The Courage For Effeetlve leadership in Nursing Issues and Recommendations for Nursing Leadership
The challenges and responsibilities facing nursing today, and its very survival as a learned profession, are perhaps more serious and realistic than they have ever been in our history. How will we, as a leadership group, respond to these challenges and indeed threats? It will take Love and Honor, yes, but I believe that it will take all of the Ccurage that we can muster-individually and collectively. Therefore, I would like to identify and discuss some of the current issues facing nursing and to suggest ways in which we can exhibit a ourage that conveys firmness of spirit that will face such dangers or difficulties without flinching or retreating; courage that provides us the mental or moral strength enabling us to venture, persevere, and withstand danger, fear o r difficulty f i r m l y and resolutely; courage that provides a confidence that will encourage and sustain us and others.' M y remarks are based on the following four premises: ( 1 ) Nursing, as a learned profession, has no dependent or interdependent functions; ( 2 ) Nursing is a profession clearly distinct from the profession of Medicine; (3) Too many leaders in nursing today are providing ineffective and questionable leadership; and ( 4 ) A clear and unambiguous differentiation of careers in nursing must become a reality. Nursing-A Learned Profession To define nursing, as a learned profession, presents no difficulty if the term "nursing" i s viewed as a noun. The mix-up occurs when one tries to define the term "nurse" as a verb. For, any dictionary clearly defines "to nurse" as an act that most anyone can do. Examples include: 1 ) to rear, to bring up, to look af!er or to give advice; 2 ) a person skilled in caring for or waiting on the infirmed, injured, or the sick and especially trained to carry out such duties under the supervision of a physician; and even 3) the act of nursing the balls in billiards keeping them close together and in good position.z But, when nursing is viewed as a noun-then one can describe and define this term quite differently. Nursing may then be defined as a learned profession. Nursing-A Profession Distinct from Medicine Nursing, as a learned profession with its own theoretical knowledge base, has no dependent or ./
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the independent practice of nursing places responsibility and accountability for nursing and the direction of its own evolution clearly with nursing and nurses. Pg. 56
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interdependent functions. Therefore the independent practice of nursing places responsibility and accountability for nursing and the direction of its own evolution clearly with nursing and nurses. As an autonomous profession, nursing is not subject .to manipulation by any other group, namely medicine. Nurses work i n a collaborative, cooperative, and collegial relationship with many other disciplines in providing health care to the ccnsumer public. Medicine has no monopoly cn health care nor do physicians possess either the knowledge or competence to credential nursing or nurses. Nurses and physicians are not interdependent. For, nurses do not need physicians to practice nursing, and physicians do not need nurses to practice medicine. At a t i m e when some members of society (even physicians and scientists included) are attacking the medical system and identifying it as the gravest health hazard we face today.3nursing has the golden opportunity to "do its thing," so to speak. The nursing profession has all the "know-how" to take the sickness out of health care. There must be clear and unambiguous action directed towards nursing's autonomy, as a scientific field of endeavor, clearly distinct from the profession of medicine. Ineffective and Questionable Leadership in Nursing The increasing turmoil on the health care scene i n general and in nursing specifically is of maior concern to those of us who have the courage and commitment to actualize nursing as a learned profession. Unfortunately, Organized nursing, as we know it, and too many nursing leaders have either chosen to evade the issues or to provide questionable leadership that must be challenged! Nursing leadership has been guilty and has played too many games. This nonsense mgst cease. New directions must be sought, and this wi!l take courage. The a i r is stale and close to becoming stagnant with what I perceive as selling nursing out to medicine. I refer specifically to three maior recent developments. They are: ( 1 ) recent decisions by the American Nurses' Association; (2) the Nurse Training Act of i975; and (3) recent announcements from the American Nurses Foundation. The American Nurses' Association The American Nurses' Association has long proclaimed itself as the "professional organization for nurses," and we know that organized nursing through a professional group can be far more effective than any one person alone pleading any cause. We know that in unity there is strength. The ANA took a courageous step forward when the Position Paper of 1965 clearly enunciated the educational preparation for nurses, namely, professional in baccalaureate and technical in associate degree program^.^ However, in m y opinion, i n 11?73 the ANA did a "turn about face" p!iblishing its "Statement cn Diploma Schools" staiing that they really didn't know the difference between professional and technical and were sorry about that Position Paper? Does one wonder then why so much confusion? Why, indeed, were physicians included on the ANA National Review Committee for Accreditation of Short-Term Conthuing Education Programs? And,-
