EDITORIAL
Vol 17 No 3 - November 2001
The argument presented in this editorial is that many of the issues which the nursing profession presently faces stem from lack of a model of professionalism which takes account of key characteristics of our own profession. The differences are so significant that models drawn from other professions become invalid. I will start by addressing the notion of equality. Ethel Bedford Fenwick, an English nursing leader at the beginning of the last century, once observed that “the nurse question is the woman question” (Dock & Stewart, 1938) implying that gender issues lay at the basis of why nurses were not treated in the same way as doctors and lawyers. That view is both correct and at the same time misleading. Following this line women originally sought equality with men by arguing that “equal” treatment means “same” treatment. Consequently nurses then argued, and have continued to do so, that professional equality means professional sameness. More recently feminists have revised the “equal means same” argument with the result that alternative debates based on differences between men and women have arisen. This same/difference debate is important to us at the professional level because, without coming to terms with our characteristics as a disciplinary group and addressing how these differ from other professions, it is difficult to articulate clearly who we are and what we do. Trying to fit nursing into the same professional model as medicine or law will always be unsuccessful because nursing has essential characteristics not found in other professions. Chief among these is its inclusiveness. Nursing care has never been carried out exclusively by nurses. The reality of nursing work is that part of the caring has always involved teaching others to care for the sick.
Many unqualified carers, usually women, care for their sick families and nurses over the years have given support and education to these carers. It is well-nigh impossible for nurses to exercise a monopoly over most aspects of caring activities. If lay persons were not involved in the caring for their sick then nurses would face many additional difficulties. The importance of lay
contribution is likely to increase with the trend toward shorter hospital stay and earlier discharge.
Because of this inclusive nature of nursing practice it has been difficult to define the boundaries through legal proscription in the same way as other disciplines have appropriated certain aspects of their work. Given that situation, our energies may be better employed improving the quality and efficacy of our practice rather than on monopolistic zeal. We would then be better prepared to articulate our role and make our knowledge translatable and accessible to lay carers. Such activities are likely to secure a place for nursing care far more effectively than can be achieved by any legislated monopoly.
In the United Kingdom (United Kingdom Central Council, 1992) the solution to scope of practice issues is seen to be to acknowledge the evolving and dynamic Nursing Praxis in New Zealand Vol. 17 No. 3 2001 Page 3 nature of the nursing role in response to the health issues of the population being served. Similarly Adrian and O’Connell (2000, p.49) state: The continuum of change, expressed in the nurse practitioner role, is not new.
The preparation and function of a registered nurse broadened and evolved dramatically in the twentieth century. There is no reason to assume that the evolution will not continue as the health needs of the community change during the twenty-first century.
Nursing is physically demanding in a way that most professions are not. It is hard, and often dirty work involving body fluids and excreta. Such work tends to be considered menial (something anybody can do) - a view which has not assisted our quest for professional status. Yet, in reality, performing basic nursing care on complete strangers is far from basic. The value of such work transcends its physical messiness and, because it is psychologically complex, great skill is required to perform it well. Cleaning people one does not know who are soiled with excreta, blood or vomitus - and in all likelihood feeling ashamed of themselves for being “dirty” or losing control - and doing this in a way that restores both their hygiene and sense of self-worth requires a very high order of skill. The ‘privilege of intimacy’ (Chiarella, 1990) that this work confers and the ‘environments of permission’ (Lawler, 1991) required for the work to be performed mean that the nursing staff know its worth, while at the same time understanding society’s abhorrence of its reality.
The paradox, however, is that those who do not know or understand the world of nursing, by and large do not want to know or understand it. Even today the public has a fairly sanitised view of nursing work (Hallam, 2000). At the same time it is central to the professional nature of nursing practice that nurses do not discuss the intimate nature of their work. In doing the things that they have to do to other human beings (with whom they have no prior relationship) nurses have the potential to strip these others of their dignity. One of the reasons why most of the time they do not have this effect is because it is understood that what transpires between nurses and patients will never be discussed in public.
Perhaps the extraordinary intimacy of the work inhibits nurses from publicly describing their level of expertise. It is most certainly not work that anybody could do. But because nurses, for professional reasons, do not openly discuss these things that point remains unstated. If we did speak publicly of it, would it then be possible for the next patient to feel comfortable? Curiously, in all the industrial decisions I reviewed in my forthcoming book, The legal and professional status of nursing, the intimate (physical) nature of nursing was never discussed.
This may in part be because nurses have always done this intimate work and so it is taken for granted. Commonly it is only when there is a change to practice - something new added - that nursing work is considered closely, particularly with respect to whether or not a pay increase is deserved. When the original work is not valued highly then such a process provides an unsatisfactory model for re-assessing work value. Because it involves manual work, ‘getting one’s hands dirty’, the management of sensitive issues of the body is not granted the same status as the management of sensitive issues of the mind. Yet to practise such work without intellectual engagement would be crass, and could lead to psychological damage. If courts and tribunals were to accord this ‘menial’ work its true value then the entire award system would need to be revisited.
The problem of nursing’s professional standing is compounded by the additional factors that nurses are a numerically large group, and moreover one that is more heterogeneous than those on which the prevailing model of professionalism is founded. The former impacts on all discussions of remuneration and the latter is reflected in the more varied pattern of career pathways, and entry and exit points. Nurses need to recognise these essential differences from other professions with respect to both the work and those who do it, and learn how to present the differences positively - to celebrate them. Without that change
progress towards better public understanding, resolution of retention issues, and emergence of a more appropriate reward system will continue to be slow.
Mary Chiarella
Professor of Nursing in Corrections Health
University of Technology
Sydney
Australia
References
Adrian, A., & O’Connell, J. (2000). Nurse practitioners. In Lumby, J. & Picone, D.(Eds.). Clinical challenges. Sydney: Allen & Unwin.
Chiarella, M. (1990). Imaging nursing - reflecting and projecting. Australian Health Review 13(4), 299-306.
Chiarella, M. (2002, in press). The legal and professional status of nursing. Edinburgh: Harcourt Brace.
Dock, L.L., & Stewart, I.M. (1938). A short history of nursing (4th ed.). New York: W.B. Saunders Co.
Hallam, J. (2000). Nursing the image: Media, culture and professional identity. London: Routledge.
Lawler, J. (1991). Behind the screens: Nursing, somology and the problem of the body. Melbourne: Churchill Livingstone.
United Kingdom Central Council. (1992). The scope of professional practice, a UKCC position statement. London: Author.
