Concept of Function for Professional Nursing Ida J. Pelletier (Orlando)

Presented at the New York Academy of Medicine

September 6, 1962

            Dean Reiter, members of the faculty, members of the graduating class, parents, guests and old classmates.

            It is a pleasure for me to participate in these exercises honoring you, the Class of 1962, and in doing so I feel honored by it--especially since you are the last class to complete the program from which I graduated--so many--I will not say how many years ago.

            Unless it is already apparent, I will tell you that this is my first commencement address. It frightened me to think that I was supposed to say something--not just anything--but words of wisdom and something to inspire you in beginning your professional life. I'm not sure that I can do this. Some years have passed, it's true, but wisdom comes at about the age of 85 and I'm not there yet--besides, how do I even know you'll remember what I say. I don't remember my own commencement or the speaker let alone the speech. I tried to remember a lot but I only remember a little of my days at Flower. It is hard to remember everything I learned especially which teachers taught me what. I probably had as many patients as you did but I remember only two. I told everybody about the first one who said that the angels of comfort and mercy were just like me. What this other patient said I kept a secret till now. She said I was a little too young at the game to be so inhuman. I can remember learning the procedure book backwards and forwards--I had a tough time getting it straight. It is sad to think that maybe half of those procedures are to longer prescribed or are just not being done by nurses anymore. Machines and some of the less overworked departments are doing them instead. It's not really so bad because I've had some reassurance from this teacher I'm thinking of who said: "Education is what you have left when you have forgotten everything or when what you know is no longer needed." If you forget what you learned at Flower then what will you have left? I think that you will have left your identity as a professional nurse. Are you professional? This may seem like a pointless question but people ask it. With a diploma (I assume you get one tonight) the school says you are and if you pass state boards the law says so too--so it really doesn't matter what you, I or anybody else thinks. Your identity, however, as a professional nurse is an entirely different matter. It concerns you personally and has everything to do with what all of you think.

            Your identity as a professional nurse stems from a clear idea of your function. That is to say, what do you do or what is your job or more importantly, what is your professional responsibility? If I could ask each of you now what is your function, I don't know what you would say. If your teachers harped on it the way I used to, your descriptions or answers would have a quality of sameness. It is this sameness of your responses which distinguishes you from people in general and in particular from other professionals. It is also this sameness which gives you the identity, the prerogatives and responsibility of a professional nurse. Do we have this sameness in the profession at large? Some say we do; some say we don't. I won't say because I really don't know. What I do know is that I find almost no disagreement in the literature and among my colleagues in regard to the ideals of nursing service. In one way or another the ideals are related to caring for the patient and in caring we meet the patients' needs. Without knowing exactly how you would describe your function, I'm relatively certain that to this you would agree. We have heard it over and over again and for as long as I can remember this ideal has not changed very much. What does change and what is hard to find (although I often do) is the relationship of the ideal to the practice. I don't mean on paper. I mean where nursing takes place--with the patient. Why does this discrepancy exist? I can think of two possibilities. Either we do not have a clear idea of our function in practice or we are not able to overcome the obstacles which divert us in our attempts to carry it out.

            I'm going to try not to mention that I think the nurses' function is in practice. I'll tell you now I don't think I succeeded but you can read a book I wrote about it if you want to know. What you think your function is now and what it is going to be in your independent practice tomorrow is much more important. One book or just the handful we have about the subject is not going to legislate what the function ought to be. Nor are the books going to solve the problems which can rob us of the noble satisfactions that can be ours for the taking. Besides I am convinced that all nurses know that their responsibility is to help the patient. When the help and the results of the help don't show up in the practice something must be standing in the way. As I see it these obstacles are:

            Pressures in the current system of nursing or the "rat race" as some people refer to it, and a resulting confusion of activity with function. Then the pressure and the confusion gang up on the nurse and push her to relinquish her responsibility and professional prerogatives and therefore her identity. Then we have a sad sack on our hands who knows she is overworked but more importantly without pride and satisfaction from her work, and somehow feeling that nursing isn't all it's cracked up to be.

            I have an example which isn't like anything you were taught but I can assure you that it took place. It isn't nice. It is the worst I could find. I use it because I think that it could happen to the best nurse unless she is clear and remains clear about her function in practice and is able to protect her identity as a professional nurse.