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Effective Leadership in Nursing nurses selected one of these physicians as its Co-Chairperson. Why would ANA believe that it would have to appease organized medicine in i t s move to accredit continuing education programs i f these programs are in nursing? If these continuing education programs are in nursing, then nurses should accredit such programs. I f nurses are being prepared to practice medicine, then they should be called "physicians' assistants,'' licensed as such, and supervised by physicians. At a time where there is increasing documentation of the determination by medicine to declare all nurses physicians' assistants and to deny the validity of safe and knowlelgeable nursing practice, why would ANA choose to iointly sponsor a conference on "Primary Health Care in the HMO/ Prepaid Group Practice" with the Group Health Foundation and the American Association of Physicians Assistants? What were the underlying motives here? Why should a system of certification which recognizes excellence in nursing practice but deliberately designed to give no recognition to education, learning and knowledge be supported? Have you wondered about the educational credentials that the ANA certified may hold? There is no way to tell. Some states (Example, New 'fork and New Jersey nurses) courageously opposed the national standards atid held for baccalaureate and higher degrees as a requirement for state certification in certain specialty areas. The Nurse Training Act of 1975 Applications for nurse practitioner programs under the Nurse Training Act of 1975 must be approved by the appropriate nursing and medical organizations. Monies in the amount of $60 million are so ear-marked over the next three fiscal years (1976-78).Another S60 million for Professional Nurse Training will give special consideration to programs conforming to the guidelines for Nurse Practitioner Programs. Will Medical Training Act monies be subjected to approval from the appropriate nursing organization? If nurse practitioner programs are to teach nursing, then nurses should be responsible for them-not physicians. Nurses in "expanded roles" (whatever the t e r m may mean) should not be practicing medicine or performing medical tasks. One cannot define a profession by defining a task, and one task m a y be p r f o r m e d by any number of different health care personnel. Nursing practice like the practice of any other health discipline is ever evolving, and nurses like all other health care practitioners must
Nursing practice like fhe practice of any other health discipline Is ever evolving, and nurses like all other health care practitioners must incorporate into their practice tools, techniques, and therapeartic measures based on advances in health sctence and technology. /IMAGE
Pg. 57
Effective Leadership it i Nursing incorporate into their practice tools, techniques, and therapeutic measures based on advances in health science and technology. Nurses have done this for years. But-nursing must determine the scope of i t s practice, who shall practice nursing, and the education for that practice. Therefore, I reject either the inclusion of physicians on nursing faculties (either to teach students or faculty members) or the appointment of physicians to serve as co-directors of so-called programs to prepare nurses for the "expanded role." I a m not opposed to seeking appropriate input, but I believe we must recognize nursing as a learned profession, i f nurses are to function as professionaj peers with other groups and are to control the practice of nursing. The American Nurses Foundation Why indeed is a physician included as a member of the Board of Trustees of the American Nurses Foundation? And, the members of the Board elected him as i t s President. I a m appalled a t such action and in addition object to using monies solicited and collected under the guise of nursing research that is awarded to others outside nursing. What does this mean for nursing research in the future? The New York State Nurses Association's 1985 Proposa I Clearly related to m y concern about ineffective and questionable leadership is the very controversial legislative proposal i n New York State to amend the education law in relation to educational requirements for professional and practical nursing. I speak specifically to this proposal, because other states (Ohio, Indiana and Maine, specifically) and indeed ANA i s studying the implications of this specific proposal on the nation. An immediate "split" has occurred among members of NYSNA and a coalition of nurses (all members of NYSNA) has formed with one objective -ta defeat the implementation of the 1985 Proposal. This coalition of nurses represents practical nurse educators, associate degree and hospital schools and baccalaureate and higher degree programs. It is called "N.U.R.S.E.S." (standing for: Nurses United for Reasonable Systems of Education and Service):' Certainly one cannot oppose the intent of any legislative proposal that attempts to clarify, standardize and elevate th2 educational requirements for the lega! practice of nursing by all nurses. And-to require a baccalaureate degree i n nursing for the professionally-educated nurse is not a "new" idea. What can be questioned, however, are the means whereby such an intent i s implemented. It is m y cortention that nursing does not have to go the route of the New York State Nurses' Association 1985 Proposal, i.e., by 1984 to require a baccalaureate degree i n nursing for all nurses. The grandfather mechanism, which exempts persons from meeting future educational requirements, would be used as a protection mechanism for those RNs currently licensed-many of whom would still be practicing in the year 2023. Can we really afford Pg. 58
to do this when we reflect on our responsibilities to society for qu3lity health care and when, indeed, nursing's very survival seems to be a t stake? Will the thousands of nurses so grandfathered in as "professionals" in 1985 function any differently or isn't the status quo being maintained? How can we simply deny and ignore several decades of baccalaureately educated graduates in nursing? I dc not believe that such a proposal will minimize Governors' nor any other legislators' intentions or attempts to revise the definition of nursing to legitimize what has so euphemistically been called "the expanded role of nurses.'' While it is true that existing multiple kinds of nursing education programs leading to licensure as a "registered professional nurse" create immeasurable public and professional confusion, it is equally true that this confusion has not stemmed from the fact that there are different programs. Rather, the confusion is created b y the fact that the graduates of these multiple programs are all labeled "registered professional nurses" without discrimination. I f it is recognized and accepted that entry into the professional practice of nursing requires a minimum of a baccalaureate degree, then to license persons through a grandfather mechanism with less than this preparation as "professionals" is educationally unsound, compromises standards of professional education and the criteria of a profession. In addition, it places unrealistic responsibilities upon those persons so licensed and catches the consumer public in the