Early on, certain individuals within each society began providing care and nourishment for those who were unable to care for themselves. As these individuals became ‘care experts,' they began to share with others the practices that worked for them and to train others as apprentices who would someday carry on their work. The evolution of modern nursing from a vocation, to the discipline and profession of nursing, began in the late 1800s as Florence Nightingale articulated her views about how nurses should be trained and educated and how patient care should be provided (Hegge, 2011).

The first training school for nurses in the United States (US) opened in 1873. Twenty years later nursing school administrators felt the time had come to network and share their best practices related to teaching the newly formed discipline of nursing. These nursing administrators formed the American Society of Superintendents of Training Schools for Nurses to establish and maintain a universal standard for training nurses; this society later became the National League for Nursing (NLN) (See Table 1). By 1896, graduate nurses were beginning to seek consistency, specifically in regard to standards in nursing education and competency in nursing practice. Nursing school alumni came together and formed a national organization designed to elevate the standards of nursing education, establish a code of ethics, and promote the interests of nursing. This organization, originally known as the Associated Alumnae of Trained Nurses of the United States and Canada, was renamed the American Nurses Association (ANA) in 1911 (ANA, 2009). Thus, the formal foundations were laid for the profession of nursing, and for the interests of professional nurses and all of society.

The purpose of this article is to describe the role of professional nursing organizations in advocating for the nursing profession and for nurses. I will discuss the characteristics of a profession, review the history of professional nursing organizations, and describe the advocacy activities of professional nursing organizations. Throughout, I will explain how the three foundational documents of the nursing profession emphasize nursing advocacy by the professional organizations as outlined in the Code of Ethics for Nurses With Interpretive Statements (ANA, 2001). Finally, I'll conclude by encouraging all nurses to engage in their professional organizations and associations, explaining how these organizations contribute to the accountability and voice of the profession to society.

Characteristics of a Profession

Beginning in the 1920s, as the new field of sociology began to study societies, disciplines, and organizations, the characteristics of, and criteria for establishing ‘what is a profession' were explored. The heyday of scholarly discourse on identifying the criteria for a ‘profession' occurred between the 1950s and 1980s (Brante, 1988; Bucher & Strauss, 1961; Cogan, 1955; Donaldson & Crowley, 1978; MacIver, 1955; Merton, 1958; & Page, 1975). Beginning in the early 1950s leaders in nursing worked to establish nursing as a profession as well as a discipline and sought direction to support their efforts. Dr. Merton, Professor of Sociology at Columbia University, was engaged as a consultant to ANA to assist the organization to better understand the requirements of a profession (Merton, 1958). In 1958 Merton defined a professional association as “an organization of practitioners who judge one another as professionally competent and who have banded together to perform social functions which they cannot perform in their separate capacity as individuals” (p. 50). Since that time the following characteristics have come to characterize a profession (Bucher & Strauss, 1961; Cogan, 1955; Hillman, 2005; Merton, 1958):

• a basis in systematic theory - a distinct way of viewing phenomena surrounding the knowledge base of the profession
• specialized competencies and practitioners who are effective in practicing the professional role
• dedication to raise the standards of the profession's education and practice
• availability of professional education as a life-long process and mechanisms to advance the education of professionals established by the profession
• the presence within the profession of individuals with varied identities and values forming groupings and coalitions that coalesce into unified segments – known as specialties with specific missions
• authority recognized by society and the clientele of the profession
• approval of the authority sanctioned by a broader community or society
• a code of ethics to regulate the relationships between professionals and clients
• self-regulation that protects practitioners and supports disciplinary criteria and actions to censure, suspend, or remove code violators
• a professional culture sustained by formal professional associations, such that the membership may develop a biased perspective through their profession's lenses.

As nursing has developed over time it has evolved to professional status. As nursing has developed over time it has evolved to professional status. Beginning in the 1950s and guided by Merton's directives, nurses throughout the nation have worked with ANA membership and staff to formulate three documents that are foundational elements of a profession. In nursing these three foundational documents are known as the Code of Ethics for Nurses with Interpretative Statements (2001), the Social Policy Statement: Essence of the Profession (2010a), and Nursing: Scope and Standards of Practice (2010b). These critical elements/statements continue to distinguish and support nursing as a profession, and to delineate its unique perspective, essence, and core processes.

