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Always a Nurse

A Profession for a Lifetime

Sanford, Kathleen D. DBA, RN, FACHE, FAAN

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Nursing Administration Quarterly: January/March 2020 - Volume 44 - Issue 1 - p 4-11
doi: 10.1097/NAQ.0000000000000399
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Abstract

WHAT, exactly, is a nurse? Is he or she simply a person who graduated from an accredited school of nursing? Or, are nurses persons who successfully passed, in the United States at least, one of the state boards of nursing examinations? Does pursuing a career outside of what has historically been considered mainstream health care mean that an individual should no longer identify with the profession? Or, is a nurse only a nurse when his or her professional role involves direct patient (or direct client) interactions and care?

For most of the public, the primary visual image of nurses is probably a group of (mostly) women dressed in scrubs, who perform a variety of personal care or technical procedures in a hospital or clinic setting. Some older individuals may still envision women in white uniforms. Others, who have recently interacted with them outside of acute care, might include both men and women in business clothes, military uniforms, or laboratory coats in their description. They may have encountered nurses in homes, schools, office buildings, birthing centers, rehabilitation centers, prisons, drugstores, or freestanding urgent care and emergency facilities.

All of these depictions have one thing in common: all the nurses in these environments are seen in roles that involve direct interactions with those they are serving. In other words, it is recognized that nurses work in a variety of settings, but very few people would associate an image of, say, a virtual clinician or an executive in an office with “nurse.”

Nurses themselves might recognize the emergence of the virtual role as an appropriate specialty for their profession. However, some may not accept that a person who no longer provides personal care is still performing the role of a nurse. (The exceptions to this may be nurses in public health positions or college professors who are part of educating nurses in schools of nursing.) Gail Latimer, MSN, RN, FACHE, FAAN, recipient of the 2019 American Organization for Nursing Leadership (AONL) Lifetime Achievement Award, referred to this way of thinking when she was interviewed at the AONL annual meeting. She stated that some colleagues could not understand why she would go to work for a large information technology (IT) company. They told her she was “going to the dark side.” Gail, who has helped a myriad of nurses understand how technology can help patients and their caregivers, said, “Innovation is happening in industry. Nurses need to take jobs there. Who better than Florence Nightingale's professional descendants to bring the lamp of caring to the world in every way? We are able to light the corners while carrying the badge that we once touched patients.”

Some nurses whose career journeys include jobs outside of the public's conception of the prototypical nurse may agree they are “no longer caregivers.” Many, however, continue to see themselves as nurses. They are proud of their nursing roots and realize that their successes, their belief systems, and the very core of their beings are the results of being a lifetime member of a very special profession: Nursing.

THE MANY FACES OF NURSING IN HEALTH CARE

Nurses can be found in a variety of health care organization roles that do not include individual hands-on patient care. These include positions in management, executive practice, education, quality, patient experience, safety, human resources, recruiting, infection control, advocacy, chaplaincy, finance, care management, medical records, audit, insurance, strategy, supply chain, legal affairs, communications, compliance, and any number of other “business” activities. Hospitals and others have long recognized the value of unique skills that nurses bring to “non-nursing” jobs.

Management and executive roles filled by nurses may either be nursing specific (such as shift supervisors, unit managers, or chief nurse executives) or general health care management (such as chief executive officers [CEOs], chief operation officers, or formal leaders of non-nursing departments). Management is a specialty, a distinction that not all nurses recognize. Those who manage (and lead) well have defined characteristics, well documented in management literature. In fact, there is a large body of management theory and researched evidence-based practices for formal leaders.1 The failure of many nurses and nurse educators to recognize nursing management and nurse executive practice as a specialty that needs specialized education and experience has resulted in some poorly prepared nurse managers. Since managers have position power that affects culture, morale, nurse engagement (and therefore patient engagement), turnover, quality, and any number of practice environment factors, this has been detrimental to the profession, individuals, and entire organizations. It has led to the placement of great clinical specialists into a new specialty for which they are inadequately prepared. Sometimes, they are neither ready to competently perform their management jobs nor ready to advocate for their nursing colleagues and patients. In some cases, their lack of preparation or suitability to the role has reinforced perceptions of other health care leaders that nurses are not interested in, or able to manage, budgets or finances. In addition, if nursing management was widely recognized as a specialty that is just as legitimate as medical, surgical, behavioral health, or critical care, perhaps, more nurses would understand that nurses in formal leadership positions have not “left” nursing (Table 1).

