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However different today's education and work settings
are from a century ago, a nurse in 2002 has some fundamental
characteristics in common with nurses at the start of
the 20th century.
And you may be surprised at just how similar.
"If you strip everything else away [in comparing
contemporary nurses with our predecessors], there's
still the core belief that nursing is about helping
people, caring for people," said nurse historian
Elizabeth Norman, Ph.D., RN, FAAN.
Norman, a professor in the doctoral program of nursing
at New York University in New York City, acknowledges
that despite all that has changed in nursing, that core
of altruism has remained intact.
"If we were able to talk to nurses from 1900,
we would probably hear that that they had a strong desire
to help people. There's still the core belief that individuals
deserve good care," she said.
But many other aspects of nursing are much different
today. The knowledge base in nursing has increased dramatically,
changing how nurses are educated. A strong sense of
professionalism is present, while the values of accountability
and interdependence are being cultivated.
Today's nurses also carry a sense of entitlement to
a fulfilling career, and have high expectations for
their workplace, focusing on labor issues as well as
patient outcomes.
"Nursing is bigger than one person or one lifetime;
we, as nurses, need to go beyond our personal experience
and circle of friends to grasp more of the profession,
its significance and its likely future," said Terry
Miller, Ph.D., RN, dean and professor at Pacific Lutheran
University School of Nursing in Tacoma, Wash. "The
best way to gain the benefits that nursing has to offer
and make a constructive contribution is to understand
how nursing evolves.
"The only way I know how to gain this understanding
is to periodically and systematically compare then to
now."
Joanne Disch, Ph.D., RN, FAAN, used to think nurses
had many more options today, as well as dealing with
such challenges as "Do more with less," and
"Improve quality and reduce cost."
But after reading Isabel Hampton Robb's Nursing Ethics:
For Hospital and Private Use (1915), she had to correct
those assumptions.
Robb wrote: "So wide a variety of important work
is now offered to [the nurse] and so much more is now
required of her, that it would appear that she is restricted
in her opportunities only by her own personal limitations."
Disch, who works at the Katharine J. Densford International
Center for Nursing Leadership at the University of Minnesota
School of Nursing, said she was struck more by the similarities
between nurses then and now. Some examples from Robb's
book:
The nature of the nurse/physician relationship: "It
was a long time before the young house physician could
bring himself to understand that the trained nurse was
there as his assistant and not as his servant."
Family reaction to a child who chooses nursing: "We
still find families who consider it below their dignity
that one of their members should enter a training school
for nurses."
The role of nursing: "They [conservative laity,
physicians] still labor under the impression that nursing
consists chiefly in manual labor and that there is no
necessity or scope afforded by it for a high degree
of education."
The workload: "Certainly, after nine or sometimes
12 or 13 hours spent in the wards, little time and less
brainpower is left for theoretical study, and even to
the most intelligent and earnest mind, fatigue is almost
the only sensation left."
Kathleen Potempa, DNSc, RN, FAAN, dean and professor
at Oregon Health & Science University School of
Nursing in Portland, agrees with Norman that today's
nurses still have the patients' best interests in mind.
"Nurses want to do the right thing in the practice
environment; they all enter [nursing school] with a
great desire to provide the best care and to make a
difference in patients' lives. They seek to better the
health of patients," Potempa said.
While working in that direction, however, Potempa said
that today's nurses are prone to let their emphases
be shifted. "Nurses, as they progress through their
work life, often become focused on their own labor issues.
They can become focused on themselves, and this leads
to enormous frustration for themselves and others working
with them."
An example of this frustration, she said, is the work
conditions of many nurses nationwide. This issue is
significant because health care reimbursement has severely
affected staffing levels and morale. When this happens,
it's difficult for nurses to focus exclusively on professional
issues, as these are intertwined with their own professional
self-esteem.
"Professional nurses today have strong attitudes
toward patient care, but also strong attitudes about
their own lifestyles and about expectations for their
lives," Potempa said.
For example, nurses can choose the configuration of
work shifts that allows the greatest amount of free
time in a workweek, such as four- or 12-hour shifts.
Nurses expect these options so they can have free time
for other choices, such as graduate school, taking care
of children or a family member, or working a second
job.
Along with expectations for their lives and the way
they live them, Potempa said that today's nurses have
grown up in an environment that has led them to put
a great deal of value on individual achievement, pleasure
and self-actualization.
In addition to such desires, nurses today also seek
to be recognized as professionals.
Miller believes that what makes a nurse a professional
is a level of awareness and accountability that goes
beyond oneself; it's recognizing that professional practice
is more than a job-it's a commitment that takes continuous
learning, work and involvement.
Regardless of job title or credentials, he said, a
professional goes above and beyond in every instance,
such as a nurse who comes upon an accident on the road
and stops to help because he or she is a professional
with a commitment to more than just a job that produces
a paycheck.
Expectations for their lives-from a steady paycheck
to professional recognition-separate many nurses of
2002 from those of a century ago. While some aspired
to leadership or entrepreneurial endeavors, >>
many nurses then were single women of lower working
classes. "Back 100 years ago," Norman said,
"most women used opportunities in nursing to improve
their living standards. They chose this acceptable profession
that would allow them to be financially independent
for a time until they met their husbands.
