The Fundamental Issue in Professional Nursing

Ida J. (Orlando) Pelletier

Presented at the

University of Tulsa College of Nursing

August 29, 1976

 

            It is a pleasure for me to be back in Oklahoma. My visit is full of nostalgia. It takes me back to 1946 and my field experience as a senior student nurse at The Talihina Indian Hospital. For this reason I am especially pleased to participate in celebrating the Fifth Anniversary of Chapman Hall and hope that my remarks are relevant in rededicating the excellence of the college in preparing nurses to practice professionally.

            My assigned task is to discuss issues in nursing. This means that I should discuss nursing in relation to the plural form of the noun--issue. The task overwhelms me and I wish I could give it up right at the start! I can't possibly mention, let alone discuss, even a representative number of the seemingly countless controversies, disagreements, and disputes surrounding "issues" which are all in heated debate. I will, however, mention a few issues which I find paradoxical--just in case some of you need to be convinced that it is right and prudent of me to abandon this task as quickly as I can. I will then discuss what I think is the single fundamental issue in professional nursing. (I'm using issue here as an intransitive verb, meaning to flow out of, to descend from a common parent or ancestor.) Everything else I have to say will be in defense of the proposition that: the function of professional nursing is a single, independent function with its own distinct product.

            At least a dozen issues have come to the fore with the emergence of the new militancy in nursing. Pronouncements at the local and national level insist that the nurse is responsible to the patient. This insistence is paradoxical since private agreements with patients to provide care by contract with private duty nurses have steadily decreased, and, in some hospitals, the private contract between the nurse and the patient has become extinct. This paradox is strengthened by a greater emphasis being placed on the professional nurse as an employee--by National Labor Relations Boards who are ruling that the State Nurse Associations are bona fide representatives of employees for collecting bargaining. Surely this sweeping trend makes the nurse responsible to the employing institution and not to the individual patient.

            Other pronouncements insist that nursing is autonomous and independent of the medical profession. This too is paradoxical since 60 million dollars have been appropriated for the three fiscal years, `76, `77, `78 for nurse practitioner programs, and an additional 60 million for traineeships with similar prescribed guidelines. The guidelines for programs concentrate on, among other things, the diagnostic use of otoscopes, stethoscopes, opthalamoscopes, vaginal speculi and lab tests, as well as memorizing protocols (established by physicians) such as which medication is to be prescribed for what symptom. Apparently, the more difficult area in the training of these nurse practitioners is learning how to decide when to call the doctor who has the medical expertise. Surely the focus of this training is on performing routine tasks previously reserved for physicians who, by the way, do some or all of the training and most of the supervision.

            The paradox surrounding the proclamation of independence is even more pronounced as nurses initiate legislation, and indeed have had passed, in Massachusetts at least, legal sanction to perform what is called "Additional Acts" but what I prefer to call medical acts. In effect, the amendments known as "Additional Acts" modify earlier legislation which prohibited anyone, including nurses, from the practice of medicine.

            A newer generation of highly educated nurses are vigorously proclaiming that nursing is a learned profession--and yet there are at least 50 baseline issues related to what and how much learning one should have before becoming licensed to practice professionally. Some say that enough learning and skill can be acquired in the two year associate degree program. Others say that the three year hospital diploma program is not only enough but better because of the emphasis on clinical experience. Others claim that a Bachelor's degree program is enough and better because greater emphasis is placed on academic learning. Aside from the basic preparation for licensure, a fair number of distinguished nurses are on record as saying that only the Master's degree prepares a truly professional nurse.

            Paradoxically, again none of these (degrees) are going to be really enough since the push is now on to mandate continuing education units in order to renew a license annually. Nowhere has the relationship between any units of continuing education and the ability to practice professional nursing been defined. Further, legislating Continuing Education units as a requirement for relicensure leaves no room for independent, individual study and development, and would make it impossible for many truly professional nurses to practice a profession to which they had already gained admission.

            Another host of issues surround the development of the profession's "Standards of Nursing Practice" and the attempts to implement the standards nationally in every nursing service.

