- Email: [email protected]
Awareness for action
Clifford H Jordan, RN
Awareness for action
As a nurse who has spent more than half his life in nursing, I hope I can share with you some of what I know and some of what I believe about nursing, which is relevant for all nurses and therefore relevant for you whose careers center in the operating rooms of the nation.
Clifford H Jordan, R N , EdD, is associate professor and director, graduate program in nursing service administration, University of Pennsylvania, Philadelphia. A graduate of the Pennsylvania Hospital School of Nursing for Men, Philadelphia, he received his BS and EdD degrees from Temple University, Philadelphia, and his M S degree from the University o f Pennsylvania. Dr Jordan presented this keynote address at the 1977 A O R N Congress i n Anaheim, Calif.
AORN is a leader among specialty organizations. It is accredited for continuing education by the American Nurses’ Association (ANA); it is currently looking at a certification program; it develops and conducts outstanding educational programs for operating room nurses; through its membership it has a commitment to support and advance the specialty practice of nursing in the operating room. For example, the Board of Directors of AORN recently created a committee to establish a new direction for nurses in the operating room. The goals for this committee are 1. define the role of the nurse in the operating room 2. suggest methods for operationalizing this role 3. be involved in implementation. Nurses who pursue careers in operating room nursing have a strong conviction about the worth of the field. Your ability t o adjust and grow with the advance in science and technology, while remaining committed to nursing practice, is commendable. The opportunities your practice provides for continuity of care before, during, and following surgery are well documented in your literature, and your determination to continue your commitment to the best care for those undergoing
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e must face up to what the patient wants and needs-from nursing.
W
surgical intervention is for the public good. In this paper, I will discuss the serious constraints to your freedom and your right to the creative, autonomous practice of nursing. I will propose directions for freeing nurses for truly independent practice. The theme for this Congress, “Reflections: awareness for action,” is very much on target at a time when action is required of nurses if we are to sustain the profession. We need to reflect on our past for what it can teach us. We need t o bring into conscious awareness the issues that confront us now. We need to act to clearly establish that nursing is now-has beenand will continue to be a distinct and essential health care service that none other than nurses are competent to practice and that none other than nurses are appropriate to control. If we are to still the increasing crescendo of criticism, we must face up t o what the patient wants and needs from nursing. Nurses must demonstrate in their practice that no one in the occupation of nursing can meet patients’ nursing needs as well as professional nurses can. I do not mean nursing as physicians, administrators, or others in health professions decide it shall be practiced but nursing as we define it-as caring about and caring for people, as direct care for which nurses are responsible and accountable. I am convinced that if nurses really want to practice nursing and 1320
many nurses insist it is what they want, we must acknowledge that nurses are not now, in sufficient numbers, demanding the right and accepting the responsibility to practice nursing-nursing whose primary responsibility is nursing care for the patient wherever he or she is. Nursing does not mean attending the desk, the physician or surgeon, or other departments. There is much in our past from which we can learn. It is sensible to see value in that which has stood the test of time and remains relevant. It is also sensible that we reject those past values that are no longer sound. We need to look critically a t our heritage to learn there is much that we still cling to that is no longer in the best interest of patients or nurses. Nursing was created in an environment of apprenticeship and a tradition of subordination. The history of the subordination of women and the history of early nursing are synonymous. Early nurses were viewed as and treated as inferior, available to do the bidding of others and appropriately subordinate to those others. Medicine still believes that nursing is subordinate to medicine-an appendage of it. In 1976, for example, at its annual convention, the American Medical Association unanimously adopted a resolution describing medicine’s position on the proper education and role for nurses-a resolution that
AORN Journal, June 1977, Vol25, No 7
clearly subordinates nursing to medicine. Reflecting on the past and fantasizing about the future will not get today’s work done. Continued inaction or no more than reaction to all that is happening in the operating room as well as other areas of specialized practice ignores our past and denies our responsibility to act now for what is presently needed if we are to prepare for-or even have-a future. We need to keep before us those issues that face nursing. We need to move into our conscious awareness what needs to be done about those issues. The issues I speak of are not new but, in fact, have been with us for sometime in one guise or another. We still have not fully settled the business of continuing education and how we can assure that nurses will accept the need for continuing education and continued competence in nursing. We may have crushed institutional licensure in one form, but a recent report from the Department of Health, Education, and Welfare calls for federal involvement in a national certification program for nurses as a possible alternative for licensure. I hope we agree that certification is the business of the profession itself. And what of the so-called expanded role of the nurse? Are nurses who see their role as expanded practicing nursing or is it delegated medical practice, ie, medical tasks the physician now says it’s OK for nurses to do? What of the present emphasis in your own field on OR nurses functioning as first assistants, which I understand means nurses might close the incision depending upon the surgery. Is that nursing? What if the patient shocks or arrests when you are sewing him up? Who is liable? Will the surgeon be accountable or will you?
