Overview and Summary: Cornerstone Documents in Healthcare: Our History, Our Future

Primary healthcare serves as a curriculum thread at my institution. We base our definition of the term on the World Health Organization’s (WHO) 1978 Declaration of the Alma Alta (WHO, 1978). This definition reflects a holistic view of nursing and healthcare that takes into account the determinants of health, shared decision-making, intersectorial collaboration, policy and politics, social justice, and access to population–based care. All of these are relevant terms for nurses who actualize the reform efforts found within the 2010 Patient Protection and Affordable Care Act (PPACA, 2010). Nurses need to understand the primary healthcare philosophical framework in order to practice effectively and safely in any setting – whether in public health, primary care, or acute care settings. To do so, it is essential that they also know the history of nursing's engagement in primary healthcare like initiatives even before the Declaration of Alma Alta. For me, history helps shape the teaching/learning experience for our students. Primary healthcare from both a historical and contemporary perspective relies on the work of nurses to develop the standards and scope of practice.

The articles in this Online Journal of Issues in Nursing (OJIN) topic resonate with my work as an educator and as a historian. I see the essence of primary healthcare fill these new OJIN articles. Within each article, we can see how nurses have practiced to the fullest extent of their education (Institute of Medicine [IOM], 2010), how nurses have responded to the changing legislation that defined practice, how nurses have determined their ethical framework in which they practice, and how shifts in nursing practice occurred in both the United States and Cambodia. To introduce the articles in this topic, I must first reflect on nursing’s history and its evolution as a profession concerned about primary healthcare.

From the beginning of the modern nursing movement in 1873, nurses advocated control of their practice and education. In 1893, nurses organized the National League for Nurses (NLN) (originally called the Society of Superintendents of Nursing) and by 1896 the American Nurses Association (ANA) (originally called the Nurses Alumnae Association). The purpose of both organizations included the development of standards of practice and education. The superintendents, like the deans of today, concerned themselves with educational standards and reforms. The ANA fought for state licensure and issues related to nursing practice. In 1912 the National Organization for Public Health Nursing formed and defined the meaning of public health nursing and created standards of practice in this growing specialty. The National Association of Colored Graduate Nurses started a few years earlier in 1908. It too concerned itself with the standards of practice and education, but also focused its goals on race inequality in nursing and healthcare. Each of the four organizations sought ways to address nursing legislation, ethical behavior, professional standards, and practice guidelines. By 1952, these four organizations restructured, and the NLN and the ANA became the two major organizations that would address nursing’s scope of practice and specialty issues regardless of backgrounds (Lewenson & Nickitas, 2016; Roberts, 1954).

Fast-forward to 2015, and we find that nursing continues to develop documents in support of nursing practice and education. Authors Deborah S. Finnell, Elizabeth L. Thomas, Wendy M. Nehring, Kris McLoughlin, and Carol J. Bickford address in the article, “Best Practices in Developing Specialty Nursing Scope and Standards of Practice,” how nurses today create, revise, and refine specialty nursing scope and standards of practice. But unlike nursing’s earlier efforts, the authors provide the readers with a structure and process to help to “demystify” the very process of developing specialty nursing scope and standard documents. They ask the reader to consider the questions of “who, what, when, why, and how,” as they undertake this important task. Their article mentors the reader through the process, providing a systemic way that has worked for these authors. A schematic can be drawn from their work that shows how a group is formed, develops a realistic timeline, incorporates foundational documents, includes a historical perspective, and addresses barriers to the process. Group cohesion, strong organizational skills, appropriate delegation and keeping to deadlines all create successful outcomes. Asking for feedback and asking for organizational support are two essential parts of the process, as well as listening and responding to criticism. Finally, the authors address the need to disseminate their new scope and standards documents, and give useful tips for readers to follow. The biggest tip, for me, is the article itself, as it guides us through this important process with realistic steps for us to use along the way. History supports the need for nurses to continually update and revise our many documents and the authors give us an important tool to accomplish this goal.

Arlene Keeling’s article, “Historical Perspectives on an Expanded Role for Nursing,” illustrates how nurses have historically practiced nursing to the fullest extent of their education (and sometimes, beyond), both in urban and rural settings. Keeling uses exemplars from history – the Henry Street Settlement, the Frontier Nursing Service, the ANA definition of nursing, and the development of the nurse practitioner role—to show how nursing practice expanded (and at times contracted) as a result of the needs of society and policies enacted. Nursing’s rich history in the delivery of primary healthcare gives credence to the recent IOM (2010) report that asks nurses to practice to the fullest extent of their educational preparation. For example, at the Henry Street Settlement started in 1893, we see the visiting nurse in urban New York City, offering medications, some typically available over the counter until legislation in the early part of the twentieth century, to families in their care. Questions like whether or not honey and glycerin was considered a nursing intervention or an intervention requiring prescriptive privilege was raised, thus further questioning the scope of nursing practice. Nurses working in Frontier Nursing Service in Kentucky during the 1920s, Keeling points out provided anesthesia to mothers in labor when so indicated until legislation passed that such practice changed in Kentucky. Keeling shows us the curtailing of nurses’ ability to administer medications and interventions without legal oversight from the medical profession. Restriction to practice continued, and became especially apparent with the role development of the nurse practitioner in the mid 1960s. Keeling asks us to look at history to see how nurses’ have practiced in the past, and how legislation, professional opinion (both in medicine and nursing), and public support can lend credence to the IOM’s Future of Nursing’s call to allow nurses to practice to the full extent of their education.