            A nurse's aide wheeled in a stretcher. Mrs. Perkins was on it. She had Hodgkin's disease but was being admitted for demerol addiction. Her face was wet with tears. She moaned softly. The head nurse, all in a rush and in the midst of a conversation, came to a dead stop to look at the new chart. At the same instant she grabbed a senior (who by the way was to graduate in three days) who was coming in the opposite direction. Luckily the medication tray, filled to the brim, didn't spill over. "Oops, I'm sorry, said the head nurse. "Could you please admit this patient now?" The student's face got red. It took a second to reply. "Can I finish giving meds out first--I'm late now and the tens are overdue." "Okay, sure but can we get her into bed now?" The aide pushed the stretcher from the hall to the room. The patient's sister, the nurse and the student followed behind. The nurse put a coat in the closet. The sister put a pair of shoes there. The student put the medication tray down. The nurse held the stretcher beside the bed. The sister was touching the patient at once, presumably assisting her to bed. "I can't. I can't. I have too much pain." "Yes, but you will feel better in bed," said the nurse. "I don't want the bed. I want a chair." "I'm sorry, but the doctor ordered bed rest," said the nurse. "Oh my god sis, take me home." "Now--now, replied the sister, "You know you have to do what the nurses tell you." "Oh my god even you," cried the patient. Mrs. Perkins sighed deeply to ask, "Can I have something for my pain, please?" The head nurse replied, "I'm sorry but the doctor doesn't want you to have medicine." Suddenly the patient clutched the pocket of her robe she was still wearing. The sister tore the patient's hands lose and pulled from the pocket a bottle of CAP's. "I'll have to take those away," said the nurse. "You are not allowed to keep pills at the bedside." "Oh my god--no--what will I do for my pain."

            As everybody but the sister was leaving, the nurse reminded the student. "Admit her as soon as you can." At the same moment the patient grabbed the aide's arm and said: "Please in god's name do something for my pain." "I am sorry ma'am, I'm not allowed to give you medicine" and pointing to the head nurse said, "I'll tell her right away."

            Back in the hall, the student rushed from one room to the other. You would notice that the cups on the tray were quickly disappearing. At the nurses' station all the cups were gone, the syringes were empty, and the student was out of breath--but the nurse talking on the telephone saw her clean the medication tray and called out that some patient or other was to have a stat medication. The student nodded, threw some papers together and dashed to Mrs. Perkins' room. "Oh, please nurse help me." "I'll try to get you something, but first turn over so I can take your temperature." While the thermometer registered, the student started to fill out the property sheet. "Do you have any jewelry with you?" "Oh, my god let me die." The sister interjected, "Just the wedding ring she's wearing." "Do you have any false teeth?" "Oh, God please help me." Again, the sister interjected and said, "Her teeth are her own." "I'm sorry that you are in such pain--but do you think you can pass your water? I need a urine specimen." It looked as if the patient was too desperate to answer. With the sister's help, the patient was placed gently on the bedpan. In leaving, the student said, "I'll be back in a flash." She went directly to the nurses' station for a look at the order sheet. Still in a rush and as if doing ten things at once, the nurse said, "You didn't give that stat. medication when I asked you to and Dr. so and so is mad at me. I know you are busy but can you take it down there right away and discontinue the I.V. while you are at it." The student took a deep breath as if it were going to give her the strength to start all over again and then said, "Can we get something for Mrs. Perkins' pain?" Suddenly, and much too loudly came from the other end of the corridor, "Please, oh my God--somebody help me." As suddenly as everything else was happening, the head nurse got on the phone and tried to get an order. She succeeded thirty minutes later. The student completely worn out by this time, administered a sterile hypodermic saying, "This needle will help your pain."

            The patient continued sobbing and calling out for God's help for the next two hours.

            Before any of you pass judgment on any of the people involved in the situation, I want you to know that the head nurse resigned two weeks after this incident took place. I had the opportunity to ask her why. She said she couldn't stand it any more--there was no time to nurse and that was really all she wanted to do. And I also want you to know that the student cried at the end of the day almost as much as Mrs. Perkins did when she said, "It was a bad day but I could take it--what I couldn't take was Mrs. Perkins' agony--I wanted to help her desperately but I had so much to do. I did three hours overtime and I still didn't finish." If anybody tries to blame or judge anybody for achieving less than the ideal in nursing practice then I think that problems of more central importance are being overlooked.