History of Professional Nursing Organizations

There are over a hundred national nursing associations and many other international organizations. Human beings have a tendency to congregate, talk among themselves, and advocate for their causes. This has certainly occurred in nursing as evidenced by the breadth and depth of the various nursing groups that seek to enhance the work of nurses generally and in their specialty areas. There are over a hundred national nursing associations and many other international organizations. The website, Nursing Organization Links (NOL, 2011), maintains a web-based list of organizations, yet acknowledges this list is not complete. Of the national and international organizations reviewed for this article, all but two are specialty-focused. Examples of these organizations include:

• setting-specific nursing (ambulatory, perioperative, long-term care)
• system-specific disorders or conditions (heart failure, nephrology, HIV-AIDS)
• age periods along the continuum of life (neonate, pediatric, adult, geriatric)
• ethnic- and cultural-specific (Hispanic, Black, Filipino, Male)
• graduate level and advanced practice nurse specialties (Clinical Nurse Specialists, Nurse Practitioner, Certified Nurse Midwives, Certified Registered Nurse Anesthetists, Nurse Executives and Administrators, Nurse Attorneys, Nurse Educators)
• educational-level-specific (undergraduate [NLN, American Association of Colleges of Nursing, (AACN)]; graduate and professional staff development [NLN, AACN, National Nursing Staff Development Organization]).

Events, such as war, politics, regulation, legislation, and improved educational practices and settings, heavily influenced the direction of nursing and its practice. One might ask what occurred to bring the nursing profession from two fledgling nursing organizations (NLN and ANA) to this marked diversity of organizations. The answer lies in societal changes and increased demands on the nursing profession. Events, such as war, politics, regulation, legislation, and improved educational practices and settings, heavily influenced the direction of nursing and its practice. Regulation via licensure was an early major milestone in ensuring public safety and quality of care. In the face of war, nurses in the military developed specialty skills in trauma care and brought these critical care skills to many settings. Parallel with the development of specialization in the 1960s and 1970s, increases in practice-specific organizations developed. In the late 1970s ANA set in motion an era of change as it began discussions to restructure its constituency model. This moved the organization from the individual member model, in which specialty practice support was administered by ‘sections and councils,' to the federation model, in which state nurses associations held the membership in ANA. As ‘practice' sections were eliminated, nurses assembled new organizations according to specialty interests. This change coincided with ANA's support of nurse participation in unions resulting from the passage of the National Labor Relations Act of 1974 (personal communication June, 16, 2011, Corinne Dorsey, Committee on History, Virginia Nurses Association; ANA, 2009).

Each of more than one hundred organizations speaks for nurses and nursing, based on their mission and vision statements that are specific to their specialty interests, goals, and purposes. One national organization, the American Nurses Association (ANA), and one international organization, the International Council of Nurses (ICN) speak to the needs of, and advocate for all nurses and the nursing profession independent of specialty areas. Table 2 presents the purpose statements of these organizations.

Advocacy Activities of Professional Nursing Organizations

Advocacy is the cornerstone of nursing – nurses advocate for patients, causes, and the profession. Our advocacy, motivated by moral and ethical principles, seeks to influence policies by pleading or arguing within political, economic, and social systems, and also institutions, for an idea or cause that can lead to decisions in resource allocation that promote nurses, nursing, and all of healthcare. In this section I will explain how the Nursing Code of Ethics strengthens nursing's position as an advocate and describe how professional associations advocate for the nursing profession, nurses, and healthcare for the citizens of the US.

Advocacy Support from the Code of Ethics

Advocacy by the profession of nursing developed within the US as visionaries, leaders, and nurses from across the nation formulated the first (and subsequent) revisions of the Code of Ethics for Nurses with Interpretive Statements, often referred to as the Code of Ethics, (ANA, 2001; also see Table 1 Timeline). The concluding statement of the Code of Ethics preface states:

...the Code of Ethics is the ethical standard for all members of the profession. No one outside of nursing can alter it. The Code of Ethics for Nurses with Interpretive Statements provides a framework for nurses to use in ethical analysis and decision-making. The Code of Ethics establishes the ethical standard for the profession. It is not negotiable in any setting nor is it subject to revision or amendment except by formal process of the House of Delegates of the ANA.

Hence the Code of Ethics is the ethical standard for all members of the profession. No one outside of nursing can alter it. It is only through the formal processes, provided in the bylaws of the House of Delegates of the ANA, that revisions and amendments can be made and adopted.

