two terms on the Board of the International Council of Nurses. My work in psychiatric-mental health nursing emphasized the nurse-to-patient relationship. |
| Linda Aiken (current) |
| My policy research agenda is motivated by a commitment to improving healthcare outcomes by building an evidence base for health services care and management and providing direction for national policymakers, resulting in greater recognition of the role that nursing care has on patient outcomes. Nurses need to be actively engaged in research to improve care. |
| Patricia Benner (current) |
| I have long been involved in nursing education and developed many initiatives to improve nursing education and, thus, nursing practice. In 1982, I published a major book that discussed the process that nurses go through from novice to expert. In 2010, I led an extensive study on the status of nursing education, the first such study since the 1922 Goldmark report and the 1948 Brown report. My report, Educating Nurses: A Call for Radical Transformation (2010), identified many areas of nursing education that need improvement. |
| Beatrice Kalisch and Phillip Kalisch (current) |
| We have worked together to recognize the importance of the image of nursing as a profession. In doing this, we have examined the many roles of nurses and issues that impact their work, such as workforce shortages. In our examination, we included different media as sources, such as films, television, fiction, and press coverage. The profession should not ignore its professional image. |
| The Year of the Nurse 2020 |
| The Year of the Nurse 2020 recognized the importance of nurses, and it was also a year of great stress due to the COVID-19 pandemic requiring nurses to take great risks and become leaders. The following link includes comments from 14 nurse leaders discussing what the Year of the Nurse means to them during a time of stress in the healthcare system and nursing profession and to the future of nursing. When these comments were made, the pandemic was just beginning, and no one really knew the impact it would have. The source for the comments from the 14 nurse leaders is https://nursing.jnj.com/nursing-news-events/nurses-leading-innovation/what-the-year-of-the-nurse-means-to-14-nurse-leaders |
| National Academy of Nursing Living Legends |
| The National Academy of Nursing selects exemplary nursing leaders for recognition of their leadership in health care in the United States and globally. The organization's website (https://www.aannet.org/home) provides information on these leaders and their contributions. |
Themes: Looking into the Nursing Profession's History
The discipline of nursing evolved slowly from the traditional role of women, apprenticeship, humanitarian aims, religious ideals, intuition, common sense, trial and error, theories, and research and was influenced by medicine, technology, politics, social issues, war, economics, and feminism (Kidd & Morrison, 1988; Lynaugh & Fagin, 1988; Perry, 1985; Brooks & Kleine-Kracht, 1983; Gorenberg, 1983; Keller, 1979; Jacobs & Huether, 1978). It is impossible to provide a detailed history of nursing's evolution in one chapter, so only critical historical events are discussed.
Writing about nursing history itself has its own interesting history (Connolly, 2004). Historians who wrote about nursing prior to the 1950s tended to be nurses, and they wrote for nurses. Although nursing throughout its history has been influenced by social issues of the day, the early publications about nursing history did not link nursing to “the broader social, economic, and cultural context in which events unfolded” but, instead, emphasized the “profession's purity, discipline, and faith” (Connolly, 2004, p. 10). Part of the reason for this narrow view of nursing history is that the discipline of history had limited, if any, contact with the nursing profession. This began to change in the 1950s and 1960s when the scholarship of nursing history began to expand, though very slowly. In the 1970s, one landmark publication, Hospitals, Paternalism, and the Role of the Nurse (Ashley, 1976), addressed social issues as an important aspect of nursing history. The key issue Ashley considered was feminism in society at large and its impact on nursing. As social history became more important, the examination of nursing, its history, and its influences on that history increased. In addition, nursing is tied to political history today. For example, it is very difficult to understand current healthcare delivery concerns without including nursing (such as the impact of the current reports on quality care). These considerations have an impact on health policy, including legislation at the state and national levels. The COVID-19 pandemic has made global health issues even more important-we have a greater understanding today of complex global health issues and needs for care, including prepared staff.
Schools of nursing often highlight their own history for students, faculty, and visitors. This might be done through exhibits about the school's history and, in some cases, a mini museum. Such materials provide an opportunity to identify how the school's history has developed and how its graduates have affected the community and the profession. The purpose of this chapter is to explore some of the broad issues of nursing history and the profession, but this discussion should not replace the history of each school of nursing as the profession develops.
Nursing's past represents a movement from a role based on family and religious ties and the need to provide comfort and care (because this was perceived as a woman's role) to educated professionals serving as the “glue” that holds the healthcare system together and emphasizing not only individual needs but community needs. From medieval times through Nightingale's time, nursing represented the role that women held in families to provide care. Over time, this care extended to anyone in need, but after Nightingale highlighted what a woman could do with some degree of education, physicians/doctors began to recognize that nurses needed to have more education. As a result, education was expanded but mainly to serve the need of hospitals to maintain a labor force. Thus, the apprenticeship model of nursing was integrated into the healthcare system, though this has changed over the years.
Why would nursing perceive a need for greater education? Primarily because of advances in science and medicine, increased knowledge of germs and diseases, and increased training of doctors, nurses needed to understand basic anatomy, physiology, pathophysiology, epidemiology, and pharmacology to provide better nursing care. Slowly, it was recognized that to carry out doctors' orders efficiently, nurses required some degree of understanding of the causes and effects of environmental exposures and of disease causation impacting acute care and public and community health. Thus, gradually, the move from hospital nursing schools to university education occurred.