"Typically, a nurse would meet an intern or resident
at the hospital where she worked. If this relationship
turned 'serious' and they married, nursing would be
her job or 'what she did' until they married. Then home,
marriage and family became their focus."
Although career planning among women was unheard of
at that time, Norman said, a minority of nurses did
choose the work with a lifelong career in mind. They
became administrators, leaders and directors of nursing
schools.
"At the beginning of the profession of nursing,
hospitals were very specific in the kind of woman they
wanted in their nursing schools," Norman said.
"If you look at early admissions booklets, you
see that the hospitals were very interested that the
woman had high moral values, came from a good family
and was physically strong."
Today, that would seem incredibly sexist, she said.
Physical strength as a prerequisite for training, however,
does make more sense when one has a clearer image of
those first training programs in the late 19th century.
Student nurses, a source of cheap labor for physicians
and hospitals, comprised the nursing staff, working
12-hour shifts six days a week under strenuous conditions
and for little pay. In fact, some were expected to pay
for their training.
In Ambulance Work And Nursing: A Handbook On First
Aid To The Injured With A Section On Nursing, Etc.,
written in the late 1800s, the unknown author interviewed
a student nurse who said, "In my opinion, the chief
evil of the present system of nursing is the long hours
the nurses are compelled to be on their feet, and there
will be no remedy for that until the day's divided into
three parts of eight hours with three relays of nurses.
The night nurses are especially hard worked, for they
are on duty 12 hours, and in the medical wards often
have not the chance of sitting down even for half an
hour; then after a hard night they have beds to make,
washing of patients, dusting and breakfast to prepare
and to give to each patient."
Before the seminal training programs proliferated on
the East Coast and moved westward, caregivers were untrained.
The same anonymous author explained: "When sickness
broke out in a family, the patient was usually nursed
by a relative with the assistance of an old servant
or a superannuated charwoman. Even in our large general
hospitals, the state of affairs was not very much better,
and the nursing staff consisted chiefly of uneducated
women who, however well-intentioned, were practically
untrained. They were in the main honest and trustworthy;
the only serious charge that could be brought against
them being that they were addicted to the use of spirits
and had a constant habit of sampling the patient's whisky
or brandy."
As another historical example, Mary Roberts Rinehart
chronicled her situation as a student nurse in 1893
in her autobiography, My Story.
"[The] hospital of one hundred and fifty beds,
and with emergency operations day and night, was staffed
with thirty nurses, all student nurses. We ran the wards,
the private rooms, the operating rooms-two of them-the
general dispensary and the eye and ear clinic. Such
a thing as a graduate nurse coming in to care for a
private patient was unknown. Typically graduate nurses
became independent private duty nurses employed by families
to care for patients in homes or hospitals. Instead,
during the second year of training, a small number of
seniors were sent out on private duty. What was paid
for them went to the hospital, not to them."
Nursing education today is vastly different, with an
evolving curriculum that imposes an extensive knowledge
base on students.
"Today's educational environment is uniquely challenging
in comparison to a century ago," Potempa said,
"because the quantity of knowledge that is relevant
to nursing practice has exploded and will continue to
explode. A century ago, you could plan a curriculum
and know it would be appropriate for a number of years.
That's not possible anymore."
Mary Jo Gorney-Moreno, Ph.D., RN, professor at the
San Jose (Calif.) State University School of Nursing
and associate vice president in academic technology,
said that 100 years ago, a nurse would turn first to
another nurse expert or a textbook for information,
but now, most nurses would turn first to an Internet
source for the most up-to-date health care information.
"As a nursing educator, I begin my search online
for new teaching material at Merlot [www.merlot.org],
the online peer-reviewed site for educational information.
Technology has revolutionized how we access information
and the amount of information available.
"As for education, San Jose State is delivering
education in a wider variety of formats than it did
in 1857. Nurses with an associate's degree can complete
their baccalaureate by taking classes online, by compressed
video (via television) or on their home computer through
streaming video. Unlike when I started nursing school
in 1965 in a diploma program and had to sign out when
I left the residence, a nursing education may now be
obtained any time, anywhere."
Other character qualities once carried significant
weight in the evaluation of a nurse's potential for
success. Florence Nightingale wrote that nurses should
possess personal and professional integrity, duty, love,
kindness and heroism.
"A fine moral character" frequently was a
requirement in early training programs, said Geri Rosato,
MS, RN, founder and now adviser of the American Museum
of Nursing at Arizona State University's College of
Nursing in Tempe. "Nurses had to be moral and have
a good character," she said. "Today, we're
so politically correct that you can't even use the word
'moral.' "
The author of Ambulance Work and Nursing defined moral
character as being truthful, honest and respectful of
others' individuality. "Respecting her moral attributes,
it may be said that a girl who has been brought up in
a country parsonage, and has had little experience of
the world, is hardly fitted for hospital work. In the
wards she will be brought in constant contact with people
of various modes of thought, and if she is unable to
adapt herself to her surroundings, her novitiate will
of necessity be a very uncomfortable one. A nurse has
to learn the very useful lesson that she is not a reformer
of other people's morals, and that her highest claim
to consideration and respect is that she carries out
her duties conscientiously. It is hardly necessary to
say that a nurse should be honest and truthful."
