NURSING

by LUZ S. Porter

ODAY, more than ever, nurses possess the T potential for tremendous influence in all areas of health care. As a profession in demand, nursing has the opportunity to use its numbers, educational diversity, and clinical expertise as a constructive influence on the health care system by learning the lessons of yesterday, building on the strengths of today, and planning for the noblest of tomorrow.

To accomplish these goals nurses need to be aware of major issues facing the profession and be capable of resolving these issues. Nurses must dis- play a strong orientation for creative leadership and an active involvement as professional persons who are willing to speak out with one strong voice despite individual differences.

At no point in history have political and economic conditions so critically threatened the survival of professional nurses as individuals and the nursing profession as a discipline. The major problems and issues to be resolved include: (1) the ongoing economic inequities for nurses in the health care system; (2) the widespread dissatisfac- tion with working conditions resulting in recruit- ment and retention problems; (3) the ambiguous

public image of nursing as a profession; as well as problems in (4) assuring quality health care to various population groups, regardless of race, sex, age, health, or socioeconomic status; (5) fostering nursing roles with responsibility, autonomy, and authority; and (6) providing nursing education that adequately prepares the nurse for profes- sional practice at different levels.

As we look to the challenges of our profession during the Eighties and for the year 2000 and beyond, the following points take on special significance. First, we must continue to deepen and expand our professional knowledge and skills along with knowledge about theories of power, change, politics, and leadership to become profes- sional and social activists, to become strategically assertive, and to make an impact on the health care delivery system. Second, we need to empha- size the responsibilities of the nurse scholar in identifying problems and framing questions whose solutions and answers will yield significant facts. Third, we must continue to recognize how much one’s health is affected by elements outside the traditional provisions of the health professions.

Looking to the future, 1 see that a clear dif-

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ferentiation of careers in nursing must become a reality. Different careers in nursing are essential and excellence is demanded of each. Education will make a difference. Education is intimately related to society and its needs. The expanded con- cept of education and how it gets implemented is perhaps the most significant change going on in nursing education today. Nursing must take the challenge of achieving new directions in keeping with the changes and complexities that face our society and the societies of other nations.

The Challenge

The human enterprise is sometimes demanding and terrifying. However, nursing cannot and must not falter. Nurses must meet the challenge by pro- viding direction and leadership for the future. We must work together to make the health care system better serve society’s needs for an improved quality of life today and tomorrow.

Predicated on the belief that nursing is responsi- ble for assisting clients in achieving their max- imum health potential, professional nursing prac- tice must be equally concerned with the preven- tive, promotive, and restorative aspects of care. Although, nursing, for a long time, has focused its attention on health restoration - usually in crisis situations. In essence, nursing has been operating in close relationship to the clients’ inability to cope with deficits and, at times, with frank disruptions in clients’ lifestyles, rather than with clients’ strengths. Nursing must be prepared to assist clients in remaining well and functioning at their maximum level. Nursing must be able to enhance a client’s ability to adequately prepare for predic- table as well as non-predictable life events. Profes- sional nursing skills must, therefore, be available in all health settings.

Nursing is built on a body of knowledge dis- creetly synthesized from the physical, biological, behavioral, and social sciences, and uniquely ap- plied as a humanistic discipline of caring for peo- ple, wherever they are (Roger, 197096-87). Re- cognizing that the health care needs of people must have top priority, the nursing profession’s main thrust must be to provide society with practi- tioners of nursing who can work in a variety of health care settings. Nursing practice, like that of

many other health disciplines, is constantly evolv- ing. As with other health care professionals, nurses must incorporate into their practice scien- tific knowledge and technological advances, as well as the tools, techniques, and measures that are preventive, promotive, and therapeutic (Rogers, 1970: 121-128).

Within a futuristic perspective, three major issues merit attention. One is the definition of nur- sing conveyed in the 1980 social policy statement of the American Nurses’ Association. Another is the issue of clinical specialization. Then there is the emergence of the generalist approach to the development of the nurse clinician, an advanced nurse practitioner.

Nursing Defined: A Professional Perspective

In 1980, the American Nurses’ Association presented a definition of nursing that clearly reflects the humanistic keystone of the nursing profession, first espoused by Florence Nightingale (1859) and reasserted a century later in Virginia Henderson’s definition of Nursing (Henderson, 1961). These definitions and their strong influence on nursing practice over the years illustrate the nurses’ long-standing commitment to providing care that promotes well-being among persons served. Commitment of the nursing profession to the care and nurturing of sick and well persons, singly and collectively, has prevailed through the years. This commitment is reaffirmed in the ANA’s 1980 social policy statement and its definition of nurs- ing. But there is another aspect of the ANA def- inition of particular significance to the develop- ment of our profession, that is, “Nursing is the diagnosis and treatment of human responses to ac- tual or potential health problems” (ANA, 1980:9). The definition underscores the role of nursing theory in the advancement of nursing practice and the development of the discipline.