Critics of Nightingale suggest that although the “lady with the lamp” image-that is, a nurse with a light moving among the wounded in the Crimea-is laudable, it presented the nurse as a caring person who would go to great lengths and even sacrifice her own safety and health to provide care (Shames, 1993). The message sent to the public was that nurses were not powerful. They were caring, but they would not fight to change the conditions of hospitals and patient care. Hospitals “owned” nurses and considered them cheap labor. This view of healthcare delivery suggests that doctors are defined by their scope of practice in treating diseases, whereas nurses are seen as promoting health, adding to the view of the lesser status of nursing (Shames, 1993). This view also led to problems between the two professions as they argued over which profession was better at caring for patients. The view that nurses are angels of mercy rather than well-educated professionals reinforces the idea that nurses care but really do not have to think; this view may be perpetuated by advertisements that depict nurses as angels or caring ethereal humans (Gordon, 2006). Most patients-especially at 3 a.m., when few other professionals are available-hope that the nurse is not just a caring person but also a critical thinker who uses clinical reasoning and judgment and knows when to call the rest of the team. As discussed in this text, there is increasing evidence to support this view of the professional nurse and needed competencies, such as the report Healthcare Education: A Bridge to Quality (Institute of Medicine [IOM], 2003), The Future of Nursing. Leading Change, Advancing Health (IOM, 2011), and The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (NAM, 2021a). In 2015, the IOM changed its name to the National Academy of Medicine (NAM), and in this text, this new name will be used for any IOM reference published as of 2015 (NAM, 2021b). These reports and others have had a major impact on the image of the profession, provide recommendations for improving care, examine the roles and responsibilities of nurses as healthcare professionals, and emphasize the need for nursing leadership and graduate education.
| Stop and Consider 1 |
|---|
| Nursing has a long history that has changed over time. |
Professionalism and Leadership: Critical Professional Concepts and Activities
Today, nursing is an applied science, a practice profession. To appreciate the relevance of this statement requires an understanding of professionalism and how it applies to nursing. Nursing is more than just a job; it is a professional career requiring commitment and leadership. Table 1-1 describes some differences in attitudes when comparing an occupation/job and a career/profession.
Table 1-1 Comparison of Attitudes: Occupation Versus CareerOccupation | Career | |
Longevity | Temporary, a means to an end | Lifelong vocation |
Educational preparation | Minimal training required, usually associate degree | University professional degree program based on foundation of core liberal arts |
Continuing education | Only what is required for the job or to get a raise/promotion | Lifelong learning, continual effort to gain new knowledge, skills, and abilities |
Level of commitment | Short-term, as long as job meets personal needs | Long-term commitment to organization and profession |
Expectations | Reasonable work for reasonable pay; responsibility ends with shift | Will assume additional responsibilities and volunteer for organizational activities and community-based events |
| Wilfong, D., Szolis, C., & Haus, C. (2007). Nursing school success: Tools for constructing your future. Jones & Bartlett Learning. |
But what does this really mean, and why does it matter? As described previously in this chapter, developing nursing into the profession it is today was not easy nor did it happen overnight. Many nurses contributed to the development of nursing as a profession; it mattered to them that nurses be recognized as professionals-and each nursing graduate continues this process.
Nursing as a Profession
The current definition of nursing, as established by the ANA, is “nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations” (2021). Exhibit 1-4 provides a historical perspective on the development of a definition for nursing, and the ANA website provides current information on the role of nurses (ANA, 2024).
| Exhibit 1-4 Definitions of Nursing: Historical Perspective |
|---|
| The following list provides a timeline of some of the definitions of nursing. |
| Florence Nightingale |
| Nursing is having “charge of the personal health of somebody … and what nursing has to do … is to put the patient in the best possible condition for nature to act upon him.” (Nightingale, 1859, p. 79) |
| Virginia Henderson |
| “The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) and that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.” (Henderson, 1966, p. 21) |
| Martha Rogers |
| “The process by which this body of knowledge, nursing science, is used for the purpose of assisting human beings to achieve maximum health within the potential of each person.” (Rogers, 1988, p. 100) |
| American Nurses Association |
| “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human responses, and advocacy in the care of individuals, families, communities, and populations.” (Fowler, 2015a, p. 89; also published in earlier ANA standards) |
| International Council of Nurses (ICN) |
| “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.” (ICN, 2023a) Data from Nightingale, F. (1859). Notes on nursing: What it is and what it is not (commemorative ed.). Lippincott; Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. Macmillan; Rogers, M. (1988). Nursing science and art: A prospective. Nursing Science Quarterly, 1, 99; American Nurses Association (ANA). (2021a). Nursing scope and standards of practice. International Council of Nurses (2023a). Nursing definitions. https://www.icn.ch/nursing-policy/nursing-definitions |
Chapter 2, “The Essence of Nursing: Knowledge and Caring,” contains an in-depth discussion of the nature of nursing, but a definition is needed here as a framework for further understanding nursing as a profession. Is nursing a profession? What is a profession? Why is it important that nursing be recognized as a profession? Some nurses may not think that nursing is a profession, but this is not the position taken by recognized nursing organizations, nursing education, and state boards of nursing that are involved in the licensure of nurses. Each state has its own definition of nursing that is found in the state's Nurse Practice Act, but the ANA definition noted here encompasses the common characteristics of nursing practice and is reflected in state board definitions.
In general, a profession-whether nursing or another profession, such as medicine, teaching, or law-includes the following characteristics (Finkelman, 2024; Huber, 2021; Lindberg et al., 1998; Quinn & Smith, 1987; Schein & Kommers, 1972; Bixler & Bixler, 1959):
Does nursing demonstrate these professional characteristics? Nursing has a standardized content, although schools of nursing may configure the content in different ways; there is consistency in content areas, such as adult health, maternal-child health, behavioral or mental health, pharmacology, assessment, evidence-based practice, research, management, and so on, guided by nursing education standards and supporting content needed for the licensure exam and practice. The National Council Licensure Examination (NCLEX) covers standardized content areas. This content is based on systematic, recognized knowledge as the profession's knowledge base for practice. Chapter 3, “Nursing Education, Accreditation, and Regulation,” discusses nursing education in more detail. It is clear, though, that the focus of nursing is practice-care provided to assist individuals, families, communities, and populations.
