Current Reality

We are in the midst of another shortage. Though scholars say it is different, because history doesn't really repeat itself, there are lessons that should have been learned. The fact that the average age of the practicing nurse is older only complicates some recurring patterns.

There has been a renewed appreciation for the presence of the RN in health care. This attitude has been the result of public opinion fueled by the increased acuity and frailty of patients in hospitals, home care and nursing homes. The American public has reason to fear for their safety and care, and nurses are seen as their advocates (Joel & Kelly, 2002). Employers are scurrying to rehire all the nurses that they let go during some of our more poorly thought out decisions on reengineering, reorganizing and restructuring. And nurses are having second thoughts about working in an environment that is unsafe and stressful. The reality of too many patients to be therapeutic, assistive personnel who practice on our license regardless of their ability, mandatory overtime, violence, HIV/AIDS, Hepatitis C, multi-drug resistant tuberculosis, latex allergy, and much more, cause us to fear for ourselves as much as our patients. In fact, only 75% of current license holders are working at jobs that require the RN credential.

The health care industry has traditionally ignored the advice of the nursing profession. Proof abounds.

An external locus has divided our strength, created internal unrest and kept nursing straddling the fence between expedient educational programs and those that create professionalism.

From the Nursing Home Reform Acts of 1987, where the industry lobbied to have "licensed nurse" substituted for "registered nurse" in the bill, under the pretext that the existing shortage would make the recruitment of RNs to nursing home practice in sufficient numbers impossible (Kelly & Joel, 1999), to the lobbying from hospital interests to continue diploma school education, while other health care fields had long ago aspired to higher levels of education, to the continuing resistance to paying a differential salary to the BSN graduate. These are only some of the most cruelly divisive situations, and clearly show how nursing has been dominated by an external locus of control. An external locus has divided our strength, created internal unrest and kept nursing straddling the fence between expedient educational programs and those that create professionalism.

Even as we have strained to make our educational programs consumer friendly with flexible admission requirements, Internet courses, external degrees, and guaranteed articulation, our enrollments have declined and the age of our students has increased. Young people making primary occupational choices are willing to invest time and effort in a field that guarantees status and prestige. And they are not impressed with what nursing promises. Nursing has been much more suited to the mid-life or retirement decision makers, where practicality may be the motive and associate degree nursing education the logical choice. Even for these atypical students, choices are made with a new appreciation for moderation in living. It is the attitude of people who put work in perspective and have a healthy self-respect for their contribution.

An Analytical Framework

This picture of the work of nursing frustrates the use of the term professionalism. While the literature contains endless definitions of the characteristics of a profession, there seem to be three areas of agreement: the professions are service-oriented, learned, and autonomous. Each of these characteristics allows for a broad range of interpretation. It helps to further consider these essential elements and identify the point beyond which compromise is impossible.

No one would debate nursing's service orientation, though as we compete for full status in liberal arts institutions, the applied science nature of nursing has often become a liability. The traditional sciences accord the highest priority to the creation and expansion of knowledge, often with little regard for its practical usefulness. This value is deeply entrenched in higher education and determines the faculty reward system and status of the discipline. Academic medicine has largely avoided this conflict by establishing educational programs outside of the liberal arts setting. The continuing commitment on the part of medicine to practice has contributed to the second-class status of physicians within the broader academic community. Simply put, society accords special privileges to professionals because of their service orientation, while the academe penalizes them for the same characteristic.

It is not quite enough to say that professions have a service orientation. That service orientation must be relevant to the times and carefully orchestrated to meet specific social needs. Orchestration includes assuring an adequate workforce for a timely service role. In designing their practice role, the professions must walk a fine line between directing the market and responding to it. If the service ceases to be relevant, timely and efficacious, the field of work will gradually disappear. Nurse practitioners and physician's assistants were the social response to the physician shortage of the 1950s; the licensed practical nurse was society's response in earlier generations to the need for increased nursing manpower. And again in the late 1980s, the American Medical Association proposed the creation of a new occupation, the Registered Care Technologist, to compensate for the shortage of nurses.