While honesty and truthfulness still are desirable
today, the reasons for entering nursing are in sharp
contrast between then and now. The concept of nursing
as a calling, the reason for which many women once entered
nursing, has faded for many. Florence Nightingale considered
her work a call from God, a vocation that took the work
beyond that of a "mere job;" she desired that
other women would respond to that same calling. Nursing
as a calling has diminished over time, Miller said.
"Nursing tended to have people who saw nursing
as a calling or vocation that had a spiritual dimension
or commitment, whether conscious or not," he said.
"Today, nursing is more of a socioeconomic stepladder."
Along with calling, nurses today also have stepped
away from the spiritual values that undergirded the
profession from its inception in the late 19th century.
Nightingale held the conviction that spirituality was
part of the essence of nursing practice.
Lynn McDonald, Ph.D., professor of sociology at the
University of Guelph, Ontario, Canada, and project director
of the Collected Works of Florence Nightingale, stated
on the project's Web site [www.sociology.uoguelph.ca/fnightingale/Introduction/index.htm]
that Nightingale saw health care as "God's work"
and incorporated spirituality into nursing curriculum.
"Nightingale's training school for nurses took
women, regardless of denomination," McDonald said.
"She abhorred the prevalent sectarian practice
of converting patients on their deathbed to another
denomination, but her school was hardly secular. Student
nurses were required to attend chapel and nurses read
prayers in the wards. Nightingale believed that nurses
needed spiritual resources to do their difficult work."
Judith Allen Shelly, doctor of ministry, MA, RN, senior
editor of the Journal of Christian Nursing, agreed.
"You can't really talk about nursing and its history
without talking about the role of Christianity."
The idea of reaching out to the poor and underserved,
which are basic Christian values, was part of nursing
[in its beginning], Shelly said. These values became
secularized, especially once nursing entered the university
and professionalism took hold. >>
"Religion is definitely a no-no in today's nursing,
but spirituality is becoming a major focus," she
said. "This comes from a desire to be inclusive
in such a way that the differences between religions
tend to be ignored and only the inner 'spirituality'
is valued."
Shelly pointed to recent nursing literature that teems
with spiritually oriented articles. The alternative
therapy movement is a demonstration of a consistent
thread of spiritual seeking, claiming roots in everything
from Hinduism, Buddhism, Taoism, Wicca and channeled
spirit guides. The growth of parish nursing, Shelly
said, is another gauge of the interest in spiritual
issues.
"This is another significant indication of nurses
seeing the strong connection between faith and nursing,
and wanting to practice in a setting where they are
free to use a faith-based approach," she said.
While spirituality again is being valued, Miller said
many contemporary nurses-especially recent graduates-fail
to value accountability. "I hope that's one of
the first values they learn, and one they integrate
into their lives and careers," he said.
"It seems pervasive; we're producing new nurses
who don't understand that they have personal accountability
beyond the responsibility of anyone else around them.
There's a belief that failure is someone else's fault."
Today, he added, a nurse needs to cultivate additional
values of independence, interdependence, collaboration,
"flat-out honesty," self-awareness and cultural
sensitivity.
Another facet of the profession that hasn't changed,
but needs to, Potempa said, is the ability to have a
professional voice. "Nursing hasn't learned yet
to speak as a profession in a unified way that is powerful,"
she said. "If you always let others-other professionals,
the union-speak for you, you never learn to be fully
accountable and to have a voice."
Potempa attributes nursing's public image to this lack
of voice, something that nurses of the past also lacked.
Nursing doesn't speak with one voice because there is
too much internal conflict, she said; nurses need to
learn to negotiate better and resist the tendency to
take a victim role and to support nurses who show leadership
ability.
"I think the most fundamental need in the field
today is true leadership," Potempa said. "Nurses
need to choose their leaders wisely and then support
them. Some nurses exhibit ambivalence toward leaders
and leadership that undermines the professional influence
of the field."
Lost in all these similarities and differences is the
nursing tradition, although some traditions carried
forward still have relevance (such as the rituals of
pinning and lamplighting).
While attending a pinning ceremony at a nursing school,
Miller spoke to an engineer from Silicon Valley who
was struck by the importance of the ritualism.
The engineer thought it unfortunate that no such tradition
existed in his own field because, he said, the beauty
of the rite of passage helps solidify one's professional
identity, giving a tone of seriousness and commitment.
"It's analogous to getting married," Miller
said. "For some people, having their wedding ceremony
publicly witnessed seals the rite of passage.
"Nursing's traditionalism helps connect nurses
with our history and shows us that our place in this
profession is special and publicly recognized. Traditions
help establish our identity."
Contact
Karen Schmidt at krnschmidt@earthlink.net.
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