What Is Nursing? an Examination of the Role of the Professional Nurse.

WHAT IS NURSING? AN EXAMINATION OF THE ROLE OF THE PROFESSIONAL NURSE.

INTRODUCTION
Nursing is a profession, the depth and breadth of which is to meet different heath care needs of the population (American Nurses Association(ANA), 2010). This demand to clarify what professionalism or profession mean in the health care field. The term ‘professionalism’ has autonomy and self-regulation as the characteristics central to it. It signifies that a profession has authority to establish standards of conduct, practice and training & regulate entry level to the profession (Downie, 1990 cited in Morrel, 2003). From professional perspective, nursing has complex natural history of identification as a vocation with aspiration of being a profession from a long time (Brown & Libberton, 2007). Today, the traditional image of nurses as doctor’s handmaiden has changed to autonomous professional image as ‘registered nurse’. English law in the United Kingdom (UK) protects this title (Peate & Offredy, 2007) and worldwide, International Council of Nurses (ICN, 1998) argued that only those who are able to provide full scope of nursing should use the title ‘nurse’. The notion of professionalism in the nursing field expected that registered nurses should aspire to practice with compassion, competence and commitment to service, with ethical and clinical standards, with leading and managing qualities and by applying conceptual and theoretical frameworks as a problem solving approach in the practice (Brown & Libberton, 2007). In this century, these characteristics are required in the nursing profession to meet the demands of hospitals in transforming their health care environments according to the changing needs of society and advancement in technology (Warren, 2009).

However, Fineout-Overholt et al. (2005) in Warren (2009) argued that the current nursing work force lack knowledge in research methods and evidence based practice to increase the positive patient outcome. To overcome this problem in the future, Nursing and Midwifery Council (NMC, 2010) has initiated policy to make nursing an all-graduate profession by 2013. Moreover, while taking in to account expectations of public from a professional nurse in this modern era, the priority areas of new policy initiatives (e.g. Modernising Nursing Careers) suggest implications having influence on pre and post registration nursing education for the true preparation of nurses in the 21st century (Department of Health (DoH), 2008). The change in pre-registration entry becomes a matter of debate between the traditional and contemporary extended role of nurses. The diversity of nursing profession gives rise to a range of definitions of nursing with different themes. Moreover, the changing demands of public as well as the practice and purpose of nursing has also contributed to defining nursing from time to time. Today, the need to explore ‘What nursing really is’ is important as it could be said that nursing is turning away from its traditional role of caring which is degraded in the higher academic education. The movement of student nurses in the universities view ‘caring’ essence of nursing as ‘too posh to wash’ (O’Driscoll et al. 2010). Nonetheless, although on one side, the issue of whether or not nurses should bound their role to caring is debated, on the other side, how nursing can achieve its professional status in the eyes of public and media is at play. In this essay, along with the exploration of nursing image in the society and the influence of politics on nursing, nursing education in the contemporary practice and the role of professional nurse will be examined. Before proceeding on the current nursing status, it is pertinent to evaluate how events in the nursing history have shaped it in the present situation.

ORIGIN OF THE PROFESSIONAL NURSING
An examination of nursing history reflects the unique place of nursing profession in the health care field (Hood & Leddy, 2003). Behind the today’s image of nursing, there is a hidden story of hardship and struggle of reformers for achieving autonomy and professionalism. The roots of nursing as it is today lie in the early nineteenth century when nurses were seen as unskilled doctor’s helpers (Hunt & Wainwright, 1994). Before this, it could be said that traditional nursing has its roots in the home, when women’s role include the care of family members. Moreover, in the mid eighteenth century, nursing profession was influenced by society’s negative attitude when nurses in the hospitals were poorly educated and portrayed through negative characters such as Sarey Gamp portrayed by Charles Dickens as drunken and immoral nurse (Chiarella, 2002). The image of nurses as ministering angels and nursing as calling from God was improved in the late nineteenth century with the work of Miss Florence Nightingale (Peet, 1995).