A body of knowledge and skills unique to the discipline, and a considerable educational investment distinguish the professions. The art of professions is cognitive artfulness. It consists of the ability to manipulate in the mind circumstances that have never been experienced, and see relevancy between situations that on the surface have little in common.

Nursing has made impressive strides in demonstrating its cognitive artfulness and exclusiveness. The existence of a variety of grand and mid-range theories allows the design of distinctive systems of caring, each focused on the same end. The required presence of nursing theories and research in the curriculum, the emphasis on theory development in graduate programs, and the governmental presence of the National Institute of Nursing Research are all indicators of our growing intellectual substance.

Autonomy has two perspectives, the autonomy of the field of work and autonomy of the individual. The public has recognized the unusual degree of knowledge and skill in professional practice, and the need for professionals to proceed with their work relatively unencumbered. Conversely, unsafe practice can seriously jeopardize the public good. The traditional model of autonomy has undergone some modifications in recent years, with the responsibility to seek and respond to input from consumers, government and other communities of interest significant to the profession. What has never been challenged is the fact that the credential to practice is awarded to an individual in recognition of a primary obligation to the recipient of service as opposed to any employer or third-party payer. This model nurtures the confidentiality and trust that have traditionally characterized the provider-client relationship, and rewards the provider with work that has a great capacity for self-expression.

We resist many of the developmental patterns that have been common to all professional fields: recognition of the need for assisting categories of technical manpower, educational up-grading, and the application of the products of scientific investigation to practice.

Balance is guaranteed by the presence of adequate peer review mechanisms.

Yet we continue to be constrained by institutional policies in the care of our patients, reticent to monitor the practice of our peers, fearful of transgressing the territorial boundaries of other disciplines, comfortable in a dependency which is more familiar than the unknown, lacking assertiveness to demand what is rightfully ours, and sometimes inappropriately reliant on external regulation and the opinions of others. We resist many of the developmental patterns that have been common to all professional fields: recognition of the need for assisting categories of technical manpower, educational up-grading, and the application of the products of scientific investigation to practice.

The Growth and Development of Professional Areas of Work

Nursing is currently involved in the same painful sequence of events experienced by other disciplines as they emerged to full professional status. As a class, the professions can trace their roots to social necessity and the call for pragmatic service. The status of a discipline is closely associated with the length and rigor of the education required for entry into practice. In contrast to nursing, the traditional professions of medicine, law and the clergy were always clear about their areas of social concern. Perhaps for this reason, they have prepared for practice in a concentrated course of studies following a pre-professional curriculum. In fact, most of their work in standardization focused on up-grading the pre-professional course of study and admission requirements. In 1900 high school graduation was not required to begin study in medical school. By 1938, three years of undergraduate education were necessary and by 1969, eighty-five percent of medical schools required a bachelor's degree. Law schools have followed a similar pattern. Given this history, and the general social structure of the United States, it is understandable why these professions chose to serve their publics within an entrepreneurial model. Freedom in practice, the absence of an early history as an employee, and direct access to clients soundly established the autonomy of the field and the clarity of the role. The practical nature of the work and a model of service delivery that reinforced independence and autonomy allowed the intellectual nature of the discipline to escape scrutiny. The nature of the discipline was further reinforced by a mode of teaching soundly rooted in the case method and Socratic approach. Although the independent practice model of American law and medicine has witnessed an upheaval in recent years, its developmental periods were from these origins.

In many ways the development of nursing can be better contrasted with the fields of social work, teaching, and engineering, The limitations of this paper do not permit us to fully chart the development of these fields, but some general observations seem relevant. Early in its history, social work was characterized as a woman's profession. Social work emerged as a discrete field due to the increased complexity of life and the breakdown of some of the traditional resources available to people through the family. In a manner similar to nursing, social work became intellectually vulnerable by building advanced preparation around functional roles. In the case of social work, these roles were in public policy and administration. Clinical practice was not considered sophisticated in the early days of the field. Clinical practice grew in strength when social work officially selected sociology as its common base, as opposed to a psychological emphasis.