Nursing as a profession has a social contract with society, as described in the ANA's Guide to Nursing's Social Policy Statement, which is now an appendix in the ANA standards, Nursing: Scope and Standards of Practice, and Nursing's Guide to the Code of Ethics for Nurses (Fowler, 2015a; ANA, 2021; Fowler, 2015b). The contract between nursing and society is based on professional and regulatory requirements but also on what society expects from healthcare services and healthcare professionals. As a profession, we have the right to autonomy in our practice, authority to practice based on our education and scope of practice, and self-governance. Society protects a profession through government legislation and regulation (for example, licensure to protect our titles and scope of practice, need to decrease staff safety risk in the workplace, and so on).
Autonomy, responsibility, and accountability are intertwined with the practice of nursing and are critical components of a profession. Autonomy is the “capacity of a nurse to determine his/her own actions through independent choice, including demonstration of competence, within the full scope of nursing practice” (ANA, 2021, p. 85). It is the right to decide and take control. Nurses have a distinct body of knowledge and develop competencies in nursing care that should be based on this nursing knowledge. When this is accomplished, nurses can then practice nursing. “Responsibility refers to being entrusted with a particular function” (Ritter-Teitel, 2002, p. 34). “Accountability means being responsible and accountable to self and others for behaviors and outcomes included in one's professional role. A professional nurse is accountable for embracing professional values, maintaining professional values, maintaining competence, and maintenance and improvement of professional practice environments” (Kupperschmidt, 2004, p. 114). A nurse is also accountable for the outcomes of the nursing care that the nurse provides; what nurses do must mean something (Finkelman, 2024). The nurse is answerable for the actions that the nurse takes. A nurse often delegates tasks to other staff members, telling staff what to do and when. The staff member who is assigned a task is responsible both for performing that task and for the performance itself. The nurse who delegated the task to a staff person is accountable for the decision to delegate the task. Delegation is discussed in more detail in Chapter 10, “Work in Interprofessional Teams.”
There is also greater emphasis on nursing research and evidence-based practice, as discussed in this text. Due to increased nursing research, there is more evidence about the impact of nursing care and the profession, for example, on better patient outcomes as demonstrated in lower mortality, shorter lengths of hospital stay, reduced hospital readmissions, reduced complications, increased patient satisfaction, and improvement in quality care (Aiken & Sloan, 2020). This text expands on these examples, which is important for RNs to recognize, and the healthcare delivery system needs to recognize that nurses make a positive difference in patient care and health.
Leadership
Leadership in nursing is an important thread throughout this text's content. It is introduced in this chapter as the history of nursing is discussed in recent major reports on nursing that have had an impact on nursing leadership. Exhibit 1-1 identifies issues that indicate nurses should be leaders in healthcare practice, policy development, and research advocating for patients, families, populations, and communities. This is even more important today with “devastating disparities in COVID-19 infection and outcomes among socioeconomically marginalized groups have resulted in a public outcry to address longstanding societal inequities that have contributed to the present situation. Nurse leaders have an opportunity and an obligation in this moment to lend their skills as scientists, innovators, advocates, and educators to lead in these efforts, advancing health equity for all” (Azar, 2021, p. 571). Nurses have the responsibility to engage in reducing health disparities, and this requires effective leadership and advocacy. Development of nurse leaders for all types of healthcare settings, acute care and public and community health, requires leadership competencies that “represent the knowledge, skills, and abilities contributing to effective leadership. Competencies are used as a framework to facilitate the growth of the nurse leader and to assess progression and mastery. They reflect what leaders need to be able to do in their roles, how they treat and interact with others, and what tools they can draw from to be an effective leader” (Hughes et al., 2022, p. 437). Leadership in nursing now places greater emphasis on the need for transformational and visionary leadership (Wei & Horton-Deutsch, 2022). This approach moves away from a hierarchical view to one in which nurse leaders strive to engage and apply inclusivity in the healthcare system. This requires knowledge about the profession, health and healthcare delivery, teamwork, collaboration, and empowering staff.
Sources of Professional Direction
Professions develop documents or statements that are important to guide professional practice, establish control over practice, and influence the quality of that practice. Some of the important sources of professional direction for nurses follow.
To meet the social contract, nursing care must be provided and should include the consideration of health, social, cultural, economic, legislative, ethical, and equitable factors and the application of the current emphasis on DEI. Content related to these issues is discussed in other chapters in this text. Nursing is not just about making someone better; it is about providing health education, assisting patients and families in making health decisions, providing direct care and supervising others who provide care, assessing care and applying the best evidence in making care decisions, communicating and working with the interprofessional treatment team, developing a plan of care with the team that includes the patient and family when the patient agrees to family participation, evaluating patient outcomes, advocating for patients, and much more. Patient/person-centered care (PCC) should be integrated into all healthcare settings and services.
State boards of nursing also assume an important role in guiding and, in some cases, determining professional direction through legislation. Each state board operates under a state practice act (state law), which allows the state government to meet its responsibility to protect the public-in this case, the health of the public-through nursing licensure requirements. Each nurse must practice, or meet the description of, nursing as identified in the state in which the nurse practices. Licensure and regulation are discussed in more detail in other content in this text.
Professional Nursing Associations
Nurses have a history of involvement in organizations that foster the goals of the profession. The existence of professional associations and organizations is one of the characteristics of a profession. A professional organization is a group that has specific goals, objectives, and functions that relate to the mission of a specific profession. Typically, membership is open to members of that profession and requires payment of dues. Some organizations have more specific membership requirements or may be by invitation only. Nursing has many organizations at the local, state, national, and international levels, and some organizations function on all these levels.
