It has recently entered the news that nursing is to undergo an educational upheaval with a shift for nursing education moving in its entirety onto degree level programmes by the year 2013 (Bowcott, 2009). This represents change on a grand scale in terms of nursing’s public image and the regard in which it is held by society.
Nursing, as a form of care, has existed for millennia. Brown and Gobbi point out that the Greeks and Romans cared for their sick in similar ways to modern nurses (Gobbi, 2007). Nevertheless, nursing in its current format as a type of work or even as a profession, has only existed since the Crimean War in which both Mary Seacole and Florence Nightingale worked. Nightingale, perhaps the more historically significant of the two given her influence over nursing practice subsequent to her organisation of the Scutari Military Hospital during the conflict, thought of nursing as a ‘calling’ (Selanders, 1993). Leaving aside the spiritual sense in which the statement was originally intended, ‘calling’ is an important concept I will draw upon in greater detail.
A calling should be seen as an internal desire to operate in a position to which the individual is devoted and perceives as inherently valuable. If this is what attracts us to become and motivates us to remain nurses then it is a crucial element in any discussion of the nature of our practice. The ability to do one’s job effectively is determined by a nurse’s passion for their art both in terms of maintenance of knowledge and in terms of motivation to operate efficiently. Consequently, it may be argued that professionalism and the financial and status benefits it brings would reduce the quality of nurses joining the health services. Can the notion of ‘calling’ be reconciled with professionalism? Furthermore, are we in control of its destiny if it is not already a profession or does the nature of nursing prevent it from being so at all?
Florence Nightingale (1859) believed that the goal of nursing was to ‘put the patient in the best condition for nature to act upon him’. Many other theories have followed Nightingale’s, but all have emphasised the caring element. Another popular definition is that of the American nursing educator and writer 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) 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 (1967, p15).
Geoffrey Millerson describes six attributes necessary to define a profession:
a) A profession involves a skill based upon theoretical knowledge.
b) The skill requires training and education.
c) The professional must demonstrate competence by passing a test.
d) Integrity is maintained by adherence to a code of conduct.
e) The service is for the public good.
f) The profession is organised. (Millerson, 1998, p4).
We can refer back to Henderson’s definition to identify nursing’s skill. In order to suggest nursing is a profession involving a skill based upon theoretical knowledge however, we must identify the theoretical knowledge held by the nurse. The nursing discipline has a unique body of knowledge comprised of conceptual frameworks, theories and practice models but despite this vast body of literature, few nurses actually base their practice upon these nursing theories (Logan et al, 2004). As Margretta Styles points out, “The professionalism of nursing will be achieved only through the professionhood of its members.” (Styles, 1982, p8).
As long as nurses fail to adhere to the theories they purport to base their practice on then they are failing to be professional. This does not prevent nursing from being a profession however, as not all nurses necessarily fail to base their practice on theory.
Great educational change was instigated through Project 2000 in 1989, as the British government sought to transfer some nurse training into universities (Hansard, 1990). This was clear evidence of a paradigm shift in nurse education towards more advanced learning and training. This has been further demonstrated recently by plans drawn up at the Nursing and Midwifery Council (NMC) advising that all nurse training must be at degree level by 2013 (NMC, 2009). Millerson would suggest the professional nurse must pass such educational benchmarks to demonstrate their competence. The courses set up in universities across the UK in response to the demands of Project 2000 are all regulated and approved by the NMC, which took over as nursing’s regulatory body from the United Kingdom Central Council (UKCC) in 2002. The foundation of the UKCC had already signalled financial autonomy from the government on its foundation in 1983. The NMC not only regulates the register by demanding a demonstration of competence through passing an approved course, but also ensures that integrity is maintained. All nurses registered in the UK are subject to the NMC’s Fitness to Practice Procedures, and may be dismissed if they are deemed to have failed to adhere to the NMC’s Code of Conduct (NMC, 2008).
Millerson’s fifth requirement, that the professional service is for the public good, can be easily argued. As the Royal College of Nursing (RCN) suggested in a recent paper on defining nursing, nurses look after the community, healthy as well as sick:
“…the purpose of nursing is to promote health, healing, growth and development, and to prevent disease, illness, injury and disability.” (RCN, 2003).
It does not seem unreasonable then to state that nursing is for the public good.
The final of the prerequisites stated, that of organisation, has already been discussed. Bodies such as the NMC and the RCN are significant not only in their ability to regulate and advise practice, but also to project an image of nursing into society. Lambert and Lambert (2005) lead us to believe that Millerson’s final demand has been met. They suggest a number of organisations set up to provide the public with adequate protection from unsafe practice and also to further enhance and advance nursing practice. Sigma Theta Tau, for example, a research organisation and honour society concerned with improving standards of healthcare with over 125,000 active members.
Barring a unique skill based upon theoretical knowledge which may be contravened by the non-compliance of nursing practitioners as discussed, Millerson’s conditions of professionhood all seem to be adequately met. However, as Watson points out, nursing is not yet recognised as a profession by the general public (Watson, 1999). This implies that the power to define nursing remains in the hands of nursing itself, which raises the question of whether it stands to benefit from professional status in society, or whether it would benefit more from a change of direction while there is still the chance of avoiding professional definition.
Regardless of Millerson’s criteria, a great debate has risen through nursing circles and significant contention still exists around the issue of professionalism. Friedson (1986) states that a profession is an occupation which achieves prestige and then power and money. It is important for us to question whether this would benefit healthcare in general. Is the career nurse interested in progression, power and status also concerned with their ‘calling’?