            Paradoxically again, the standards came at a point when the directive authority of nursing services started to become what is called "decentralized," but what I call "eradicated"--leaving no nurse in command, so to speak, to implement the standards promulgated by the national organization. Also, the standards came at a point when patients, if not carried, are all but being pushed out of hospitals if all they require is a nurse's care. They are sent home or to nursing homes or to long-term facilities--places where the fewest number of professional nurses work--places that now have more beds than do hospitals.

            Perhaps the new militancy, the emphasis on independence, professional autonomy, academic learning and attempts to standardize practice, in some way relates to some casual observations in the area of employment opportunities. Increasingly, advertised positions in clinics, emergency rooms, health centers, and school, college and industrial health departments stipulate that only registered nurses who have had special practitioner training, under the supervision of a physician, need apply. Formerly, it was sufficient to be a registered professional nurse with appropriate clinical experience. Even the clinical specialist, a role developed independently by Nursing, is presumably finding fewer and fewer job opportunities to put her special skills to work. In addition, there is an increasing tendency to hire clinical faculty for part time--only because students do not spend full time in clinical experience. The inescapable implication is that teaching students how to care for patients is a part-time job. Further, there is a marked increase in what was already an existing tendency to reduce numbers of professional nurses giving direct care, and increasing the numbers of other care givers. And still further, some employers are decreasing the number of full-time RN positions but increasing per diem hiring of a different nurse each day as if nurse-patient relationships had nothing to do with patient care and they do it to avoid fringe benefits and salary increments.

            I hesitate to even mention the job opportunities for nurses to work in utilization review and Professional Standards Review organizations as workers in the control of health care costs. But since I did mention utilization something comes to mind that should have become an issue in nursing but did not. A short story goes with it.

            In March of 1974, my husband was leafing through Time magazine and I was busy writing. Suddenly, he asked" "Ida, how is your blood pressure?"

            "Fine," I said, "but why are you asking me?"

            "No reason," he replied, "I was just curious."

            Later, I leafed through Time and found the source of my husband's question. Well my blood pressure did go up and as you will see it has not come down since!

            There was a full page advertisement for Blue Cross/Blue Shield. A photograph of a woman's head, bust and arms covered two thirds of the page. She seemed overdressed, overdecorated, and over-indulged; presumably intended to portray an unsympathetic character. Five enormous rings were on her fingers. Her bare shoulder was draped with a fox fur collar and several strands of pearls. She stared out of the page through half closed eyelids--smoking a cigar.

            In 1/2 inch bold black lettering the ad read: "MARY PINKNEY HAS A RECORD AS LONG AS YOUR ARM." In considerably smaller print the ad read, and I quote:

            "At least a dozen doctors have examined her medical records in the last year and they all agree.

            "Mary Pinkney has a long history of chronic heart burn, not chronic ulcer. The problem is there is no telling her that. She keeps going to doctors. And they keep telling her the same thing.

            "The case in point is one of simple economics.

            "When patients demand more than they need, medical coverage is going to cost more than it has to.

            "Along with doctors and hospitals we've been able to uncover some of the causes of rising costs through a program called Utilization Review.

            "You might call it a kind of check up procedure. Where doctors examine doctors to determine whether the medical services and price were what they should have been.

            "Our goal is that you get the health care you need at a fair price. And that's not only our responsibility, but the responsibility of doctors, hospitals, and patients alike.

            "As for Mary Pinkney, she is just going to have to change her ways.

            "We've all be paying for her long enough."

            (This advertisement stated in very fine print: "One of a series prepared on behalf of the public at large.")

            A subsequent advertisement was captioned: "SOME PATIENTS ARE GUILTY OF MAL-PRACTICE;" but I don't have time to discuss that one.

            Although Mary Pinkney did not become an issue in Nursing, surely any professional nurse would concur with me in asking at least some of the following questions:

            Why does an insurance company discriminate against the Mary Pinkneys, who are policyholders, because of the form their suffering happens to take?

            Why aren't the complaints of the Mary Pinkneys viewed as yet undefined desperate pleas for help and worthy of a professional nurse's care?