I found reading, “Cornerstone Documents, Milestones, and Policies Shaping the Direction of Public Health Nursing 1890-1950” by authors Joan Kub, Pamela Kulbuk, and Doris Glick, exciting!  They show us how public health nursing practice has changed in response to the social, political, and economic context of the times. Both WWI and WWII influenced the need for public health nursing in the communities at home and in response to the needs of the military. A change in rural public health nursing, for example, shows the how nursing responded to the health of those at home during WWI. The American Red Cross, known for support during man made and natural disasters, also found a role in bringing care home to families in the community. Changes in healthcare legislation became increasingly relevant to the changing definition of public health nursing, and the meaning continues to evolve.

In Elizabeth Epstein and Martha Turner’s article titled, “The Nursing Code of Ethics: Its Value, Its History,” we see how nursing’s ethical code developed, its history, and its recent revision that reflects current thinking in nursing practice. Nursing’s code of ethics is in keeping with the ethical codes of other professions. It informs us about how to act responsibly with others in society and to care for individuals, families, communities, and populations. Nurses, like other professionals, have an obligation to be morally responsible to keep confidences and to be non-judgmental. To do this and respond ethically and morally to other issues that arise in our work, the profession looks to ethical codes for guidance. The authors provide us with a brief history of how ethics in nursing has evolved over time, from concern with personal characteristics, to ethical concerns at three levels: societal, organizational, or population/individual patients. All nurses at all levels and in all settings encounter bio-medical ethical issues on a daily basis. From the broader societal perspective, ethical questions, such as whether care is a right or privilege resonate loudly among many (and is addressed in the definition of primary healthcare discussed earlier). At the organizational level, for example, increased moral distress can be attributed to poor ethical climates. On an individual level, nurses address ethical issues related to autonomy, informed consent, and patient rights. Issues nurses face daily reflect in their work when helping patients make decisions about advanced planning and end-of life care. Nurses can alleviate some of the difficulties by advocating, speaking up, collaborating, staying informed, and being present. The authors provide a case study that helps assess the ethical issues and refers us to the Code of Ethics for guidance. They help us to reflect about the ethical dilemma, the risk-benefit factors, patient autonomy, and nursing integrity. They also note that while the Code can offer guidance, nurses must consider the outcomes – emphasizing a necessity to weigh and balance the different provisions. Nursing judgment plays an important role in ethical decisions and the newly revised Code of Ethics in 2015 serves as a beacon to support this process.

Several years ago, my husband and I traveled to Cambodia to see Angkor Wat in Siem Reap. We witnessed the beauty of a predawn visit to the sacred site and saw the water lilies come to life as the sun rose in the East. We reveled in the historical archeological foundations and learned more about the political strife in the country. Our guide spoke about the land mines that still resided in the countryside, and serendipitously pointed one out to our small tour. The meaning of this did not escape us; as we drove through the countryside we realized the imminent danger that the population encountered on a daily basis. On one drive, our guide pointed out a woman on a bicycle who he said was a public health nurse. I asked if we could stop and speak with her and he was kind enough to do so. He interpreted our conversation, and she spoke about her work as a nurse who visited the community. Her supplies were neatly tucked away bag on the bicycle and she spoke about visiting mothers and babies, as well as those with chronic illness. I was unable to learn more about her or her work, but I was reminded of her again reading the article by Richard Henker, Manilla Prak, and Virya Koy. In this article titled, “Development and Implementation of Cornerstone Documents to Support Nursing Practices in Cambodia,” the authors describe the major role that the Ministry of Health has played in the establishment and approval of cornerstone documents, including evidenced based protocols the nursing process, and the Code of Ethics for Nurses and the Scope of Practice and Standards of Care for Cambodian nurses. In a country that experienced major political upheaval and civil war from the 1970s until the 1990s, creating these meaningful documents has been slow in coming, but so relevant to the improvement of healthcare. The authors note that final approval and dissemination of the documents is expected sometime in 2015. Following Khmer Rouge regime, we learn that under 50 physicians remained in the entire country. This is an amazing loss and one that a country does not recover from easily. There is no mention of how many nurses survived the genocide that occurred, but the delay in developing relevant documents that support nursing practice until today may represent some evidence of a lack of educated nurses in this war torn country. History, culture, and politics influenced the development of these documents. The Cambodian nurses share their own special story; emerging from war and devastation, they emerge to provide evidence based care based on standards of practice to meet the needs of their population. 

This article, like others in this OJIN topic, speaks about the development of relevant documents nurses need to practice ethically and safely. The journal editors invite you to share your response to this OJIN topic addressing Cornerstone Documents either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Sandra B. Lewenson, EdD, RN, FAAN
Email: Slewenson@pace.edu

© 2015 OJIN: The Online Journal of Issues in Nursing
Article published May 31, 2015