Comments on A.N.A.'s Social Policy Statement of 1980

Ida J. Orlando (Pelletier)

Presented at

Southeastern Massachusetts University

College of Nursing Honor Society

First Annual Induction Ceremony

October 15, 1983

 

 

Dean Passos, members of the honor society and faculty of the College of Nursing and honored guests,

            For the next 25 minutes I'm going to be talking about the importance of defining a distinct function for professional nursing. In doing so I'll try to focus your attention on what a professional nurse is; what professional nursing produces and what justifies its existence as an independent profession.

            Before I begin, I want to congratulate those of you who are the first from this college to enter a society whose work will provide leadership and bring honor to our profession. As leaders, you share in the burden of responsibility to protect our essential function in a society which is constantly changing. Protection necessitates repetitive persistence in articulating and defending our function else some changes may cause society to ignore our honorable past--and to extinguish our future.

            While our leadership over time changes, as does society, protection of our function must be constant in order to provide a continuity of guidance--to the public--to consumers of professional nursing--to practitioners and teachers of nursing--to organizers and administrators of nursing services and schools--to researchers who work to find new knowledge to improve practice, teaching and the organization of our services and schools.

            This outline of your burden assumes that the function of professional nursing in society has already been defined and there are those who believe that the American Nurses Association's Social Policy Statement of 1980 did just that. I'm here to try to convince you that it did not.

            I take issue with their statement on two counts. The first is relevant to the definition of nursing itself, and the second to the absence of guiding statements for professional nurses in practice and for the public served by them.

            The definition being promulgated reads "Nursing is the diagnosis and treatment of human responses to actual or potential health problems." Altogether, this bunch of words should have operational meaning to practicing nurses and to some people who at one time or another got a little or a lot of a nurse's care. I find no operational meaning in this definition, and defy anyone to explain it in practice, let alone explain it to a distressed individual calling out "Nurse, Nurse!" "Nurse, please help me." "Nurse, why don't you help me?"--an individual paying big bucks for nursing service--be the service professional or not.

            My first point: A distinction was not made between lay and professional nursing. A definition of Nursing, not a definition of Professional Nursing was stated which would allow one to believe they are the same. A distinction must be made and I can't make it unless you study with me a definition of what it means "to nurse." I learned about this transitive verb from my favorite dictionary, Funk and Wagnals, 1936.

"To nurse" means = to encourage, to look after = to nourish, protect and nurture = to give curative care to an ailment

            We all know that dictionaries, over time conform to usage. It is remarkable to me that the transitive verb "to nurse" has remained stable. Definitions of a nurse, however, have  changed in two respects that I am aware of. Prior to 1954, Webster defined a nurse as "an assistant to physicians and surgeons." In 1963, I found Webster's emphasis changed to "one who cares for the sick and infirm under the supervision of a physician."

            There are days I want to blame Florence Nightingale for the usage Webster put in print because one phrase of the Nightingale Pledge reads "I will endeavor to assist the physician in his work." On other days, I want to believe that if she were in the midst of proponents for the Equal Rights Amendment, her pledge would read instead, "I will endeavor to help the patient even while the physician does his own work."

            Nightingale's Pledge doesn't really matter. What matters is to distinguish a nurse and nursing from a professional nurse and professional nursing. Neither Webster nor Nightingale has done this, only the profession can.

            All people nurse themselves or get nursed or nurse others a lot, if not, most of their lives. They find encouragement, nurturance, nourishment, protection and curative care with whatever familial, personal or public means are available to them. Thus, nursing gets accomplished with no resulting attendant distress. This is lay nursing and is relatively easy to accomplish. The activity needed to accomplish the care is known, clearly understood, assumed to be useful and indicated or already known to be useful and indicated. In general, these activities can be described as routine, routinely repetitive or custodial in nature--no matter the results.

            In this context, everybody is doing a little or a lot of nursing which heightens the importance of distinguishing lay nursing done by a person including those in nursing care positions from nursing done by professional nurses.