Table 1. - Nurse Management as a Specialty
  • Specialties of a profession require practitioners to exhibit specific competencies. They have unique bodies of knowledge and best practices, which are informed through research.

  • Nursing specialists often establish specialized organizations for education, research, and other intellectual exchanges between members, primarily for the purpose of improving the specialty's ability to serve others.

  • There are >100 specialty nursing groups “in which nurses engage to develop and maintain competence....”2

  • While registered nurses in the United States all take a general nursing examination (state “boards”) for initial registration, specialists may also become certified in their specialty or obtain graduate degrees specific to their specialty.

  • Examples of organizations for nurses that choose to lead in nursing management include the following:

    • The American Organization for Nursing Leadership (AONL, formerly AONE), the “Voice of Nursing Leadership” ... “whether you're an aspiring nurse leader, an established director, or a seasoned executive.”3

    • The Association for Leadership Science in Nursing (ALSN, formerly CGEAN, Council on Graduate Education for Administration in Nursing), which is “where academia and practice collaborate to advance the science of leadership in nursing.” ALSN has a focus on nursing administration and leadership as well as research at both the graduate and undergraduate levels.4


Nurse CEOs are even more likely to be seen as no longer belonging to the nursing profession. Some have allowed their licenses to lapse; some do not use “RN” after their names. This is in stark contrast to physician CEOs, who consistently identify themselves as “doctors” (MD or DO). Others recognize that their nurse experience has enriched their professional lives and should give them more credibility as individuals who know that they are leading a clinical enterprise, not just a business that happens to provide health care. They are proud to claim nursing and to have other know that they have touched patients and can relate to the challenges faced by caregivers (Table 2).

Table 2. - Responses to Question: How Has Being a Nurse Made You a Better CEO?
CEO Question: How Has Being a Nurse Made You a Better CEO?
Laurie Harting, CEO, Greater Sacramento Division, CommonSpirit Health I have been a hospital or Division CEO for 15 y and I know my clinical background has provided me with the knowledge and expertise to talk directly with the physicians and nurses about practice patterns, supplies, and hospital operations. I know that once they learn that I am a nurse, they relax when they speak with me because they don't have to explain everything in the same level of detail that they do with nonclinical administrators. My clinical knowledge also allows me to challenge comments or complaints made by nurses because I have walked in their shoes—and sometimes I can offer alternative ways to think about a situation. I love being a nurse and I will always identify myself as a nurse.
Larry P. Schumacher, Senior VP Operations & CEO, Southeast Division, CommonSpirit Health Being a nurse with bedside and community experience has given me significant clinical credibility with physicians and clinical disciplines. My history gives me an expedient way to clearly comprehend their problems and help the clinical team work toward solutions. I think it has also given me the ability to listen intensely. I know and appreciate that clinicians want to be heard, and as a CEO who has been on the front lines, others can accept that I know and understand what I am hearing.
Linda Hunt, President, Arizona Division, CommonSpirit Health Being a nurse has taught me many lessons which have prepared me to be a CEO. The first lesson is that it takes a well-coordinated team to deliver outstanding patient care or run a complex health care organization. I know that clear concise communication, honesty, trust, and collaboration are all key attributes to being both a successful leader of organizations and a caregiver. The most important lesson I have learned is to listen attentively with your ears and your heart. Many times, it is more about what is not being said than what is being expressed. As a nurse, I developed a sixth sense that taught me to trust my instinct in situations and be observant and dig deeply to find out what is really going on. Your gut reaction, many times, is the best guide to form your actions.
Julie J. Sprengel, President, Southwest Division, CommonSpirit Health Being a nurse gives us the unique perspective of not only clinical expertise but also being a part of the sacred journey of vulnerability which is at the core of the patient's experience. The best CEOs are those who truly understand their business but, more importantly, their “customers” and their employees. I would argue that there is no one better to understand and lead health care than someone who knows both.
Abbreviation: CEO, chief executive officer.