middle! The larger society has turned its attention to the universities for many reasons. Among them is the recognition of the critical importance of theoretical knowledge and the success of scientific inquiry in dealing with physical and social problems! Why do so many in nursing choose to ignore what the "larger society" has recognized through the years? I a m appalled a t the support that many Deans and Directors of baccalaureate and higher degree programs are giving this Proposal and I have spoken out against this Proposal since its inception. It i s not sufficient t o oppose a proposal without offering an alternative one. Therefore, 1) recognizing nursing, as a learned profession and 2) acknowledging the existence of an already established group of professionally-educated nurses (though never licensed as such) it seems logical to suggest the following: 1. leave the present license for RNs and LPNs as is; 2. seek and obtain a new licensing law that the educational requirement for a license, as a professionally independent nurse (IN), will be the minimum of a baccalaureate degree in nursing; 3. use a grandfather mechanisrn to permit those nurses already holding a baccalaureate and / or higher degree in nursing and already licensed as RNs and/ or professional nurses to become licensed as professionally independent nurses (IN) for life without further examination; and 4. require all future professionally educated independent nurses (INS) to take a new State Board Examination that would be designed to test for safe professionally independent practice in nursing. Such an approach i s supported by the Society for /IMAGE
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Advancement in Nursing, Inc. (SAIN).’ I f an already established group of professionallyeducated nurses were licensed to practice professionally independent nursing-under a .new lawthen I would make three predictions as follows: 1. Reimbursement for the services of such nurses in the social insurance system, o r better known as third party reimbursement, would become a reality for we know that all registered nurses are not qualified to receive third party reimbursement. 2. Such nurses would take the leadership in a program of national health insurance to continue and expand then long-established practice i n providing access to the health care system (including admitting and discharging of clients to hospitals and other health care facilities) for nursing care based on a nursing diagnosis of clients’ needs. This would show tangible reductions in steadily rising health costs. In April 1976 the President‘s Council on Wage and Price Stability contended that the monopoly-like control by physicians of health services and the passive role of patients had helped push health care costs up at a record speed. 3. There would be a realistic and meaningful certification system for specialty areas requiring graduate level education in nursing, recognizing the value of education, learning, and valid knowledge. It would not be necessary to seek licensure for specialty practice. I make these predictions, because Nursing a t last would have clearly established in the law that group of nurses qualified to assume the responsibility of and accountability for the professionally independent practice of nursing. There are some who have called those of us who would seek a new license “politically naive and unsophisticated.” I contend ;hat the concept of a third or new license is already in the minds of some legislators when one examines attempts in New York State by Cahill and Stone to license certain nurses differently to perform different functions but-under medical supervision. l o The concept is valid, but the control of nursing must be with nurses-not with physicians o r any other group. Differentiation of Careers in Nursing Applicants to nursing should be counseled into the program for which they are best qualified from the beginning. All registered nurses do not need baccalaureate degrees nor can society afford it. Rather, excellence must be demanded in all programs. Too many nurses have viewed baccalaureate education as the substitute for hospital schools. Whereas, associate degree programs were in fact designed explicitly for this purpose. Career and educational difference in nursing must be recognized and must become a reality. Failure to do so only serves to support nursing’s traditional anti-educationism. We need to differentiate careers on a continuum
It is within Oh& self-eption concerning facts or situations abou?the need for this clear differentiation along this continuum, that, in my opinion, all ether delusions in nursing Die.
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Effective Leadership in Nursing beginning with recruitment and extending throughout education, program accreditation, licensure/ credentiating / certification, practice, continuing education and in research. It is within this self-deception concerning facts or situations about the need for this clear differentiation along this continuum, that, in m y opinion, all other delusions i n nursing lie. I believe that this differentiation would change the image of nursing with regard to the media, to nurses, employers, consumers, the educational system and the world at large. What Can We Do? Let each of us be sure that we do not become a part of those nurses who indeed hold the desired credentials but do not provide the effective leadership that nursing needs today. We must have the courage of our convictions. We cannot change our story according to the audience, rather we must tell it like i t is-regardless of how unpopular and painful the truth may seem. The eftective way is not usually the popular approach. But, we are not running a popularity contest and nursing must not be sold short. We can learn to compromise without sacrificing our principles nor succumbing to the pressures of expediency. Nursing leaders in the past have been cited for their ingrained capacity for meeting strain or difficulty without fear or with fortitude and resilience of spirit or mind. Today, we must do the same thing. We must possess and demonstrate an ability to hold our own; to fight for our principles; and keep up our morale when opposed, interfered with, or checked. We must possess the courage to fight for ideals even though they may never be fully realized. We can be certain that the independent role is what we want unequivocally and then move to fulfill the responsibilities inherent in such a role. We can be social and political activists. We cannot be conspicuous by our absence in local, state and national affairs. Nursing can be heard and make itself heard. We can be a y g r e s s i v y n o t waiting to be asked in the fine tradition of dependency. We must be involved. We must be consumer-advocates realizing fully what this means to change consumers from passive to active participants in their demands for health services from the cradle to the grave. It will take courage to speak out frankly and informatively on health issues that will enhance the health potential of a l l people. Nursing does have a