            In contrast to lay nursing, professional nursing is required whenever the individual's ordinary routine activities do not and cannot bring forth encouragement, nurturance, nourishment, protection and curative care. Rather, the individual suffers distress because "the cause" of the inability "to nurse" the self is now known. This distress resulting from unknown, unmet needs for help continues or escalates in intensity. The distress is contained in the individuals' reactions to immediate experience. While the distress itself cannot be directly observed at the outset the verbal and non-verbal manifestations of it can be observed in the behavior of the individual. Some common verbal forms include complaints of any kind, refusals, demands and questions. Non-verbal forms include anything the individual's body does. The need for help is initially and seemingly not known, nor is the individual able to communicate it. Not known, not communicated until the professional nurse's investigation is conducted.

            Thus, the nursing process must first find out from the individual "the cause" of the distress, that is, "the cause" of the inability "to nurse" the self. As "the cause" and the individual need for help is identified activity is designed to insure that the distress is relieved and in doing so the inability to care for the self is cured or ameliorated. Professional nursing does this, lay nursing does not, nor does lay nursing guarantee this result. In failing to make this distinction, the Policy Statement in effect ignored what professional nurses have been doing since long before I was a baby, and ignored what these nurses continue to accomplish in all of their professional doing.

            At the very least, the Policy Statement should have recognized professional nurses--not necessarily every single registered nurse, but should have recognized most of them because many accomplish stunning results in restoring or improving the individual's capacity to care for the self. In failing to give professional nurses this recognition I predict that the divisive diversity among them will continue. Had they been recognized in this way it might have served to unify all professional nurses with and without academic degrees with a singular basic professional identity.

            The second point I want to raise about the definition is that it does not attend to a distinct professional function nor does it attend to the product our profession delivers to society.

            I'll repeat the definition being promulgated in case some of you forget it. "Nursing is the diagnosis and treatment of human responses to actual or potential health problems."

            I cannot help but think that I was right when I told those who prepared the first draft of the Policy Statement that they should first and foremost at the risk of excluding all else attend to having the definition reflect a distinct function and to make some generalized statement as to the product of that function.

            Before I continue I should define function and product for you as I did for them.

            By function I do not mean the verb activity; I mean the noun. The noun applied to nursing means: What is it that characterizes every activity of every nurse while practicing professional nursing? By product I mean what is it that characterizes the outcome or result of professional nursing?

            I will discuss function first.

            The definition being promulgated is too general for our or any other profession. It does not articulate a distinct function nor does it permit understanding the difference between nursing, other professions namely, medicine and other people who also worry about "actual or potential health problems." I don't know where the definition came from, certainly not from my commentary. I do know it came from something other than observed facts in the practice of the majority of registered nurses who practice professional nursing.

            To date, I have not observed a professional nurse diagnose a human response though I've seen some registered nurses diagnose medical conditions from signs and symptoms of disease, categorized by the profession of medicine. Instead I always see the professional nurse respond to observations of the individual's verbal and non-verbal behavior. These behaviors when specified cannot as yet be classified as general human responses.

            To date, I have not observed professional nurses treat human responses although I have seen some registered nurses treat signs, symptoms and conditions according to protocols developed by physicians. Instead I always observe the professional nurse treat the individual with extreme care and professional concern for whatever inability is causing distress in any and all settings.

            The central concern for professional nursing is not diagnosis and treatment of human responses but attending to individuals when in distress because they can't find their own encouragement; they can't look after themselves; they can't nourish, protect and nurture themselves; they can't give themselves curative care when they are ailing.

            The resulting distress from unclear unmet needs for help continues or escalates in intensity which is what places critical importance on our profession's interventions. I don't know that relationship between what nursing does and "actual or potential health problems" but I know there are relationships between

Distressful suffering and the individual's and the family's sense of well being.

            Distressful suffering and the progress of an individual's condition.

            Distressful suffering with attendant financial costs and the absence of relief.

            Distressful suffering and the individual's ability to comply with medically prescribed diagnostic and treatment procedures known as "doctor's orders."

            I'm compelled to digress and say a few words about who the doctor orders. We live after all in a free democratic society. Medical orders are for and directed to patients who are free to comply or not to comply. They are not for and are not directed to professional nurses who may not interpret doctor's orders in any other way. Our professional commitment is to the individual who may or may not require the nurse's help in reaction to the doctor's orders or in reaction to anything else for that matter. Helping the patient identify and meet immediate needs for help may sometimes result in more active participation and compliance with doctor's orders or may result in the new found ability to initiate discussion and exploration of the orders with the doctor.

            I ask that you study another transitive verb with me, that is, what it means "to doctor." I refer once more to my favorite dictionary, Funk and Wagnals of 1936.