“Nurses as hospital administrators” is not a new phenomenon. In fact, historians Margarete Arndt and Barbara Bigelow have published several articles about the history of hospital management, as described in Table 3.

Table 3. - Nurses as the Early Hospital Administrators
Early hospital administrators were called superintendents. The majority were nurses, other than physicians, who were mostly in academic institutions. Margarete Arndt, who teaches at the Clark University Graduate School of Management in Worcester, Massachusetts, has studied extensively the evolution of “hospital administration, including how the field was “masculinized.”5
In 1929, a book was published, titled Hospital Administration a Career: The Need for Trained Executives for a Billion Dollar Business, and How They May be Trained. In 1934, the University of Chicago established the first graduate program in hospital administration, with the book's author, Michael Davis, as the program leader. In the 1940s, other universities began to offer this degree. Once these MHA programs were established, hospitals who wanted educated administrators could only hire men because university graduate programs admitted virtually no female students.6
Arndt has also described the problems faced by female hospital superintendents that business leaders felt would be solved by moving to educated businessmen as hospital administrators:
  1. Less than ideal relationships with physicians5;

  2. The need to find funds (capital) for new technologies; and

  3. The increasing costs of health care.6

Abbreviation: MHA, master in hospital administration.

A third group of nurses who are sometimes accused of having “left” nursing (and “joined” medicine) are those who have selected advanced practice specialties. Although they are educated in schools of nursing, have nursing licenses, have “nurse” in their specialty titles (nurse midwife, nurse anesthetist, nurse practitioner, etc), and are under the jurisdiction of state boards of nursing, they are sometimes not identified with the profession. By definition, physicians and advanced nurse practitioners are not the same:

Doctors, at their core, are scientists; they study diseases and how to cure them. Nurse practitioners, at their core, are healers. The vast majority began their careers as registered nurses, and focus their care on wellness of the whole body and mind. That's not to say that doctors never take a more holistic approach to health, or that Nurse Practitioners don't use scientifically tested treatments—there's plenty of overlap—but their basic approach to patient care differs at the philosophical level.2

In addition, their biggest professional support continues to come from nursing organizations and nurse leaders who advocate for them and for laws/regulations that allow them to practice at the top of their licenses (Table 4).

Table 4. - Examples of Nursing Organizations Supporting Education and Practice of Advanced Practice Nurses
  • The American Nurses Association (ANA) “strongly supports full practice authority for all APRN roles. Full practice authority is generally defined as an APRN's ability to utilize knowledge, skills, and judgement to practice to the full extent of his or her education and training.”7

  • The American Academy of Nursing (AAN) position statement: “Full practice authority for advanced practice registered nurses is necessary to transform primary care.”8

  • The American Association of Colleges of Nursing (AACN) position statement includes recommendations that “the practice doctorate be the graduate degree for advanced practice nursing practice preparation,” and “practice-focused doctoral programs need to be accredited by a nursing accrediting agency recognized by the United States Secretary of Education.”9

  • The National League for Nursing (NLN) is gravely concerned about language in the AMA (American Medical Association) resolution that implies APRN-certified nurses have not completed the necessary educational and training requirements to serve as primary care practitioners. APRNs are committed, the NLN contends, to providing health services to the full scope of their education and practice. The NLN supports the creation and expansion of collaborative models between nurses and physicians that continually increase access to outstanding patient care, particularly to individuals and families in underserved communities, with the goal of advancing the health of our nation.10

  • The American Association of Nurse Practitioners (AANP) supports “NPs in all areas of practice, so that you can focus on your patients,” and works to “remove barriers and secure full and direct access to NP services.”11

Abbreviations: APRN, advanced practice registered nurse; NP, nurse practitioner.

NURSES IN ROLES OUTSIDE OF TRADITIONAL HEALTH CARE

While most nurse leaders recognize the natural fit between nurses and health care roles that do not quite fit the stereotypes, many members of the public do not realize the variety of ways that nursing is practiced. They might be surprised to learn that there are organizations such as The American Association of Nurse Attorneys (TAANA) and the National Nurses in Business Association (NNBA).