However, if we look at contemporary medicine practice and at contemporary nursing practice, it may be that what was once clearly medical practice is no longer clearly medical practice. If we believe that a part of the nursing process requires that we incorporate into nursing practice that which was once traditionally considered to be medical practice, let us be sure of two very important things-that we articulate it into nursing practice and that we can describe it and rationalize it within the nursing process. Then, let us call it nursing. What are nurses doing in their practice that is nursing and what are nurses doing that should be the responsibility of others? Again, in the OR-what are you doing that is clearly a physician’s responsibility? Remember medical practice acts require that physicians diagnose and treat pathology and make it illegal for other than physicians to do that. Do the concerns of OR nurses center on the patient or do OR nurses believe that patients are solely the surgeon’s responsibility? We have historically and into the present been expected to be and often willingly have accepted being jacks- or janes-of-all-trades. Is that what you want? We have for too long been regarded as handmaidens by physicians and others. Is that what you want? If these are what you want, then we can all fold our tents and go home. If not, then our course of action is clear-we must move more deliberately to control nursing and nursing practice. Do nurses have or do they seek the authority to make decisions concerning nursing practice? If nurses are denied this authority, are they activating their dormant power and seizing the right and the responsibility to practice nursing? Are we exercising
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ursing’s diversity is both a strength and a weakness.
N
the independence our nurse practice acts define under law? Are we given or are we demanding parity with physicians in all matters related to our respective practices? Nurses are indeed a hardy group. We have faced and somehow lived through many crises as nursing has continued its struggle to evolve into an undisputed health profession. We have indeed had some success, but have we made it clear to other health professionals and t o the public that nursing is a vital service and not simply a paramedical occupation? Consider how much of what nurses are expected t o do they are assigned to do because of what I call fatal availability. No other group of hospital personnel is universally on duty 24 hours a day-every day. Nurses are always there. Our present professional concerns are woven into the fabric of our society as it is in 1977, not as it was in 1877. Today, societal forces render existing problems more complex. With 980,000 actively practicing nurses, we are the largest of health care professions. Our strength in numbers, however, is useful only if we take a united stand. Nursing’s diversity is both a strength and a weakness. It is a strength in that we have always tried to match our growth to an increasingly complex society with increasingly complex needs. Our diversity makes possible our versatile contribution to health 1324
care. Our diversity is also a negative factor. We have divided and subdivided ourselves until we no longer have a community of interest with which all nurses, regardless of their specializations, can identify. Our diversity has resulted in divisiveness. We are polarized and grouped into factions. But these are not reasons to back away-are they? As reasonable persons no one specialty group in nursing or the ANA should act as though it is alone on its own little island. The issues facing nursing are certainly controversial and even mind boggling. It remains, however, nursing’s job to settle the controversy and find solutions, or I can assure you others who truly believe they do and should control nursing will impose solutions on us. We need to see nursing as a collective, and we need to exercise our collective responsibility as health professionals beyond our own self-interest and personal gain. It is right and appropriate that specialty groups have and work for their special interests, but cannot all nurses work for nursing’s common goals? The tendency of one specialty group of nurses to isolate itself from other specialty groups must be set aside if we are to advance all of nursing to its rightful place in the constellation of health professions. In this era of social revolution we are living in, when more and more
AORN Journal, June 1977, Val 25,No 7
individuals are again uniting to assert and secure the rights and privileges guaranteed all persons in a free society, it is absolutely inconceivable to me that those in nursing would want less for nurses. Denial of our rights by others, ruthlessness on the part of others to keep us down must be countered by ruthlessness when necessary, militancy when necessary, and a 1977 revolution if necessary! If such a position by nurses is to succeed, we have to close ranks, stand collectively for what we know is right, and speak out without asking for permission and without waiting for the approval of those whose business is not nursing. I believe we are too easily satisfied. A raise in pay quiets many nurses, while many more are satisfied with even less. I also believe we are too easily intimidated, too easily made to feel guilty. If you don’t do it the patient will suffer. But who, I ask, is doing nursing while nurses are doing everybody else’s work? Our origin as subordinated, submissive apprentices still plagues us, and that denies our human dignity and our right to human equality. Control of nursing practice is the single most crucial issue before us, and we’d better face that fact and deal with it or we will deny our past and deal a death blow to the future we are required to secure for those who will follow us. If we talk about the control of nursing and its practice, we either imply or make explicit the relationship between control and power. There is enough power to go around. However, those who have it do not want to give it up or even share it. They hold on to it, often by extreme measures, against those they have power over. They often exercise it capriciously and use it to control others who do not have it.
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Examples of the power employers exercise over nurses are legion. Nurses are fired without cause if they displease their superiors; they are demoted or transferred or moved willynilly t o areas where they are not competent to practice. Even benefits due are withheld to punish nurses. The power of the physician results from his own self-induced omnipotence, and it is visited upon nurses and patients in very contr olling ways. I take the position that nurses have only dormant power, even though we represent an enormous power potential, which some nurses seem loathe to activate. Sociologists who have studied nurses for years have stated that nurses are too insecure, have a poor self-image, are docile and passive as the role of women requires. Nurses do not accept one another and often they do not see each other as peers. Nurses seem all too willing and satisfied, I fear, to go along with bureaucratically imposed constraints to their freedom and t o wallow in an organizational structure that sets one nurse against another in a subordinate-superior hierarchial relationship-a structure that isolates nurses from each other and certainly works against a peer relationship among nurses. Our divisiveness further isolates us from each other. How can we answer the question, “Who are our peers?’’ Does each subdivision of the profession only speak for and participate in decisions for that subunit? The present health care system, or nonsystem as many refer to it, is the result of many years of change coming out of ideas and actions that arose from a system of values. These values (one, that women, by their very nature, are inferior to men) influenced the development of nursing and nurses as subservient and medicine and
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e have to speak for nursing with authority and pride, not whimper over our fate.
