Professional Roles for the Advanced Practice Nurse

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© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION PART 1 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Professional Roles for the Advanced Practice Nurse © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

In Part 1 of this book, we will consider the In Chapter 2, Pulcini defines advanced role ©of Jonesthe advanced & Bartlett practice nurseLearning, from LLCpractice nursing from a traditional© Jones per- & Bartlett Learning, LLC historical,NOT present-da FOR SALEy, and futureOR DISTRIBUTION perspec- spective and traces the historyNOTof the FORroles. SALE OR DISTRIBUTION tives. This content is intended to serve as a Traditionally, and as discussed by Pulcini, general introduction to select issues in pro- advanced practice has been limited to clin- fessional role development for the ad- ical roles and includes the clinical nurse vanced practice of nursing. As students specialist, nurse practitioner, certified © Jones &progress Bartlett in the Learning, educational processLLC and de- nurse–midwife,© Jones and certified & Bartlett registered Learning, LLC NOT FOR vSALEelop greater OR knowledge DISTRIBUTION and expertise, role nurse anestheNOTtist ;FORthe last SALE three roles OR reDISTRIBUTION- issues and role transition should be inte- quire a license beyond the basic RN license grated throughout the entire program. to practice. This book, however, uses an ex- In Chapter 1,Wolf presents a brief his- panded definition of the advanced practice tory of nursing and its progress toward nursing that reflects current thinking. As © Jones & Bartlett Learning,professional LLC practice. Although not spe©- Jonesyou read & thisBartlett chapter Learning,, keep in mind LLCthis ex- NOT FOR SALE OR DISTRIBUTIONcific to the role of the advanced practiceNOT pandedFOR SALEdefinition OR and DISTRIBUTIONat the same time ap- nurse, the information presented in this preciate the development of the advanced chapter will assist the advanced practice clinical roles for nursing practice. nurse to gain a broader perspective on Since Pulcini’s work in 2004, much has nursing and healthcare organizations and transpired related to the role and educa- their© future. Jones This & discussion Bartlett lays Learning, the foun- LLCtion of nurses for advanced practice.© Jones Most & Bartlett Learning, LLC dationNOT for aFOR deeper SALE understanding OR DISTRIBUTION of the revolutionary is the mandateNOT to have FOR the SALE OR DISTRIBUTION historical development, current practice, clinical doctorate as the requirement for and future opportunities for advanced advanced clinical practice nursing by 2015 practice in nursing. (American Association of Colleges of © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION111

2 I Part 1 Professional Roles for the Advanced Practice Nurse

Nursing, 2007).© Jones With &this Bartlett change, many Learning, mas- LLCand nurse researcher, a different© setJones of educa- & Bartlett Learning, LLC ter’s programs for advanced practice nurses will tional requirements exists. The clinical nurse transitionNOT to the FOR doctoral SALE level. TheOR rationaleDISTRIBUTIONleader as a generalist will remainNOT as a FORmaster’s SALE OR DISTRIBUTION for this position by the American Association of program. For nurse educators, the position of Colleges of Nursing (AACN) was based on sev- AACN, although not universally accepted within eral factors: the profession (as demonstrated by the existence of master’s programs in nursing education), is © JonesI The & Bartlettreality that Learning, current master’s LLC degree © Jones & Bartlett Learning, LLC that didactic knowledge and practical experience NOT FORprograms SALE often OR require DISTRIBUTION credit loads equiva- NOT FOR SALE OR DISTRIBUTION lent to doctoral degrees in other healthcare in pedagogy is additive to advanced clinical professions knowledge. Nurse researchers will continue to be prepared in PhD programs. Thus there will only I The changing complexity of the healthcare be two doctoral programs in nursing, the DNP environment and the PhD. It will be important for readers to © Jones & Bartlett ILearning, LLC © Jones & Bartlett Learning, LLC The need for the highest level of scientific keep abreast of this movement as the profession NOT FOR SALE OR DISTRIBUTIONknowledge and practice expertise to assureNOTfurther FOR develops SALE and OR debates DISTRIBUTION this issue for impli- high-quality patient outcomes cations for their own practice and professional In an effort to clarify the standards, titling, and development and within their own specialty. The outcomes of clinical doctorates, the Com- best resource for this is the AACN website and mission on© JonesCollegiate & BartlettNursing Education Learning, theLLC websites of specialty organizations.© Jones & Bartlett Learning, LLC (CCNE)—the accreditation arm of AACN—has The last three chapters of Part 1 discuss the decided thatNOT only FOR practice SALE doctoral OR DISTRIBUTIONdegrees future of advanced practice nursingNOT FORand the SALE OR DISTRIBUTION awarding a doctorate of nursing practice (DNP) evolution of doctoral education—in particular, will be eligible for accreditation. In addition, the practice doctorate. Within today’s rapidly the AACN has published The Essentials of Doctoral changing and complex healthcare environment, © JonesEducation & Bartlett for Advanced Learning, Nursing Practice, LLC which members of ©the Jones nursing & profession Bartlett are Learning, chal- LLC sets forth the standards for the development, lenging themselves to expand the role of ad- NOT FORimplementation SALE OR and DISTRIBUTION program outcomes for vanced practiceNOT nursing FOR SALEto include OR highly DISTRIBUTION DNP programs. skilled practitioners, leaders, educators, re- Needless to say, this recommendation has searchers, and policymakers. not been fully supported by the entire profes- In Chapter 3, Carter reviews the historical sion. For instance, the American Organization development of doctoral programs, which pro- © Jones & Bartlett ofLearning, Nurse Executives LLC (AONE, 2007) does not© Jonesvides important & Bartlett background Learning, information LLC re- NOT FOR SALE ORsuppor DISTRIBUTIONt requiring a doctorate for managerialNOTgar FORding howSALE the professionOR DISTRIBUTION has arrived at the or executive practice based on expense, time aforementioned decisions. Of particular note is commitment, and the cost benefit of the de- his discussion of the controversy surrounding gree. It also suggests nurses may migrate toward the development of the clinical doctoral pro- a master’s© degree Jones in business, & Bartlett social Learning, sciences, grams.LLC Carter traces the roots of© the Jones PhD for & re- Bartlett Learning, LLC and public health in lieu of nursing. Further, search and clinical doctorate for practice. As AONE suggestsNOT thereFOR is SALE a lack of OR evidence DISTRIBUTION to doctorates in nursing developedNOT in the FOR latter SALE OR DISTRIBUTION support the need for doctoral education across part of the last century, the emerging diversity all aspects of the care continuum. In contrast, in titling and role expectations called for clarity doctoral and master’s education for nurse man- and direction for the profession. © Jonesagers & and Bartlett executives Learning, is encouraged. LLC In Chapter© 4,Jones Chism &defines Bartlett the DNP Learning, de- LLC For other advanced practice roles, including gree and compares and contrasts the research NOT FORthose ofSALE the clinical OR nurse DISTRIBUTION leader, nurse educator, doctorate andNOT the practice FOR doctorate.SALE OR The DISTRIBUTIONfocus

