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This essay explores the following question: 'What is nursing?' An examination of the role of the professional nurse.' Various national and international definitions of nursing are discussed, followed by an examination of public perceptions of nursing. The changing role of the nurse in the 21st century is outlined, including a discussion of changes in the educational requirements of nurses. The evidence presented within the essay is synthesised to inform a conclusion to the question posed.
The aim of this essay is to answer the following question: 'What is nursing? An examination of the role of the professional nurse.' In answering this question, the concept of professionalism will be explored, as well as how far this is reflected in the role of the nurse in the 21st century. Firstly, the various national and international definitions of nursing will be discussed, along with an examination of some of the common myths and stereotypes inherent within society. This will be followed by an examination of the changing role of nursing, the various patient and nurse perceived components of nursing, and the move towards a more academic-oriented profession. Nursing as a profession will be discussed, followed by a conclusion that summarises the key points raised within this essay.
There are a number of myths and stereotypes surrounding the nursing profession, including that nurses are female, white, young, wear uniforms, and work in hospitals. All of these myths can be challenged. Indeed, 63% of nurses are over 40-years of age and 29% over 50-years of age (Nursing and Midwifery Council, NMC, 2007, p.5). In fact, less than 2% are under 25-years old (NMC, 2007, p.5). Just as patients are being affected by an ageing population, so is the nursing workforce. In the UK, 27% of National Health Service (NHS) community nurses are over 50-years of age and will have retired within the next 10-years (Ball and Pike, 2009, p.15). Although the majority of nurses do fit the female stereotype, there are many male nurses (NMC, 2007, p.5). Nevertheless, figures for male nurses were stable from 2004 to 2008 (NMC, 2008, p.5), indicating a possible need to tackle discrimination in the form of the stereotype that male nurses are homosexual (Harding, 2007, p.636-644). Nurses in the UK come from many different nationalities, including Black and ethnic minorities recruited internationally (RCN, 2007, p.19). The number of UK nurses originally registered in other countries, including Asia and Zimbabwe have been shown to be increasing (RCN, 2007, p.20). The annual number of international work permits approved in 2005 was 129,660, with the top occupations being nursing and caring (19.9%) (Salt and Millar, 2006, p.1).
Only a small aspect of what nursing is can be answered by challenging the myths and stereotypes of the profession, and the definition remains unclear. It has been argued that "A definition of nursing would be too restrictive for the profession" (United Kingdom Central Council, UKCC, 1999, p.15). On the other hand, "If we cannot name it, we cannot control it, finance it, research it, teach it, or put it into public policy" (Clark and Lang, 1992, p.109). Furthermore, it is part of the social mandate of a profession to be clear about the nature of their work and the service offered (Donabedian, 1976). Defining nursing is especially important in the 21st century, where Florence Nightingale's words still hold true: "The elements of nursing are all but unknown" (Nightingale, 1859). This is because of the paradox of nursing, which is that the better the nursing care is, the less likely it will be explicitly identifiable (Clark, 1997, p. 144-152).
Florence Nightingale (1859) was possibly the first to attempt to define the nursing profession, describing nursing as putting "the patient in the best condition for nature to act upon him." (p.75). In 1960, Henderson broadened the definition as being "To assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he has the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible . . . In addition she helps the patient to carry out the therapeutic plan as initiated by the physician. She also, as a member of a team helps others as they in turn help her, to plan and carry out the total programme whether it be for the improvement of health, or recovery from illness, or support in death" (p.3). In this definition, Henderson recognises the independent and interdependent aspects of nursing that are critical to understanding the complexity of the profession. The definition also highlights the difference between nursing and medicine, whereby the nurse's purpose is to the help the patient, not the doctor.
There are many other definitions of nursing, which vary internationally, the most influential international definition being that which was developed by the American Nurses Association (1980): "nursing is the diagnosis and treatment of human responses to actual or potential threats to health." This definition encapsulates the process of clinical decision-making, which has become a core component of nursing.
The most modern UK definition is that offered by the Royal College of Nursing (RCN, 2003), who state that nursing is "The use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems and to achieve the best possible quality of life, whatever their disease or disability, until death" (p.3). In this core definition, there are six defining characteristics to the nursing profession: 1) a particular purpose (i.e. to promote health, prevent disease, and minimise the distress experienced by people with disease or disability); 2) a particular mode of intervention (i.e. personal care, education, advice, and advocacy); a particular domain (i.e. defined by individual responses to experiences of health, illness and disability); a particular focus (i.e. a holistic approach); a particular value base (i.e. ethical values, including the respect of individual dignity and autonomy); and, a commitment to partnership (i.e. partnership working with patients, their relatives and carers, and a multidisciplinary team). It has been emphasised that the uniqueness of nursing compared to other health professions is not in each of these characteristics, but in their combination (RCN, 2003, p.8).