Professional organizations often publish journals and other information related to the profession and offer continuing professional educational opportunities through meetings, conferences, and other formats. As discussed previously, many of the organizations, particularly the ANA, are involved in developing professional standards. Some organizations are very active in policy decisions at the governmental level, taking political action to ensure that the profession's goals are addressed and advocating for health care in general. This activity is generally done through lobbying and advocacy. Some organizations are involved in advocacy in the work environment, for example, a union, with the aim of making the workplace environment better for nurses.
Major Nursing Associations
The following description highlights some of the major nursing organizations (keep in mind that many other professional organizations exist). Organizations that focus on nursing specialties have expanded. Other organizations related to nursing education are described in Chapter 3, “Nursing Education, Accreditation, and Regulation.” To give you a perspective of the many organizations representing different aspects of the profession, Exhibit 1-5 lists some of these organizations and their websites.
| Exhibit 1-5 Examples of Specialty Nursing Organizations |
|---|
| Academy of Medical-Surgical Nurses: http://www.amsn.org
Academy of Neonatal Nursing: http://www.academyonline.org American Academy of Ambulatory Care Nursing: http://www.aaacn.org American Academy of Nursing: http://www.aannet.org American Association for Men in Nursing: http://aamn.org American Association of Colleges of Nursing: http://www.aacnnursing.org American Association of Critical-Care Nurses: http://www.aacn.org American Association of Nurse Anesthetists: http://www.aana.com American Association of Nurse Practitioners: http://www.aanp.org American Association of Occupational Health Nurses: http://www.aaohn.org American College of Nurse-Midwives: http://www.midwife.org American Nurses Association: http://www.nursingworld.org American Nurses Foundation: https://www.nursingworld.org/foundation/ American Nursing Informatics Association: http://www.ania.org American Organization for Nursing Leadership: https://www.aonl.org American Psychiatric Nurses Association: http://www.apna.org American Public Health Association: http://www.apha.org Association for Nursing Professional Development: http://anpd.org Association of periOperative Registered Nurses: http://www.aorn.org Association of Rehabilitation Nurses: http://www.rehabnurse.org Association of Women's Health, Obstetric and Neonatal Nurses: http://www.awhonn.org Council of International Neonatal Nurses: http://www.coinnurses.org Emergency Nurses Association: http://www.ena.org Gerontological Advanced Practice Nurses Association: http://www.gapna.org National Association for Home Care & Hospice: http://www.nahc.org Hospice and Palliative Nurses Association: https://advancingexpertcare.org/ International Council of Nurses: http://www.icn.ch National Association of Clinical Nurse Specialists: http://www.nacns.org National Association of Neonatal Nurses: http://www.nann.org National Association of Orthopedic Nurses: http://www.orthonurse.org National Association of Pediatric Nurse Practitioners: http://www.napnap.org National Association of School Nurses: http://www.nasn.org National League for Nursing: http://www.nln.org National Student Nurses' Association: http://www.nsna.org Oncology Nursing Society: http://www.ons.org |
American Nurses Association (ANA).
The ANA is the organization that represents all RNs in the United States, but not all RNs belong to the ANA. It also represents nurses who are not members because many in health care, government, and business view the ANA as the voice of nursing. When the ANA lobbies for nursing, it is lobbying for all nurses, not just its membership. This organization represents more than 4 million RNs through its multiple constituent member associations and state and territorial associations, although the actual membership is much less than the total number of RNs in the United States (ANA, 2023a). Generational issues influence professional organization membership levels. New nurses typically do not join organizations. This organization also advocates and supports national health concerns, such as the many initiatives today to address diversity, equity, and inclusion (Jolley & Peck, 2022). In 2022, the ANA published a position statement on this issue, noting that the organization “is committed to decolonizing the nursing profession through the active dismantling of systems, structures, policies, and narratives that make possible the racial injustices and health inequities that are both experienced and facilitated by the profession” (ANA, 2022). In addition to being a professional organization, some state chapters have formed labor unions. Participation in the labor union is optional for members, and each state organization's stance on unions has an impact on membership. The ANA's major publication is American Nurse Today. The organization's 2023-2025 strategic plan identifies the following vision, mission, and goals (ANA, 2023b).
Vision: A healthy world through the power of nursing.
Mission: Lead the profession to shape the future of nursing and health care.
Goals:
The ANA has three affiliated organizations: the American Nurses Foundation (ANF), the American Academy of Nursing (AAN), and the American Nurses Credentialing Center (ANCC).
American Nurses Foundation (ANF).
The ANF is the American Nurses Association philanthropic initiative founded in 1955, supporting the profession's efforts as a leader in healthcare delivery (ANF, 2023a). Its major goal is to provide funding through grants for nursing research; however, due to the COVID-19 pandemic and its impact on the United States and healthcare delivery, the ANF decided not to award any grants in 2020 (ANF, 2023b). After the pandemic, the ANF returned to its funding initiatives. Its strategic plan for 2021-2024 describes the following that support its goals:
Examples of some of its major initiatives that demonstrate how it impacts the profession and health care are the following (ANF, 2023b):
American Academy of Nursing (AAN).
The AAN was established in 1973, and it serves the public and the nursing profession through its activities to advance health policy and practice (AAN, 2021a). The academy is considered the “think tank” for nursing. Membership as an academy fellow is by invitation; fellows may then include “FAAN” in their credentials. There are approximately 2,900 fellows, representing nursing leaders in education, management, practice, and research. This is a very prestigious organization, and fellows must demonstrate their leadership in practice, management, and academic nursing (AAN, 2021b). The AAN also publishes the journal Nursing Outlook. Examples of some of the AAN's current initiatives follow (AAN, 2021c):
American Nurses Credentialing Center (ANCC).
The ANA established the ANCC in 1973 to develop and implement a program that would provide tangible recognition of professional achievement. Additional programs were added to the work done by the ANCC (2023), including the:
National League for Nursing (NLN).