References I 3

of the DNP© Jones degree is & expertise Bartlett in clinical Learning, prac- LLCneurs, along with advanced practice© Jones nurses’ & in-Bartlett Learning, LLC tice. Additional foci include the Essentials of creased involvement in public health program- Doctoral NOTEducation FOR for Advanced SALE NursingOR DISTRIBUTION Practice ming and integrative and NOTcomplementary FOR SALE OR DISTRIBUTION as outlined by the AACN (2007), which include health modalities. leadership, health policy and advocacy, and information technology. Role transitions for ad- REFERENCES © Jonesvanced & Bartlett practice nurses Learning, prepared LLCat the doctoral American Association© Jones of Colleges & Bartlett of Nursing. Learning, (2007). LLC level will call for an integration of roles focused Doctor of Nursing Practice. Retrieved from NOT FORon the SALE provision OR DISTRIBUTIONof high-quality, patient- http://www.aacn.nche.edu/DNP/DNPPositionNOT FOR SALE OR DISTRIBUTION Statement.htm centered care. American Organization of Nurse Executives. (2007). Lastly, in Chapter 5, the authors discuss Consideration of the Doctorate of Nursing emerging roles of DNP graduates as nurse edu- Practice. Retrieved from http://www.aone.org © Jones & Bartlett Learning,cators, nurse LLCexecutives, and nurse entrepre-© Jones/aone/docs/PositionStatement060607.doc & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONCHAPTER OBJECTIVES NOT FOR SALE OR DISTRIBUTION 1. Define professionalism. 2. Discuss the development of nursing as a profession over the last century. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT 3.FORConsider SALE futur ORe trDISTRIBUTIONends in nursing that have the potential toNOT FOR SALE OR DISTRIBUTION positively affect the profession of nursing.

© Jones &INTRODUCTION Bartlett Learning, LLC pressures. These© Jones include & demands Bartlett to Learning,jus- LLC tify healthcare service outcomes, the drive NOT FOR NSALEursing’s OR quest DISTRIBUTION for professionalism has NOT FOR SALE OR DISTRIBUTION shaped nursing education and practice, to maintain biomedical and technological past and present, in the United States and currency, and a recurrent nursing shortage. abroad. The emergence of professional Looking back through nursing history, one practice models over the past quarter cen- can see that crises in the healthcare system create opportunities for nursing. Too © Jones & Bartlett Learning,tury represents LLC the latest in professionaliz-© Jones & Bartlett Learning, LLC ing trends. This effort by nurses and often, nursing’s responses to crises have NOT FOR SALE OR DISTRIBUTIONhealthcare managers to restructure theNOT noFORt created SALE outcomes OR DISTRIBUTIONthat serve both the workplace and nursing work highlights interests of the profession and the public. the evolution of nursing from a simple Today, as nurses once again find them- matter of tasks to the complexity of selves in the midst of a crisis, there is an op- knowledge-based© Jones & practice Bartlett in rapidly Learning, chang- LLCportunity to renegotiate the organizational© Jones & Bartlett Learning, LLC ing healthcare organizations. The current realities of health care and to advance the healthcareNOT FORenvironment SALE is OR faced DISTRIBUTION with a contribution of professionalNOT nursing FOR to SALE OR DISTRIBUTION wide range of regulatory and financial healthcare outcomes.