W
physicians as dominant. Are there among you enough to reject this chauvinistic, sexist indictment? The issue of control of our own practice is not a new one-our movement throughout our history is replete with evidence of our continuing struggle to assert our right to define and thereafter to control nursing. But we must ask again-how many nurses have helped to keep nurses down by perpetuating the very system of subordination that oppresses? How many nurses, for example, are satisfied, maybe even happy, with the status quo? How many nurses like and play the physician-nurse game? How many nurses reject accountability for their own practice and embrace instead the doctrine of respondeat superior or let the master answer, when, of course, the master is the physician. Paternalism is not the behavior that spawns independence, and it is not the basis for real and sound collegial relationships. Without equivocation I say that nursing is an independent profession and that nursing has no dependent functions. I say that for the most part collegial relationships are not developing among physicians and nurses and that organized medicine is pressing harder to control nursing as nursing is moving to control its own destiny. Isn’t it ironic that physicians who still enjoy great public adulation and
who are in the top 1%income bracket in the US are threatened by nurses? And they are threatened-their behavior to constrain us as we change our roles to keep pace with changing practices and as we seek to enact legislation for direct reimbursement of nursing services makes that evident. Isn’t it ironic that in a free society, one of the few that stands for and protects individual freedom, so many are still oppressed as nurses are oppressed where they practice-oppressed because so much of their individual freedom is denied and so much of their professional independence is denied? We have to act now. We have to take the initiative, not continue as followers. We have to take risks, not play it safe. We have to speak for nursing with authority and with pride, not whimper over our fate. We have to activate our power, not cower in the face of intimidation or threat. Nursing has declared its independence. 0 We have acted to develop and promulgate standards of nursing practice (the first profession to do so). 0 We have acted to recognize excellence in nursing practice through certification. 0 We have acted to establish the need and requirement for continuing education for nurses. 0 We have acted to insure the rights
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of nurses to organize and be represented in collective bargaining in matters related to their practice and their economic and general welfare. We have acted to create a federation of nursing organizations, a mechanism for helping all nurses regardless of their specialty to come together on common concerns and common goals. As nurses have done all of these things and more, there are countervailing forces that continue to cloud our vision, slow or stop altogether our progress toward the rapidly approaching 21st century, and even threaten our existence. At present, for example, as nurses are changing their practice to reflect the explosion in knowledge and technology, as nurses are standing tall out of the shadow of medicine, as nurses are moving deliberately to more independence in decisions about patientklient healtWillness needs, organized medicine and those who would control nursing are acting aggressively to block our progress and “keep us in our place” as physicians often put it. Physicians’ voices are growing more and more strident as they proclaim that they and they alone are morally, legally, and ethically accountable for patient care. There are then constraints to our efforts to liberate nurses from bondage and servitude-a servitude perhaps not of our making but perhaps reinforced by nurses as they look outside of the nursing profession for answers or approval and status. Do you who practice nursing in the OR want to take your direction from the surgeon? If so, what direction does he give? Is he competent to direct nursing care? Do you want to perpetuate the masterservant relationship? If you believe that physicians in the OR and else-
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where should direct medical and nursing practice, then what is the future of nursing in the OR? If nurses admit they are not prepared to practice medicine (and I hope as nurses they do not want to), when will physicians publicly admit that nursing practice is different and distinct from medical practice and as physicians they are not prepared and therefore not competent to practice nursing? If the American Medical Association and the American Hospital Association insist on continuing to have committees on nursing, as they now do, let us insist that organized nursing immediately establish committees on medicine and hospital administration. How do we move in the direction I urge? We do it first by effecting a unity of purpose for nursing that now seems to be lacking. We do it by exhibiting more respect for our sister and brother nurses than is evident now. We do it by agreeing that nursing and medicine are two distinct and different professions and that jurisdictional disputes and turf guarding must stop in the interest of the publics we serve. We do it by agreeing on what nursing is and we do know what nursing is. In our eagerness to please others, we may deny what nursing is so we can, for ourselves at least, rationalize doing what is not nursing. Is the approval of the physician more important to nurses than the approval and recognition of other nurses? I truly hope this is not the case, but as a long-time nurse and a long-time observer of the nursing scene, I worry that approbation from physicians counts more for nurses than approbation from nurse colleagues. It is not easy to cast off the restraints that for so long have bound us, but if we love nursing and if we are proud of it, then the work will be easier and very satis-