            To "doctor" means = to treat medicinally

                                     = to repair

                                     = to alter with a view to deceive or adulterate

            I will not dwell on the magic of medicine nor the wondrous benefits it continues to provide, I only wish to point out that "to doctor" does not mean "to nurse" nor does "to nurse" mean following in or competing with the footsteps of the doctor.

            Distress resulting from unknown unmet individualistic needs for help in the life of the citizenry is all that can possibly justify nursing as an independent profession in society.

            To return to defining "nursing as the diagnosis of human responses." I applaud what the nursing diagnosticians are trying to do because I think they are trying to classify nursing phenomena, but I'm unhappy with the concept as it is being developed. My reasons follow:

            The word diagnosis has two meanings. It is either interwoven with identification of disease from signs and symptoms or interwoven with investigation, that is, analysis of cause. I emphasize investigation of cause. We know the nursing diagnosticians do not wish to diagnose disease and none of the diagnoses I've seen attend to cause.

            I'm going to state some diagnoses which appeared in a national publication and ask that you raise your hand if the statement I make is true about you during the last week or so.

(100%) How many of you have had "a decrease in activity tolerance"

( 90%) How many of you have had "a knowledge deficit"

( 90%) How many of you have had "an alteration of comfort"

( 90%) How many of you have had "a sleep disturbance"

( 40%) How many of you have had "ineffective coping"

            This was a list of nursing diagnoses made on an acute care unit of patients recovering from heart attacks.

            The problem as I see it is that these statements can't possibly be used as diagnoses, let alone nursing diagnoses, because they do not attend to "cause."

            If only the diagnosticians had started by classifying observable facts from nursing situations such as:

            Categories of observed behavior which professional nurses investigate

            Categories of "causes" of inability to nurse the self

            Categories of distress which result from unmet needs for help

            Categories of activity which meet needs for help

            Categories of observed behavior after the need for help is met

            Even if my thoughts about nursing diagnosis are wrong the Policy Statement should have at the very least made specific reference to how society and practice benefits from a nursing diagnosis or what happens to people when practice does not "diagnose and treat human responses to actual or potential health problems."

            Concern for health problems or health care or meeting health needs as a service, or health and prevention of disease as a goal, does not give nursing the distinction it has practiced and is promulgating something we have not yet demonstrated.

            Everybody is in the act. It is practically illegal for anyone not to attend to potential or actual health problems of the citizenry. Think of the essential contribution of garbage collectors to potential health problems in terms of the frequency of service and the numbers of people served and of the potential response of most humans if the garbage is not collected.

            The importance of professional nursing in the health of the citizenry could possibly be talked about but only after what nursing means by "health" is clearly defined. Our future research may indeed show how the "health" of a person may be affected when unable "to nurse" the self, alone or with one's own resources whether or not under medical care and whether or not the person has a definable disease. This ends my discussion of function, I will now discuss product.

            "The diagnosis and treatment of human responses to actual and potential health problems" says nothing about what professional nursing is supposed to accomplish as a product of service. You recall the product of service should answer the question--What characterizes the behavior of the person served after our professional function is carried out? My best, now 25 year old rudimentary formulation reads, "Improvement in the immediate verbal and non-verbal behavior when compared to the behavior of the individual before the immediate need for help was ascertained and met."*  Before I continue, I want to emphasize one aspect of the definition "to nurse," it meant: To give curative care to an ailment.

            As a young nurse I thought that when I or the students I was teaching helped relieve the immediate distress and some signs and symptoms disappeared, that this was a medical not a nursing outcome. It took two years to realize--and that was 23 years ago--that I was wrong. When the individual is helped to identify and meet the immediate need for help curative care of distress as experienced by the individual does take place--and when it does it restores or improves the individual's capacity to care for the self which was what the distress was all about in the first place.

            Improving and restoring the individual's capacity to care for the self is what professional nurses strive for in practice. They know they accomplish it when they achieve the product of their service: Improvement in the verbal and non-verbal behavior of the individual served.

