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From the editor the enemy within
FROM THE EDITOR THE ENEMY WITHIN
Carole A. Anderson, PhD, RN, FAAN
I
n my state (and} I assume} in many others) there is a battle being fought between organized medicine and nursing. This battle centers on the roles of physicians and nurses} how they can or cannot work together} and on control. Specifically} the battle surrounds pending legislation that gives title recognition to advanced practice nurses in Ohio} recognition that is long overdue and substantially behind most of the rest of the country. Nonetheless} the state medical association has many concerns with the bill} the most substantial of which are questions concerning "supervision" versus "collaboration" and} interestingly enough, required educational preparation. The first concern is one with which we nurses are all familiar: the degree of autonomy that an advanced practice nurse can exercise in the delivery of services. This struggle over physician control of nursing practice is not new and, after much debate} will in all likelihood be resolved through compromise. The second concern is different. Physicians are concerned that the bill does not mandate a master's degree NURS OUTLOOK
1994;42:149-50.
Copyright'" 1994 by Mosby-Year Book, Inc. 0029-6554/94/$3.00 + 0 35/39/56935
NURSING OUTLOOK
for the currently certified and that it also does not give authority to the state board of nursing to establish this educational requirement. That concerns them} as well it should. How did it happen that the bill equivocates on requiring the master's degree as the educational requirement for all advanced practice nurses? The answer is simply that consensus could not be reached among nurses themselves. This is opposition to requiring graduate preparation for advanced practice from nurses currently functioning in what they perceive to be an advanced practice role who do not possess the requisite educationel preparation. Because they lacked the essential educational credentials} they would not support a bill that required the master's degree for advanced practice. Nurses fighting within their own ranks is also not a new phenomenon. But why do we do it? Why do we fight with one another for the dubious privilege of retaining the lowest educational entry requirement among all health professions? Why is it that after this fight, which has prevented the profession from moving in the way that others (e.g., pharmacy and physical therapy) have moved} we wonder
JULY/AUGUST 1994
that other professions don't think of us as their colleagues? Why do many nurses still hold the opinion that educational programs are unavailable to them when the numbers of RN completion and master's programs have increased substantially in the past 30
Because they lacked the essential credentials, they would not support a bill that required the master's degree for advanced practice. years? The answers to these questions are complex, but I will advance a few ideas. Over 90% of nurses are women. A substantial body of sociological literature documents the social reality that women in our society are less valued than men, are treated unequally} and are, essentially, an oppressed group. LiAnderson
149
The second explanation for our lack brary shelves are filled with documentation of this unpleasant, but real, of movement on increasing the educapicture of women in this country. tional requirements for our profession What happens to people who occupy is economic. Why should nurses support a higher level of education when, this social status? Sociologists refer to oppressed group unlike other occupations, the remubchsvlot. antagonism and fighting neration is essentially the same for all among the group members. This inter- nurses?The explanation is found in the nal struggle ranges from vocalized ideo" fact that differentiated practice has not logicdisagreement to physical violence been a reality in most clinical settings, that can escalate to hideous propor- and, also, collective bargaining units tions. This phenomenon is a curiosity. have not bargained for differentiated Why , it is asked, do groups who are in pay scales. So we have treated a nurse such need of advancement fight among as a nurse as a nurse and asked each of themselves in ways that reinforce their them to perform the same role. Nurses devalued status in the eyes of others? have advanced to administrative posiBecause, it is argued, the group mem- tions without increasing their educabers have incorporated the value of the tion, and this advancement typically is larger society, and perversely, they too accompanied by economic gain. Nurses have not been hindered economically by the current system . A third reason may be found in Why do groups in looking closely at the changing demo" graphics of nursing and how they need of might influence what does and does advancement fight not happen. In a recent statewide