            This example makes it clear that in day to day practice the nurse can forget what her real job is, if she tries to carry out too great a number of activities. After all there are just so many hours on duty and if every minute is spent on what routine, administration, and doctors prescribe, then obviously you can't get around to helping the patient. Certainly the student in the example was preoccupied in this way--including three hours overtime. Now the head nurse and the student did do the things that had to be done but nothing they did or said directly helped Mrs. Perkins. Her expressions of agony did not change, if anything, they got worse.

            You can rely on the fact that most people generally yield to what they think is the greatest pressure for expected performance. Nursing and hospital administration and doctors are exceptionally competent in making known certain requirements in the form of policy, rules, regulations and medical orders. When these things are not fulfilled, short of the letter of the law, a memorandum gets issued or a meeting is held to remind the staff of what has to be done. In the case of the example of the medical order, the doctor got mad at the head nurse when the prescribed medication wasn't given stat. I don't have to convince anyone here that the nurses would have been in pretty hot water if Mrs. Perkins had a couple of diamonds lying around that were misplaced or lost and there was no signed property sheet anywhere to be found. By and large, the patient does not have the finesse or wherewithal to issue a clear "memorandum" of the kinds of help he is going to need from you but when he yells loud enough somebody does do something. At the moment, Mrs. Perkins was heard to cry out from the other end of the hall the nurse did do "something;" she got on the phone and got a sterile hypo. This wasn't the something by the way the patient kept asking for, but more of this later. At the moment, I am trying to emphasize the burden of work under pressure to finish what we are expected to do. Let's assume, you owe three people fifty dollars each but you only have one hundred dollars. One of the three may need his fifty dollars badly but he doesn't ask you for it. If he talks to you at all he may just complain about the weather or the fact the he can't afford a new car. The second threatens to take you to court and the third says he is going to expose you as a welsher if you don't pay up. Which of the three are you going to pay back first? Another way to say it is that the "wheel that squeaks gets the most grease."

            There are many nurses who believe, and I happen to be one of them, that the nurse can carry out routine and prescribed activities in harmony with the individual patient's requirements for help. I want to add a little bit to the example I gave to illustrate this. You remember it was prescribed that the patient not receive any pain medication and at the request of the nurse a sterile hypo was allowed. You also remember the nurse carried out the order of no pain medication first by not giving anything and secondly by telling the patient that the doctor didn't want her to have anything for pain. Now, the next morning the night nurse reported and I quote: "Every three hours and right on the dot--she yelled out, `Nurse come quick--bring me a needle.'" It was already arranged for the student to be free enough to care for Mrs. Perkins. The student found out that the patient called for the needle because she was afraid of dying alone and that she kept checking every three hours to see if the nurse would come. Mrs. Perkins was learning that they indeed would. As it worked out up to this point, the patient said that she wouldn't be afraid if the nurse came in to check her every fifteen minutes. For the rest of the day the student did and this patient presumably addicted to demerol was free of any complaint or sign of pain without needles of any kind.

            So it is possible for the nurse to give the specific help the individual patient needs, and incidentally, fulfill what has been prescribed in this case--no pain medication. I just know you are all wishing you could ask, "But how many patients can I take care of in this way?"--and that is exactly the point I want to make. As a professional person it is your responsibility to make that decision--not in a vacuum or by just picking a number out of the air and then driving nursing administration crazy with it--but through the deliberate conscientious study of your own nursing experience. Your decisions will be based on the evidence you accumulate. As a professional person it is your prerogative to do this and I might add in light of the example, it is certainly also a responsibility. The results of your study would then be topics of discussion for those general staff meetings I mentioned earlier. The number of patients you can accept responsibility for will vary with a whole range of conditions that I can't go into now. What is important is that you discuss and solve with nursing administration those problems which not only prevent you from fulfilling your responsibility but as noted in the example force you to relinquish it entirely. You will then be able to devise ways, for example, for the nurse's aide to assist you directly in your efforts to help patients. I know we give lip service to this idea. For example, it is often stated on paper that the aide works under the direction of the nurse but my question is which direction. It seems to me that what is really happening, and of course generally, is that the aide is doing more and more of what routine prescribes and the nurse is doing more and more of what the doctors prescribe--but that doesn't change the nature of the problem I'm talking about. The advances in medicine simply make it necessary for doctors to prescribe more diagnostic and treatment procedures. In other words there are more and things that have to be done. Time was when an order sheet ran two pages only for the critically ill. Today if you are in for observation, your medical orders may run for four pages. So all it really means is that the aide is helping out with the volume of work that has to be done. It also means that doctors need more and more assistance--Lord knows they need it--but in certain ways I see this as a problem for their own profession to work out. It is the problem of our profession to assist the patient being treated and to decide exactly what kinds of assistance we need in order to fulfill our function.