            The phenomena of concern for professional nursing should therefore have been stated as what it has been and continues to be: Distress caused by the inability "to nurse" the self and the self alone cannot identify or get the needed help. Thus the distinct function of professional nursing is to find out and meet immediate needs for help. The product of professional nursing should have been formulated in at least general terms of what professional nursing accomplishes: The restoration or improvement in the individual's capacity to care for the self. Behaviors which qualify as restoration or improvement have been demonstrated* and in many cases published.*

            Nursing is the only profession focused on the inability "to nurse" the self and has been steadfast in responding as a collective to this inability whenever required 24 hours a day, 7 days a week or intermittently as required by a single professional nurse with the same full service.

            In neglecting to formulate a distinct function and product, the Policy Statement cannot possibly guide the practice of professional nurses, teachers, researchers, organizers of  services and schools--nor can it possibly guide consumers or the public in making choices for or evaluating nursing services nor can it guide social policies, some of which result in legislation. I've only time to discuss the guidance needed by professional nurses in practice.

            Any distinct formulation of function and product whether or not the formulations suited me would have provided guidance for professional nurses to actively assume independent authority to perform that function and be autonomous in achieving that product. Authority to function as a professional nurse is derived from the function of our profession. Authority of physicians, institutions and agencies have nothing to do with it nor would they knowingly interfere with the whole purpose of professional nursing services being provided in the first place.

            This is what our professional authority is all about--no one gives it to us, we assume the authority to perform our function and in doing so achieve our product.

            Registered nurses already have legal sanction to practice but are in desperate need of a guiding statement to support their active but unclear attempts to fully attend to individuals who are unable "to nurse" themselves. The absence of clarity as to their functional authority is there because of the absence of the guiding statement; and the guiding statement is absent because a distinct function has not been articulated by our current national leaders.

            The Social Policy Statement did discuss "authority for nursing practice" as a contract between society and the nursing profession but in my view, this discussion had nothing to do with the professional nurse in practice who is trying to survive the never ending struggle which results from a misinterpretation of authority to practice professional nursing as distinct from medical authority and the authority of the institution or agency in which these nurses work.

            In the midst of this struggle the distressed individual is unable to assert authority as a consumer to insure that the professional nursing service he or she is paying for is received.

            To assume one's own authority in practice would in turn function as a guide to the responsibilities of the nurse in the following work relationships:

            To the person served

            To other nurses with line or staff authority

            To other professions

            To any other person encountered at work

Now the Social Policy Statement did discuss three types of working relationships:

            "A command type" described as "primitive"

            "A detente type" described as "armed neutrality"

            "A collaborative type" described as "true partnership"

            This discussion was obtuse and may have been an indirect way of saying the nurse does not work under the physician and that primitive commands and armed neutrality were undesirable and that true partnership was sought. I made up what I think they were trying to say--but the nature of our current problem should have been made explicit. They could have made it explicit if a function distinct from that of medicine had been formulated in the definition which was promulgated.

            Thus, the responsibilities of professional nurses in work relationships remains to be definitively articulated on a national scale.

 

            I want to say just a few words about the Policy Statements chapter on "Specialization in Nursing Practice." I don't think it's possible to delineate a specialty in a profession without first defining the core of the profession's function.

            Specialization in nursing, to date, has followed specialization as defined by the profession of medicine. Since professional nursing is needed when individuals are unable "to nurse" themselves then it may be possible to delineate special forms of inability which could become specialized areas in nursing. To date, I have not found special forms of inability "to nurse" the self, rather, special or particular forms of inability seem to cross all medical specialties. However, I do believe there may be special forms of inability "to nurse" the self as an infant, as a child, as an adolescent, as an adult, as a mother while pregnant or rearing children, or as a family member of an individual being served by professional nursing.

            I am not a prophet of doom when I say that health care systems, health policy, legislation, and authority of medicine, the authority of institutions and agencies are molding new job descriptions which registered nurses fill and discontinuing other jobs which insured the continuity of responsibility to provide and direct professional nursing services.

            I have just enough time to tell you a short story about one job that was discontinued. Since the beginning of my professional consciousness I always pointed with great pride to the Frontier Nursing Service in Kentucky. Not that I ever had anything to do with it, but they had it made as an independent professional nursing service, and I nor any professional nurse I knew had it made as well.

            The Frontier Nursing Service was founded, organized and completely controlled by professional nurses in response to the inabilities of people in that area "to nurse" themselves. In 1974 on national television I heard the nursing director talk about the service and her imminent retirement. Barbara Walters asked for the name of the nurse who would be taking her place. I literally wept when I heard it would not be a nurse, but that a physician would take her place instead.