They may know that nursing specialties include hospice, camp, cruise ship, public health, dialysis, correctional (prison), and flight nursing. These roles are still considered hands-on. Some community members may have crossed paths with nurses who are health coaches or who serve as occupational nurses, with responsibility for the health and safety of workers in industry. It is less likely that they are aware that nurses serve as informaticists, who combine the sciences of nursing and analytics; telehealth clinicians, who triage patients and help them discern next steps for care they may need; forensic nurses, with special training in protection of evidence, who care for the victims of trauma or violence in the criminal justice system; case managers, who coordinate an individual's care across the confusing landscape of a fragmented health system; or nurse writers, who compose educational/academic materials, author articles for journals or magazines, write history books, or even develop television and movie scripts that involve health care.

Nurses perform all of these roles and more. Some are also lobbyists for patients and the professionals who care for them. Some serve on boards, where they can bring the voice of these groups to decision tables. Others have determined that their knowledge and passion for healing individuals, communities, and nations can be most influential when they serve as elected officials. Table 5 describes nurse who have served (or are currently serving in) the Congress of the United States.

Table 5. - Nurses Serving in the Congress of the United States of Americaa
Congresswoman Lois Capps was a member of the United States House of Representatives from March 1998 until January 3, 2017. She represented California's 24th District. She worked for 20 y as a nurse and health advocate for public schools. She was a strong supporter of the Patient Protection and Affordable Care Act. She founded the Congressional Nursing Caucus and the School Health and Safety Caucus. She also co-founded, among others, the Congressional Caucus on Women's Issues, the Biomedical Research Caucus, the House Cancer Caucus, the Heath and Stroke Coalition, and the Caucus on Infant Health and Safety.13
Congresswoman Lauren Underwood, from the 14th District of Illinois, was elected in January 2019. Her nursing history includes working with the Medicaid Plan in Chicago, acting as senior advisor at the US Department of Health and Human Services, and assisting communities across the country to prevent and respond to disasters, bioterrorism threats, and public health issues. She has also taught advanced practice students.13
Congresswoman Eddie Bernice Johnson elected by the 30th District of Texas was previously the chief psychiatric nurse at the VA hospital in Dallas. She assumed office on January 3, 1993, after 16 y in that position.12 Before being elected to Congress, she served in the Texas State House and the Texas State Senate. She chairs the Committee on Science and Technology and sits on the Committee on Transportation and Infrastructure.
Abbreviation: VA, Veterans Affairs.
aNurses also serve in several state government legislatures, where they have been “working hard to right some wrongs they see happening to nurses and the general public.”14

THE PAST, PRESENT, AND FUTURE FOR NURSING

There are multiple books that chronicle the history of nursing. Some record the life stories of individual nurses, such as Mary Eliza Mahoney, Edward Lynn, Clara Barton, John Hogan, Catherine McCauley, Walt Whitman, Juan Ciudad, and, of course, Florence Nightingale. Others, such as in the beautiful book by Patricia Donahue, Nursing, the Finest Art: An Illustrated History,15 trace the history of a profession essential to the well-being of humanity.

The calendar is about to turn to the year 2020, which has been declared the Year of the Nurse and Midwife by the World Health Organization. Governments around the world have endorsed this, recognizing that the goal of universal health care will not be accomplished without these professionals. 2020 is also the 200th anniversary of the birth of Florence Nightingale and the third year of the international “Nursing Now” campaign, which has a goal of increasing worldwide health by improving the profile and status of nurses. Acknowledging the variety of roles that nurses play in their quest for universal “wellness” can help with that objective.

Today's nurses continue to use their intelligence, skill, experience, passion, and holistic concern for all people in more diverse arenas than ever before. This article is followed by a series of first-person accounts of jobs that might not, at first consideration, look like nursing roles. The nurse authors of these narratives are a very small sample of those who have pursued education and opportunities that took them away from the bedside, but who retain their identity as nurses. Every one of them speaks about how their nursing education (including training based on the Nursing Process—see Table 6) and experience as direct caregivers have provided the foundation for their lives and current work. They have not “left” their profession. They have carried nursing—embodied by their intellect, healing energy, love, and desire to improve the wellness of the world—with them ... because they are nurses.