Social work labored under disadvantages that were even greater than those of nursing. Social work has grown simultaneously with the history of organizations, and social workers have historically been salaried. Social workers in some states were not regulated until very recently, and consequently did not have the boundaries of their practice established by government. It is only since 1999 that all states and the District of Columbia have had credentialing requirements for social work practice and title protection. Though the bachelor's degree is required for entry into practice, an advanced degree is standard for many positions. (Stanfield & Hui, 2002) But despite this progress, the regulatory requirement for the presence of social workers in institutions is frequently no more than tokenism. In reality, social work as compared to nursing has experienced greater standardization of education and practice, but less support of government.

Elementary and secondary schoolteachers can also trace their heritage to a technical education, namely, within the normal school system. As the scientific base for teaching grew, the baccalaureate became the necessary credential for teachers. Minimum standards for practice were formalized through statutory requirements in a state, and seniority in a school system and advanced educational achievement were recognized in the workplace through the advocacy of strong collective bargaining programs. Regardless of critics of governmental regulation, a whole class of professionals has been allowed to direct their practice in the best interests of the clients they serve. And collective bargaining has allowed them to expand their educational base and control their work environment.

Engineering provides another useful comparison. Engineers emerged from the ranks of craftsmen as the sciences of mechanics, chemistry and electricity became more theoretical and complex. It is only in the last 20-30 years that engineering programs incorporated more than a smattering of liberal education. When the scholarly nature of the discipline as an applied science began to grow, a technical level of worker surfaced that would function under the direction of the professional engineer. Engineering has moved to specialist preparation with the first university degree as opposed to maintaining commitment to the generalist as the entry into practice position.

In summary, as professional areas developed, they seemed to have a clear picture of the service they provide and the knowledge and skills necessary to meet that commitment. Preparing for practice has been the initial concern, with a more liberalizing education only being proposed once the discipline matures and has some control over standardization of educational requirements. In most established fields, liberalizing and broadening the perspective of the professional has been accomplished through a pre-professional curriculum. In disciplines that developed later, professional and general studies have paralleled one another. All of these disciplines maintain intense practice experiences within the educational program or through an extension of the educational program. The student teaching experience, residencies in medicine, moot court, the law clerkship or legal clinics, and the residency in social work all intend to socialize the neophyte into the field and provide a transition to professional accountability.

This tendency to move in the direction of higher levels of education is not exclusive to the disciplines reviewed. Many of the health professions have followed suite, including occupational and physiotherapists, speech and language pathologists and audiologists, genetic counselors, pharmacists (already moving to the Pharm.D.), dieticians, and more. (Area Health Education Center [AHEC], 2002)

And For Nursing, The Past is Prologue

By witnessing this evidence from the progress of other professional fields, it is obvious that nursing has resisted the normal course of occupational development. More correctly, any progress towards educational standardization or up-grading could jeopardize a substantial workforce for the health care industry. It was to no one's benefit to accomplish these things, except nurses themselves.

Organized nursing has had an historical commitment to advancing the educational preparation for practice.

Associate degree nursing was a response to social and consumer need, and provided the technical associate that so many other professions have birthed.

As entry into practice programs became more diversified with the introduction of the associate degree and the growth of community colleges, that agenda was modified to include the need to standardize and distinguish between levels of practice. The associate degree as a route to preparing for a career in nursing did not require extensive justification. Its cost-efficiency had been proven and in many instances it served as the vehicle for preparing the bulk of the nursing workforce in days of declining diploma education. Associate degree nursing was a response to social and consumer need, and provided the technical associate that so many other professions have birthed.

The changed scope of nursing practice, the intellectual growth of the discipline, and the increased demands of the service environment bring an ethical obligation to consider complementary changes in nursing education, to revisit the "entry" issue.