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fying. We must take the risks and be secure in the knowledge that the payoff will profit nurses now and in the future. Our own dignity as human beings requires that we do no less. There is presently much attention and attendant success focused on primary nursing-simply defined as professional nurses being responsible and accountable for the care of a group of patients over a 24-hour period. Consistent with this model for direct care by professional nurses is the concept of an autonomous nursing staff.' This concept is essentially a means of organizing so that the mutual expectations of nurses and physicians for each other can be met with regularity. To create an autonomous nursing staff requires a change in attitude but not a new technology. It can be achieved without a large capital outlay. Autonomy has as its basic requirement personal accountability and shared power and influence. This accountability and power are outcomes of restructuring the organization, whereby nursing is organized for practice-not bureaucratic housekeeping. To develop and implement an autonomous nursing staff, the concept of parity with all of its implications must be in central focus. While nurses have had a stake in health care since its beginning, nurses have not enjoyed parity. Parity means equality, and that equality that we have not had is vital if nurses are to exert power in decision making in the care process. According to Luther Christman, a strong supporter of this concept, an autonomous nursing staff is designed explicitly to permit 1. the expression of clinical selfdirection among nurses 2. the acceptance of after-the-event sanctions rather than before-theevent control. Instead of relying on prior control of 1334
nursing practice through such mechanisms as an appointed hierarchy of supervisors and administrators, individual practitioners will be selfdirecting in their nursing practice and accountable for it. They will have to submit to the same risks that physicians must accept in the area of legal and professional malpractice. The model for nursing practice must reflect the consistency of patient assignment-a 24-hour responsibility for patients and clients. It is instructive to look at this proposal in historical perspective. This kind of autonomy is precisely what Nightingale and Dock and Wald were struggling to obtain for nursing. Let's compare briefly this model or an autonomous nursing staff with the typical hierarchical structure almost universal in organizing nursing care. Universally, nursing staff behaves mechanically and care is ritualized. Patients are managed by morning routines, afternoon routines, procedures, policies, rules, and orders that for the most part seem to have been designed for the convenience of staff instead of the needs and welfare of patients. Staff autonomy places the responsibility for the adequacy and safety of nursing care directly on nurses. Nurses would be collectively accountable to their patients and to the boards of trustees, which would appoint them to practice positions. Christman proposes that to discharge this responsibility nurses must, in general, use a process similar to that employed by medical staff. Nurses must 1. control access to staff and practice privileges 2. confirm background credentials of nursing staff applying for appointments 3. review clinical work through ongoing committees
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4. see that less-than-adequate care and practice are determined and remedied 5. delimit practice privileges in accordance with nurses' specialty 6. develop quality assurance mechanisms 7. delineate requirements for continuing education 8. participate in the educational preparation of nursing students 9. engage in peer review of nursing care. What all of this means and requires is that institutions and agencies employing nurses must be restructured-away from the industrial model toward the professional model, ie, decision-making autonomy at all levels and for each discipline. Each discipline, nursing in this case, would become accountable for its own practice. This also requires a relaxation of employer domination over employees. Nurses in their practice would be guided by nurse practice acts, which provide the legal base for nursing practice in the several states. I am optimistic about the future of nursing. The doors are opened. Some light has begun to crowd the darkness. It remains to be seen whether nurses will pass through the opening and into the light and grapple with the future or remain comfortable and passive and submissive. There are risks, but the professional excitement of improving care to patients can become a stimulus to the growth of our profession and the elimination of outmoded stereotypes. Autonomy for nurses is feasible. It is professionally exciting. It cannot be done for nurses. It must be done by nurses. Notes 1. Luther Christman, "The autonomous nursing staff in the hospital," NJPC Bulletin 2 (October 1976) 16-21.
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New criteria for brain death Criteria for determining brain death, even though machines may keep the heart beating and the lungs breathing, are listed in the March 7 Journal of the American Medical Association. The National Institute of Neurological and Communicative Disorders and Stroke sponsored a study in which 503 patients were examined in nine medical centers. The study concluded that determination of cerebral death requires the following. 1. All appropriate examinations and treatment procedures have been performed. 2. The brain is completely unresponsive, breathing without the machines has stopped, pupils are dilated, reflexes such as blinking are missing, and the electrocardiogram is silent for 30 minutes at least six hours after the stroke or accident. 3. If one of these standards is met imprecisely or cannot be tested, a confirmatory test must be made to demonstrate the absence of blood flow in the brain. The final rule allows diagnosis of a dead brain to be made in patients with small amounts of sedative drugs in the blood, in patients undergoing treatment procedures that make examination of cranial nerves impossible, and in patients otherwise meeting the criteria but whose pupils are not dilated. According to the project coordinator for the study, A Earl Walker, MD, of the University of New Mexico School of Medicine, Albuquerque, brain death and irreversible coma can be distinguished. Brain death means total destruction of the brain. Irreversible coma refers to a vegetating state in which all cerebral functions are lost, but certain vital functions, such as respiration, temperature, and blood pressure regulation, may be retained. Legal statutes in a number of states recognize brain death but not irreversible coma as a means of certifying death.