Inspite, Miss Nightingale’s view of nursing as a vocation can be analysed critically in contrast to contemporary nursing image as a profession. Peet (1995) argued that her ‘docility and purity’ model (based on moral and character training in spite of education) of nursing with religious paradigm linked it to the God instead of medicine (Peet, 1995). Miss Nightingale’s way of defining nursing was as “Nature alone cures... And what nursing has to do... is to put the patient in the best condition of nature to act upon it” (Royal College of Nursing (RCN), 2003, p.6). Peet (1995) also argued that in her model, the main influence is on changing environmental conditions (environmental engineering) in spite of nursing the patient. Thus, her view of nursing relates it to the health sciences (sanitary science) instead of medical sciences. In contradict to this, in the present situation, nursing is a discipline of medicine. ANA (1980, p.9) in RCN (2003, p.8) defined nursing as” Nursing is the diagnosis and treatment of human response to actual or potential threats to health”. Thus, Miss Nightingale’s concept of nursing failed to get support in the modern nursing (Peet, 1995).

Thereafter, Miss Florence Nightingale set the scene for nursing as subservience to medicine rather than as an image of autonomous profession. According to her views, “real nursing existed in obeying the physician’s and surgeon’s order intelligently and perfectly” (Nightingale, 1882a, p. 326 cited in Peet, 1995, p. 37). This definition of nursing has diplomatic approach. On one side, it reflects her opinion that nursing is the skilled servant of medicine. On the other side, it also explores that the real obey of orders rely on understanding (to obey intelligently and perfectly) of orders. This view have influence on Nightingale’s concept of education for nurses that includes observation, reflection and training as its central part. It is explained in Nightingale (1882a, p. 321 in Peet (1995), p.45) as “Observation tells how the patient is; reflection tells what is to be done; training tells how it is to be done”. These elements of nursing education are still alive in today’s theory practice debate and reflection in practice has been pursued actively in the modern nursing as a main characteristic of profession (Peet, 1995).

However, modern nursing began its rise to professional standard in the military hospitals during the Crimea war when the work of Miss Florence Nightingale and her band of nurses set the scene for nursing as profession. In this period, she introduced cleanliness and ventilation as basic standards of nursing care (Whyte, 2010). This time, the well-known reformer of nursing developed the idea of need for nursing training and laid the foundation for nursing status by opening the school for nursing training at St. Thomas Hospital. As such, the importance of nursing care was influenced in America during the Civil War. Thus, it were her humanistic principles (emotional connection) and commitment to service in the Crimean War with British soldiers that established her fame and are still reflected in the modern nurse-patient relationship as a unique characteristic of profession (Williamson et al., 2008; Brown & Libberton, 2007).

Thereafter, in the late nineteenth century and early twentieth century, ‘character building’ strategy of Miss Florence Nightingale was overtaken by Miss Ethel Bedford Fenwick (a nursing reformer) with an aim of achieving more professional status and self-governance for nurses (Williamson et al., 2008). In 1887, Mrs. Fenwick and her supporters formed the British Nurses’ Association, later on known as Royal Nurses Association with an aspiration of establishing registration that determines the fitness for practice based on scientific training and medical knowledge to protect the public from incompetence practice (Williamson et al., 2008). The international nature of the movement started by Mrs. Fenwick was signalled in the foundation of International Council of Nursing in 1899 that was dedicated to improving the professional standards of nursing throughout the world (Williamson et al., 2008). Thus, whatever the nursing is today, is influenced by the actions of predecessors and has been engaged in turning itself in to profession from long time. Today, nurses working in the hospitals are well educated and trained and have an image of professionals.

ROLES AND CHARACTERISTICS OF THE PROFESSIONAL NURSE
In the past, the image of a nurse was clear as, “The nurse is someone whose studies give her or him just enough knowledge to follow and apply the decisions taken by the doctor or surgeon” (Gordon, 2000, p.218 cited in Harmer, 2010, p.295). In this century, with the diversity of the nursing profession and the extension of the role of the nurse, defining a new nurse is becoming complex. The identity of nursing is becoming blurred while trying to advance the profession (Harmer, 2010). According to Styles (2005) cited in Allen (2007), the attributes that are expected in nursing as a profession are higher academic education, research based specialised body of knowledge, distinct service to society, code of ethics, autonomy, accountability and authority over work. Based on these characteristics and fitness to practice, International Labour Organisation (ILO, 2005, p.12, L.20) described a professional nurse as “having the education and training recognised as necessary for assuming highly complex and responsible functions and authorised to perform them”. The most important developments that have shaped new approaches to nursing as a profession is the extension of the role of nurses. In this century, the aspect of profession is addressed by new roles occupied by nurses (e.g. Nurse Consultant, Nurse Practitioners (NPs), Clinical Specialists etc.) that provide high degree of autonomy in their work (Williamson et al., 2008).