The nine provisions of the Code of Ethics for Nurses are listed in Table 3. I have added the ‘(advocacy)' notation because the focus of this article is on nursing advocacy. The Code and subsequent publications (for detailed reading and explanations see ANA, 2001; Fowler, 2008; Monsen, 2009; Pinch & Haddad, 2008) guide the profession in applying the Code of Ethics to nursing. In the Code of Ethics for Nurses, the concept of advocacy for the individual nurse is openly named in Provision Three (See Table 3). Advocacy by the nurse is an implied theme in most of the provisions and highlighted in Provisions 6, 7, and 8.

The Profession's Advocacy Efforts

In Provision 9 (Table 3) the professional associations, created by nurses for nurses to articulate nursing values, integrity, practice, and social policy, demonstrate advocacy and self-regulation. In the US, ANA is the organization that solicits and coordinates ideas from individuals, and from the nursing specialties and associations, deliberates regarding these ideas, and develops them based on the Code of Ethics and the other two ‘framework documents' that serve as the basis of the nursing profession. The three framework documents include:

• The Code of Ethics for Nurses - asserts the values and commitment to excellence for patients, society, and nurses individually and collectively as a profession (ANA, 2001);
• The Social Policy Statement - details the authority, based on the social responsibility of the profession to society. It serves as nursing's contract between the profession of nursing and society to uphold the highest values and standards in delivering its service of nursing care (ANA, 2010a); and
• The Scope and Standards of Practice in Nursing - delineates the scope of nursing practice and then defines the standards of professional nursing practice and accompanying competencies (ANA, 2010b).

Nurses, healthcare consumers, legislatures, organizations, and other stakeholders are encouraged to provide comments that influence the wording and conceptual development of these documents. From conception, and through subsequent revisions, these documents have been created by members and representatives of the professional associations. This work is transparent in that drafts are posted and open for public comment through multiple announcements using a variety of venues and formats. Nurses, healthcare consumers, legislatures, organizations, and other stakeholders are encouraged to provide comments that influence the wording and conceptual development of these documents. All of these comments are analyzed and deliberated to determine the appropriateness of their inclusion within the framework documents. These dynamic documents are reviewed regularly; they evolve as society and the landscape of nursing and healthcare change.

The following paragraphs describe how our various nursing professional organizations work together to advocate for nurses and nursing. This occurs by maintaining a spirit of unity, engaging in political advocacy, keeping nurses informed, disseminating professional knowledge, and promoting professional development.

Many specialty organizations...educate the public, policy makers, healthcare administrators, and professionals on specific issues.Unity in advocacy. Each of the specialty organizations advocates for nurses as their organizational goals pertain to its members, specialty, and practice settings. Many specialty organizations, and their members, educate the public, policy makers, healthcare administrators, and professionals on specific issues. Nursing organizations are cognizant of the power of unity and engage in collaborative ventures with other nursing and health-related professional organizations when appropriate. Table 1 lists the early collaboration efforts between nursing organizations; Table 4 lists additional and more current examples example of working together and forming alliances.

CNPE membership information:

www.nursingworld.org/FunctionalMenuCategories/AboutANA/WhoWeAre/AffiliatedOrganizations

http://nursingworld.org/DocumentVault/About-ANA-docs/Org-Affiliates-Obligations.pdf

Goals of political advocacy include greater nurse involvement in providing access to care, influencing the cost and quality of care, determining the scope and authority of practice, and increasing and improving the healthcare workforce. Political advocacy. Members and experts from many specialty organizations work with ANA lobbyists in the U.S. Congress and the various state legislatures to inform and persuade legislators concerning the needs of nursing and the general public regarding healthcare issues and quality care. Some of these activities have included, and continue to include advocating for a greater nursing presence in the current Patient Protection and Affordable Care Act (P.L. 111-148, March 2010) (ANA, 2011a; Gallagher, 2010). Goals of political advocacy include greater nurse involvement in providing access to care, influencing the cost and quality of care, determining the scope and authority of practice, and increasing and improving the healthcare workforce. Many specialty organizations advocate for the removal of barriers to the use of advanced practice nurses, to allow them to practice to their full scope of practice across all settings and in all states and also to receive just payment for their services rendered.