AORN Journal, June 1977, Vol25, No 7
Awareness for action
As a nurse who has spent more than half his life in nursing, I hope I can share with you some of what I know and some of what I believe about nursing, which is relevant for all nurses and therefore relevant for you whose careers center in the operating rooms of the nation.
Clifford H Jordan, R N , EdD, is associate professor and director, graduate program in nursing service administration, University of Pennsylvania, Philadelphia. A graduate of the Pennsylvania Hospital School of Nursing for Men, Philadelphia, he received his BS and EdD degrees from Temple University, Philadelphia, and his M S degree from the University o f Pennsylvania. Dr Jordan presented this keynote address at the 1977 A O R N Congress i n Anaheim, Calif.
AORN is a leader among specialty organizations. It is accredited for continuing education by the American Nurses’ Association (ANA); it is currently looking at a certification program; it develops and conducts outstanding educational programs for operating room nurses; through its membership it has a commitment to support and advance the specialty practice of nursing in the operating room. For example, the Board of Directors of AORN recently created a committee to establish a new direction for nurses in the operating room. The goals for this committee are 1. define the role of the nurse in the operating room 2. suggest methods for operationalizing this role 3. be involved in implementation. Nurses who pursue careers in operating room nursing have a strong conviction about the worth of the field. Your ability t o adjust and grow with the advance in science and technology, while remaining committed to nursing practice, is commendable. The opportunities your practice provides for continuity of care before, during, and following surgery are well documented in your literature, and your determination to continue your commitment to the best care for those undergoing
d+ AORN Journal, June 1977, Vol25, No 7
1317
e must face up to what the patient wants and needs-from nursing.
W
surgical intervention is for the public good. In this paper, I will discuss the serious constraints to your freedom and your right to the creative, autonomous practice of nursing. I will propose directions for freeing nurses for truly independent practice. The theme for this Congress, “Reflections: awareness for action,” is very much on target at a time when action is required of nurses if we are to sustain the profession. We need to reflect on our past for what it can teach us. We need t o bring into conscious awareness the issues that confront us now. We need to act to clearly establish that nursing is now-has beenand will continue to be a distinct and essential health care service that none other than nurses are competent to practice and that none other than nurses are appropriate to control. If we are to still the increasing crescendo of criticism, we must face up t o what the patient wants and needs from nursing. Nurses must demonstrate in their practice that no one in the occupation of nursing can meet patients’ nursing needs as well as professional nurses can. I do not mean nursing as physicians, administrators, or others in health professions decide it shall be practiced but nursing as we define it-as caring about and caring for people, as direct care for which nurses are responsible and accountable. I am convinced that if nurses really want to practice nursing and 1320
many nurses insist it is what they want, we must acknowledge that nurses are not now, in sufficient numbers, demanding the right and accepting the responsibility to practice nursing-nursing whose primary responsibility is nursing care for the patient wherever he or she is. Nursing does not mean attending the desk, the physician or surgeon, or other departments. There is much in our past from which we can learn. It is sensible to see value in that which has stood the test of time and remains relevant. It is also sensible that we reject those past values that are no longer sound. We need to look critically a t our heritage to learn there is much that we still cling to that is no longer in the best interest of patients or nurses. Nursing was created in an environment of apprenticeship and a tradition of subordination. The history of the subordination of women and the history of early nursing are synonymous. Early nurses were viewed as and treated as inferior, available to do the bidding of others and appropriately subordinate to those others. Medicine still believes that nursing is subordinate to medicine-an appendage of it. In 1976, for example, at its annual convention, the American Medical Association unanimously adopted a resolution describing medicine’s position on the proper education and role for nurses-a resolution that
AORN Journal, June 1977, Vol25, No 7
clearly subordinates nursing to medicine. Reflecting on the past and fantasizing about the future will not get today’s work done. Continued inaction or no more than reaction to all that is happening in the operating room as well as other areas of specialized practice ignores our past and denies our responsibility to act now for what is presently needed if we are to prepare for-or even have-a future. We need to keep before us those issues that face nursing. We need to move into our conscious awareness what needs to be done about those issues. The issues I speak of are not new but, in fact, have been with us for sometime in one guise or another. We still have not fully settled the business of continuing education and how we can assure that nurses will accept the need for continuing education and continued competence in nursing. We may have crushed institutional licensure in one form, but a recent report from the Department of Health, Education, and Welfare calls for federal involvement in a national certification program for nurses as a possible alternative for licensure. I hope we agree that certification is the business of the profession itself. And what of the so-called expanded role of the nurse? Are nurses who see their role as expanded practicing nursing or is it delegated medical practice, ie, medical tasks the physician now says it’s OK for nurses to do? What of the present emphasis in your own field on OR nurses functioning as first assistants, which I understand means nurses might close the incision depending upon the surgery. Is that nursing? What if the patient shocks or arrests when you are sewing him up? Who is liable? Will the surgeon be accountable or will you?