6 I Chapter 1 The Slow March to Professional Practice

NURSING© ASJones A PROFESSION: & Bartlett Learning, LLCcently, health services research ©studies Jones have &in- Bartlett Learning, LLC KEY IDEAS FOR INTEGRATION tegrated the concept of nursing autonomy. For NOT FOR SALE OR DISTRIBUTIONexample, a recent study by NOTAiken, FOR Clarke, SALE OR DISTRIBUTION What makes work professional work? Nursing Sloane, Sochalski, and Silber (2002) suggested has struggled with this question throughout its that increasing nursing autonomy and control history. For most of the 20th century, nursing over the practice setting was associated with was considered a semiprofession or a profession © Jones & Bartlett Learning, LLC improved patient© Jones care outcomes. & Bartlett Learning, LLC in progress by sociologists (Bucher & Strauss, Nursing can no longer be viewed as a sub- NOT FOR1961; Etzioni,SALE 1969).OR DISTRIBUTION The attention that nurs- sidiary functionNOT of medicineFOR SALE that is ORproscribed DISTRIBUTION ing leaders have given to professional develop- by doctors’ orders; nursing care now reflects a ment is manifest in the push for control over patient-centered approach based on nursing educational standards, efforts to develop a the- theory and shaped by a nursing process of rea- ory base for nursing practice, the growth of pro- © Jones & Bartlett Learning, LLC © Jonessoning. & Current Bartlett legal Learning,and professional LLC regula- fessional organizations and journals, and, more tions legitimate this nurse-driven process of NOT FOR SALE ORrecently, DISTRIBUTION the reorganization of nursing workNOTpractice. FOR SALEThe body OR of statutoryDISTRIBUTION and case law within professional nursing practice models. that governs nursing practice holds nurses ac- The nature of professional nursing work differs countable to a definition of practice that rec- today from what it did for the sacred three pro- ognizes and codifies practice in accordance fessions of© medicine,Jones & law, Bartlett and the Learning,clergy in withLLC current nursing knowledge© Jonesand clinical & Bartlett Learning, LLC 1900. The autonomous solo professional ser- practice standards. Accountability is inherent ving the publicNOT with FOR exper SALEt knowledge OR andDISTRIBUTION skill to autonomy. By definition, NOTaccountability FOR SALE OR DISTRIBUTION is now a rare phenomenon. Few occupations calls for professionals to accept responsibility can claim pure professional autonomy, because or to account for their actions (Merriam- the reach of corporate and institutional control Webster’s Collegiate Dictionary, 2006). The de- © Jonesnow &dominates Bartlett most Learning, sectors of the LLC economy. mand for professional© Jones accountability & Bartlett has Learning, been LLC Autonomy, a hallmark of professionalism, spurred on by the health-outcomes movement NOT FORcan be SALE differentiated OR DISTRIBUTIONinto autonomy of decision and patient safetyNOT concerns. FOR SALE OR DISTRIBUTION making relative to the client and/or patient Professionalism should and does benefit the care and autonomy from the employing insti- public. However, professionalism also arises out tution (Manthey, 1991). Autonomous practi- of self-interest and provides a means by which tioners are those who have direct lines of access occupational groups exert influence to advance © Jones & Bartlett toLearning, clients, who LLC are responsible for their own© Jonestheir own & Bartlettinterests in Learning,society. The interest LLC may NOT FOR SALE ORpractice DISTRIBUTION decisions, and who are accountable toNOTref FORlect a desireSALE for ORgreater DISTRIBUTION societal power and/or clients, peers, and professional organizations, an increase of rewards or benefits for the group. as well as to the courts, for their conduct As such, the quest for professional status by (Marram, Schlegel, & Bevis, 1974). The nursing nursing reflects an attempt to access and profession has struggled with the idea of au- © Jones & Bartlett Learning, achievLLCe mobility. Professionalism,© Jonesby reflecting & Bartlett Learning, LLC tonomy because most nurses are employed and the underlying meritocratic values of our soci- subordinatedNOT to theFOR authority SALE of organizationsOR DISTRIBUTIONety, offers a rational system for distributingNOT FOR sta- SALE OR DISTRIBUTION such as hospitals (Ashley, 1976; Reverby, 1987; tus and rewards. Wolf, 1993). The claim to autonomy with re- Professionalization provides access to social gard to the freedom to make decisions about mobility. According to Hughes (1971), there © Jonespatient & Bartlett care has advancedLearning, over LLC the past few are two types© of Jones mobility. & The Bartlett first is the Learning, rise of LLC decades, fueled by the development of primary the individual by entering an occupation of NOT FORnursing SALE models OR (Hegyvary, DISTRIBUTION 1982). More re- high prestigeNOT or by achievingFOR SALE special OR success DISTRIBUTION in