            There are a sufficient number of people who have observed nurses performing routine and prescribed activities for days on end. After a while they come up with the conclusion that at a lower level the nurses' function overlaps with domestics and at a higher with the doctor. This is nonsense. In one breath it says you don't have to know anything and in the next you have to know some of what a doctor knows . . . but this view is understandable. The nurse in the example put a coat in the closet, the student cleaned a tray and collected urine--all more or less domestic activities and in the same day the student administered medications--tasks which do require some medical know-how. This view of nursing function makes it little wonder that the next door neighbor, the sister, nursemaids, handmaidens, housekeepers, medical technicians and assistants and volunteers can join the ranks--not to mention practical nurses (whatever that term really means), aides, orderlies, attendants and so on. I do not mean to underestimate the contributions of these people--I simply want to point out that we should be able to identify the differences in practice, I remind you, not on paper.

            In our example the sister, the aide, the student and the head nurse were all touching the patient as they moved her from the stretcher to the bed. Except for the fact that all of these people were wearing distinctive clothing, I would defy anyone to know for sure--who the aide was--who the nurse was--who the student was and for that matter who the sister was since she was doing essentially the same thing . . . and everybody was getting the same results. Anybody could have done or said what was done and said in that situation. That takes  care of activities at the "low level"--like the domestic. What about the medications the student gave--"the higher level" of her function. Most people can read labels, especially if they are told to all the time the way we are or they can get someone else to read the label for them. Certainly people can be trained in less than three years to do what is prescribed--the way it is prescribed. Patients and their relatives do it all the time. It didn't take you three years to learn how to do things according to the way in which they are prescribed.

            Activities at this "high level" if they can even be called that, are indeed prescribed by the doctor; but I think it is an error to say that nursing function overlaps with the doctor's. What the nurse does is to help the patient carry out what has been prescribed. The doctor's function is the treatment and prevention of disease and in order to fulfill his function he prescribes. His order is not for the nurse to carry out (as it is often interpreted) but for the patient to carry out, and the nurse helps the patient to do so when the patient cannot do it alone. Orders which a doctor would never allow a patient to carry out under any circumstances would in my view be his responsibility alone, together with any assistant or technician whose services he requires. We do know that some nurses function almost exclusively as assistants and other non-nurses do nothing else. This is fine because doctors need a great deal of help to do their job but we must not confuse assisting the doctor to fulfill his function with the professional task of the nurse. In spite of Webster's definition of nursing, I don't think the professional nurse should think of herself as the physician's assistant. When she does, the result is a confusion of nursing function in practice. The example I used clearly pointed this out. Besides, if we were nothing more than assistants to another professional group, we would lack the basic prerogatives of the professional status, i.e., independent judgment and decision making and personal responsibility for the decisions we make in carrying out our own distinctive services. I'd like to go back to the example again. Almost automatically and before anything was done to help Mrs. Perkins, the nurse and student did and said what was prescribed. In effect they were assisting the doctor in so far as making sure that his orders were carried out. It was the doctor's judgment which determined their actions while the patient's desperate need went unmet. Only when the student approached the patient in her professional role did she begin to use her own judgment about how to help the patient with what the doctor ordered. Only then were we able to see the distinctive service the nurse gave and what resulted from that service.

            A short time ago I read the following remark, "In the absence of the doctor the nurse is fully responsible for the care of the patient but she does not have the authority of his profession." I took this to mean that the nurse is responsible whether the doctor is on hand or not and that under no circumstances does the nurse diagnose medical conditions or prescribe medical treatment.