It will take couruge to speak out fronkly and Infornatively om health issues that will enhance the health potential of all people. signal contribution to make to health care. Health care is more than illness-oriented care and it cannot be hospital-oriented. It i s imperative also that the consumer public participate in this process. /IMAGE
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Effective Leadership in Nursing ~~~
It will take courage to stand sometimes what seems to be virtually alone in defense of one’s rights. It is not easy. It will take commitment t o a strong and bold resolution and a set purpose. We must be tenacious, filled with stubborn persistence and an unwillingness to recognize defeat. Our convictions must be strong, and we must hold to them with unswerving tenacity. We can hold ourselves and the nursing profession in high esteem. We must view health care, in its broadest sense, and value the significant contribution that nurses both individually and in groups have to improve its nature, amount and quality. Our goal is first-rate health care not second-rate medical care. We must be proud t o be nurses-determined to carry out our obligations to society. We must not apologize for being “just a nurse.” There is a constant c r y for unity in nursing. But, there can be no unity until we can make some of the painful decisions about the problems facing us and until we can value diversity. Risk-taking takes courage. It is not a pleasant task. If it were, more people would be doing it. Even though you may find yourself alone a t the beginning, one begins to build a reputation, and then others begin to join. No one person will change the system alone, but then there
No one person will change the system alone, but then there is no system that cannot be changed. i s no system that cannot be changed. But one must always be careful not t o become a victim of the system in the process. The Real World I a m concerned and distressed when the continuous cry is heard that academe is not preparing nurses to function in the real world. And-as I examine and reflect on what I see happening in that so-called world of nursing, then I a m convinced that it isn’t the real world at all but rather a very unreal world that we must change. I contend, then, that i t is in the academic environment where nursing is viewed as a learned profession, that the real world of nursing exists and where nurses are prepared to cope with that unreal world out there and to make the necessary changes.
...it is in the academic environment where
nursing is viewed as a learned professioii, that the real world of nursing exists and where nurses are prepared 00 cope with that unreal world out there and Po ma& the necessary changes. If indeed the “real“ world is fixed, immovable, and has no imaginary part-as opposed to the non-existent, hypothetical, abstract or the possible Pg. 60
way even through conjecture-then I will take m y chances in the “unreal” world. For, I believe that man and the universe evolve from the pragmatic to the imaginative to the visionary. And i f reality is how one perceives it, then it will differ for each of us according to the conceptual system we bring to it. Therefore, I believe that il is more likely that reality will be reconciled with idealism when faculties stimulate students to be creative, and when they provide them freedom ,to think, to examine issues, to question and to assist them in developing new insights and a whole new perspective on the profession of nursing in a frustratingly complex social system. Please don‘t misunderstand me-I a m not denying the need for professionally.educated nurses to learn and know how to do essential psycho-motor skills; rather I am emphasizing the need to learn and develop those intellectual skills that really determine the effectiveness of all others. For, safe practice is not possible with an inadequate or obsolete knowledge base. The history of mankind i s a tribute to the human capacity to cope with change. The confusion found in today‘s picture of Nursing indicates the need for a reaffirmation of our capacity to establish order out of the chaos through change. We must review and weigh our alternatives for meaningful outcomes. It will take creativity, selectivity, critical thinking, analysis, and indeed courage. REFERENCES 1. Webster’s Third New lnternational DIclionary of the
English Language Unabridged. Springfield, Mass. : G 8. C Merriam Company, 1971. 2. Ibid. 3. ILLICH, IVAN. Medical Nemesis: The Expropriation of Health. New York: Pantheon Books. A Divlsion of Random House, 1976. 4. AMERICAN NURSES’ ASSOCIATION. “A Position Paper: Educational Preparation for Nurse Practitioners and Assistants to Nurses.” New York: The Association, 1965. 5 . “Statement on Diploma Nurse Education,” The American Nurse. Vol. 5, No. 6, June, 1973. 6. NEW YORK STATE NURSES ASSOCIATION. “NYSNA Legislative Program for 1976: Approved by the NYSNA Board of Directors, September 4, 1975 and Adopted by the NYSNA Voting Body, October 8, i975.” The Association, December 3, 1975. Newsletter (N.U.R.S.E.S., 700 New 7. N.U.R.S.E.S. Scotland Avenue, Albany, N.Y. 12208). a. BALDRIDGE, J. VICTOR. Power and Conflict i n the University: Research in the Sociology of Complex Organizations. New York: John Wiley 8. Sons, Inc., 1971. 9. “Why Separate Licensure for Nursing’s Baccalaureate Degree Graduates!“ SAIN Newsletter, Vol. 1 , No. 2, Spring 1975. (SAIN, Inc., Cooper Station, Box 307, 11th St. & 4th Ave., New York, N.Y. 10003). 10. “A Proposal to Revise the Nurse Practice Act to Provide for the Expanded Role of the Nurse.’’ Submitted by a Sub-committee of the Health Planning Commission to Kevin Al. Cahill, M.D., Special Assistant to the Governor for Health Affairs, July 20, 1975; and Robert D. Stone, Counsel and Deputy Commissioner for Legal Affairs, New York State Education Department, Albany. An act to amend the education law, in relation to the practice of nursing.