Roots of Nursing Contradictions I 7

his or her© profession. Jones & The Bartlett second is Learning, the collec- LLCnizations. Nurses have historically© Jones highlighted & Bartlett Learning, LLC tive effort of an organized occupation to im- this phenomenon. More recently, other tradi- prove itsNOT place FOR and SALEincrease OR its powerDISTRIBUTION in tional professions (physicians,NOT lawyers) FOR have SALEbe- OR DISTRIBUTION relation to other occupational groups. In the come organizational professions. Yet, despite case of nursing, mobility has traditionally been nurses’ central role in healthcare services, they measured against or referenced to other groups, have struggled to develop, assert, and be recog- © Jonessuch & asBartlett physicians. Learning, LLC nized for their© Jones professional & Bartlett expertise. Learning,Imbued LLC Since the 1970s, interest in professionalizing with managerialism, nursing work in hospitals NOT FORnursing SALE work ORhas emerged DISTRIBUTION in healthcare organi- has evidencedNOT a professional FOR SALE paradox OR (Fourcher DISTRIBUTION zations as a means to provide a substitute moti- & Howard, 1981). The application of nursing vation for workers with blocked access to knowledge and skill in managing patient care in structures of mobility. The ideological draw of hospitals has a long history of being subjugated © Jones & Bartlett Learning,professionalism LLC is that it offers the promise ©of Jonesto nursing & Bartlett and hospitalLearning, administration. LLC higher status and control. A crucial issue that Nursing expertise has more often than not been NOT FOR SALE ORarises DISTRIBUTION out of the trend to professionalize workNOT is invisibleFOR SALE and undervalued, OR DISTRIBUTION and autonomy of the struggle of workers, including nurses, to ex- practice has been absent. ercise control over the context (environment) and content of their work. The ability to exer- ROOTS OF NURSING cise control,© Jones however & tentative, Bartlett appears Learning, to me- LLC © Jones & Bartlett Learning, LLC diate individual and collective tensions that CONTRADICTIONS arise fromNOT the FORheightened SALE expectations OR DISTRIBUTION of a The concept and actual practiceNOT of FOR nursing SALE OR DISTRIBUTION more educated nursing workforce. By profes- work has evolved dramatically over the past 100 sionalizing the workplace, management seeks years. But like many evolutionary paths, old or to counter more traditional collective action, outdated conceptions of nursing persist. As a © Jonessuch & asBartlett unionism. Learning, Educated to beLLC professionals result, both© popular Jones and & professionalBartlett Learning, concep- LLC in colleges and universities, nurses now expect tions of nursing are riddled with contradictory NOT FORto exercise SALE their OR knowledge DISTRIBUTION and skills without views. PriorNOT to Florence FOR Nightingale’sSALE OR reformsDISTRIBUTION organizational or bureaucratic constraint. The in England, nursing was largely women’s work. heightened expectations of nurses represent a Nursing was viewed as an extension of mother- double-edged sword, offering a challenge to tra- hood, midwifery, or religious duty. By the late ditional hierarchical controls and opportunity 19th century, women working as nurses began © Jones & Bartlett Learning,for institutional LLC enhancement. © Jonesto fill & a roleBartlett in the administrationLearning, LLC of poverty. NOT FOR SALE OR DISTRIBUTIONAs hospitals and other healthcare institu-NOT BecauseFOR SALE health care OR and DISTRIBUTION nursing care of the sick tions confront the increasing complexity in were intertwined with poverty, caring for the health care, the application of professional sick was largely caring for the poor. Nursing knowledge and skills becomes essential to insti- was commonly carried out by impoverished tutional ©functioning. Jones &That Bartlett professional Learning, knowl- LLCwomen who worked as nurses© inJones almshouses & Bartlett Learning, LLC edge and skills serve institutional goals to solve caring for the poor, the sick, and the destitute. institutionalNOT problems FOR SALE is now OR embraced DISTRIBUTION by These untrained, able-bodiedNOT paupers FOR worked SALE OR DISTRIBUTION healthcare administrators as an asset, rather for room and board. The harsh reality was that than a threat to traditional authority.Perrow these nurses were viewed as part of the chaotic (1972) observed in his classic treatise on bureau- environments in which they worked. The © Jonescracy & thatBartlett professionals, Learning, far from LLC antithetical to Dickinsonian© imageJones of Sairey& Bartlett Gamp, a Learning,low-class LLC institutional bureaucracy, are in fact readily har- drunkard and disheveled woman, was reflective NOT FORnessed SALE to serve OR the DISTRIBUTIONneeds and problems of orga- of the persistentNOT FOR stigma SALE that NightingaleOR DISTRIBUTION