The definiton addresses four defining charac- teristics of nursing, namely: phenomena, theory application, nursing action, and evaluation of the effects of action in relation to phenomena. This statement has defined nursing in terms of the phenomena to which it addresses action, its use of theory to guide action, and its evaluation of the ef- fects of action (ANA, 1980: 11-12). These defining

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characteristics are explained briefly as follows:

Phenomena refer to human responses to actual or potential health problems-the events of con- cern to nurses. These responses could be health- restoring or health-supporting. Health-restoring responses are the reactions of individuals and groups to actual health problems (e.g., pain and sleeplessness). Health-supporting responses are the concerns of individuals and groups about potential health problems (e.g., problematic af- filiative relationships and deficiencies in decision- making and the ability to make personal choices).

Theory relates the concepts, principles, and processes used by nurses to refine their observa- tions and to understand the phenomena to which nursing actions are directed. Nurses use many or a variety of theories as a basis for understanding the dynamics and patterns of interactions in any clin- cal situation. Thus, the theoretical base for nurs- ing practice is a synthesis of self-generated con- cepts and concepts drawn from other fields.

Actions refer to nursing strategies to ameliorate, improve, or correct conditions for the prevention of illness and promotion of health. Ac- tions taken by nurses must be described and ex- plained within a theoretical context in regard to the identified phenomena and expected outcomes. Highly developed technical and interpersonal skills in carrying out nursing strategies are as im- portant as the keen observation and cognitive competencies required for the nurse in explaining the problem at hand and formulating effective nursing actions.

Effects connote the outcomes of nursing actions intended to be beneficial in relation to identified human responses. Evaluation of outcomes of nur- sing actions provides a data base for determining whether those actions have been effective in resolving or improving the conditions to which they were directed. Unsystematic evaluation or testimonials of beneficial effects contribute little to the development of the theoretical basis of nur- sing because they cannot be treated as scientific evidence.

Research findings on relationships between par- ticular nursing actions and specific phenomena

determined under controlled conditions are ur- gently needed. Essential to the development of the science and art of nursing is the approach to prac- tice in which investigation and documentation of nursing structure, processes, and outcomes are in- terrelated. Indeed, such an approach is evident in the four defining characteristics of nursing, pre- viously described. This approach is depicted in the use of the nursing process, commonly adopted as the framework for organizing practice.

The ANA Standards of Nursing Practice (ANA, 1973) relate to the nursing process. The standards, which apply to all types of nursing practice, not only provide a broad basis for evaluation of prac- tice, but also for recognizing the rights of the con- sumer of nursing services. The standards describe a “therapeutic alliance” of the nurse and the per- son for whom she or he provides care or with whom the nurse interacts. Figure 1 shows the rela- tionship between the four defining characteristics of nursing practice to nursing process, and stan- dards of nursing practice.

The characteristics of phenomena and theory application are implicit in the standards involving data collection, diagnosis, and planning. The characteristics of nursing action are reflected in the standards involving planning and treatment. Those of effects are reflected in the standards in- volving evaluation and revision. The interrelation- ships of these four characteristics of nursing, nurs- ing process, and the standards of nursing practice are exemplified in nursing practice at all levels.

As is true for any profession, the development of nursing depends on the integration of theory, practice, and research. The practice of nursing demands professional intent and commitment which subscribe to the ANA standards of nursing practice and the ANA code of ethics. The level and sophistication of nursing practice, however, varies with the education and skills of the in- dividual nurse. Some nurses are generalists and some, specialists.

Nurse generalists, who provide the bulk of nurs- ing care, use a comprehensive approach to health care and can meet diversified health concerns of individuals, families, and communities. Nurse specialists, on the other hand, are experts in pro- viding specific care in a particular area of the broader range of general nursing practice. Spe-

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cialized nursing practice aims at clarifying, revis- ing, and strengthening existing practices in selected areas of nursing (ANA, 1980: 19-20).

Nursing Specialization: Fragmented vs. Integrated Approach

A number of concerns have prevailed as to the issue of specialization in nursing. Since the turn of the century, these concerns have been a significant point of critical examination and deliberation among nurse educators, administrators, practi- tioners, as well as the public. Some have argued that specialization represents an intensive practical experience or a completion of hospital-based “post-graduate” courses in an area of nursing. In- deed, this approach to nursing specialization represents a specific way of looking at the field and its practice. As such, it must necessarily be of a narrow focus. It posits that there is a heterogen- eity of clinical interests and levels of competence within nursing. This view stems from the vast amount and complexity of knowledge and tech- nology which creates a demand for professionals to give special attention to application in delimited practice areas.

Others have asserted that nursing specializa- tion relates to an area of nursing practice enriched by intensive self-directed studies or a post-basic study by interested practitioners. This approach stems from an acknowledgement of the complexity of services identified as far exceeding the prevail- ing knowledge and skills of general practioners. Furthermore, a few professional pioneers seek greater depth of understanding of phenomena within a small segment of nursing by testing new practices aimed at correcting or resolving iden- tified problems.

