"A full and ongoing dialogue between nursing and its public is crucially important to the renegotiation of the contract between nursing and society. This is the essential task facing nursing and society over the next decade* (Secretary's Commission, 1988, Vol. 1, p. iii). This introduction to the Final Report of the 1988 Commission on Nursing challenges nurses, nurse educators, and nursing organizations to participate fully in this renegotiation.
As the dialogue between nursing and society progresses, an essential question for consideration is whether nurses have the tools to participate effectively in the search for solutions to the problems that face nursing and society in meeting health care needs. The crises facing nursing today can be summarized under three headings: status and power; economics; and numbers. The issues of status and power have a direct bearing on remuneration for nurses and the number of nurses who enter and remain in the field. This article proposes the need for explicit consideration of status and power issues in nursing research, in theory, and at all levels of nursing education and suggests, as have others, that the concept of power is one that has been too long overlooked by nursing educators, authors, theorists, and researchers (Inlander, 1988). The exploration of the concept of power in nursing curricula helps prepare nurses to participate in the dialogue on health care mentioned by the Secretary's Commission (1988).
Technical Proficiency and the Nursing Role
Nurse educators are justifiably proud of their record in preparing nursing students to enter the work force as professional nurses. This pride is often expressed in terms of the percentage of graduates of a program who pass their licensing examination. Passage of this examination can be seen as an indication that a given program is no less efficient than another program in preparing students to carry out basic nursing functions.
The licensure examination, while indicative of basic proficiency at a minimally required level, gives no assurance that the new professional nurse will have a strong sense of self as a nurse, will understand the role of nurses in society, or have basic abilities to enter the health care arena as a full participant. Nurses should enter practice with a strong professional self-concept, prepared to determine policies in their work settings and to participate in the political and social discourse of their society. Without these skills, they will not only be ill-equipped to participate in the critical dialogues of their world, but also will experience frustration and alienation.
One cannot be surprised that nursing graduates may not be prepared to enter the arena of sociopolitical discourse. Historically, the role of nurse has been linked to the role of women in society (Reverby, 1987) and has also been defined in terms of the locus of participation in the health care system. Starr (1982) documents the centrality of the hospital as the major educator and employer of nurses during most of this century. These authors remind readers that the dominant forces in American society - a white, corporate patriarchy - would perceive autonomous and assertive nurses as threatening to their hegemony. These are the vested interests controlling the health care system, interests best served by nurses who are less assertive, less autonomous and less powerful than others in the health care arena.
For example, Ashley (1976) discusses the role of the nurse as an adversary of physicians and hospital administrators. This adversarial relationship is based on competition between groups for status and rewards. Other authors such as Roberts (1983) and Grissom and Spengler (1976) expand Ashley's analysis of the adversarial nature of these relationships.
Objections to defining the relationship as adversarial are understandable. The assertion that conflict may be inherent in the relations between nurses and other health care providers may be uncomfortable. Many nursing authors, however, have begun to explore disharmonious relationships between nursing and other groups in the health care system.
Brooten, Hayman, and Naylor (1988) recognized the opposition to nursing autonomy by physicians and hospital administrators who have "adopted active strategies to impede or weaken the nursing organizations and to defeat their goals for reform" (p. 28) in nursing education and health care delivery. Ashley (1976) also reviewed nursing's relationship to hospital organizations and physicians and observed that "nurses lack autonomy and work in an atmosphere of subordination to physicians" (p. 73). Such a finding is hardly surprising to any nurse. Ashiey contends that the defining characteristics of the nurse role are grounded in the relationship between men and women at the turn of the century and that nursing leaders have not gone "far enough in examining the repressive atmosphere with which they had to contend in an effort to change the political, social, and economic status of women entering nursing" (p. 101).
Stevens (1983) summarized discussions on power from several sources and presents what have become almost standard definitions of the concepts of power, influence, leadership, and politics. The commonly accepted broad definition of "power" is the ability to influence the behavior of another. Extensive discussions of the traditional notion of power may be found in Wieczorek (1985) and Brooten et al. (1988).
Compared to these established definitions of power, nurses usually emphasize not power, but authority and managerial leadership (Brooten, 1984). For example, in discussing managerial leadership in nursing, Brooten speaks of power as an aspect of professionalism and says that nurses have been reluctant to use power consciously. She attributes this to two factors: nurses often begin from a belief that they are powerless; and nurses have tended traditionally to internalize attitudes of subordination projected on them by authority figures.
Others provide further grounding for Brooten's assertion. Rogge (1987) writes, The majority of nurses resist participating in political activities, contending their purpose is to care for patients, not become embroiled in politics* (p. 26). Lerner (1985) adds that nursing education, long controlled by hospitals, allowed others to set standards of nursing practice. "If nurses were powerless to set their own standards of practice, they could not perceive of themselves as having power in relationship to other professionals within the health care system* (p. 90).
Broadening the Scope of Nursing Practice and Professionalism
Licensing examinations tend to overlook assessment of the graduate's knowledge of issues and community involvement, and measures of nursing competence may overlook such issues as well. Of the 68 nursing competencies identified by Clayton (1983), patient care skills and instrumental tasks were clearly consensus choices. While these are unquestionably important, political involvement, affiliation with professional organizations, and commitment to social improvement are notably absent. Though some may argue that these are not pressing concerns of nursing, the American Nurses Association (ANA) (1980) and other organizations have made numerous policy pronouncements regarding the importance of nursing's contributions te the pursuit of the social good.