8 I Chapter 1 The Slow March to Professional Practice

sought to ©escape Jones with the& Bartlettformal education Learning, of a LLC20th century, held nursing to© conventional Jones & Bartlett Learning, LLC higher class of women (Dean & Bolton, 1980; standards of female subservience within a hier- Williams, NOT1980). FOR SALE OR DISTRIBUTIONarchy of a moral female authority.NOT Nursing FOR was SALE OR DISTRIBUTION Although some few nurses saw their work as embraced as a feminine endeavor that was to be a religious service, the role of religious values the singular focus of the nurse’s life. Imbued waned with the disintegration of church-based with inherent religious values, nursing was © Jonesnursing & Bartlett orders with Learning, the rise of Protestantism LLC in viewed as a selfless© Jones act, and & the Bartlett reward for Learning, nurs- LLC England. Hospitals, lacking the support of reli- ing work was deemed intrinsic to the work it- NOT FORgious SALEnursing OR orders, DISTRIBUTION struggled to provide self. Nightingale,NOT althoughFOR SALE a feminist OR DISTRIBUTION and nursing care that was haphazard at best. supporter of women’s suffrage, struggled with Nurses lacked a systematic set of skills, a knowl- contradictions of class and gender as she ad- edge base, or training. Nightingale sought to vanced her campaigns for nursing and health. © Jones & Bartlett modernizeLearning, nursing LLC by developing a trained© JonesDespite & Nightingale’s Bartlett Learning,political opinions, LLC mod- nursing labor force composed of a higher class ern nursing was reconceptualized as a woman’s NOT FOR SALE ORof DISTRIBUTIONwomen. NOTcalling, FOR and SALE hence OR doubly DISTRIBUTION subordinated to the Nightingale also sought to link nursing edu- paternalism of society. cation with the more formalized development of hospitals. Influenced by her experiences in NURSING TAKES ROOT IN THE the Crimea,© NightingaleJones & recognizedBartlett thatLearning, nurs- LLC © Jones & Bartlett Learning, LLC ing care was the major determinant of hospital UNITED STATES outcomes.NOT A brilliant FOR andSALE politically OR DISTRIBUTION astute The universal traditions and nursingNOT functionsFOR SALE OR DISTRIBUTION woman, she took on nursing reformation with of caring for the sick have existed for centuries. a passion born of her religious beliefs and desire The power of Nightingale’s reforms to formal- to reform social expectations for women. ize and reshape nursing has been evident in © JonesNightingale & Bartlett advanced Learning, her case LLC for training their global ©reach. Jones In the & United Bartlett States, Learning, as in LLC nurses based on data. Nightingale contributed many other countries, the importation of the NOT FORsome ofSALE the earliest OR biostatisticalDISTRIBUTION data of hospi- NightingaleNOT schools FOR of nursing SALE legitimated OR DISTRIBUTION tal conditions and outcomes, drawing connec- nursing work as an occupation for women. tions between the environments of care and the Hospital-based schools of nursing offered contribution of nurses (Dossey, 1999). women access to education and the potential Despite Nightingale’s innovative ideas to for employment, creating an option for a sus- © Jones & Bartlett systematizeLearning, the LLCeducation of nurses, the origins© Jonestainable & livelihood.Bartlett Learning,Employment LLCas a head NOT FOR SALE ORof DISTRIBUTIONmodern nursing were seeded with social con-NOTnurse FOR or SALEprivate duty OR nurse DISTRIBUTION was a welcome al- straints. Nightingale (1866) wrote to a friend ternative to agrarian domesticity or mill work. that “the whole reform in nursing both at home The demand for nursing grew in response to and abroad has consisted of this: to take all hospital growth. As industrialization spurred power over© the Jones nursing &out Bartlett of the hands Learning, of men theLLC growth of larger communities,© Jones hospitals & Bartlett Learning, LLC and put into the hands of one female trained proliferated and became a central feature of head and NOTmaking FOR her responsibleSALE OR for DISTRIBUTION every- community life (Rosenberg, 1989).NOT Social FOR re- SALE OR DISTRIBUTION thing. . .” (p. 25). Nightingale and her contem- formism was a major force because it spurred poraries purposely overlooked the traditions of the development of both public health and men in nursing, such as the work of the Knights hospital-based services to provide health care to © JonesTemplar & Bartlett (Bullough Learning, & Bullough, LLC 1984). The the growing ©industrial Jones labor & Bartlett force (Rosenberg, Learning, LLC concept of nursing discipline projected by 1989; Starr, 1982). From 1875 to 1924, the NOT FORNightingale, SALE as OR well asDISTRIBUTION by nursing leaders in the number of hospitalsNOT FOR grew from SALE just ORover 170DISTRIBUTION to