suramong themselves vey of over 2000 newly graduated RNs,1 it was found that second career in ways that nurses (when compared to their tradireinforce their tional counterparts) are older, more devalued status in likely to be married with children, the eyes of others? place less emphasis on the academic quality of the school they attended, find nursing appealing for socioeconomic reasons, (e.g., place a higher hold disdain for each other. So they act value on money and job availability), in ways that reveals that disdain-they and come from more "traditional" fight each other. Certainly we have backgrounds in which their mothers witnessed women attacking other never worked outside the home. Does women on the issue of equal rights. this changing profile moderate against Women have railed against other elevating educational requirements bewomen who fight for equality, argu- cause the status quo meets the desire ing, for example, that they will destroy for career and upward social mobility? the family. And we certainly have seen Finally, an interesting analogy this phenomenon in nursing-nurses emerges between the failure of nursing who fight with nurses over specifying to reach consensus on educational prepan educational requirement that would aration for entry and advanced practice give us parity with other health pro- roles and the failure of this country to fessionals. In 30 years of trying, we ratify the Equal Rights Amendment have been unable to accomplish this. that would have provided equality of Legislators have told us repeatedly to rights under the law for women. In a get our act together and they will sup- provocative account of the ERA battle, port us, In Ohio, it is the physicians Jane Mansbridge draws several concluwho are holding to higher standards of sions that we might want to study.! The first is that when no tangible beneducation for nurses. 150
Anderson
efits are found in a change, there is an unwillingness on both sides to compromise and to dispense with ideology in favor of practical political reasoning . A .secondconclusion is that those who do not want to change often organize to create an effective backlash. And last!y J in any attempt to organize for a general interest rather than for a particular interest, the general interest will inevitably count less in the political process. At times, the realities of our struggle weigh heavily, but they are always balanced by the remarkable achievements that nurses have and are making in spite ofour travails. In many parts of this country I see advanced practice nurses making substantial contributions to the health care of many, par" ticularly those who have limited or no access to care. We do practice what we preach -that all people have a right to health care. I see our body of research growing, research that is making a difference in the care we provide. Nurse educators are working very hard to make curricular changes that will pre" pare OUI graduates for a rapidly changing health care environment. I feel a substantial commitment to the proiession from many, and I am privileged to interact on a regular basis with power" ful, gifted, talented nursing leaders, On balance, I am more hopeful than not, but we must continue to work hard to make needed changes by following Mansbridge's recommendation for pro" moting the common good by keeping our organizations strong and wellfunded and by maintaining an internal dialogue on substantive issues. The enemy without is a more deserving foe than the enemy within. _
REFERENCES 1. Lerner DJ, D' Agostino RB, Musolino S, Malspeis S. Breaking with tradition, the new groups in professional nursing. Medical Care 1994;32(1),67-80, 2, Mansbridge JJ. Why we lost the ERA. Chi· cago. University of Chicago Press, 1986.
VOLUME 42 • NUMBER 4
NURSING OUTLOOK
Carole A. Anderson, PhD, RN, FAAN
I
n my state (and} I assume} in many others) there is a battle being fought between organized medicine and nursing. This battle centers on the roles of physicians and nurses} how they can or cannot work together} and on control. Specifically} the battle surrounds pending legislation that gives title recognition to advanced practice nurses in Ohio} recognition that is long overdue and substantially behind most of the rest of the country. Nonetheless} the state medical association has many concerns with the bill} the most substantial of which are questions concerning "supervision" versus "collaboration" and} interestingly enough, required educational preparation. The first concern is one with which we nurses are all familiar: the degree of autonomy that an advanced practice nurse can exercise in the delivery of services. This struggle over physician control of nursing practice is not new and, after much debate} will in all likelihood be resolved through compromise. The second concern is different. Physicians are concerned that the bill does not mandate a master's degree NURS OUTLOOK
1994;42:149-50.