follllfflAGE
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The challenges and responsibilities facing nursing today, and its very survival as a learned profession, are perhaps more serious and realistic than they have ever been in our history. How will we, as a leadership group, respond to these challenges and indeed threats? It will take Love and Honor, yes, but I believe that it will take all of the Ccurage that we can muster-individually and collectively. Therefore, I would like to identify and discuss some of the current issues facing nursing and to suggest ways in which we can exhibit a ourage that conveys firmness of spirit that will face such dangers or difficulties without flinching or retreating; courage that provides us the mental or moral strength enabling us to venture, persevere, and withstand danger, fear o r difficulty f i r m l y and resolutely; courage that provides a confidence that will encourage and sustain us and others.' M y remarks are based on the following four premises: ( 1 ) Nursing, as a learned profession, has no dependent or interdependent functions; ( 2 ) Nursing is a profession clearly distinct from the profession of Medicine; (3) Too many leaders in nursing today are providing ineffective and questionable leadership; and ( 4 ) A clear and unambiguous differentiation of careers in nursing must become a reality. Nursing-A Learned Profession To define nursing, as a learned profession, presents no difficulty if the term "nursing" i s viewed as a noun. The mix-up occurs when one tries to define the term "nurse" as a verb. For, any dictionary clearly defines "to nurse" as an act that most anyone can do. Examples include: 1 ) to rear, to bring up, to look af!er or to give advice; 2 ) a person skilled in caring for or waiting on the infirmed, injured, or the sick and especially trained to carry out such duties under the supervision of a physician; and even 3) the act of nursing the balls in billiards keeping them close together and in good position.z But, when nursing is viewed as a noun-then one can describe and define this term quite differently. Nursing may then be defined as a learned profession. Nursing-A Profession Distinct from Medicine Nursing, as a learned profession with its own theoretical knowledge base, has no dependent or ./
...
the independent practice of nursing places responsibility and accountability for nursing and the direction of its own evolution clearly with nursing and nurses. Pg. 56
D21/IMAGE
October 1976 - Vol. 8 No. 3
interdependent functions. Therefore the independent practice of nursing places responsibility and accountability for nursing and the direction of its own evolution clearly with nursing and nurses. As an autonomous profession, nursing is not subject .to manipulation by any other group, namely medicine. Nurses work i n a collaborative, cooperative, and collegial relationship with many other disciplines in providing health care to the ccnsumer public. Medicine has no monopoly cn health care nor do physicians possess either the knowledge or competence to credential nursing or nurses. Nurses and physicians are not interdependent. For, nurses do not need physicians to practice nursing, and physicians do not need nurses to practice medicine. At a t i m e when some members of society (even physicians and scientists included) are attacking the medical system and identifying it as the gravest health hazard we face today.3nursing has the golden opportunity to "do its thing," so to speak. The nursing profession has all the "know-how" to take the sickness out of health care. There must be clear and unambiguous action directed towards nursing's autonomy, as a scientific field of endeavor, clearly distinct from the profession of medicine. Ineffective and Questionable Leadership in Nursing The increasing turmoil on the health care scene i n general and in nursing specifically is of maior concern to those of us who have the courage and commitment to actualize nursing as a learned profession. Unfortunately, Organized nursing, as we know it, and too many nursing leaders have either chosen to evade the issues or to provide questionable leadership that must be challenged! Nursing leadership has been guilty and has played too many games. This nonsense mgst cease. New directions must be sought, and this wi!l take courage. The a i r is stale and close to becoming stagnant with what I perceive as selling nursing out to medicine. I refer specifically to three maior recent developments. They are: ( 1 ) recent decisions by the American Nurses' Association; (2) the Nurse Training Act of i975; and (3) recent announcements from the American Nurses Foundation. The American Nurses' Association The American Nurses' Association has long proclaimed itself as the "professional organization for nurses," and we know that organized nursing through a professional group can be far more effective than any one person alone pleading any cause. We know that in unity there is strength. The ANA took a courageous step forward when the Position Paper of 1965 clearly enunciated the educational preparation for nurses, namely, professional in baccalaureate and technical in associate degree program^.^ However, in m y opinion, i n 11?73 the ANA did a "turn about face" p!iblishing its "Statement cn Diploma Schools" staiing that they really didn't know the difference between professional and technical and were sorry about that Position Paper? Does one wonder then why so much confusion? Why, indeed, were physicians included on the ANA National Review Committee for Accreditation of Short-Term Conthuing Education Programs? And,-