The Changing Organization of Work I 9

more than© Jones7,000 (Rosner, & Bartlett 1989). However,Learning, as LLCply not generally available” (p. ©183). Jones Despite & for- Bartlett Learning, LLC noted by Stevens (1989), the central role that ward movement with the establishment of uni- health careNOT would FOR take SALEin American OR society DISTRIBUTION was versity schools of nursing at Columbia,NOT FOR Yale, andSALE OR DISTRIBUTION being shaped by the growing power of medi- Western Reserve, the push to establish college en- cine. A benevolent paternalism pervaded the trance as a requirement for practice was eclipsed structure of healthcare services and harnessed by the hospital training schools. The fundamen- © Jonesthe & potential Bartlett of nursing Learning, to support LLC the role of tal professional© Jones goal to control & Bartlett the entry Learning, into the LLC medicine and hospitals (Ashley, 1976). By the profession was overridden by hospitals’ needs for NOT FORearly SALE 1900s, ORthe growth DISTRIBUTION of hospitals in the a cheap laborNOT supply. FOR SALE OR DISTRIBUTION United States generated an unprecedented de- The rapid expansion of a nursing labor force mand for nurses. The growth of technology occurred with little regard for educational qual- from basic advances such as X-rays and anes- ity. Hospital administrators recognized the eco- © Jones & Bartlett Learning,thesia fueled excitementLLC in hospital investment.© Jonesnomic & benefit Bartlett of usingLearning, student LLC labor, and Physicians invested their money and technol- physicians began to appreciate the good nursing NOT FOR SALE ORogy DISTRIBUTION into hospitals, securing power in their com-NOT careFOR offered SALE by graduates OR DISTRIBUTION of such training. But munities as well. Hospitals became a focal point by the 1930s, concerns about overproduction of of community life, and hospitals became both a nurses emerged and were underscored by the symbol of the prosperity of a community and a Great Depression. A third of all hospital schools focus for© social Jones reformism. & Bartlett Learning, LLCof nursing closed between ©1929 Jones and 1939. & Bartlett Learning, LLC The thirst for a cheap and rapidly produced Nurses, no longer able to secure private duty labor supplyNOT overshadowed FOR SALE concerns OR DISTRIBUTIONover stan- work, sought employment in hospitalNOT FOR wards SALEfor OR DISTRIBUTION dards of quality education. From 1900 to 1920, hourly or group nursing work. But as Reverby the nursing profession grew “from one in which (1979) noted, hospitals were slow to hire gradu- there were more than 10 times as many physi- ates as staff nurses, despite admonishments by © Jonescians & asBartlett nurses, to Learning, one in which LLC there was less the nursing© leaders Jones and & the Bartlett American Learning, Nurses LLC than one physician for every nurse” (Burgess, Association. Modified grouped private duty NOT FOR1928, SALE p. 43). AsOR hospitals DISTRIBUTION grew, schools of nurs- nursing effortsNOT served FOR as aSALE transition OR to DISTRIBUTIONthe de- ing were created to provide a labor force for the velopment to staff nursing. The dire economic hospitals, often at the expense of adequate edu- conditions of the Depression reshaped nursing cation (Ashley, 1976). As Dock and Stewart work and healthcare services. Nursing shifted (1938) noted in their history of nursing, “the ex- away from private freelance work to organized © Jones & Bartlett Learning,cess of poor schools LLC and poorly prepared nurses© Jonesnursing & servicesBartlett in hospitals Learning, and public LLC health. NOT FOR SALE ORwas DISTRIBUTION attributed in large measure to the appren-NOT AsFOR nursing SALE became OR embedded DISTRIBUTION in hospitals, the ticeship system that prevailed, with its overem- primacy of the nurse–patient relationship—a phasis on practice service at the expense of characteristic of private duty nursing—eroded, education” (p. 183). Formal studies of nursing and the nurse became subordinated to the pa- education,© suchJones as the & Goldmar Bartlettk repor Learning,t (1923) LLCternalism of the hospital (Ashley© ,Jones1976; Dock & &Bartlett Learning, LLC and the grading committee report of the Stewart, 1938). NationalNOT League FOR for Nursing SALE Education OR DISTRIBUTION (1926), NOT FOR SALE OR DISTRIBUTION addressed the issue of raising standards for nursing education. Dock and Stewart (1938) sug- THE CHANGING ORGANIZATION gested that despite the many recommendations OF WORK © Jonesfor & reform, Bartlett “the systemLearning, was too LLC deeply rooted The organizational© Jones culture & Bartlettof hospitals, Learning, charac- LLC and the funds for putting nursing schools on a terized by strong gender-based roles and a hier- NOT FORsound SALE economic OR and DISTRIBUTION education basis were sim- archical authorityNOT FORstructure, SALE was fertile OR groundDISTRIBUTION