Recent authors have moved beyond traditional nursing theory and practice, often abstracted from nursing's social context, in order to explain the usual depiction of nurses engaged only in nursing care with individuals. The nursing paradigm with its four basic concepts of person, health, nursing, and environment (Chinn & Jacobs, 1987) has the potential to include necessary elements for the broader approach advocated here. Chopoorian (1986) calls upon nurses to "reach beyond the privatized concerns of the individual to the surrounding world for analysis and explanation" (p. 53). She provides a thorough discussion of environment, which suggests that exploring the sociopolitical context in which person, health, and nursing exist "will uncover new possibilities for nursing and practitioners to contribute to the solution of societal problems" (p. 53).
Movement from a notion of health behavior as an individualistic, patient-as-person view to a reconceptualized notion of health behavior set in a broader social level of analysis is also the view advocated by Williams (1989). Williams' analysis of health promotion compares classical liberal political theory and individualistic health promotion to a societal-based, feminist perspective. She asserts that placing nursing in a wider context will require rethinking of what constitutes nursing practice.
Hie prevailing view of nursing practice as the rendering of services to individuals/families/groups in the context of a direct interpersonal model, the medical model of practice, provides no framework for acting to change the structural determinants of health and behavior . . . (Williams, 1989, p. 22).
Williams advocates the addition of "action to benefit the health of people" (p. 22) as an essential nursing activity and stresses that nursing curricula should include experiences that prepare graduates for this expanded definition of nursing practice. Munhall (1988) stresses this when she points to the need for nursing curricula that reflect the centrality of advocacy for patients and policies as basic aspects of nursing philosophy (p. 227).
During the last decade, a host of nursing authors have contributed to the discussion of nursing theory and its relation to nursing practice and, implicitly, the role of nurses in society. Their analyses range from a view of nurses as an oppressed group (Roberts, 1983) to more sophisticated philosophical analyses of nursing theory that seek to avoid isolating nursing and health care from the social fabric. A value-free, objective approach to nursing theory and research is the dominant perspective found in most nursing literature. "The rhetoric of science, and especially the pretense of objectivity . . . has had the effect of obscuring the values dimension of nursing theory" (Yeo, 1989, p. 35).
One need only look to standard considerations of nursing theory to realize that relationships are often seen in an apolitical vacuum that fails to take into account social status and power distinctions, the unequal distribution of rewards and wealth in society, the subordination of women, and social change as contextual variables in the health profiles of groups and societies. Analyses that include these broader concepts lead also to a reflection on the role of nursing in the societal processes by which groups strive to reach optimal levels of health. Possession of insight, organizational skills, and analyses based on these understandings will prepare nurses to assert a powerful influence on the continually evolving health care system.
The call for nurses to participate in the social and political processes that bring about changes in the health care system is not new. There are a plethora of historical examples of nurses striving to establish a place for nursing and to promote health care for members of society. Nurses have been active in various political and social movements since the early years of professional nursing. Reverby*s (1987) history of nursing points to the overlooked struggle by nurses for autonomy in the light of societal expectations of altruistic service. Biographies of WaId and Sanger describe these early nursing leaders who practiced nursing in the broader context advocated here (Lagemann, 1979) and brought public health changes through political action.
Rogge (1987) writes of nurses who participated in the building of health care during war time and their struggles in the political arena. It would seem that this history, which is partially based in conflict and political struggle, has been overlooked or written out of nursing's popular history because it recalls adversarial relationships and not consensual agreement on objectives for the health care system.
It is this adversarial relationship that is recalled by feminist and critical social theory. Alien (1987), for example, analyzes the ANA Social Policy Statement and suggests that a reappraisal is necessary to look for hidden assumptions about the nature of health and the nature of groups in promoting health. Williams (1989), in her study of the philosophical-political bases of health promotion, advocates the preparation of nurses for engaging in political activities that promote health through community organizing, coalition building, and other political activities. Roberts (1983) argues that problems of initiative, self-esteem, and assertiveness in nursing do not result from a lack of nursing leadership, but from the position of nurses as an oppressed group that shares characteristics of oppression with other groups throughout history. These are but a few of the authors who call for approaches to nursing that cause nurses to analyze and reflect on their role in society.
The profession also should consider the role of nurses and nursing in preparing new nurses to enter the field. Just as educators have begun to consider how nursing education takes place in the clinical setting (Benner, 1984), educators and clinicians alike must consider the context in which nursing and health care delivery take place.
Nursing educators have been challenged to integrate critical thinking and reflection into the nursing curriculum. They also are being challenged to recruit nursing students from an increasingly heterogeneous population. Assumptions about the role of nurses and their standing in the community of health care providers may change as the demographic profile of nursing changes.
Altering the nursing curriculum at all levels to prepare nurses for participation in our society's debates on the health of its people can have a major impact on the role and future supply of nurses. As nurses are better prepared to enter the political arena, broadly defined from community activism and advocacy to elected office, the resultant change in the image of nursing will likely provide dividends to both nursing and society. Nursing may move to a position of parity in the health care arena that is more in accordance with its numbers in the work force. This visibility and increased stature will demonstrate the potentially dynamic and fulfilling nature of nursing and will serve as incentive to those who may consider entry into the field.
It is inevitable that changes in our health care system will continue at a rapid pace. As these changes occur, the question that remains is whether nurses will be leaders and equal participants in determining the kinds of changes that take place or will nurses be followers who accept the pronouncements of others?
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