However, if we look at contemporary medicine practice and at contemporary nursing practice, it may be that what was once clearly medical practice is no longer clearly medical practice. If we believe that a part of the nursing process requires that we incorporate into nursing practice that which was once traditionally considered to be medical practice, let us be sure of two very important things-that we articulate it into nursing practice and that we can describe it and rationalize it within the nursing process. Then, let us call it nursing. What are nurses doing in their practice that is nursing and what are nurses doing that should be the responsibility of others? Again, in the OR-what are you doing that is clearly a physician’s responsibility? Remember medical practice acts require that physicians diagnose and treat pathology and make it illegal for other than physicians to do that. Do the concerns of OR nurses center on the patient or do OR nurses believe that patients are solely the surgeon’s responsibility? We have historically and into the present been expected to be and often willingly have accepted being jacks- or janes-of-all-trades. Is that what you want? We have for too long been regarded as handmaidens by physicians and others. Is that what you want? If these are what you want, then we can all fold our tents and go home. If not, then our course of action is clear-we must move more deliberately to control nursing and nursing practice. Do nurses have or do they seek the authority to make decisions concerning nursing practice? If nurses are denied this authority, are they activating their dormant power and seizing the right and the responsibility to practice nursing? Are we exercising
AORN Journal, June 1977, Vol25, No 7
1323
ursing’s diversity is both a strength and a weakness.
N
the independence our nurse practice acts define under law? Are we given or are we demanding parity with physicians in all matters related to our respective practices? Nurses are indeed a hardy group. We have faced and somehow lived through many crises as nursing has continued its struggle to evolve into an undisputed health profession. We have indeed had some success, but have we made it clear to other health professionals and t o the public that nursing is a vital service and not simply a paramedical occupation? Consider how much of what nurses are expected t o do they are assigned to do because of what I call fatal availability. No other group of hospital personnel is universally on duty 24 hours a day-every day. Nurses are always there. Our present professional concerns are woven into the fabric of our society as it is in 1977, not as it was in 1877. Today, societal forces render existing problems more complex. With 980,000 actively practicing nurses, we are the largest of health care professions. Our strength in numbers, however, is useful only if we take a united stand. Nursing’s diversity is both a strength and a weakness. It is a strength in that we have always tried to match our growth to an increasingly complex society with increasingly complex needs. Our diversity makes possible our versatile contribution to health 1324
care. Our diversity is also a negative factor. We have divided and subdivided ourselves until we no longer have a community of interest with which all nurses, regardless of their specializations, can identify. Our diversity has resulted in divisiveness. We are polarized and grouped into factions. But these are not reasons to back away-are they? As reasonable persons no one specialty group in nursing or the ANA should act as though it is alone on its own little island. The issues facing nursing are certainly controversial and even mind boggling. It remains, however, nursing’s job to settle the controversy and find solutions, or I can assure you others who truly believe they do and should control nursing will impose solutions on us. We need to see nursing as a collective, and we need to exercise our collective responsibility as health professionals beyond our own self-interest and personal gain. It is right and appropriate that specialty groups have and work for their special interests, but cannot all nurses work for nursing’s common goals? The tendency of one specialty group of nurses to isolate itself from other specialty groups must be set aside if we are to advance all of nursing to its rightful place in the constellation of health professions. In this era of social revolution we are living in, when more and more
AORN Journal, June 1977, Val 25,No 7
individuals are again uniting to assert and secure the rights and privileges guaranteed all persons in a free society, it is absolutely inconceivable to me that those in nursing would want less for nurses. Denial of our rights by others, ruthlessness on the part of others to keep us down must be countered by ruthlessness when necessary, militancy when necessary, and a 1977 revolution if necessary! If such a position by nurses is to succeed, we have to close ranks, stand collectively for what we know is right, and speak out without asking for permission and without waiting for the approval of those whose business is not nursing. I believe we are too easily satisfied. A raise in pay quiets many nurses, while many more are satisfied with even less. I also believe we are too easily intimidated, too easily made to feel guilty. If you don’t do it the patient will suffer. But who, I ask, is doing nursing while nurses are doing everybody else’s work? Our origin as subordinated, submissive apprentices still plagues us, and that denies our human dignity and our right to human equality. Control of nursing practice is the single most crucial issue before us, and we’d better face that fact and deal with it or we will deny our past and deal a death blow to the future we are required to secure for those who will follow us. If we talk about the control of nursing and its practice, we either imply or make explicit the relationship between control and power. There is enough power to go around. However, those who have it do not want to give it up or even share it. They hold on to it, often by extreme measures, against those they have power over. They often exercise it capriciously and use it to control others who do not have it.