            Why are the Mary Pinkneys scolded for having minor ailments like heart burns instead of major ones like chronic ulcers?

            Why should the Mary Pinkneys develop presumably respectable chronic ulcers before anybody helps them when all that ails them are less respectable heart burns?

            Why are the doors to help shut to the Mary Pinkneys who panic when they have nowhere else to turn? Why does the panic have to escalate to the point where respectable diseases like heart attacks become acquired before the doors to help open again?

            Why isn't the largest caring profession--Nursing--even mentioned in the advertisement as it discusses responsibility for treatment and care?

            Why does Mary Pinkney's insurance have to pay for so many costly medical visits which bring so little relief?

            Why does the Nursing profession watch the Mary Pinkneys go to the wrong places for help when, as in the case of the advertisement, twelve doctors agreed that Mary Pinkney did not have a medical problem?

            Why can't the Mary Pinkneys and countless others who have no medical problem go to nurses or Nursing Service Departments for help?

            Why can't the Mary Pinkneys call the nurse to visit them at home, on request, for whatever distresses they cannot cope with alone?

            And one more question--tantamount in my mind--perhaps for personal reasons: Why in the early organization of visiting nurse services did nurses on their own enter the homes of the distressed Mary Pinkneys when help was needed; and why did it then shift and become impermissible to visit a second time without a doctor's order?

            Throughout my entire career I had one place to point to with great pride and that was the Frontier Nursing Service in Kentucky. To be sure that service--as far as I know--did not practice medicine--it was against the law. But I am just as sure that they helped people obtain the services of physicians when they were unable to assist in relieving the patient's immediate distress. The Frontier Nursing Service was founded, organized, developed and controlled by professional nurses in response to the suffering of individuals and families in that area. Two years ago I saw the then retiring nursing director on national television and literally wept when she reported that a medical director was taking her place.

            I am now confident that you will allow me to put the plural form of the noun "issue" to rest, and begin a discussion of what I think is the fundamental, single issue in professional Nursing. Remember that I use "issue" here as an intransitive verb, meaning to flow out of, to descend from a common parent or ancestor.

            So what is the antecedent of the issues I mentioned and the countless more I am not courageous enough to mention?--issues that, in my experience, have not really changed--each issue has only become more complex. From my point of view, none will be resolved for the benefit of patients until Nursing collectively articulates a distinct professional function and demonstrates in practice and research in no uncertain terms what the product of that function is.

            I want to emphasize distinct and say what I mean by it in relation to function and product. By distinct function I mean what is it that characterizes and justifies nursing's work as a profession. Whatever it is must be identifiable in every nurse-patient contact, whether the patient has a disease or not. By a distinct product I mean what is the form the result takes after the function is fulfilled. Thus, by distinct product I mean--what is it that the patient cannot produce alone or definitively get from anybody else that is not trained to practice nursing professionally.

            Without having articulated a distinct professional function, and therefore product, it is difficult if not impossible to take a positive stance in acquiring and maintaining the professional authority to carry it out or to have any consensus on what basic professional preparation will train the nurse to practice professionally.

            I would like to begin a discussion of the issue as I see it with a quote from The Standards of Nursing Practice, published by The American Nurses Association in 1973:

            "Nursing practice is a direct service, goal directed and adaptable to the needs of the individual, family and community during health and illness."

            As useful as this statement may be it is not enough. It does not say what the function or the product of the practice is, and is too generally applicable to any other practice. For certain all professional practices, and I must include, for emphasis, non-professional practices such as butchers and garbage collectors; all provide direct service which is goal directed and adaptable to the needs of people whether they are sick or not.

            I don't know why Nursing has not collectively articulated its distinction as a profession but I think Florence Nightingale had something to do with it. Since 1893, when the Nightingale pledge was formulated, thousands upon thousands have pledged: "With loyalty will I endeavor to aid the Physician in his work." I would like to think that we would have developed statements of role and identity by now if the pledge had read instead: "I will help the patient from the patient's point of view while the physician does his work from a medical point of view." Implicit in this wish is that the nurse's focus is with the patient's experience--no matter who is doing or assisting in the physician's work.