Definitions of nursing are also incorporated in codes of ethics. This is the case in the Dutch Professional Code for Nursing, which commences with the question, 'what is nursing?' (NU91, 1997). Other countries, such as Australia, define nursing according to legislation or other specifications of nursing's scope of practice (i.e. what nurses do) (International Council of Nurses, ICN, 1998). This is not, however, the case in the UK, where responsibility lies with the profession's regulatory body, the NMC. The UK has, nevertheless, also primarily focused on what nurses do, in terms of roles and tasks, with it being argued that this is inadequate as what people do is dependent on circumstances, which change over time. This was acknowledged by the UKCC (1992), who stated that nursing "will continue to be shaped by developments in care and treatment, and by other events which influence it." This takes account of changes in policy, the country's economic stability, and changing demographics, etc. This also highlights the dynamic, complex nature of nursing as a profession.
Regardless of definition and whether the focus is on legislation or clinical practice, on what nurses do or who nurses are, the definitions all agree that nursing is about health, not just illness, and that nursing is a service available to all, regardless of age or setting. Furthermore, an important agreed upon aspect of nursing is the identification of "human responses to actual or potential health problems" as being the primary concern of nursing practice (RCN, 2003). Building on the notion of the 'human response,' it seems appropriate to examine the public's perceptions of what nursing is (i.e. their human response to nursing).
The Components of Nursing
The government document, 'Equity and Excellence: Liberating the NHS' (DH, 2010), sets out a vision for the transformation of the NHS transformation to a system where patients are at the heart of everything the NHS does. Indeed, patients and the public are having a greater say in what they want and expect from health professionals, including nurses. According to recent work in public consultation (DH, 2007), there are four key components of nursing identified as important to patients: getting the basics right and not leaving it to chance; fitting in with their life; treating them as a person rather than a symptom; and, working with them in partnership as opposed to them being a passive receiver of care. Patients also want nurses to have a caring and humane attitude, put the patient first, deliver high standards of service, and provide easy, timely and convenient access to care. In particular, patients emphasised how nursing is 'caring about' not just 'caring for' (Henderson et al., 2007, p.146). It is these components and characteristics that comprise nursing in the public eye.
In this public consultation, the attitude and approach of nurses in terms of the most important factors of nursing were the same as patients, highlighting the importance of the patient/nurse relationship within the profession. The main reason for entering the nursing profession was to 'make a difference' in people's lives. To nurses, five main aspects comprising the profession were valued the most and perceived to encapsulate what nursing is. These aspects were: making a difference to patients' lives; close contact with patients; delivering excellent care; working in a team and being a role model; and, continued professional development (CPD). Overall, good nursing was seen to be about the 'how' rather than the 'what' of health care delivery (i.e. how nursing care was provided rather than what care was provided). This contrasts historic perceptions of nursing as physical care (Novak, 1988), highlighting the complex nature of the contributing factors to changes in the nursing role.
The Changing Role of Nurses
Historically, nurses have expanded and extended their roles in many ways over the years. For example, nurses now take on greater responsibility for tasks traditionally carried out by doctors, such as prescribing medication (Jones, 1999). For the year ending 31st March 2008, there were a total of 49,428 nurses and midwives who held a prescribing qualification, which had risen from 37,683 in 2005 (RCN, 2008, p.10). The largest increase was in the qualification of Nurse Independent/Supplementary Prescriber, which increased from 2,151 nurses and midwives in 2005 to 13,965 in 2008 (RCN, 2008, p.10).
Prescribing is just one example of how nursing has changed over the years. Nursing care is now being provided closer to home and within the community, in part due to a drive towards achieving shorter hospital stays and thus an increasing need within the community for post-hospital support (RCN, 2010, p.3). Such work places greater autonomy and accountability to nurses, as well as increasing the professional nature of the role in terms of the quality of education and training needed. Indeed, a vast majority of nursing now takes place in the home and local community such as health centres, care homes, and schools, where nurses deliver care, treatment and support (RCN, 2010). Nurses have a number of roles in the community, including supporting families with a new baby, teaching schoolchildren how to manage conditions such as asthma or diabetes, enabling adults with learning disabilities to live independently, assessing and treating primary care patients, providing rehabilitation to people at home after an operation, and providing care to those who wish to die at home. There is now a greater choice for patients in terms of where they receive nursing care.
In the 21st century, nurses now also work for many different types of employer, not just the NHS. Indeed, changes in the law enable nurses in primary care to become partners in general practices or run nurse-led practices. The White paper, 'Our Health, Our Care, Our Say' provides entrepreneurial opportunities for nurses (DH, 2006), which has led to a rise in social enterprises, where nurses have identified what is not working in health care and actively changed the system in order to address these problems (Dawes, 2009, p.22-25). The 2004, the ICN estimated that about 1% of registered nurses are nurse entrepreneurs. There are generally two factors that motivate nurse entrepreneurism: 'push factors' (i.e. unemployment or job dissatisfaction) or 'pull factors' (i.e. market opportunities) (Traynor et al, 2006). With job cuts due to the recession and job dissatisfaction due to pressure on the NHS to meet targets, nurses are taking the social enterprise route.