            I think I've made a case for my view that nursing function cannot be said to overlap with that of others. Nor can one defend the limiting of the nurse's job to the kinds of routines people ordinarily perform or that can readily be taught to them. If this were so, then by 1975 according to the Honeywell Corporation, nursing function will be superseded by some of the more ingenious machines which are expected to be in general use by that time. They will dispense prescribed medication; they will observe and record the patient's temperature, pulse, respiration and blood pressure and I don't know what else. This would eventually mean that the nurse will be monitoring machines, records and obtaining information at five times the rate now possible. there will be more keys to carry, unlike the nurse in the psychiatric hospital, who now has fewer at least for the present. There will be more than a narcotic box to guard and more and more requisitions to make out for the repair of electro-magnetic and communications systems. I haven't been reading much these days except cook books but I did come across an article with a weird and to me preposterous title

--"The Electronic Nurse." I did not read it for fear that someone was trying to say outright that the nurse could be replaced by a machine or that she was nursing a machine.

            Now then can we describe the nurse's distinctive function? Certainly not by the activities decided upon by others in authority. The professional nurse works within the framework of the routines prescribed by administration and doctors. This means that she does not independently set policy, or change rules and regulations; that is administration's job (although she may well have a voice in such procedures). She does not diagnose or prescribe for medical conditions (although her voice may well bring crucial observations to the doctor's attention which may well change diagnosis or treatment). The distinctive function of the professional nurse can only be arrived at by the study of activities she independently decides are indicated in order to help the patient. For her function to be valid such helping activities ought to be discernable in every nursing situation or at least contribute toward such a goal. In other words, she must be able to describe her activities on behalf of the patient and also to describe the results of these activities. I would like to illustrate this function and at the same time emphasize that it does not overlap with anyone else's. In the example given, the doctor's order read, "no medication for pain." The doctor did not prescribe how the patient could be helped to do without her drug. In doing her job as a professional person the nurse explored the situation and decided to visit the patient every fifteen minutes. This made it possible for the nurse to help the patient do what was prescribed and at the same time relieve the patient of her distress. Clearly this activity did not overlap with the doctor's who was treating the patient for demerol addiction.

            I intimated earlier that professionals and non-professionals alike can enforce policy. In the example, since patients are not allowed to keep pills at the bedside, the sister and the nurse both did the same thing; they saw to it that the policy was upheld. They did not try to find out what help the patient needed to relinquish the pills on her own. Perhaps the patient could have discussed the fear of dying alone there and then. The head nurse was working under pressure and the sister could not be expected to be aware of the problem although this could be expected of the nurse. The sister was under no obligation to find out what help the patient needed to give up the pills; this was the professional responsibility of the nurse.

            Only those actions which help the patient may be considered as belonging to the distinctive function of the professional nurse in her practice. When these actions are being carried out no matter who is being nursed or where it identifies us all as professional nurses.

            Before I end my remarks I would like to mention that I have often been challenged in the suggestion that carrying out the routines prescribed by doctors and administration may lead to a conflict between such activities and professional nursing function. Maybe it doesn't; it is only an opinion. I am sure, however, that it certainly doesn't help the nurse to keep that function clear. The nurse does work under pressure often enough that she develops automatic responses to it. It seems to me the speed with which most nurses can keep up with such demands is unequaled in any other field. But what about the days when the pressure lets up and she has more time. I'm sure I don't have to tell you. On such days some nurses catch up on routine and administrative things that they otherwise let go, because all their time had been used for medically prescribed activity. If there is no catching up to do then some nurses get bored and still others, I'm happy to observe, manage to give "qualitative and comprehensive" nursing care. It is less than fair to the institution and the patient to practice professional nursing only once in a while. I dare say it is sufficient cause for malpractice suits in nursing..

            I would give most anything to know what you are thinking because I would like to know that if I have not inspired you, I have challenged at least one of you. Be that as it may, I have tried to highlight what I think is of central importance in protecting your professional function and identity in practice. Of course, it cannot be done without your personal, independent, persistent and responsible action--the true mark of any professional. Whether or not I have inspired you, I hope that I have impressed upon you that your contribution to people when they need you cannot, at least in the present state of our knowledge, be outmoded by the social and technological changes of our time.

Thank you.