10 I Chapter 1 The Slow March to Professional Practice

for the application© Jones of &industrial Bartlett management Learning, LLCders under a system where work© conception Jones was& Bartlett Learning, LLC methods. The ideas of scientific management clearly separate from execution. made an easyNOT leap FOR from SALEfactory floor OR toDISTRIBUTION hospi- That the adage “a nurse is a nurseNOT is FOR a nurse” SALE OR DISTRIBUTION tals in the first half of the 20th century. was born in this period reflects the view that Frederick Taylor, the architect of many scien- nurses were considered an interchangeable part tific management ideas, was of a new breed of of the hospital machine. Although many nurses © Jonesindustrial & Bartlett engineers. Learning, His primary LLC concerns preferred to ©work Jones as private & Bartlett duty nurses, Learning, the LLC were enhancing worker productivity and limit- changing economics of the Great Depression NOT FORing the SALE threats ORof unions DISTRIBUTION so as to increase the made this anNOT unstable FOR option SALE by ORthe 1930s DISTRIBUTION profits from capitalism. Scientific methods (Reverby, 1999). As a result of application of sci- were intended to extract labor from workers at entific management methods to nursing, pa- the shop-floor level by dividing work into dis- tient care became fragmented, task oriented, © Jones & Bartlett creteLearning, tasks to beLLC done by individual workers.© Jonesand management & Bartlett focused. Learning, Case-based LLC nursing, “Taylorism” spread to hospitals and was em- rooted in the tradition of private duty nursing, NOT FOR SALE ORbraced DISTRIBUTION by nursing leaders, and the quest for effi-NOTfell FOR victim SALE to what OR was viewedDISTRIBUTION as progress. New ciency in hospital operations mirrored the models of care, such as group nursing and func- factory push toward mechanistic functioning. tional nursing, reflected the pooling of scarce The application of Taylor’s scientific manage- nursing labor resources to meet the needs of the ment methods© Jones to hospitals & Bartlett included divisionLearning, of orLLCganization, not the patient. © Jones & Bartlett Learning, LLC labor, the task orientation of functional nurs- Following World War II, team nursing being, and standardizedNOT FOR and SALE proscriptive OR DISTRIBUTION proce- came the common model of nursingNOT FOR care or- SALE OR DISTRIBUTION dure manuals. Hospitals were in a unique ganization. The team nursing concept was position to maximize the control and the exe- influenced by wartime experiences and the cution of nursing work, because they were often emerging human relations school of manage- © Jonesboth & the Bartlett diploma Learning,schools for training LLC nurses ment. The goal© wasJones to create & Bartlett a team of nursingLearning, LLC and the employer. The hospital culture was able care providers led by a professional nurse. NOT FORto secure SALE the loyaltyOR DISTRIBUTION of nurses through both Emphasis wasNOT placed FOR on effective SALE communica- OR DISTRIBUTION school ties and training (Wolf, 1993). tion and delegation to enhance team function- Management in hospitals emerged largely at ing. However, nursing shortages often resulted the ward level. Mobility in nursing became tied in team leaders struggling to provide care with to the management structure. Nursing leader- inadequately trained staff. The result of the © Jones & Bartlett shipLearning, embraced LLC managerialism, because it of-© Jonesteam approach & Bartlett was more Learning, a functional LLC approach NOT FOR SALE ORfered DISTRIBUTION the potential for mobility and statusNOTto FOR care, withSALE emphasis OR DISTRIBUTION on task completion recognition for women. Subordinated to physi- rather than patient care (Hegyvary, 1982). cians, nurses were unable to gain control over Because of tradition and nursing shortages, access to patients, use of technology, or applica- remnants of mechanistic task performance con- tion of knowledge.© Jones Nursing& Bartlett leader Learning, Isabel tinuedLLC to permeate the work culture© Jones of hospitals & Bartlett Learning, LLC Stewart attempted to advance scientific nurs- and counter professionalization attempts. ing, whichNOT she thought FOR SALEcould be OR employed DISTRIBUTION in Nursing leader Lydia Hall, a NOTfierce opponent FOR SALE OR DISTRIBUTION conjunction with industrial methods for stan- of team nursing, challenged nursing to put its dardization and efficiency of hospital care to rhetoric of professionalism to the test of prac- wrest control from hospitals. However, her aca- tice. In 1963, she instituted a system of profes- © Jonesdemic & approachBartlett to Learning,building a scientific LLC basis for sional nursing© Jones practice &at Bartlettthe Loeb CenterLearning,, LLC practice was viewed skeptically by nurses and Montefiore Medical Center, in New York City. NOT FORnever SALEgained ORsufficient DISTRIBUTION financial support The Loeb modelNOT of careFOR emphasized SALE nursingOR DISTRIBUTION au- (Reverby, 1987). Nurses continued to follow or- tonomy and accountability, giving the nurse © Jones and Bartlett Publishers. NOT FOR SALE OR DISTRIBUTION