...nurses can respond in a variety of ways...to ask decision makers to support and advocate for nurses... Informing nurses. The ability of professional organizations to communicate quickly with their members is one of the many benefits of involving a variety of organizations in collaborative efforts. Newsletters and bulletin alerts keep members aware of issues and help explain developments that may affect nurses and patient care delivery. Issue-specific communication to members often request nurses to respond to late-breaking developments. In this age of communication, nurses can respond in a variety of ways, e.g. through phone calls, email, Tweets, and Facebook™ postings, to ask decision makers to support and advocate for nurses, letting them know how a given proposal will affect those who give and those who receive healthcare. Of the more than three million nurses in the U S, 2.6 million are actively involved in the workforce (Bureau of Health Professionals, 2011); many, if not most of them, have access to electronic communications. These nurses have the ability to analyze the information provided and to respond quickly. The power of over two million voices at the national level is awesome! It can significantly influence the development of policy and legislation.

The privilege of participating in association advocacy is an important benefit of membership in one's professional organization(s). Today professional organizations have list-servs and networking information-sharing features that strengthen a nurse's ability to advocate for nurses and nursing. The privilege of participating in association advocacy is an important benefit of membership in one's professional organization(s). As the associations continue to strengthen communication support structures, professional membership increases in value by offering a mechanism for communicating via secure, intra-member, social networks.

Dissemination of professional knowledge. In addition to regular communication with membership, many associations solicit scholarly manuscripts of relevance to members and publish the latest advanced knowledge in a specialty area and/or the profession. Several organizations now have the capacity to publish books that meet the needs of nurses practicing in specialty areas. Through business agreements with the associations some companies provide literature review searches, allow access to nursing and medical databases, distribute titles of newly published journal articles, and/or provide integrated, online services to provide nurses with the evidence-based answers they need to address pressing clinical questions. These publications and literature searches can help provide the data needed to advocate for changes in nursing care.

Professional development. Professional organizations provide for the professional development of their membership. Some associations provide continuing education contact-hour credits for free or at a significant discount. Webinars and web-based media formats also aid nurses in learning new information. Frequently these offerings focus on advocating for nurses and nursing and teaching, for instance, how to contact and work with legislators and how to advocate for new ways to strengthen healthcare.

Conclusion

The goal of advocacy efforts by professional associations is to educate association members, all professional nurses, and the public... The goal of advocacy efforts by professional associations is to educate association members, all professional nurses, and the public about the importance of broad-base membership, creative ideas, esprit de corps, and energetic participation in helping the profession improve and move to higher levels. In prior eras, visionary nurses realized the need for associations in order to meet the changes occurring in the social, cultural, and economic sectors of their world. Elected association leaders today remain responsive to their members and incorporate members' input by devising new mechanisms to advance healthcare through the nursing profession, thus allowing members to contribute to the accountability and voice of the profession to society.

When greater numbers unite in one voice, stronger and more powerful arguments can be advanced to achieve advocacy outcomes. Accolades and kudos to the professional registered nurses who are engaged, involved, and contributing members of our associations -- these nurses are advocating for and advancing the profession of nursing and the healthcare we offer to our patients.

Acknowledgement: The author thanks Rita Munley Gallagher, former ANA Senior Policy Fellow, for her thoughtful review and contributions. The author appreciates the review and comments of Carol J. Bickford, current Senior Policy Fellow, ANA Department of Nursing Practice and Policy. She also appreciates the contributions of Corinne Dorsey, Historian, Virginia Nurses Association.

Author

Jennifer H. Matthews, PhD, RN, A-CNS, CNE, FAAN
Email: jmatthewsRN@comcast.net

Dr. Matthews is Professor of Nursing at Shenandoah University in Winchester, VA. She also serves as an Adult-Health Clinical Nurse Specialist and Clinical Staff Nurse at Warren Memorial Hospital, Front Royal, VA. Dr. Matthews is a member of the American Academy of Nursing and the American Nurses Association's Committee on Bylaws. She serves as a Senior Magnet ® Appraiser for the Magnet Nursing Services Recognition Program (American Nurses Credentialing Center). Her work with the Magnet Program and the Virginia Nurses Association has enhanced her ability to advocate for policies related to nursing practice and quality nursing care. Dr. Matthews earned her PhD in Nursing Administration and Policy from George Mason University, Fairfax, VA; her Master of Science in Business Management from Troy State University (European Division), Wiesbaden, Germany; and her Master of Science in Nursing from the Medical College of Virginia, Richmond.