Given a supportive environment, the more educated practitioner will be the most cost-efficient.

Today's health care delivery system challenges the nurse with increased technology, the mandate for cost-containment, a new consumerism and growing demand for self-care, diminished use of in-patient facilities, and the continual call for counseling and health education. More attention is directed to utilization review and quality assurance, and the need for case coordination in vertically integrated systems. The requirement for highly sophisticated providers and more independent decision-making is obvious. Given a supportive environment, the more educated practitioner will be the most cost-efficient. This means commitment to a longer and more demanding education than the baccalaureate degree. Moreover, the increased demand for nursing services, as evidenced by the growing presence of chronic illness and an aging population, sustains the case for associate degree education.

Partitioning the nursing workforce in this way addresses another issue of contention. Contrasting the nurse prepared at the graduate level to the associate degree nurse demonstrates a significant difference in competency, one that is obvious to nurses, and additionally to the consumer, the industry and allied healthcare interests.

This proposal is admittedly vague, and leaves many bigger questions. How would titling be handled?

There is the tendency to personalize the issue and to feel threatened by policy decisions that will only impact future generations.

Nurses have traditionally derived their identity from their statutory titles rather than their academic degrees. The result is possessiveness of the title "registered nurse" and reticence for any one group to relinquish continuing right to this title. There is the tendency to personalize the issue and to feel threatened by policy decisions that will only impact future generations. So be it. Accepting that this credential only signifies safety in practice and is based on role delineation studies that measure performance in the year following graduation, it is a minimal standard.

How would specialization be handled? Would an additional credential be awarded to signify specialty competence? Would the "entry into practice" credential allow for specialization? How would this affect workforce projections? Would the largest number of nurses be needed at the associate degree or the graduate level? How would this impact the licensed practical nurse, if at all?

We are confronted with occupational decision-makers who are demanding a feeling of fulfillment and personal expression from their work. Nursing has had difficulty keeping that promise.

Then there will be those nay-sayers who caution against instituting more change in the wake of the recent slow, but steady, recognition of advanced practice nurses by state legislatures and the federal government. To them I would say that nursing would always be a work in the process of "becoming."

Despite all of these potentially difficult questions, the time has come to face a reality from which we can run, but cannot hide. We are confronted with occupational decision-makers who are demanding a feeling of fulfillment and personal expression from their work. Nursing has had difficulty keeping that promise.

Author

Lucille A. Joel, EdD, RN, FAAN
E-mail - joel@nightingale.rutgers.edu

Lucille Joel is a professor at Rutgers-the State University of New Jersey College of Nursing, and was Director of the Rutgers Teaching Nursing Home from 1982 to 1998. Dr. Joel is a past president of both the American Nurses Association and the New Jersey State Nurses Association. She is also immediate past First Vice-President of the International Council of Nurses (ICN) headquartered in Geneva. Dr. Joel holds official status as ICN's representative to UNICEF and the UN. She is co-author of Dimensions of Professional Nursing and The Nursing Experience, both published by McGraw-Hill, and an international advisor to the American Journal of Nursing.

Dr. Joel has served as a professional-technical advisor to the Joint Commission on the Accreditation of Health Care Organizations and chaired the FDA's steering committee on nursing and medical devices. She served as the ANA representative to the board of the Computer-Based Patient Record Institute, and as the association's liaison to the Centers for Medicare and Medicaid Services (CMS) in work on quality and case mix reimbursement for long-term care. She is a member of the Board of Trustees of the Commission on Graduates of Foreign Nursing Schools (CGFNS).

Lucille Joel is the recipient of many honors including honorary doctorates from Villanova, Georgetown, Thomas Jefferson, and the Medical College of Pennsylvania/ Hahnemann Universities. Dr. Joel maintains a practice as a nurse-psychotherapist, and has taught advanced practice nursing students since 1975. She has been intimately involved with change and growth in the field. In recognition of this work, she was recently awarded Honorary Membership by the National Conference of Gerontological Nurse Practitioners.

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