The NLN is a nursing organization that focuses on excellence in nursing education. Its membership is primarily composed of schools of nursing and nurse educators. The organization began in 1893 as the American Society of Superintendents of Training Schools. It holds several educational meetings annually and provides continuing education options and certification for nurse educators. The NLN 2022-2024 strategic plan's mission is “to promote excellence in nursing education to build a strong and diverse nursing workforce to advance the health of our nation and the global community,” and its four major goals are (NLN, 2022):
American Association of Colleges of Nursing (AACN).
The AACN is the national organization for educational programs at the baccalaureate level and higher. The organization is particularly concerned with the development of standards and resources and promotes innovation, research, and practice to advance nursing education. The organization represents more than 865 schools of nursing at the baccalaureate and higher levels (AACN, 2023c). The dean or director of a school of nursing serves as a representative of the AACN. The organization holds annual meetings for nurse educators that focus on different levels of nursing education. The AACN has been involved in creating and promoting new roles, such as the clinical nurse leader (CNL), focusing on higher quality care standards, and the doctor of nursing practice (DNP) degree, as well as other levels of nursing educational programs, which are discussed in other chapters of this text. The major AACN publication is the Journal of Professional Nursing. This organization's 2023-2025 strategic plan's vision is: “Nurses are transforming health care to improve health and achieve health equity,” and its goals are as follows (AACN, 2023d):
Organization for Associate Degree Nursing (OADN).
The Organization for Associate Degree Nursing (OADN; formerly N OADN) represents associate degree (AD) nurses, AD nursing programs (community colleges), and individual member nurse educators. The organization joined the ANA as an organizational affiliate in December 2016, along with 30 other specialty nursing organizations that are ANA affiliates (OADN, 2020). The OADN focuses on enhancing the quality of AD nursing education, strengthening the professional role of the AD nurse, and protecting the future of AD nursing during healthcare changes. Its strategic plan for 2022-2025 focuses on the values of equity, inclusion, authenticity, excellence and innovation, and vision (OADN, 2022).
Sigma Theta Tau International (STTI).
STTI is a not-for-profit international organization based in the United States. This nursing honor society was created in 1922 by a small group of nursing students at what is now the Indiana University School of Nursing. Its mission is to provide leadership and scholarship in practice, education, and research to improve the health of all people. Membership in this organization is by invitation to baccalaureate and graduate nursing students who demonstrate excellence in scholarship and to nurse leaders who demonstrate exceptional achievements in nursing. STTI has more than 100,000 active members, and more than 100 countries are represented in its membership (STTI, 2023).
Schools of nursing may form STTI association chapters. The chapters are where most of the work of the organization takes place. There are about 600 chapters at institutions of higher education, which include schools in Armenia, Australia, Botswana, Brazil, Canada, Colombia, England, Ghana, Hong Kong, Ireland, Israel, Jamaica, Japan, Jordan, Kenya, Lebanon, Malawi, Mexico, the Netherlands, Pakistan, Philippines, Portugal, Scotland, Singapore, South Africa, South Korea, Swaziland, Sweden, Taiwan, Tanzania, Thailand, the United Kingdom, and the United States of America (STTI, 2023). This is an important organization, and students should learn more about their school's chapter (if the school has one) and aspire to an invitation for induction into STTI. Inductees meet specific academic and leadership standards. The major STTI publications are the Journal of Nursing Scholarship, Reflections on Nursing Leadership, and the newest publication, Worldviews on Evidence-Based Nursing. The organization manages a major online library for nursing resources, the Virginia Henderson International Nursing Library, through its website. Its vision is “connected, empowered nurse leaders transforming global healthcare,” and its mission is to develop leaders and improve health care (STTI, 2023).
International Council of Nurses (ICN).
The ICN, founded in 1899, is a federation of 130 national nurses' associations representing more than 28 million nurses worldwide (ICN, 2023b). This organization is the international voice of nursing and focuses on activities to better ensure quality care for all and sound health policies globally. Its activities focus on (1) professional nursing practice (for example, specific health issues, International Classification of Nursing Practice), (2) nursing regulation (for example, regulation and credentialing, ethics, standards, continuing education), and (3) socioeconomic welfare for nurses (for example, occupational health and safety, salaries, migration, and other issues). The ICN headquarters is in Geneva, Switzerland. Its mission is to represent nurses globally, supporting the professional advancement and well-being of nurses and advocating for health.
National Student Nurses Association (NSNA).
The NSNA has a membership of approximately 60,000 students enrolled in diploma, AD, baccalaureate, and general graduate nursing programs in 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands (NSNA, 2023). It is a national organization with chapters within schools of nursing. Its major publication is Imprint. Its mission focuses on (NSNA, 2023):
Joining the NSNA is a great way to get involved and begin to develop professional skills needed for the future (such as learning more about being a leader and a follower, critical roles for practicing nurses). The NSNA website provides an overview of the organization and its activities. Attending a national convention is also an opportunity to find out about nursing in other areas of the country and network with other nursing students. Annual conventions attract more than 3,000 nursing students and are held at different sites each year. This professional networking also affords students opportunities to learn about graduate education, specialty groups, and nursing careers. Active engagement in your school's NSNA chapter and national activities provides you with experiences to develop leadership competencies and provide you with skills for later professional engagement in nursing professional organizations.
Why Belong to a Nursing Professional Organization?
The previous section described many nursing professional organizations; additional information is found in Chapter 3, “Nursing Education, Accreditation, and Regulation,” about some of these organizations. Why is it important to belong to a professional organization? Joining a professional organization and becoming active in the organization's activities is a professional obligation. Membership, ideally with active involvement, can help nurses develop leadership skills, improve networking, and find mentors. Additionally, membership gives nurses a voice in professional issues and, in some cases, health policy issues. It provides a range of opportunities for professional development/lifelong learning. Nurses usually represent a large voting bloc in any state. By using this political power through nursing and other professional organizations, nurses can speak in one powerful voice. Yet, as nurses, we have often failed to pull together. Membership in a professional organization is one way to develop one strong voice.