Etzioni (1969) and Forsyth and Danisewicz (1985) all suggest that nursing is in fact a semi-profession due largely to the lack of autonomy of practice. Etzioni defined nursing as an occupation with less autonomy and less involvement in the creation and application of knowledge. It is significant however to note the dates of these articles; the emergence of new roles such as the Nursing Specialist is evidence of the increased autonomy enjoyed by modern nurses (Castledine 2002). Vollmer and Mills (1966) try to persuade us that professionalisation is a dynamic process. The collective efforts of nursing organisations such as the RCN might therefore change Etzioni’s view. What I will proceed to discuss is whether changing this view would be beneficial to nursing and whether we ought to pursue professional status at all.
The benefit to be found in professionalisation has also proven a contentious issue in the debate. In the prologue to ‘Postmodern Nursing and Beyond’, Jean Watson (1999) describes how nursing struggles within itself and the world around it. She describes how nursing struggles to be seen, heard and valued for its strengths whilst remaining immobile in its struggle for authenticity. Indeed, Muff (1982) suggested that the nurse has retained the image of ‘handmaiden to the physician’ and Jutras (1988) reiterates this point . Professionalisation arguably offers the modern nurse the authentication required to debunk this dated stereotype and begin to be seen, heard and valued by society and by medical colleagues in the healthcare setting. The contemporary ‘professional’ nurse would benefit from recognition of their efforts in society and for their skills. Furthermore, the same nurse would be equally valued by their employers, not only in monetary terms, but in terms of the value attributed by colleagues and clients to their thoughts, feelings, opinions and choices as a part of the decision-making process in any productive healthcare team.
Sigma Theta Tau International have attempted to advance nursing practice by instigating movements such as ‘Nurses for a Healthier Tomorrow’. Such efforts by professional organisations displays a need for nursing to be taken seriously in its own right and this requires the eradication of preconceptions such as that of the nurse as an assistant to the doctor. This image exists both in the working environment and in society at large (Jutras, 1988). In order to deliver excellence and value in care, the informed and practical decisions made by nurses in the care setting must be taken into consideration and implemented to the benefit of service users.
Liaschenko and Peter argue that emphasising nursing as an autonomous profession is unproductive as it is relational health care work, stating that “striving for uniqueness can move the focus of a group’s efforts on to the group itself, taking it away from those the group has intended to serve.” (Liaschenko and Peter, 2004, p490). By this Liaschenko and Peter mean that nursing is not only focussed upon the practitioner-patient relationship, but that it is also focussed upon facilitating and co-ordinating care within highly complex organisations. As they rightly suggest, this is an important aspect of the nurse’s role and we must consider that it may not be entirely beneficial for nursing to pursue professional status. Losing focus on holism and management in this way may lead us to more insular and less global practices, reducing the quality of the nurse’s uniquely holistic care. In addition to this, Rutty (1998) suggests that nursing must be careful about its aims and direction with regard to professionalisation and warns that it risks losing focus on care.
Chambliss (1996) invites us to consider that nurses ‘do whatever nobody else wants to do’, implying that their work can be tedious, unpleasant or difficult. It is important therefore to consider whether a ‘professional’ nurse not motivated by calling would perform essential yet possibly menial tasks required for the adequate care of a client or whether their career would take precedence over their practice.
Anthony Heyes (2005) argues that nursing represents better ‘value’ to society as a ‘vocation’ as it avoids attracting the ‘wrong sort’ to the occupation. He argues that those nurses prepared to work for less than what would be considered a ‘professional’ wage are the same nurses motivated by the need to care and are better for it. It could be said therefore that professionalisation may attract others besides those who are motivated by ‘calling’ alone, which is potentially damaging to quality of care.
Folbre and Nelson (2006, pp130) however, suggest that Heyes has neglected the effect of pay on employee morale and displays bias between nursing and other professions, they ask: ‘Why don’t we see similar articles on badly paid executives being good executives?’. It can also be posited that without adequate status and reward, academic and driven individuals are put off joining the profession which leads to a shortage of new knowledge entering the occupation. Klaas (1961) would agree, arguing that the motivation of service to society (which helps to define a profession according to Millerson’s criteria) should be adequately rewarded.
In conclusion, I believe the solution to this final conflict lies within Advanced Nursing Practice (ANP) and new Nursing Specialist roles. Whilst Heyes is right to suggest that nurses motivated solely by career may be more likely to overlook essential caring tasks, he is wrong to propose that existing nurses should not be rewarded for it. Equally Folbre and Nelson are right to suppose that financial reward and increased status are motivating to intelligent and driven nurses from a strong academic background, but they fail to acknowledge Heyes’ prudent observation. Further, as Vollmer and Mills have stated previously, as nurses we still have the power to influence public perceptions to the benefit of service users and we can thus deter Heyes’ selfish career-driven nurses from joining the profession by retaining the notion of vocation for basic nursing. As Millerson has suggested however, despite public perceptions to the contrary, nursing still has the right to call itself a profession, at least of some sort – semi or otherwise. We may still benefit from Folbre and Nelson’s motivated and intelligent nurses however by encouraging them to build towards and succeed as professional Nurse Specialists, with all the status and financial reward that those roles might bring.
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©David Rickerby. This article is licensed under a Creative Commons Attribution 4.0 International Licence (CC BY).