Copyright'" 1994 by Mosby-Year Book, Inc. 0029-6554/94/$3.00 + 0 35/39/56935
NURSING OUTLOOK
for the currently certified and that it also does not give authority to the state board of nursing to establish this educational requirement. That concerns them} as well it should. How did it happen that the bill equivocates on requiring the master's degree as the educational requirement for all advanced practice nurses? The answer is simply that consensus could not be reached among nurses themselves. This is opposition to requiring graduate preparation for advanced practice from nurses currently functioning in what they perceive to be an advanced practice role who do not possess the requisite educationel preparation. Because they lacked the essential educational credentials} they would not support a bill that required the master's degree for advanced practice. Nurses fighting within their own ranks is also not a new phenomenon. But why do we do it? Why do we fight with one another for the dubious privilege of retaining the lowest educational entry requirement among all health professions? Why is it that after this fight, which has prevented the profession from moving in the way that others (e.g., pharmacy and physical therapy) have moved} we wonder
JULY/AUGUST 1994
that other professions don't think of us as their colleagues? Why do many nurses still hold the opinion that educational programs are unavailable to them when the numbers of RN completion and master's programs have increased substantially in the past 30
Because they lacked the essential credentials, they would not support a bill that required the master's degree for advanced practice. years? The answers to these questions are complex, but I will advance a few ideas. Over 90% of nurses are women. A substantial body of sociological literature documents the social reality that women in our society are less valued than men, are treated unequally} and are, essentially, an oppressed group. LiAnderson
149
The second explanation for our lack brary shelves are filled with documentation of this unpleasant, but real, of movement on increasing the educapicture of women in this country. tional requirements for our profession What happens to people who occupy is economic. Why should nurses support a higher level of education when, this social status? Sociologists refer to oppressed group unlike other occupations, the remubchsvlot. antagonism and fighting neration is essentially the same for all among the group members. This inter- nurses?The explanation is found in the nal struggle ranges from vocalized ideo" fact that differentiated practice has not logicdisagreement to physical violence been a reality in most clinical settings, that can escalate to hideous propor- and, also, collective bargaining units tions. This phenomenon is a curiosity. have not bargained for differentiated Why , it is asked, do groups who are in pay scales. So we have treated a nurse such need of advancement fight among as a nurse as a nurse and asked each of themselves in ways that reinforce their them to perform the same role. Nurses devalued status in the eyes of others? have advanced to administrative posiBecause, it is argued, the group mem- tions without increasing their educabers have incorporated the value of the tion, and this advancement typically is larger society, and perversely, they too accompanied by economic gain. Nurses have not been hindered economically by the current system . A third reason may be found in Why do groups in looking closely at the changing demo" graphics of nursing and how they need of might influence what does and does advancement fight not happen. In a recent statewide suramong themselves vey of over 2000 newly graduated RNs,1 it was found that second career in ways that nurses (when compared to their tradireinforce their tional counterparts) are older, more devalued status in likely to be married with children, the eyes of others? place less emphasis on the academic quality of the school they attended, find nursing appealing for socioeconomic reasons, (e.g., place a higher hold disdain for each other. So they act value on money and job availability), in ways that reveals that disdain-they and come from more "traditional" fight each other. Certainly we have backgrounds in which their mothers witnessed women attacking other never worked outside the home. Does women on the issue of equal rights. this changing profile moderate against Women have railed against other elevating educational requirements bewomen who fight for equality, argu- cause the status quo meets the desire ing, for example, that they will destroy for career and upward social mobility? the family. And we certainly have seen Finally, an interesting analogy this phenomenon in nursing-nurses emerges between the failure of nursing who fight with nurses over specifying to reach consensus on educational prepan educational requirement that would aration for entry and advanced practice give us parity with other health pro- roles and the failure of this country to fessionals. In 30 years of trying, we ratify the Equal Rights Amendment have been unable to accomplish this. that would have provided equality of Legislators have told us repeatedly to rights under the law for women. In a get our act together and they will sup- provocative account of the ERA battle, port us, In Ohio, it is the physicians Jane Mansbridge draws several concluwho are holding to higher standards of sions that we might want to study.! The first is that when no tangible beneducation for nurses. 150
Anderson
efits are found in a change, there is an unwillingness on both sides to compromise and to dispense with ideology in favor of practical political reasoning . A .secondconclusion is that those who do not want to change often organize to create an effective backlash. And last!y J in any attempt to organize for a general interest rather than for a particular interest, the general interest will inevitably count less in the political process. At times, the realities of our struggle weigh heavily, but they are always balanced by the remarkable achievements that nurses have and are making in spite ofour travails. In many parts of this country I see advanced practice nurses making substantial contributions to the health care of many, par" ticularly those who have limited or no access to care. We do practice what we preach -that all people have a right to health care. I see our body of research growing, research that is making a difference in the care we provide. Nurse educators are working very hard to make curricular changes that will pre" pare OUI graduates for a rapidly changing health care environment. I feel a substantial commitment to the proiession from many, and I am privileged to interact on a regular basis with power" ful, gifted, talented nursing leaders, On balance, I am more hopeful than not, but we must continue to work hard to make needed changes by following Mansbridge's recommendation for pro" moting the common good by keeping our organizations strong and wellfunded and by maintaining an internal dialogue on substantive issues. The enemy without is a more deserving foe than the enemy within. _
REFERENCES 1. Lerner DJ, D' Agostino RB, Musolino S, Malspeis S. Breaking with tradition, the new groups in professional nursing. Medical Care 1994;32(1),67-80, 2, Mansbridge JJ. Why we lost the ERA. Chi· cago. University of Chicago Press, 1986.
VOLUME 42 • NUMBER 4
NURSING OUTLOOK