Nurses who attend meetings, hold offices, and serve on committees or as delegates to large meetings benefit more from membership than those who do not actively participate. Submitting abstracts for a presentation or poster at a meeting is an excellent experience for nurses and offers even more opportunities for networking with other nurses who might also provide resources and mentoring for professional development. There are some factors that are important to recognize as you consider joining a professional organization. Belonging to a nursing association requires money for membership dues, a commitment to the association, and time to engage in the organization.
Students can begin to meet this professional obligation by joining local student organizations, which may or may not be directly related to the nursing program but to the campus in general, and developing skills that can be used after graduation when they join professional organizations. Membership offers opportunities to serve as a committee member, even chair a committee, and develop leadership skills. Organizational communication methods can be observed, and the student can participate in the processes, learning from leaders in the organizations about planning, coordination, collaboration, and many other important experiences that can be applied as professional nurses. Engagement in organizations allows members to participate in making decisions about nursing and health care in general. When new nurses enter the profession today, they find a healthcare system that is struggling to improve its quality and keep up with healthcare changes, and nurses need to be engaged in the process to improve health care. Professional organizations also sometimes band together-increasing collaboration to have a greater voice about critical healthcare policy issues, such as the need to expand the nursing profession or improve care in a local area. Ideally, this should sometimes be done with interprofessional organizations, not just nursing organizations.
Nursing Workforce
Nursing is one of the largest healthcare professions, and nurses have many opportunities to serve as leaders in health care. Nurses work in a variety of settings, such as hospitals, clinics, home health care, hospice care, long-term care, rehabilitation, physician offices, school health, employment services, and numerous other service sites. Most nurses work in acute care hospital settings, but this is changing as more care moves into the community. The Future of Nursing: Leading Change, Advancing Health (IOM, 2011) is a significant report on nursing, and it has led to additional reports and examination of the profession. There is now an initiative to further examine nursing that extends to 2030 that focuses on the following (NAM, 2021a):
The Campaign for Action and its progress reports related to The Future of Nursing are discussed in this text as important sources of evaluating nursing profession outcomes-education and practice (Robert Wood Johnson Foundation [RWJF], AARP and AARP Foundation, 2023); NAM, 2021a)
According to the employment projections for 2019-2029 by the U.S. Bureau of Labor Statistics, employment opportunities for registered nurses are expected to increase by 7%, which is faster than expected for most other occupations. It is not clear at this time the impact the COVID-19 pandemic might have on the number of students entering nursing programs, graduating, and practicing, as well as the number of nurses who may leave active practice and, thus, impact another shortage (Dewart et al., 2020; NLN, 2020). We have experienced several years of fluctuating nursing shortages. As the number of nurses in practice and nursing school enrollments changes, any nursing shortage, whether this is geographic specific or HCO specific, affects access to care in the years to come-and there can be great variation from one area of the country to another. Demographic changes are an important factor; for example, the older adult population in the United States is increasing rapidly and requiring more health care. Other factors also impact need, such as from 2010 to early 2017, the Affordable Care Act (ACA) extended insurance coverage to more people-but the future of the ACA is still in question as there have been efforts to make changes in the law. Taken together, these developments signal that the demand for nurses and other healthcare professionals will increase. Changes in future federal legislation and their impact on states need to be followed by the nursing profession to determine the impact on nursing practice and the need for nurses. Chapter 5, “Health Policy and Political Action,” discusses these issues more and the need for nurses to be advocates.
Some staffing data found in the 2018 National Sample Survey of Registered Nurses (NSSRN), administered by the Health and Resources and Services Administration (HRSA), an HHS agency, noted the following (HHS, HRSA, 2023):
These data change over time, and the routine collection of data through the HRSA survey represents useful information for the profession. Many factors impact data, such as the COVID-19 pandemic and changes in U.S. economic status. These surveys require time to collect and analyze, so they are typically not reported in the current year. In addition to this government survey, the National Council for State Boards of Nursing conducts a workforce survey every 2 years. The survey that was conducted during the COVID-19 pandemic indicated that “[i]n the wake of the COVID-19 pandemic, the nursing workforce has undergone a dramatic shift with the loss of hundreds of thousands of experienced RNs and LPNs/LVNs. The nursing workforce has become younger and more diverse with increases reflected for Hispanic/Latino and male nurses. An increasing proportion of the RN workforce holds a baccalaureate degree or higher, moving closer to goals established by the National Academy of Medicine. Salaries have notably increased for nurses, likely due to inflation and increased demand for nursing services. With a quarter of the population contemplating leaving the profession, the impact of the pandemic may still be felt in the future” (Smiley, 2022, p. 190).
In examining the nursing workforce, it is important to recognize that nursing is a profession. It meets all the requirements for a profession and serves as a major profession in healthcare delivery and the healthcare workforce. In the early part of its history, nursing was not viewed as a profession, as noted in the review of nursing history described earlier in this chapter, but it is now recognized as a profession based on knowledge that reflects its dual components of science and art with clear roles and responsibilities in the healthcare workforce. Chapter 2, “The Essence of Nursing: Knowledge and Caring,” explores the art and science of the profession of nursing, expanding on the view of nursing as a profession and an active member of the healthcare workforce. A critical concern in the nursing workforce today is the transition to practice-how do healthcare organizations know when new graduates they have hired are ready to be fully active members of the care team (McNamara et al., 2016)? This requires input from nursing education and practice as new nurses are assisted to transition positively. The content in this text reflects on many issues related to the workforce and transition to practice.