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Examples of the power employers exercise over nurses are legion. Nurses are fired without cause if they displease their superiors; they are demoted or transferred or moved willynilly t o areas where they are not competent to practice. Even benefits due are withheld to punish nurses. The power of the physician results from his own self-induced omnipotence, and it is visited upon nurses and patients in very contr olling ways. I take the position that nurses have only dormant power, even though we represent an enormous power potential, which some nurses seem loathe to activate. Sociologists who have studied nurses for years have stated that nurses are too insecure, have a poor self-image, are docile and passive as the role of women requires. Nurses do not accept one another and often they do not see each other as peers. Nurses seem all too willing and satisfied, I fear, to go along with bureaucratically imposed constraints to their freedom and t o wallow in an organizational structure that sets one nurse against another in a subordinate-superior hierarchial relationship-a structure that isolates nurses from each other and certainly works against a peer relationship among nurses. Our divisiveness further isolates us from each other. How can we answer the question, “Who are our peers?’’ Does each subdivision of the profession only speak for and participate in decisions for that subunit? The present health care system, or nonsystem as many refer to it, is the result of many years of change coming out of ideas and actions that arose from a system of values. These values (one, that women, by their very nature, are inferior to men) influenced the development of nursing and nurses as subservient and medicine and
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e have to speak for nursing with authority and pride, not whimper over our fate.
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physicians as dominant. Are there among you enough to reject this chauvinistic, sexist indictment? The issue of control of our own practice is not a new one-our movement throughout our history is replete with evidence of our continuing struggle to assert our right to define and thereafter to control nursing. But we must ask again-how many nurses have helped to keep nurses down by perpetuating the very system of subordination that oppresses? How many nurses, for example, are satisfied, maybe even happy, with the status quo? How many nurses like and play the physician-nurse game? How many nurses reject accountability for their own practice and embrace instead the doctrine of respondeat superior or let the master answer, when, of course, the master is the physician. Paternalism is not the behavior that spawns independence, and it is not the basis for real and sound collegial relationships. Without equivocation I say that nursing is an independent profession and that nursing has no dependent functions. I say that for the most part collegial relationships are not developing among physicians and nurses and that organized medicine is pressing harder to control nursing as nursing is moving to control its own destiny. Isn’t it ironic that physicians who still enjoy great public adulation and
who are in the top 1%income bracket in the US are threatened by nurses? And they are threatened-their behavior to constrain us as we change our roles to keep pace with changing practices and as we seek to enact legislation for direct reimbursement of nursing services makes that evident. Isn’t it ironic that in a free society, one of the few that stands for and protects individual freedom, so many are still oppressed as nurses are oppressed where they practice-oppressed because so much of their individual freedom is denied and so much of their professional independence is denied? We have to act now. We have to take the initiative, not continue as followers. We have to take risks, not play it safe. We have to speak for nursing with authority and with pride, not whimper over our fate. We have to activate our power, not cower in the face of intimidation or threat. Nursing has declared its independence. 0 We have acted to develop and promulgate standards of nursing practice (the first profession to do so). 0 We have acted to recognize excellence in nursing practice through certification. 0 We have acted to establish the need and requirement for continuing education for nurses. 0 We have acted to insure the rights
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of nurses to organize and be represented in collective bargaining in matters related to their practice and their economic and general welfare. We have acted to create a federation of nursing organizations, a mechanism for helping all nurses regardless of their specialty to come together on common concerns and common goals. As nurses have done all of these things and more, there are countervailing forces that continue to cloud our vision, slow or stop altogether our progress toward the rapidly approaching 21st century, and even threaten our existence. At present, for example, as nurses are changing their practice to reflect the explosion in knowledge and technology, as nurses are standing tall out of the shadow of medicine, as nurses are moving deliberately to more independence in decisions about patientklient healtWillness needs, organized medicine and those who would control nursing are acting aggressively to block our progress and “keep us in our place” as physicians often put it. Physicians’ voices are growing more and more strident as they proclaim that they and they alone are morally, legally, and ethically accountable for patient care. There are then constraints to our efforts to liberate nurses from bondage and servitude-a servitude perhaps not of our making but perhaps reinforced by nurses as they look outside of the nursing profession for answers or approval and status. Do you who practice nursing in the OR want to take your direction from the surgeon? If so, what direction does he give? Is he competent to direct nursing care? Do you want to perpetuate the masterservant relationship? If you believe that physicians in the OR and else-
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where should direct medical and nursing practice, then what is the future of nursing in the OR? If nurses admit they are not prepared to practice medicine (and I hope as nurses they do not want to), when will physicians publicly admit that nursing practice is different and distinct from medical practice and as physicians they are not prepared and therefore not competent to practice nursing? If the American Medical Association and the American Hospital Association insist on continuing to have committees on nursing, as they now do, let us insist that organized nursing immediately establish committees on medicine and hospital administration. How do we move in the direction I urge? We do it first by effecting a unity of purpose for nursing that now seems to be lacking. We do it by exhibiting more respect for our sister and brother nurses than is evident now. We do it by agreeing that nursing and medicine are two distinct and different professions and that jurisdictional disputes and turf guarding must stop in the interest of the publics we serve. We do it by agreeing on what nursing is and we do know what nursing is. In our eagerness to please others, we may deny what nursing is so we can, for ourselves at least, rationalize doing what is not nursing. Is the approval of the physician more important to nurses than the approval and recognition of other nurses? I truly hope this is not the case, but as a long-time nurse and a long-time observer of the nursing scene, I worry that approbation from physicians counts more for nurses than approbation from nurse colleagues. It is not easy to cast off the restraints that for so long have bound us, but if we love nursing and if we are proud of it, then the work will be easier and very satis-