The rapid and continued change within the nursing profession indicates that there will be yet another different picture of nursing in the future. Today's agenda for nurses is very much based on the White Paper (DH, 2006) and strengthening the work of nurses alongside GPs in commissioning local health services, supporting nurses in change, and focusing on the importance of CPD. There is a move towards thinking beyond nursing as a uni-dimensional concept but as part of a wider interdisciplinary concept. Indeed, there has been an essential culture change in nursing towards sharing ownership and responsibility for the wider health system with both patients and other health professionals.
In the document 'Future of Nursing and Midwifery in England 2010: Frontline Care,' a report by the Prime Minister's commission, emphasis has been placed on the need for investment and improvement in the basic and continuing education of nurses (Prime Minister's Commission, 2010). If the health service is to be transformed, then the way it is delivered by frontline professionals such as nurses also needs to be transformed. One of the largest changes that will affect nursing is the GP commissioning consortia responsible for commissioning local services (Lewis, 2011, p.5). Great efforts are being made to ensure that nurses are part of GP commissioning decisions (Lewis, 2011, p.5).
In preparing nurses for greater autonomy and responsibility, as well as further change within their workforce, the need for extra training and higher qualifications are now required of the profession.
The World Health Organisation (WHO, 2010) have developed a 'Framework for Action on Interprofessional Education and Collaborative Practice.' This framework purports to be "a call for action policymakers, decision-makers, educators, health workers, community leaders and global health at cuts to move towards embedding interprofessional education and collaborative practice in all of the services they deliver" (p.11). There is an emphasis on supporting nurses with changes in the NHS through CPD, with research and teaching from institutions of higher education being seen as playing a primary role in assisting nurses to meet the challenges facing their profession. It has been recognised that there needs to be a commitment to funding post-registration CPD for nurses, especially in terms of developing essential and effective leadership skills required in a persistently changing workforce and health system (Beasley, 2010, p.63).
In the UK, traditionally, nurses could either complete a 3-year diploma or a 3-4 year degree to qualify as a nurse. However, under new UK rules announced in 2009, the government has stated that by 2013 all nurses will have to be trained to degree standard, with a degree schedule that meets strict quality criteria (The Press Association, 2011). Nurses now require a high level of technical competence, clinical knowledge and decision-making skills in addition to their more traditional caring role. By qualifying to degree level, graduate nurses will have the range of skills they need to deal with the challenges of modern nursing. Although some have been sceptical about this, others believe it is an historic moment in terms of nursing gaining credence as a profession; after all, other health professionals are required to study to degree level or higher (The Press Association, 2011).
This is where the UK has been behind other countries, including Scotland and Wales. Nursing education has developed in universities in countries such as the USA, Canada, Australia, and the Netherlands, including the development of a discipline-specific knowledge base - nursing science. So, whilst some have questioned whether nursing is becoming too academic (Middlemiss, 2010, p.1), others believe quality care comes from evidence-based knowledge gained through education and research (Barnsteiner, 2010, p217-25). It could be argued that placing a greater emphasis on education and science in nursing does increase its credentials as a profession without taking away the humanistic component of the role.
Nursing as a Profession
Given the education and practical training, as well as the regulation and ethical codes associated with nursing, then nursing does indeed fit the criteria of being a 'profession' (Funder, 2010). Nevertheless, 'The Next Stage Review' (Department of Health, DH, 2008) promotes a new professionalism for nursing and has been referred to as a 'springboard' from which to reset nursing values, behaviours and relationships. The vision of 'tomorrow's nurse' defines professional registered nurses as skilled and respected practitioners who provide effective high quality care across a range of settings. They are valued members of a multidisciplinary team and work in partnership with patients and carers in delivering personalised care. The vision for tomorrow's nurses is that they are confident, effective leaders and champions who have a role not just in patient care but also policy-making. In this vision the nurse has three key professional roles: practitioner, partner, and leader. Thus, this vision recognises the dynamic and changing nature of nursing and health care, with these three roles providing opportunities for nurses to utilise their skills and knowledge in ways that other professions have been empowered to do so.
In the words of Christine Beasley (2006), Chief Nursing Officer, "nursing is more than the sum of its parts. Any health system needs nurses who are intellectually able and emotionally aware and who can combine technical clinical skills with a deep understanding and ability to care, as one human to another. This is a constant of nursing. It is the value base on which public trust rests and the profession is grounded. As a profession it is our promise to society" (p.63).
Despite the changing role of the nurse, from Florence Nightingale's era to the 21st century, it is likely that the nursing profession will continue to change now and in the future. In particular, with increasingly technical environments and the focus on evidence-based health care, it has been suggested that nursing needs to build on its heritage through scientific learning within a humanistic framework in an effort to confront the challenges presented by continued social, economic and demographic change. This will, indeed, be a challenge, but as demonstrated throughout this essay, nursing is a dynamic profession, responsive to adaptation required to meet the needs of patients and the public. Nursing is a patient-centred profession capable of meeting these challenges through partnerships with patients and multidisciplinary teams. Overall, nursing is about humanism, skill, knowledge, CPD, and working compassionately with "human responses."