            To wish that the pledge were focused on the experience of the patient from the patient's point of view does not imply that the physician does not need or should not use all the assistance he can muster. I only mean, and I'll talk more of it later, that two masters cannot be served simultaneously. The expression "doctor's orders" should not be understood as orders for nurses to comply with. If the nurse does automatically comply with the doctor's orders she is serving the doctor. Rather doctor's orders should be understood exactly as they are: directed to patients for patients to comply with if patients so choose. This leaves the nurse free to assist the patient with whatever the patient is unable to do alone--including assisting the patient if he needs help to comply or not comply with the doctor's orders.

            It may help you to understand my fervent wish if I tell you that long before I pledged my assistance to the physician in his work, I was haunted by two questions and some inescapable facts. The questions were: "What makes me professional?" and "What am I supposed to produce professionally?"

            Except for the administration of medications I saw no difference between what I did and what the nurses' aides and orderlies did in the hospital in which I trained--although I did get blamed when they did something wrong. I couldn't understand why I had to hand out so many medications when most of my patients were able to take their own but it was not allowed. On the other hand, when they went home they took their own medications or some family member helped them with very little instruction. Besides, whatever benefit resulted from medication or other prescribed treatment for that matter was not to my credit as a member of the nursing profession but instead to the credit of the medical profession.

            These questions continued to haunt me as a teacher because if I couldn't answer the questions I simply couldn't help a student learn to produce an undefined product. I thought a Bachelor's degree in Public Health Nursing might provide the answers. It did not. I thought a Master's degree in Mental Health Consultation would answer the questions for me. It did not. Yet the patient's suffering was forever before me and I did what I was taught to do--respond with whatever the doctor ordered or with established non-medical protocols.

            Even if Florence Nightingale had nothing to do with the preponderance of assistance to physicians, nurses have, in practice and education, attempted to simulate the physician in his work in all medical specialties. Busy with a focus on the medical model and brainwashed, so to speak, made nursing too preoccupied to seize the opportunity to first formulate and then articulate its own distinction.

            By this time some of you may like what I have been saying and some of you may not; but all of you probably think I'm going to tell you what I think is distinct about nursing. I may later but not now. I tried to say what I think in a book published 15 years ago, and then I tried to say the same thing again in reporting a research project in another book five years ago. Apparently I didn't explain it right, and in thinking about it I'm quite sure now that I did not. So I'm going to explain it differently--not in terms of what I think but in terms of what nurses told me was unique about nursing. They didn't necessarily tell me in words but through the care they gave patients and the way they judged nurse-patient situations.

            So I have another story.

            Twenty-two years ago I was on the faculty of the Yale School of Nursing. I was there trying to integrate mental health concepts into the basic nursing curriculum, and at that time I still didn't know what a nurse was supposed to produce professionally. For three years I participated and observed in the clinical work of faculty, students, and other nurses in any and all types of patient situations.

            All of the students enrolled in the basic nursing program already had a Bachelor's degree, some already had Master's degrees and a few already had a PhD, but all were being prepared to qualify for State Board Examinations. These students did clinical work in a setting that not only produced its own three year diploma graduates but a setting which also provided clinical experience for neighboring Bachelor's programs. So we had the mix of educational backgrounds that I spoke of earlier. The nurses in the patient settings (to make it short) came from everywhere. There seemed to be no end to the debates among the nurses, particularly the head nurses who dealt with all the students, as to which of the various programs prepared nurses best.

            The nursing faculty was all nurses. They taught nursing arts: medical, surgical, pediatric, obstetrical, psychiatric, and public health nursing and, of course, they supervised student practice. The basic sciences were taught in other schools of the university. Faculty curriculum meetings were full of healthy debate trying to decide what content from which field of learning was most important, when to offer it, and for how much time. Although the decisions that were made were responsibly adhered to--no one really ever agreed with anybody else on any issue under discussion including the final evaluations of students. One faculty member would judge a student as the personification of Florence Nightingale while the same student was judged by another faculty member as a disaster for nursing. On occasion I did find two faculty members in agreement but invariably found that they had been trained at the same school.