| Stop and Consider 2 |
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| The nursing workforce is complex and focuses on nursing as a profession. |
The Image of Nursing
The image of nursing may appear to be an unusual topic for a nursing text, but it is not. Image is part of any profession. It is the way a person appears to others, or in the case of a profession, the way a profession appears to other professionals and others in the work environment and to the public-in nursing's case, consumers of health care. Image and the perception of the profession affect recruitment of students; the public's view of nurses; funding for nursing education and research; relationships with healthcare administrators and other healthcare professionals, government agencies, and legislators at all levels of government; and ultimately, the profession's self-identity. Just as individuals may feel depressed or less effective if others view them negatively, professionals can experience similar reactions if their image is not positive. Image influences everything the profession does or wishes to do. How nurses view themselves-their professional self-image-has an impact on professional self-esteem (Buresh & Gordon, 2013). How one is viewed has an impact on whether others seek that person out and how they view the effectiveness of what that person might do. Every time a nurse says to family, friends, or members of the public that he or she is a nurse, the nurse is representing the profession. “We cannot expect outsiders to be the guardians of our visibility and access to public media and health policy arenas. We must develop the skills of presenting ourselves in the media and to the media-we have to take the responsibility for moving from silence to voice” (Buresh & Gordon, 2013, p. 15). The professional introduction is an example of critical communication that sets the stage for a nurse-to-patient relationship, and it is associated with the image of nursing. Saying one's name, first and last, and title and explaining one's role is an important step in establishing trust and maintaining accountability-demonstrating professionalism (LeBlanc et al. 2016). Most nurses do not even consider the implications of the introduction and quickly move on to a task that must be done. They may not provide their first and last name due to concerns about their privacy, though this does not really protect privacy because it is easy for a patient to find out a nurse's name.
The public's views of nursing and nurses are typically based on personal experiences with nurses, which can lead to a narrow view of a nurse, often based only on a brief personal experience. This experience may not provide an accurate picture of all that nurses can do and provide in the healthcare delivery process. In addition, this view may be influenced by the emotional response of a person to the situation and the encounter with a nurse. During the COVID-19 pandemic, there has been much more information in the media about nurses and their critical roles in healthcare delivery. After the resolution of the pandemic, it is hoped that the public's positive views of nurses will continue.
But the truth is that most often, the nurse is invisible. “Although nurses comprise the majority of healthcare professionals, they are largely invisible. Their competence, skill, knowledge, and judgment are-as the word ‘image' suggests-only a reflection, not reality” (E. Sullivan, 2004, p. 45). Consumers (patients, families) may not understand the knowledge and competencies required to be a nurse, may not recognize they are interacting with a nurse, or they may misidentify someone as a nurse. When patients go to their doctor's office, they interact with staff, and often, patients think that they are interacting with a licensed registered nurse. Most likely, they are not-the staff person may be a medical assistant of some type or a licensed practical/vocational nurse. In hospitals, patients interact with many staff members, and there is little to distinguish one from another, so patients may refer to most staff as nurses. Uniforms do not help identify roles because many staff wear scrub clothes and lab coats, and there has been less emphasis placed on professional attire. In the past, hospitals had strict dress codes, with standard uniforms per type of staff. Over time, this approach changed-affecting not only what staff wore but also their appearance, such as hair, wearing of jewelry, and so on. Healthcare organizations now find it difficult to change dress codes without staff complaining this is not needed. One HCO conducted an extensive study on the issue of dress and image, examining how patients viewed nurses, and noted at the conclusion of the study that standardizing nurse uniforms would have a positive impact on the nurse's professional image, and this then would affect the nurse-to-patient relationship (West et al., 2016). The pandemic has brought us another image issue-the use of personal protective equipment (PPE) makes it even more difficult to identify healthcare professionals-doctors, nurses, respiratory professionals, and others or even to see their faces. Some staff put photos of themselves outside the PPE so that the patient and other staff can see who they are. PPE also makes it more difficult to relate to one another-patient to staff and staff to staff. Not seeing facial expressions or other physical characteristics has an impact. In addition, during the pandemic, even when not wearing PPE, many people wore masks, which makes interactions and communications different, such as patient-staff, family-staff, nonclinical staff, and so on.
The public values nurses. When a person tells another that he or she is a nurse, the typical response is positive. However, many people do not know about the education required to become a nurse and maintain current knowledge or about the variety of nursing education entry points that all lead to the RN qualification. Consumers generally view nurses as good people who care for others. In the annual Gallup Poll “nurses remain the most trusted profession, with 78% of U.S. adults currently believing nurses have high honesty and ethical standards. However, that is down seven percentage points from 2019 and 11 points from its peak in 2020 (Brenan & Jones, 2024). This high vote of confidence has been consistent in this annual poll for 18 years, but changes have occurred during the COVID-19 pandemic. What is not mentioned in the poll is the knowledge and competency required to do the job properly, which are important aspects of the nursing profession.
You might wonder why it is so important for nurses to make themselves more visible. You chose nursing, so you know that it is an important profession. Nevertheless, many students have a narrow view of the profession, much closer to what is portrayed in the media-the nurse who cares for others but with less emphasis on understanding the required knowledge base and competency needed to meet the complex needs of patients. There continues to be limited recognition that nursing is a scientific field. The profession needs to be more concerned about accurate visibility because the profession needs to attract qualified students and keep current nurses in practice.