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Effective Leadership in Nursing nurses selected one of these physicians as its Co-Chairperson. Why would ANA believe that it would have to appease organized medicine in i t s move to accredit continuing education programs i f these programs are in nursing? If these continuing education programs are in nursing, then nurses should accredit such programs. I f nurses are being prepared to practice medicine, then they should be called "physicians' assistants,'' licensed as such, and supervised by physicians. At a time where there is increasing documentation of the determination by medicine to declare all nurses physicians' assistants and to deny the validity of safe and knowlelgeable nursing practice, why would ANA choose to iointly sponsor a conference on "Primary Health Care in the HMO/ Prepaid Group Practice" with the Group Health Foundation and the American Association of Physicians Assistants? What were the underlying motives here? Why should a system of certification which recognizes excellence in nursing practice but deliberately designed to give no recognition to education, learning and knowledge be supported? Have you wondered about the educational credentials that the ANA certified may hold? There is no way to tell. Some states (Example, New 'fork and New Jersey nurses) courageously opposed the national standards atid held for baccalaureate and higher degrees as a requirement for state certification in certain specialty areas. The Nurse Training Act of 1975 Applications for nurse practitioner programs under the Nurse Training Act of 1975 must be approved by the appropriate nursing and medical organizations. Monies in the amount of $60 million are so ear-marked over the next three fiscal years (1976-78).Another S60 million for Professional Nurse Training will give special consideration to programs conforming to the guidelines for Nurse Practitioner Programs. Will Medical Training Act monies be subjected to approval from the appropriate nursing organization? If nurse practitioner programs are to teach nursing, then nurses should be responsible for them-not physicians. Nurses in "expanded roles" (whatever the t e r m may mean) should not be practicing medicine or performing medical tasks. One cannot define a profession by defining a task, and one task m a y be p r f o r m e d by any number of different health care personnel. Nursing practice like the practice of any other health discipline is ever evolving, and nurses like all other health care practitioners must
Nursing practice like fhe practice of any other health discipline Is ever evolving, and nurses like all other health care practitioners must incorporate into their practice tools, techniques, and therapeartic measures based on advances in health sctence and technology. /IMAGE
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Effective Leadership it i Nursing incorporate into their practice tools, techniques, and therapeutic measures based on advances in health science and technology. Nurses have done this for years. But-nursing must determine the scope of i t s practice, who shall practice nursing, and the education for that practice. Therefore, I reject either the inclusion of physicians on nursing faculties (either to teach students or faculty members) or the appointment of physicians to serve as co-directors of so-called programs to prepare nurses for the "expanded role." I a m not opposed to seeking appropriate input, but I believe we must recognize nursing as a learned profession, i f nurses are to function as professionaj peers with other groups and are to control the practice of nursing. The American Nurses Foundation Why indeed is a physician included as a member of the Board of Trustees of the American Nurses Foundation? And, the members of the Board elected him as i t s President. I a m appalled a t such action and in addition object to using monies solicited and collected under the guise of nursing research that is awarded to others outside nursing. What does this mean for nursing research in the future? The New York State Nurses Association's 1985 Proposa I Clearly related to m y concern about ineffective and questionable leadership is the very controversial legislative proposal i n New York State to amend the education law in relation to educational requirements for professional and practical nursing. I speak specifically to this proposal, because other states (Ohio, Indiana and Maine, specifically) and indeed ANA i s studying the implications of this specific proposal on the nation. An immediate "split" has occurred among members of NYSNA and a coalition of nurses (all members of NYSNA) has formed with one objective -ta defeat the implementation of the 1985 Proposal. This coalition of nurses represents practical nurse educators, associate degree and hospital schools and baccalaureate and higher degree programs. It is called "N.U.R.S.E.S." (standing for: Nurses United for Reasonable Systems of Education and Service):' Certainly one cannot oppose the intent of any legislative proposal that attempts to clarify, standardize and elevate th2 educational requirements for the lega! practice of nursing by all nurses. And-to require a baccalaureate degree i n nursing for the professionally-educated nurse is not a "new" idea. What can be questioned, however, are the means whereby such an intent i s implemented. It is m y cortention that nursing does not have to go the route of the New York State Nurses' Association 1985 Proposal, i.e., by 1984 to require a baccalaureate degree i n nursing for all nurses. The grandfather mechanism, which exempts persons from meeting future educational requirements, would be used as a protection mechanism for those RNs currently licensed-many of whom would still be practicing in the year 2023. Can we really afford Pg. 58
to do this when we reflect on our responsibilities to society for qu3lity health care and when, indeed, nursing's very survival seems to be a t stake? Will the thousands of nurses so grandfathered in as "professionals" in 1985 function any differently or isn't the status quo being maintained? How can we simply deny and ignore several decades of baccalaureately educated graduates in nursing? I dc not believe that such a proposal will minimize Governors' nor any other legislators' intentions or attempts to revise the definition of nursing to legitimize what has so euphemistically been called "the expanded role of nurses.'' While it is true that existing multiple kinds of nursing education programs leading to licensure as a "registered professional nurse" create immeasurable public and professional confusion, it is equally true that this confusion has not stemmed from the fact that there are different programs. Rather, the confusion is created b y the fact that the graduates of these multiple programs are all labeled "registered professional nurses" without discrimination. I f it is recognized and accepted that entry into the professional practice of nursing requires a minimum of a baccalaureate degree, then to license persons through a grandfather mechanism with less than this preparation as "professionals" is educationally unsound, compromises standards of professional education and the criteria of a profession. In addition, it places unrealistic responsibilities upon those persons so licensed and catches the consumer public in the middle! The larger society has turned its attention