The concept of “advanced clinical nurse” be- gan to change in the 1950’s as universities offered programs for preparation as “clinical specialists in nursing” (Burd, 1966). It was not until the 1960’s that post-basic education for specialization in clinical nursing was provided in graduate pro- grams. By 1980, more than 75 colleges and univer- sities offered such programs (National League for Nursing, 1979).

The ANA in its publication, Nursing: A Social Policy Statement, asserted that specialization in

nursing is now clearly established. The develop- ment of specialization has underscored the re- examination and revitalization of the generic foundation in which the specialization is rooted. Requirement of the baccalaureate degree in nurs- ing for entry for specialty practice, administra- tion, and teaching, and of a doctoral degree that includes emphasis on research competence emerge as necessary to the fulfillment of nursing’s social responsibility. In this context, the specialist in nur- sing practice is also a generalist in that she/he has a baccalaureate in nursing and, therefore, can pro- vide the full range of nursing care.

Specialization requires adding an organized and systematic body of knowledge, as well as compe- tencies, to the generic nursing base. Such practice is usually restricted to specific areas of care.

Advanced/specialized nursing practice involves the utilization of a wide range of theories to gain depth of understanding of the phenomena of con- cern to nurses. The synthesis of a number of perti- nent theories with the nurse’s clinical experiences provides a solid base for resolving poorly under- stood phenomena within the scope of nursing. Above all, specialization involves empirical and controlled research to refine existing nursing prac- tices or to evolve new knowledge as a basis for fur- ther advances in nursing knowledge and practice.

One might note that many of the graduate pro- grams in nursing focus on a specialized field, somewhat defined by medically oriented cate- gories or specific types of health problems, and oriented to restorative care or rehabilitation. There is, at present, a beginning interest in the development of graduate programs in nursing which focus on relations among parts or the inter- relation among specialized fields. These programs take an integrated approach to the advanced study of nursing.

The advent of specialization in accordance with the prevailing emphasis suggests that nursing has moved from a global to a more specific way of looking at the field and its practice. This is not so for graduate programs with an integrative per- spective. Such programs directed by the central goal to prepare nurses as clinicians for the advanced practice of nursing moves from the basic gen- eralist perspective of the baccalaureate program to an expanded and deepend generalist emphasis in

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the graduate program (West Virginia University School of Nursing, 1981 : 156. Unlike conventional graduate programs where a concentrated study is focused on a well-defined segment of nursing, in- tegrative graduate programs are focused on ad- vanced study and practice of nursing in a global perspective. Unlike other graduate programs which provide a minor area of concentrated study on a functional role, such as, teaching and ad- ministration, integrative graduate programs pro- vide an advanced study on professional role development which depicts the synthesis of teaching, practice, and research in nursing. This is undoubtedly a bold approach to graduate educa- tion in nursing, but it offers a wide range of in- novative roles for advanced nursing practice.

Graduate education in nursing, an essential preparation for advanced nursing practice, represents a refining of professional interests either by focusing on a part of the whole of nurs- ing practice or by focusing on relations among parts. The phenomena of concerns selected by specialists in nursing may relate either to a specialized field or to the interrelation among specialized fields (ANA, 1980).

Nursing is an exciting career limited only by one’s imagination and creativity. Nurses can make this exciting career even more exciting by accep- ting the challenge of the many dimensions of ad- vanced nursing practice. Nursing has come a long way in graduate education and it will continue to develop. Graduate education in nursing reflects the hallmark of the advancement of the nursing profession.

As a profession, nursing has responded by ad- vancing, perhaps slowly, its authentic place in keeping with changing professional and social

demands. One cannot but be aware of the intensity with which social, political, cultural, economic, and educational forces have changed- and will continue to change -nursing in particular, and health care in general. One cannot ignore the fact that time and experience will alter all perspectives, but the future of nursing rests on the resolution of today’s issues. Resolving these issues is appro- priately placed within the province of nursing education. As is the question of what changes are needed in the educational system so that graduates from all programs will be able to adapt to the changing health care system and be ready for the year 2000?

References

American Nurses’ Association, Nursing: A Social Policy Statement, Kansas City, Mo.: ANA, 1980.

Burd, Shirley F., “The Clinical Specialization Trend in Psychiatric Nursing,” unpublished Ed.D. thesis, Rutgers, The State University of New Jersey, 1966, as cited in ANA’s Nursing: A Social Policy State- ment, p. 22, 1980.

Henderson, Virginia, Basic Princtples of Nursing Care, London: International Council of Nurses, 1961.

National League for Nursing Division of Baccalaureate and Higher Degree Programs, Master’s Education in Nursing: Route to Opportunities in Contemporary Nursing, 1979-80, New York: The League, 1979.

Nightingale, Florence, Notes on Nursing: What It Is and What It Is Not, London: Harrison and Sons, 1859, preface and p. 75, (Facsimile edition, J.B. Lippincott Co., 1946).

Rogers, Martha E., Introduction to the Theoretical Basis of Nursing, Philadelphia: F.A. Davis Co., 1970.

West Virginia University School of Nursing, SeCf-Study Report, 1981.

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