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fying. We must take the risks and be secure in the knowledge that the payoff will profit nurses now and in the future. Our own dignity as human beings requires that we do no less. There is presently much attention and attendant success focused on primary nursing-simply defined as professional nurses being responsible and accountable for the care of a group of patients over a 24-hour period. Consistent with this model for direct care by professional nurses is the concept of an autonomous nursing staff.' This concept is essentially a means of organizing so that the mutual expectations of nurses and physicians for each other can be met with regularity. To create an autonomous nursing staff requires a change in attitude but not a new technology. It can be achieved without a large capital outlay. Autonomy has as its basic requirement personal accountability and shared power and influence. This accountability and power are outcomes of restructuring the organization, whereby nursing is organized for practice-not bureaucratic housekeeping. To develop and implement an autonomous nursing staff, the concept of parity with all of its implications must be in central focus. While nurses have had a stake in health care since its beginning, nurses have not enjoyed parity. Parity means equality, and that equality that we have not had is vital if nurses are to exert power in decision making in the care process. According to Luther Christman, a strong supporter of this concept, an autonomous nursing staff is designed explicitly to permit 1. the expression of clinical selfdirection among nurses 2. the acceptance of after-the-event sanctions rather than before-theevent control. Instead of relying on prior control of 1334
nursing practice through such mechanisms as an appointed hierarchy of supervisors and administrators, individual practitioners will be selfdirecting in their nursing practice and accountable for it. They will have to submit to the same risks that physicians must accept in the area of legal and professional malpractice. The model for nursing practice must reflect the consistency of patient assignment-a 24-hour responsibility for patients and clients. It is instructive to look at this proposal in historical perspective. This kind of autonomy is precisely what Nightingale and Dock and Wald were struggling to obtain for nursing. Let's compare briefly this model or an autonomous nursing staff with the typical hierarchical structure almost universal in organizing nursing care. Universally, nursing staff behaves mechanically and care is ritualized. Patients are managed by morning routines, afternoon routines, procedures, policies, rules, and orders that for the most part seem to have been designed for the convenience of staff instead of the needs and welfare of patients. Staff autonomy places the responsibility for the adequacy and safety of nursing care directly on nurses. Nurses would be collectively accountable to their patients and to the boards of trustees, which would appoint them to practice positions. Christman proposes that to discharge this responsibility nurses must, in general, use a process similar to that employed by medical staff. Nurses must 1. control access to staff and practice privileges 2. confirm background credentials of nursing staff applying for appointments 3. review clinical work through ongoing committees
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4. see that less-than-adequate care and practice are determined and remedied 5. delimit practice privileges in accordance with nurses' specialty 6. develop quality assurance mechanisms 7. delineate requirements for continuing education 8. participate in the educational preparation of nursing students 9. engage in peer review of nursing care. What all of this means and requires is that institutions and agencies employing nurses must be restructured-away from the industrial model toward the professional model, ie, decision-making autonomy at all levels and for each discipline. Each discipline, nursing in this case, would become accountable for its own practice. This also requires a relaxation of employer domination over employees. Nurses in their practice would be guided by nurse practice acts, which provide the legal base for nursing practice in the several states. I am optimistic about the future of nursing. The doors are opened. Some light has begun to crowd the darkness. It remains to be seen whether nurses will pass through the opening and into the light and grapple with the future or remain comfortable and passive and submissive. There are risks, but the professional excitement of improving care to patients can become a stimulus to the growth of our profession and the elimination of outmoded stereotypes. Autonomy for nurses is feasible. It is professionally exciting. It cannot be done for nurses. It must be done by nurses. Notes 1. Luther Christman, "The autonomous nursing staff in the hospital," NJPC Bulletin 2 (October 1976) 16-21.
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New criteria for brain death Criteria for determining brain death, even though machines may keep the heart beating and the lungs breathing, are listed in the March 7 Journal of the American Medical Association. The National Institute of Neurological and Communicative Disorders and Stroke sponsored a study in which 503 patients were examined in nine medical centers. The study concluded that determination of cerebral death requires the following. 1. All appropriate examinations and treatment procedures have been performed. 2. The brain is completely unresponsive, breathing without the machines has stopped, pupils are dilated, reflexes such as blinking are missing, and the electrocardiogram is silent for 30 minutes at least six hours after the stroke or accident. 3. If one of these standards is met imprecisely or cannot be tested, a confirmatory test must be made to demonstrate the absence of blood flow in the brain. The final rule allows diagnosis of a dead brain to be made in patients with small amounts of sedative drugs in the blood, in patients undergoing treatment procedures that make examination of cranial nerves impossible, and in patients otherwise meeting the criteria but whose pupils are not dilated. According to the project coordinator for the study, A Earl Walker, MD, of the University of New Mexico School of Medicine, Albuquerque, brain death and irreversible coma can be distinguished. Brain death means total destruction of the brain. Irreversible coma refers to a vegetating state in which all cerebral functions are lost, but certain vital functions, such as respiration, temperature, and blood pressure regulation, may be retained. Legal statutes in a number of states recognize brain death but not irreversible coma as a means of certifying death.
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