            In this background I was busy reconstructing as faithfully as I could all the separate contacts faculty, students and nurses had with patients in which I was also a participant. The record of the contact contained only what I heard the person say and what I saw in the sequence in which it took place. My records of these contacts read like anecdotes. Some were short and some were long, but the number of them started to pile up. I didn't know what to do with them because I still didn't know what a nurse was being trained to produce, let alone know where to put what mental health concept so that the concepts would get integrated.

            But I did manage to keep them in chronological order. Three years later I had to make some sense out of these anecdotal recordings, which by then numbered two thousand. I simply couldn't do it. All I wanted to do, which is really all I was able to do and did do, was to divide the anecdotes into two piles. Those I judged as good nursing went into one pile and those I judged as bad nursing went into a second pile.

            Now I had two piles instead of one but no sense in either pile. In looking for sense I tried to categorize the anecdotes according to the advice of a sociologist. Primary and secondary needs he said. The attempt to follow his advice failed to materialize because a primary need like food was not a primary need for the patient at a given moment and in some cases would have proved harmful if considered primary. Likewise, a secondary need like having a loved one near proved to be primary at other given moments.

            I also tried to categorize the anecdotes according to the advice of a psychiatrist who suggested categories of hostility, aggression, empathy, anxiety and grief. This attempt also failed for two reasons. It was difficult to decide which observations (that is, what the person said or did) belonged to which category and none of the categories seemed to relate to my categorizations of good and bad outcomes.

            So I studied the anecdotes again and decided it would be a good idea to make one list of good outcomes and another list of bad outcomes. It was a good idea because I wanted to feel as if I was working and earning my salary. Some of the good outcomes were the relief of pain--constipation--nausea--and cessation of vomiting--all without medication. Unstable blood pressure became stabilized with no change in medication. Patients about to be catheterized voided spontaneously. (I might add that on one obstetrical unit catheterization trays disappeared except for when needed for the collection of sterile specimens.)

            Some more outcomes on that good list: the courage to take a first step after repeated refusals to try; removal of restraints from patients who were labeled "disoriented;" and lastly, a  child's active cooperative participation in instructing the nurse when to insert the needle--when in the beginning of the contact the child screamed.

            Some of the outcomes on the bad list were simply in reverse of the good ones. Complaints of pain intensified and larger doses of pain medication administered. Cathartics were prescribed and administered for complaints of constipation with no resulting bowel movement. Blood pressures remained unstable with no change in medication. Patients unable to sleep even with hypnotics. Patients had bigger and more forceful methods of restraint applied, and children screamed in restraint as injections were administered.

            So I had a pile and a list of good outcomes and I had a pile and a list of bad outcomes and I developed a "fixation" so to speak with the two lists so I kept the lists but mixed the anecdotes all up again. (That is, I put them back in their original chronological order, and took off on a different tack.) Mind you, I did not know then what I was doing.

            I arbitrarily pulled out every 20th anecdote and out of a sample of 100 I pulled every 10th anecdote. With these 50 anecdotes I started to look for nurses--almost any nurse--from anywhere, not just from Yale, who was willing to do a relatively short task for free. They had to read the 50 anecdotes in chronological order and decide if the record represented to them good or bad nursing care.

            One nurse who read them for me held a then fashionable Federal title now extinct: Regional Nurse Mental Health Consultant. (It may interest you to know that when that title became extinct the national, yet slow, movement to decentralize nursing services started.)

            Professors, associates and instructors of nursing who enjoyed their relationships as well as those who argued openly with each other, and other teachers in nursing who never knew one another, read and groups the anecdotes as did nurses who worked with children and adults with medical, surgical, or psychiatric conditions. Nurses with special training in chemistry, physics, psychology, sociology, medical sociology, art, social work, architecture, mathematics, research, public health administration and psychiatry performed the same task.

            Students and nurses from three year diploma programs, from Bachelor's programs, from Master's programs, and post graduate programs, performed the same task for free.