Table 6. - The Nursing Processa (A Scientific Method Taught and Used by Nurses to Ensure Quality of Patient Care)
I. Assessment The nurse gathers information about the patient's psychological, physiological, sociological, and spiritual status. This is done through patient interviews, physical examinations, patient and family history, and general observation.
II. Diagnosis The nurse makes an educated judgment about potential or actual patient health problems. Multiple diagnoses are sometimes made for a single patient. These include present problems and risks of future problems.
III. Planning Nurse and patient agree on diagnoses. A plan of action is then developed. Each problem is assigned a clear, measurable goal. Nurses refer to standardized terms and measurements for tracking patient wellness.
IV. Implementing Nurse follows through on plans of action, which are specific to each patient. Actions include monitoring, direct care, performance of technical procedures, educating and instructing patients and family, and referring or contacting patient for follow-up.
V. Evaluating Nurse evaluates whether goals for wellness have been met. Possible outcomes are improvement in patient condition, stabilized patient condition, or the patient's condition deteriorated. If the patient has shown no improvement or wellness goals have not been met, the process begins again from the first step.

REFERENCES

1. Bass B, Bass R. The Bass Handbook of Leadership Theory, Research, and Managerial Applications. 4th ed. New York, NY: Free Press; 2008.
2. Schneider A. Nursing organizations: the role they play in professional development. AMN Healthc Educ Ser. https://www.rn.com/nursing-organizations. Accessed October 5, 2019.
3. American Organization for Nursing Leadership. Home page. https://www.aonl.org. Accessed October 5, 2019.
    4. Association for Leadership Science in Nursing. Home page. https://nursingleadershipscience.org. Accessed October 5, 2019.
      5. Arndt M. Education and the masculinization of hospital administration. J Manag Hist. 2010;16(1):75–89.
        6. Arndt M. Hospital administration in the early 1900's: visions for the future and the reality of daily practice. J Healthc Manag. 2007;2(1):34.
          7. American Nurses Association. ANA's principles for advanced practice registered nurse (APRN) full practice authority. https://www.nursingworld.org/∼4af5d1/globalassets/docs/ana/ethics/principles-aprnfullpracticeauthority.pdf. Accessed October 5, 2019.
            8. Bosse J, Simmonds K, Hanson C, et al. Position statement: full practice authority for advanced practice registered nurses is necessary to transform primary care. https://www.nursingoutlook.org/article/S0029-6554(17)30558-4/fulltext. Accessed October 5, 2019.
              9. American Association of Colleges of Nursing. AACN position statement on the practice doctorate in nursing. https://www.aacnnursing.org/DNP/Position-statement-on-the-practice-doctorate-in-nursing. Accessed October 5, 2019.
                10. National League for Nursing. News release: the National League for Nursing decries AMA resolution 214 opposing expanded practice role for advanced practice registered nurses outlined in multi-state compact. http://www.nln.org/newsroom/news-releases/news-release/2017/11/22/the-national-league-for-nursing-decries-ama-resolution-214-opposing-expanded-practice-role-for-advanced-practice-registered-nurses-outlined-in-multi-state-compact. Published November 22, 2017. Accessed October 5, 2019.
                  11. American Association of Nurse Practitioners. Home page. https://www.aanp.org. Accessed October 5, 2019.
                    12. Congress.gov. 93rd-116th Congress (1973-2020). About members. https://www.congress.gov/member. Accessed October 5, 2019.
                      13. American Nurses Association. Nurses serving in congress. https://www.nursingworld.org/practice-policy/advocacy/federal/nurses-serving-in-congress. Accessed October 5, 2019.
                        14. Larson J. Nurse legislators: representing health care in state government. https://www.americanmobile.com/nursezone/nursing-news/nurse-legislators-representing-health-care-in-state-government. Accessed October 5, 2019.
                          15. Donahue P. Nursing, the Finest Art: An Illustrated History. St Louis, MO: CV Mosby; 1985.
                          16. Nursingprocess.org. The 5 steps of the nursing process. https://www.nursingprocess.org/Nursing-Process-Steps.html. Accessed October 5, 2019.
                            Keywords:

                            diverse nursing roles; nursing process; nursing specialties

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