Firstly, the core role of new professional nurse (NPs) is characterized by ‘dynamic practice’ that is based on high level of clinical knowledge and skills in patient assessment and implementation of care with in the scope of practice (Carryer et al., 2009). The most important quality in this professional role of nurses is that the assessment of patients is based on bio-psycho-social model that provides holistic evaluation of the patient to maintain physical, emotional and social comfort of the individual (Hunt & Wainwright, 1994)l. According to the observation of de Meis et al. (2007) cited in Harmer (2010), as the nursing is becoming more scientific and knowledgeable profession, nurses prefer medical roles and the traditional role of care is passed to unregistered healthcare assistants like junior staff. This activity is taking nursing away from its unique contribution of distinct service based on nursing models of care towards medical models of cure. This action increases the gap in the nurse-patient relationship (Hunt and Evans, 1994 cited in Harmer, 2010). Thus, there is a need to keep insight at the traditional role of nurses. Secondly, the new role of professional nurses such as NPs provide ‘professional efficiency’ that is supported by autonomy and authority in the professional practice (Carryer et al., 2009). Today, the NPs working in the Primary health care settings in collaboration with the physicians have a legal right to use their clinical judgements to improve the patient outcome. However, according to Bahadori & Fitzpatrick (2009), due to blurring of the boundaries between Nurse Practitioners and physicians, inter-professional conflicts arise that decreases the autonomy of NPs. This affects the efficiency and affectivity of professional practice in spite of the competency of professional nurses. To overcome this, there is a need to improve nurse-physician communication to explore the accepted roles of NPs in the primary settings (Bahadori & Fitzpatrick, 2009).

Thereafter, ‘accountability’ is also an important aspect that characterizes a professional nurse today. As a professional nurse has an authority to perform the function autonomously on the basis of his or her own knowledge, as such, he or she is accountable for the performed action (Hood & Leddy, 2003). There are nursing bodies such as Nursing & Midwifery Council in UK and The National Council of State Boards of Nursing in other countries that set the standards for safe practice and guide the nurses about the scope and limits of professional practice (Hood & Leddy, 2003). In addition, ‘clinical leadership’ is also one of the hallmark characteristic of a professional nurse. This attribute involves an in-depth knowledge of ethical and legal dimensions of practice, policy directives and research based body of knowledge for accountability towards work (Carryer et al., 2009). This role also empowers the professional nurse to build relationship with the health care team members to assure the fulfilment of holistic needs of the patient (Hood & Leddy, 2003). Thus, there is a set of attributes that are implied in the professional role of nurses. To fulfil this criterion, there is a need of specialised and advanced nursing education.

NURSING EDUCATION AS AN ISSUE
While examination the role of professional nurse, the issue that arises related to nursing education is to keep pace with the advancement of nursing knowledge (Ellis & Hartley, 2004). Since the nursing became a profession, the standard of newly qualified nurses entering the workforce has been a subject of debate throughout the world. Australian nursing education was transferred into universities in 1980s and has experienced positive changes in the nursing culture. In the United States as well, the development of nursing profession includes the movement of nursing education into the higher learning institutions (Rich & Nugent, 2010). The first step to meet the criteria of professionalism in the nursing field as taken by the NMC (2010) is graduate only entry in the pre-registration programme. Secondly, today, besides the debate on ‘is it necessary to be a graduate’, the matter of main emphasis is on how future nurses should be prepared to handle the difficult complex working environment when entering the workforce (Salminen et al., 2009). Today, in the nursing curriculum, the main emphasis is on applying nursing theories and the application of research based practice to develop competence in the future nurses (Ellis & Hartley, 2004). As the nursing profession develops, the stereotypical practice mode of nursing (doctor’s handmaiden) changes in to the practice mode based on theories and models that provide rationale for nursing action instead of blindly following physician’s orders (Hood & Leddy, 2003). With the development of nursing science, there is an increased number of nursing models, for instance - Newman’s Health Care System Model, Roy’s Adaptation Model, Orem’s Self-Care Deficit Theory, Peplau’s Interpersonal Relations and other conceptual frameworks that provide direction in the nursing practice (Hood & Leddy, 2003). Thus, there is a need to develop the skill of critical thinking and reflective practice to reduce the theory-practice gap in the nursing field.