to the universities for many reasons. Among them is the recognition of the critical importance of theoretical knowledge and the success of scientific inquiry in dealing with physical and social problems! Why do so many in nursing choose to ignore what the "larger society" has recognized through the years? I a m appalled a t the support that many Deans and Directors of baccalaureate and higher degree programs are giving this Proposal and I have spoken out against this Proposal since its inception. It i s not sufficient t o oppose a proposal without offering an alternative one. Therefore, 1) recognizing nursing, as a learned profession and 2) acknowledging the existence of an already established group of professionally-educated nurses (though never licensed as such) it seems logical to suggest the following: 1. leave the present license for RNs and LPNs as is; 2. seek and obtain a new licensing law that the educational requirement for a license, as a professionally independent nurse (IN), will be the minimum of a baccalaureate degree in nursing; 3. use a grandfather mechanisrn to permit those nurses already holding a baccalaureate and / or higher degree in nursing and already licensed as RNs and/ or professional nurses to become licensed as professionally independent nurses (IN) for life without further examination; and 4. require all future professionally educated independent nurses (INS) to take a new State Board Examination that would be designed to test for safe professionally independent practice in nursing. Such an approach i s supported by the Society for /IMAGE
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Advancement in Nursing, Inc. (SAIN).’ I f an already established group of professionallyeducated nurses were licensed to practice professionally independent nursing-under a .new lawthen I would make three predictions as follows: 1. Reimbursement for the services of such nurses in the social insurance system, o r better known as third party reimbursement, would become a reality for we know that all registered nurses are not qualified to receive third party reimbursement. 2. Such nurses would take the leadership in a program of national health insurance to continue and expand then long-established practice i n providing access to the health care system (including admitting and discharging of clients to hospitals and other health care facilities) for nursing care based on a nursing diagnosis of clients’ needs. This would show tangible reductions in steadily rising health costs. In April 1976 the President‘s Council on Wage and Price Stability contended that the monopoly-like control by physicians of health services and the passive role of patients had helped push health care costs up at a record speed. 3. There would be a realistic and meaningful certification system for specialty areas requiring graduate level education in nursing, recognizing the value of education, learning, and valid knowledge. It would not be necessary to seek licensure for specialty practice. I make these predictions, because Nursing a t last would have clearly established in the law that group of nurses qualified to assume the responsibility of and accountability for the professionally independent practice of nursing. There are some who have called those of us who would seek a new license “politically naive and unsophisticated.” I contend ;hat the concept of a third or new license is already in the minds of some legislators when one examines attempts in New York State by Cahill and Stone to license certain nurses differently to perform different functions but-under medical supervision. l o The concept is valid, but the control of nursing must be with nurses-not with physicians o r any other group. Differentiation of Careers in Nursing Applicants to nursing should be counseled into the program for which they are best qualified from the beginning. All registered nurses do not need baccalaureate degrees nor can society afford it. Rather, excellence must be demanded in all programs. Too many nurses have viewed baccalaureate education as the substitute for hospital schools. Whereas, associate degree programs were in fact designed explicitly for this purpose. Career and educational difference in nursing must be recognized and must become a reality. Failure to do so only serves to support nursing’s traditional anti-educationism. We need to differentiate careers on a continuum
It is within Oh& self-eption concerning facts or situations abou?the need for this clear differentiation along this continuum, that, in my opinion, all ether delusions in nursing Die.
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Effective Leadership in Nursing beginning with recruitment and extending throughout education, program accreditation, licensure/ credentiating / certification, practice, continuing education and in research. It is within this self-deception concerning facts or situations about the need for this clear differentiation along this continuum, that, in m y opinion, all other delusions i n nursing lie. I believe that this differentiation would change the image of nursing with regard to the media, to nurses, employers, consumers, the educational system and the world at large. What Can We Do? Let each of us be sure that we do not become a part of those nurses who indeed hold the desired credentials but do not provide the effective leadership that nursing needs today. We must have the courage of our convictions. We cannot change our story according to the audience, rather we must tell it like i t is-regardless of how unpopular and painful the truth may seem. The eftective way is not usually the popular approach. But, we are not running a popularity contest and nursing must not be sold short. We can learn to compromise without sacrificing our principles nor succumbing to the pressures of expediency. Nursing leaders in the past have been cited for their ingrained capacity for meeting strain or difficulty without fear or with fortitude and resilience of spirit or mind. Today, we must do the same thing. We must possess and demonstrate an ability to hold our own; to fight for our principles; and keep up our morale when opposed, interfered with, or checked. We must possess the courage to fight for ideals even though they may never be fully realized. We can be certain that the independent role is what we want unequivocally and then move to fulfill the responsibilities inherent in such a role. We can be social and political activists. We cannot be conspicuous by our absence in local, state and national affairs. Nursing can be heard and make itself heard. We can be a y g r e s s i v y n o t waiting to be asked in the fine tradition of dependency. We must be involved. We must be consumer-advocates realizing fully what this means to change consumers from passive to active participants in their demands for health services from the cradle to the grave. It will take courage to speak out frankly and informatively on health issues that will enhance the health potential of a l l people. Nursing does have a