Another factor related to image is the nurse's voice is typically silent, and this has demoralized nursing (Pike, 2001). This is a strong statement and may be a confusing one. What is the nurse's voice? It is the “unique perspectives and contributions that nurses bring to patient care” (Pike, 2001, p. 449). Nurses have all too often been silent about what they do and how they do it, but this has been a choice that nurses have made-to be silent or to be more visible. Both external and internal factors affect the nurse's voice and this silence. The external factors that continue to be relevant include the following (Pike, 2001):
Nurses who can deal with internal factors can be more visible and less silent about nursing and better advocate for patients. The internal factors that impact if a nurse will speak out include (Pike, 2001):
Nurses' loss of professional pride and self-esteem can also lead to a more serious professional problem: Nurses feel like victims and then may act like victims. Victims do not take control but rather see others as being in control; they abdicate responsibility. They play passive-aggressive games to exert power. This can be seen in the public image of nurses, which is predominantly driven by forces outside the profession. It also affects the nurse's ability to collaborate with others-both other nurses and other healthcare professionals. It is all too easy for nurses to feel like victims, and this perception has led to some nurses viewing physicians in a negative light, emphasizing that “physicians have done this to us.” Consequently, nurses may have problems saying they are colleagues with other healthcare professionals and acting like colleagues. Colleagueship “involves entering into a collaborative relationship that is characterized by mutual trust and response and an understanding of the perspective each partner contributes” (Pike, 2001, p. 449). Colleagues have the following characteristics:
What is unexpected is how nurses' silence may have a negative impact on patient care. This factor may influence how a nurse speaks out or advocates for care that patients need, how effective a nurse can be on the interprofessional treatment team, and how nurses participate in healthcare program planning and implementation of services. Each nurse has the responsibility and accountability to define themselves as a colleague, and empowerment is part of this process.
The nursing role has experienced many changes, and many more will occur in the future. How has nursing responded to these changes and communicated them to the public and other healthcare professionals? Suzanne Gordon (2006), a journalist who has written extensively about the nursing profession, noted that often the media are accused of representing nursing poorly when, in reality, the media are simply reflecting the public image of nursing (Buresh & Gordon, 2013). Nurses have not taken the lead in discussing their own image of nursing-what it is and what it is not. It is not uncommon for a nurse to refuse to talk to the press because the nurse feels no need to do so, may not feel competent to do so, or fears employer reprisals. When nurses speak to the press-often when being praised for an action-they say, “Oh, I was just doing my job.” This statement undervalues the reality that critical thinking and clinical reasoning and judgment on the part of nurses make a difference in the health of patients (individuals, families, communities) every day. What is wrong with taking that credit? Because of these types of responses in the media, nursing is not directing the image but rather accepting how those outside the profession describe nursing.
Gordon and Nelson (2005) commented that “nursing needs to move away from the ‘virtue script' toward a knowledge-based identity” (p. 62). The “virtue script” continues to be present in current media campaigns that are supported by the profession. For example, a video produced by the NSNA mentioned knowledge but not many details; instead, it included statements such as “[Nursing is a] job where people will love you” (Gordon & Nelson, 2005). How helpful is this approach? Is this view of being loved based on today's nursing reality? Nursing practice involves highly complex care; it can be stressful, demanding, and at times rewarding, but it is certainly not as simple as “everyone will love you.” Why do nurses continue to describe themselves in this way? “One reason nurses may rely so heavily on the virtue script is that many believe this is their only legitimate source of status, respect, and self-esteem” (Gordon & Nelson, 2005, p. 67). This, however, is a view that perpetuates the victim mentality.
| Stop and Consider 3 |
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| The image of nursing is not simple to describe and has an impact on nursing practice. |
Discussion
Connect to Information for EBP
Godsey, A., Houghton, D., & Hayes, T. (2020). Registered nurse perceptions of factors contributing to the inconsistent brand image of the nursing profession. Nursing Outlook, 68(6), 808-821.
Questions:
You are asked to develop an Electronic Reflection Journal that you will use after you complete each chapter. This is the place for you to reflect on some aspects of the chapter's content identified at the end of the chapter. This is your space; be creative. You may also want to keep notes about issues that you want to expand on as you progress through your nursing education. If you are using technology that allows you to make visuals, use drawings and graphics as one method to reflect in your journal.
In your first entry in your Electronic Reflection Journal, consider the following questions related to the image of nursing. Connect your responses so that you can better understand the importance of image to the profession and the meaning of the profession.
Special assignment for this chapter: Write your own definition of nursing and include it in your Electronic Reflection Journal. Work on this definition throughout this course as you learn more about nursing. Save the final draft, and at the end of each semester or quarter, go back to your definition and make any changes you feel are necessary. Keep dated drafts of each definition so that you can see your changes. When you graduate, review all your definitions, illustrating how you have developed your view of professional nursing. Ideally, you might then review your definition again 1-year postgraduation.
Divide into teams of four students each. Develop a mini-survey (several questions) about the image of nursing and nurses. Each team member should use the survey and collect data from a designated number of people; pick a variety of people-age, gender, type of work, and so on.
After team members have collected the data, summarize and analyze the team data to identify any themes and unusual views.
How does what you learned relate to the content in this chapter? List the similarities and differences, and then discuss your findings with your student discussion team and compare them with their findings.
The planning and discussion for this collaborative learning can be done in person or online. If there is an opportunity, the student teams can then share their results with one another-but remember, if questions that were used in the survey are different, this impacts the data collected. This collaborative experience will help you understand some steps used in research projects and provide practice in discussion, arriving at a consensus, and effective teamwork.
Case 1
You and your friends in the nursing program are having lunch after a class that covered content found in this chapter. One of your friends says, “I was bored when we got to all that information on professionalism and nursing organizations. What a waste of time. I just want to be a nurse.” All of you are struggling to figure out what you have gotten yourselves into. You turn to your friends and suggest it might be helpful to have an open, respectful discussion on the comment just made. So, over lunch, you all talk about the comment. It was clear that the students who had read the chapter were better able to discuss the issue, but everyone had an opinion.
Case 1 Questions
Case 2
The NSNA chapter in your school wants to help the school develop a campaign to increase enrollment. You have volunteered, along with three other members, to meet with the associate dean to discuss ideas for the campaign. The associate dean tells you that the school is going to use its standard marketing materials and shows them to you. The materials focus on the importance of being a caring person to be a “good” nurse. When you ask to see print materials and materials to be posted on the internet, you are told that the focus is on print, and you see a photo of a nurse holding a patient's hand.
Case 2 Questions