To achieve the above stated aim in the contemporary nursing field, the nursing education is moving from hospital-based learning programmes towards higher learning institutions. These types of programmes provide nursing more professional image among other health care professionals (Rich & Nugent, 2010). In contradiction to this, these non-apprenticeship type educations limit the refinement of clinical skills of new nurses (Rich & Nugent, 2010). This increases the theory-practice gap in another ways as stated by Paterson & Grandjean (2008, p. 303) in Rich & Nugent (2010, p. 231), new nurses can “theorize but not catheterize”. To decrease the gap in other sense as well, Rich & Nugent (2010, p.231) suggested that “changes are needed in order to provide quality education and prepare competent nurses who can practice in a complex health care system that is consistently adapting to a changing model of health care”. Thereafter, according to Andre and Banes (2010), the nursing education should also include the social, economical and political impacts upon health in the context of nursing practice that needs special implications in the present situation.

FACTORS INFLUENCING CONTEMPORARY PROFESSIONAL PRACTICE
In this century, the nursing practice is influenced by many social, economical and political factors such as economics, consumer demands, health policy formulations and others. Firstly, increase in the health care cost present challenges for nursing and this forces the nursing practice to move from in-patient to outpatient care such as post-hospitalisation rehabilitation, health education settings and community clinics (Kozier et al., 2008). This role of professional nurses is reflected in the recent definition of RCN (2003, p.14) as “The use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability until death”.. After that, in this century, people are more educated and aware about health care needs that influence the changes in the nursing practice. Today, consumers are involved in the decision-making process regarding care that makes the nursing services more interesting than ever. These days, consumers demand not only freedom from illness, instead also feeling of wellness and vitality. This has great influence on the changing nursing practice. (Kozier et al, 2008).

Next to it, nursing profession also has its relationship with the socio-political context to acquire power and influence at macro level of the public health policies (Pelc, 2009). This socio-political role of nurses is based on the health promotion effect model that extends the boundaries of traditional preventive medical model in nursing care and move towards the political leadership. This promotes the health at community level with the aim of creating and influencing public health policies (Davies, 2004). The involvement of public health nurses and nurse practitioners in policy formation reduces the policy-practice gap (Gleeson, 2010). For instance, as traditionally, policy makers and public health nurses work in different spheres. The outcomes of policy implementation may be different from that intended by policy makers. Nurses have unique contribution in implemented policies. Their involvement in policy reformation evaluates the impact of policies on public health before implementation by sharing their personal and professional experiences (Scott & West, 2000). This will results in definite positive patient outcome. In addition, the political power of nurses is interrelated to professionalism as stated by Rutty (1998) in Ponte et al. (2007, Sec.2, L.9), “having power allows nurses to guide nursing practice and function as professionals; when power is absent or not utilized, others are more likely to step in and decide what nursing is and what nurses do”. Thus, today, nursing profession also involve political advocacy along with bedside advocacy to improve the public health at holistic level.

CONCLUSION
In summing up, nursing is a dynamic profession that is still emerging in this century and has been influenced by the changing needs of the society from a long time. It is a profession that shapes and shaped by the society. A look at the history of nursing concludes that although the present day nursing is quite different from that was practised years ago, yet it has its influence in the contemporary practice. The role of professional nurses in the 21st century is self-regulated and different professional organisations such as American Nurses Association, International Council of Nurse, Royal College of Nursing and others regulate nursing. Today, in the provision of nursing education, the main stress is on producing nursing practitioners with critical thinking and appraising skills. This is what consumers demand today from nurses along with emotional awareness. Regarding defining nursing, it has a range of definitions having different themes with a motive to prevent illness, to cure disease and to promote health of the public. In the present situation, nursing professionals are involved in politics and they should do this to speak for public health improvement. Nurses should participate in nursing associations. This helps nurses jointly to influence policies that affect nursing practice. Furthermore, nursing education should develop skill in the future nurses along with critical thinking and leadership qualities in them to make the nursing workforce competent, proficient and expert while entering the practice.

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