It will take couruge to speak out fronkly and Infornatively om health issues that will enhance the health potential of all people. signal contribution to make to health care. Health care is more than illness-oriented care and it cannot be hospital-oriented. It i s imperative also that the consumer public participate in this process. /IMAGE
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Effective Leadership in Nursing ~~~
It will take courage to stand sometimes what seems to be virtually alone in defense of one’s rights. It is not easy. It will take commitment t o a strong and bold resolution and a set purpose. We must be tenacious, filled with stubborn persistence and an unwillingness to recognize defeat. Our convictions must be strong, and we must hold to them with unswerving tenacity. We can hold ourselves and the nursing profession in high esteem. We must view health care, in its broadest sense, and value the significant contribution that nurses both individually and in groups have to improve its nature, amount and quality. Our goal is first-rate health care not second-rate medical care. We must be proud t o be nurses-determined to carry out our obligations to society. We must not apologize for being “just a nurse.” There is a constant c r y for unity in nursing. But, there can be no unity until we can make some of the painful decisions about the problems facing us and until we can value diversity. Risk-taking takes courage. It is not a pleasant task. If it were, more people would be doing it. Even though you may find yourself alone a t the beginning, one begins to build a reputation, and then others begin to join. No one person will change the system alone, but then there
No one person will change the system alone, but then there is no system that cannot be changed. i s no system that cannot be changed. But one must always be careful not t o become a victim of the system in the process. The Real World I a m concerned and distressed when the continuous cry is heard that academe is not preparing nurses to function in the real world. And-as I examine and reflect on what I see happening in that so-called world of nursing, then I a m convinced that it isn’t the real world at all but rather a very unreal world that we must change. I contend, then, that i t is in the academic environment where nursing is viewed as a learned profession, that the real world of nursing exists and where nurses are prepared to cope with that unreal world out there and to make the necessary changes.
...it is in the academic environment where
nursing is viewed as a learned professioii, that the real world of nursing exists and where nurses are prepared 00 cope with that unreal world out there and Po ma& the necessary changes. If indeed the “real“ world is fixed, immovable, and has no imaginary part-as opposed to the non-existent, hypothetical, abstract or the possible Pg. 60
way even through conjecture-then I will take m y chances in the “unreal” world. For, I believe that man and the universe evolve from the pragmatic to the imaginative to the visionary. And i f reality is how one perceives it, then it will differ for each of us according to the conceptual system we bring to it. Therefore, I believe that il is more likely that reality will be reconciled with idealism when faculties stimulate students to be creative, and when they provide them freedom ,to think, to examine issues, to question and to assist them in developing new insights and a whole new perspective on the profession of nursing in a frustratingly complex social system. Please don‘t misunderstand me-I a m not denying the need for professionally.educated nurses to learn and know how to do essential psycho-motor skills; rather I am emphasizing the need to learn and develop those intellectual skills that really determine the effectiveness of all others. For, safe practice is not possible with an inadequate or obsolete knowledge base. The history of mankind i s a tribute to the human capacity to cope with change. The confusion found in today‘s picture of Nursing indicates the need for a reaffirmation of our capacity to establish order out of the chaos through change. We must review and weigh our alternatives for meaningful outcomes. It will take creativity, selectivity, critical thinking, analysis, and indeed courage. REFERENCES 1. Webster’s Third New lnternational DIclionary of the
English Language Unabridged. Springfield, Mass. : G 8. C Merriam Company, 1971. 2. Ibid. 3. ILLICH, IVAN. Medical Nemesis: The Expropriation of Health. New York: Pantheon Books. A Divlsion of Random House, 1976. 4. AMERICAN NURSES’ ASSOCIATION. “A Position Paper: Educational Preparation for Nurse Practitioners and Assistants to Nurses.” New York: The Association, 1965. 5 . “Statement on Diploma Nurse Education,” The American Nurse. Vol. 5, No. 6, June, 1973. 6. NEW YORK STATE NURSES ASSOCIATION. “NYSNA Legislative Program for 1976: Approved by the NYSNA Board of Directors, September 4, 1975 and Adopted by the NYSNA Voting Body, October 8, i975.” The Association, December 3, 1975. Newsletter (N.U.R.S.E.S., 700 New 7. N.U.R.S.E.S. Scotland Avenue, Albany, N.Y. 12208). a. BALDRIDGE, J. VICTOR. Power and Conflict i n the University: Research in the Sociology of Complex Organizations. New York: John Wiley 8. Sons, Inc., 1971. 9. “Why Separate Licensure for Nursing’s Baccalaureate Degree Graduates!“ SAIN Newsletter, Vol. 1 , No. 2, Spring 1975. (SAIN, Inc., Cooper Station, Box 307, 11th St. & 4th Ave., New York, N.Y. 10003). 10. “A Proposal to Revise the Nurse Practice Act to Provide for the Expanded Role of the Nurse.’’ Submitted by a Sub-committee of the Health Planning Commission to Kevin Al. Cahill, M.D., Special Assistant to the Governor for Health Affairs, July 20, 1975; and Robert D. Stone, Counsel and Deputy Commissioner for Legal Affairs, New York State Education Department, Albany. An act to amend the education law, in relation to the practice of nursing.
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