            I gave the task to nurses who seemed warm and loving and to nurses who seemed bitter and sometimes cruel.

            I gave the task to nurses whose work I adored and I gave the task to nurses whose practices I could not bear to observe.

            All these nurses with divergent views, education, experience, interests and temperaments, grouped the anecdotes in exactly the same way that I did. This explained the fixation I developed with my lists of good and bad outcomes.

            I thought then and I still think that uniformity of judgment was absolutely elegant and positively stunning. Judging nursing care as good or bad was a point around which I found all nurses--including me--could rally. At long last, there was no issue, no disagreement, no controversy and no dispute.

            And then the light dawned. I decided that if the anecdotal account was the only material available to base the judgment on, then what made good or bad nursing happen had to be contained in the anecdotal record from which all these uniform judgments were made. Stated another way: specific items and/or conditions producing the good or bad outcomes had to be contained in the records which were so judged and could therefore be commonly identified.

 

            So what was in all the records that all those nurses judged so uniformly as good as distinct from those they judged bad? I tried to specify those items and conditions in my book: The Dynamic Nurse Patient Relationship. The "deliberative nursing" formulations were contained in every record judged as good. This formulation by the way has been renamed "the discipline of nursing process." The "automatic nursing" formulations were contained in every record judged bad and these formulations have also been renamed as simply "nursing process," to mean a process of care without professional discipline.

            I stated earlier that I think there is one single fundamental issue in professional nursing which is the ancestor to all the other issues, and that all of my remarks would attempt to defend the proposition that the function of professional nursing is independent and that it has its own distinct product. For this reason, I don't have time to discuss the process of care contained in the anecdotes and will try to confine the discussion to function and product.

            In the records judged as good the nurse's focus was on the immediate verbal and non-verbal behavior of the patient from the beginning through the end of the contract; whereas in those judged as bad the nurse's focus was on prescribed activity or something that had nothing to do with the patient's behavior.

            In the contacts judged as good the nurse found out: l) what was happening to the patient from the patient's point of view; 2) what the immediate distress was; 3) that the patient was distressed because he had an immediate need for help; 4) that the patient was unable to produce the outcome of relief without the nurse's help. These items, commonly contained in all the contacts judged as good, led me to the inescapable conclusion that the function of professional nursing is to find out and meet the patient's immediate needs for HELP.

            In the records judged as good the immediate verbal AND non-verbal behavior of the patient changed for the better when compared with the behavior recorded for the beginning of the contact. In contrast, the records judged as bad had no record of change in the behavior of the patient or the change recorded was for the worse.

            This lead me to the conclusion that the product of the professional nurse's work is to be found in the immediate behavior of the patient, and that a professional service has not transpired until that same immediate behavior has improved (from the patient's point of view).

            Finding what nurses accomplished by the end of the nurse-patient contact (that was not accomplished or present at the beginning of the contact) wasn't as easy to find as I may make it sound. The formulations I stated do seem simple and hundreds of nurses since have told me that the simplicity of those formulations are deceptive and exceedingly difficult to conform to in ALL situations until after they are trained. This fit, so to speak, with what I found most fascinating in my trying to make sense out of all those anecdotes.

            Even the nurses whose care resulted in good outcome--including myself--could not describe the process by which the good outcome was achieved and the same nurses who produced the good outcomes in one situation produced bad outcomes in other situations. This lead me to the inescapable conclusion that professional training was required in order to guarantee not only the production of good outcomes but to be in a position to predict them also.

            I feel compelled to say that I have never met a Registered Nurse who would not respond to the patient's immediate need for help once she knows what it is. The problem is that at the outset of the nurse patient contact the patients verbal and non-verbal behavior does not automatically inform the nurse of the need for help. The patient's initial inexplicit, unclear cry for help places burden, not blame, on our profession to learn how to find out from ALL patients what help is needed in order to help ALL patients change their behavior in the  direction of improvement.

