Over the past year I have been engaged in dozens of conversations with nursing leaders who at some point or another come to question the state of "nursing professionalism" in today's health care system. Most of these comments seem to point to a general lack of responsibility, knowledge of nursing practice, and commitment on the part of many of those in nursing. These observations come primarily from the service sector and from leaders who are responsible for delivering on the growing demands for safer practice environments, higher patient satisfaction, and more efficient operations. The concept of nursing professionalism is an important but poorly understood issue that merits broader consideration and ongoing conversation. Here are some thoughts on where to start.
In many cases the lack of nursing professionalism, as imprecise as the notion is, comes in the context of a generational comment along the lines of, "young nurses today just don't…" You fill in the blank. Such comments have been made as long as there have been multiple generations in a profession and are as common today in medicine, pharmacy, and other health professions as they are in nursing. Nonetheless there does seem to be a perception that the ways in which younger nurses practice, and their commitment to the profession, is different from what leaders remember from their early practice life. Whenever such an ethical claim is raised against a generation by their elders it is important to try to understand the context of the practice. Today, in most in-patient settings, there is a much higher level of acuity and shortage of resources that merge in such a manner that place enormous demands on new entrants to the profession. Couple this with a growing separation between education and practice and there may be tentativeness in the young professional that is borne out of uncertainty and the stark knowledge of clinical missteps. This apprehension may be seen by others as a lack of commitment or motivation.
The work environment for the next generation of nursing professionals has received considerable attention over the past five years as the specter of the nursing shortage loomed and financial officers of hospitals realized the costs of turnover, high vacancy rates, and replacement workers. However, the translation of this awareness into substantive remaking of the work culture for patient care service is notable as the exception, not the industry standard. Nurses still have difficulty making their professional voice heard, are exposed to "toxic" environments created by other professionals, and, at the end of the day, are seen as just one more commodity needed for the production of a unit of health care. When understood and treated as just a factor of production, it is not surprising that young nurses respond in kind and fail to give up their best professional selves to the service of the institution; an institution which expresses value for nurses at every turn, but far too often fails to create a practice environment that recognizes and rewards their contributions.
The profession itself is not immune from contributing to this dynamic, and accounts of professional hazing or "eating the young" are a part of nursing and other health professional cultures as well. Or, as one senior nursing colleague recently put it, "we don't need any help from medicine oppressing young nurses; we do a good enough job ourselves." One thing is certain, young practitioners are not entirely composed of a generation of professional orphans. If they are performing in a certain way, they most likely have picked up these social cues from professional role models and institutional employers as to how to comport themselves in practice.
The changing environment of health care, new financial, social and professional expectations of the next generation of nurses, and faulty institutional responsiveness, both in service and education, contribute to the growing concern over nursing professionalism. Regardless of where you sit, these factors seem to contribute to the current practice model of nursing. The elements needed to change the practice model should be drawn from both the core competencies and professional skills of nurses and the demands and needs of the emerging system of care, regardless of how ill-formed they are today.
My crystal ball is no better than any other, but squinting into the future it seems that the aging population, with its growing levels of chronic disease and demands for more consumer responsive care, is likely to be a prime mover of the future system. The need to incorporate technology, both information and care management, to drive care out of in-patient settings into ambulatory, community, and home settings will also be a dynamic force. This movement will inevitably create a different balance between the professional, who now provides all service directly, and the patient, who is more actively involved in and responsible for their own care. Who owns health care information from patient record to treatment modality will be of vital importance. In the future, the ability to manage diverse teams of professionals to add value to the patient and the system will be just as important as the development of culturally sensitive and responsive approaches to care.
The elements that nursing professionals bring to these daunting though briefly stated challenges are impressive. Nursing is at its core about care management and is what is valued by patients, physicians, and systems that understand their mission. Other professions have taken on care management over the last decade, but nursing stands first and foremost for the traditions, knowledge, and practice arts of managing the care of a patient.
Nurses are also the masterful managers of teams. They communicate with patients and their families, and to a broader professional community, and bring back critical information and education. They also, more than any other profession, coordinate care across the boundaries of technical and professional expertise and identity. This practice is possible because they understand the integration between diagnosis, treatment, and care management and have the effective skills and experience to lead these team efforts.
In part because of this efficacy with teams, nurses are also the primary health care professional to make the system work for patients. Along with their skills, nurses' orientation to the patient offers the justification to make an often cumbersome and unresponsive system turn and serve the patient's needs. In part this is because the nurse is trained to look beyond the single episode of care and often sees the widest continuum of patient care needs.
Nurses are also charged with improving the system based upon the practice and science of the profession. This skill set and orientation have not always been provided to nurses in the hospital, clinic, or public health setting, but professional nurses have proven that when empowered to make the assessments and collaboratively design the improvements, they are a powerful force for change.
Finally, the nursing practice model is or should be about leadership. Combining the four previous competencies gives the professional nurse the context and skills for leading change. This leadership is as much at the bedside, in the school clinic, and the ambulatory practice of primary care as it is formally leading institutions.
These and other elements need to be rearticulated into a future-directed nursing practice model. A practice model of this sort would value deep reform and substantial change. If nursing could focus on advancing such a new proactive model, it would find that it had little time for the oppression of the younger nurse by the older nurse, or the continual battles between those prepared in two-year and four-year programs or the growing chasm between the service and education sectors.