            It stands to reason that if every professional nurse-patient contact guaranteed improvement in the patient's behavior then everything in the system of care would become more efficient. The patient relieved of his immediate distresses is more able to utilize the  care of nurses and whatever the doctor orders.

            I have time for only one example which illustrates in fairly dramatic terms the product of professional nursing. Strictly speaking, it was not a professional nursing situation for me and I did not clearly identify the patient's immediate need for help (although I have an idea of what it was) but it does illustrate the product of professional nursing as I have tried to describe it. In contrast, I will also illustrate the focus of another nurse on the medical model.

            The incident took place in a chronic disease hospital which has since been renamed as a long term care facility. It was a chilly October morning.

            "What type of patient do you want to see?" the nurse asked, I said, "It didn't matter" and asked if we could find out if the patient in the very first room would allow us to visit.

            "Oh, no, " replied the nurse, "You don't want to go in there. It's a very chronic case. She has Huntington's Chorea and she almost never talks."

            (I want to digress a moment and call your attention to the medical focus of the nurse--like in the brainwashing I spoke of earlier. In this case the nurse categorized the patient not according to the care the patient needed but according to the diagnostic label placed on the patient's condition by a physician.)

            Anyway, I insisted and we entered the room of the patient with Huntington's Chorea.

            As we entered the room I shivered and noted that the window was wide open. The nurse said:

            "Hello, Mary. This is Mrs. Pelletier who wants to visit you," and then added as she touched the diaper, the only cover Mary had on, "Oh good you are still dry."

            Mary's thin arms and legs were flailing about, presumably in an uncontrollable manner. Her head was bobbing up and down and side to side. Her whole body seemed to be pivoting on the base of her spin in alternating directions.

            Before I could speak the nurse said: "Mary you will be getting your medication in a few minutes."

            Then I said, "The nurse just told you I wanted to visit you, is it alright with you if I do?"

            The nurse looked at me and said: "She won't answer you," and indeed Mary did not.

            I tried again: "Mary your room seems awfully cold to me, does it seem cold to you?"

            For an instant Mary's head stopped bobbing to look at the nurse (who did not speak this time) and in the same instant Mary's lips moved. She did not speak as her head resumed its bobbing.

            I said: "Mary, I thought you were going to answer me, because I saw your lips move and if you were going to answer me, I'll be happy to wait until you do."

            A minute of so passed in which no one spoke. The nurse must have sensed that I thought the patient was suffering with the uncontrollable flailing because she looked at me and repeated what she told the patient earlier: "She gets medication for it and its due in about ten minutes."come--including myself--could not describe the process by which the good outcome was achieved and the same nurses who produced the good outcomes in one situation produced bad outcomes in other situations. This lead me to the inescapable conclusion that professional training was required in order to guarantee not only the production of good outcomes but to be in a position to predict them also.

            I feel compelled to say that I have never met a Registered Nurse who would not respond to the patient's immediate

            Mary replied: "I don't know."

            "Do you suppose it was because your feet were cold?"

            Mary clearly and with emphasis this time replied: "NO."

            Suddenly tears formed in Mary's eyes as she said: "I don't feel so nervous now."

            "Is it sadness because it looks as if you want to cry?"

            "No, I'm not sad. I feel better, I feel calm."

            "Then why the tears?"

            "Because no one talks to me the way you do and you don't work here."

            The nurse then said: "Mary it's good to hear you talk again. You're never this calm even with your medication."

            The medication had not yet been administered but the product of professional nursing was achieved and with a patient who had Huntington's Chorea.

            In closing I want to leave you with two definitions of verbs from my favorite dictionary:

            To doctor       means to prescribe for or to treat medicinally; to repair; to alter with a view to deceive or adulterate.

            To nurse        means to promote and foster an individual's growth and development; to look after; to encourage; to foster and cherish; to nourish, to protect and nurture. Last but not least another meaning of the verb to nurse is to give curative care to an ailment.

            Thus, the nursing of individuals whenever and for whatever reasons they suffer or anticipate their own helplessness in immediate situations in every nurse-patient contact may enormously heighten the contribution of professional nursing to the alleviation of human suffering.