Instability in the Nursing Labor Force I 11

responsibility© Jones for providing & Bartlett care and Learning, making LLCtraining schools to colleges ©and Jones universities. & Bartlett Learning, LLC care decisions for his or her patients during the Early doctoral programs developed as hybrid full durationNOT of FORtheir hospital SALE stay OR (Hall, DISTRIBUTION 1969). degrees, between nursing and NOTfields suchFOR as SALEed- OR DISTRIBUTION Her visionary efforts planted ideas for change; ucation, sociology, psychology, and biology. however, few hospitals adopted her model. These graduate programs had as their primary focus the development of a pool of nursing ed- © Jones & Bartlett Learning, LLC ucators. But© within Jones a few & years, Bartlett collegiate Learning, nurs- LLC INSTABILITY IN THE NURSING ing education institutions expanded programs NOT FORLABOR SALE FORCE OR DISTRIBUTION in nursing administrationNOT FOR SALE and clinical OR special-DISTRIBUTION Despite the emphasis on efficiency and ratio- ization. Graduate education became the pri- nality in hospital management, the nursing mary incubator for nursing theory and the labor force continued to be wracked by instabil- growth of professional knowledge and values. © Jones & Bartlett Learning,ity. Recurrent LLC nursing shortages during the© JonesBy &the Bartlett 1970s, a cultureLearning, of professionalism LLC 1940s and 1960s led to the policies that in- emerged in nursing, fueled by the growth of NOT FOR SALE ORcreased DISTRIBUTION the production of more nurses—short-NOT nursingFOR SALE scholarship. OR ThisDISTRIBUTION resulted in a gap be- training nurses in particular. These nursing tween nurses’ expectations and the experiential shortages set the pattern for subsequent policy reality of nursing work. This gap, or reality initiatives dominated by hospital interests shock (Kramer, 1974), was evidenced by the (Grando,© 1998). Jones Hospital & Bartlett administrators Learning, and LLCrapid turnover in staff nursing© Jones and nurses’ & Bartlett Learning, LLC nursing leaders first encouraged licensed practi- growing discontent. Despite the move to a cal nursesNOT and thenFOR associate SALE degree OR nurses.DISTRIBUTION In more efficient hospital functioning,NOT FOR the nurs- SALE OR DISTRIBUTION the midst of the shortages, attempts to fill nursing labor force continued to be wracked by in- ing positions were like filling a leaking bucket. stability. Once again, nursing shortages led to Nurses were clearly unhappy with work condi- the increased production of nurses, in particu- © Jonestions & Bartlettand compensation. Learning, Shortages LLC of nurses lar short-training© Jones nurses. & Hospital Bartlett administra- Learning, LLC left team nurse leaders working alone as cap- tors and nursing leaders encouraged the NOT FORtains SALE of understaffed OR DISTRIBUTION nursing teams. While hos- addition ofNOT associate FOR degree SALE nurse OR production DISTRIBUTION pital nursing administrators struggled with the as a solution. outflow of nurses, nursing educators struggled Nursing education, long tied to hospitals with the quest to professionalize nursing. The through the tradition of hospital diploma development of nursing knowledge and skills schools, began to break free in the 1960s. The © Jones & Bartlett Learning,took on renewed LLC urgency at mid-century.© Jonesfederal & government Bartlett tookLearning, up more ofLLC the finan- NOT FOR SALE ORN DISTRIBUTIONursing scholars such as Virginia HendersonNOT cialFOR burden SALE for nursing OR DISTRIBUTION education. But as nurs- (1966) sought to reclaim the primacy of the ing education moved into colleges, the trade-off nurse–patient relationship and expand the was the loss of nurses’ loyalty to hospitals, a focus of nursing care beyond efficiency to a central characteristic of hospital-diploma- process-oriented© Jones effectiveness. & Bartlett Learning, LLCschool nurses. While hospital© administrators Jones & Bartlett Learning, LLC The post–World War II period led to in- struggled with the outflow of nurses, the creased federalNOT fundingFOR SALE for nursing OR and DISTRIBUTION health growth of college-based programsNOT at FOR the bac- SALE OR DISTRIBUTION care. Along with the funding came a new closer calaureate and associate degree levels infused scrutiny of hospital costs. As the federal govern- nursing with a new drive for professional status. ment became more involved with funding hos- As the development of nursing knowledge and © Jonespit &al care,Bartlett the drive Learning, to disentangle LLC educational skills took ©on Jones more status & Bartlett and legitimacy, Learning, the LLC costs from nursing care costs took force. predominance of nursing management as the NOT FORBy SALE the late OR 1960s, DISTRIBUTION funding of nursing educa- primary meansNOT of FOR career SALEmobility OR came DISTRIBUTION to an tion began to move away from the hospital end (Wolf, 1993). © Jones and Bartlett Publishers. NOT FOR SALE OR DISTRIBUTION

12 I Chapter 1 The Slow March to Professional Practice

MILITANCY© Jones ROCKS & THE Bartlett Learning, LLCworkers. The ANA-associated state© Jones nursing &or- Bartlett Learning, LLC HOSPITAL BOAT ganizations were viewed as the lesser of two evils NOT FOR SALE OR DISTRIBUTIONbecause the professionalism inherentNOT FOR in the SALE OR DISTRIBUTION Discontent with the reality of nursing work re- nursing leadership tempered the militancy. flected the changing values and expectations of Hospital administrators explored a variety nurses. With rising expectations of profession- of means to fight the spread of hospital union- alism, nurses’ desires for control over their work ism (Kohles, 1994). Treating various types of © Joneswere & influenced Bartlett by Learning, the new social LLC realities of © Jones & Bartlett Learning, LLC hospital workers as contract workers was com- women’s employment. Nursing was no longer NOT FOR SALE OR DISTRIBUTION mon, but thisNOT approach FOR was SALE neither OR cost- DISTRIBUTION nor viewed as a transient occupation for women to outcome-effective for nursing. Another ap- keep them busy until they married. The grow- proach was to create a new work culture and ing careerism sharpened nurses’ lenses to work- structure that would divide nurses from other place realities. Turnover rates in hospitals hospital employees. This served a double pur- © Jones & Bartlett reflectedLearning, the discontent LLC with working condi-© Jones & Bartlett Learning, LLC pose. First, it helped to insulate other hospital tions and benefits. Nurses, college educated and NOT FOR SALE OR DISTRIBUTION NOTworkers FOR SALEfrom nursingOR DISTRIBUTION collective action. empowered by the emerging women’s move- Second, it held the potential to curb the mili- ment, were no longer willing to bow to the pa- tancy. To effectively bridge the reality gap that ternalism of hospital administrators. had led to nurse militancy, nursing and hospi- At various points in nursing history, nurses tal administrators needed to realistically grap- had discussed© Jones or attempted & Bartlett the use of Learning, collective LLC © Jones & Bartlett Learning, LLC ple with the roots of nurses’ frustration. The action or unionism. The rate of nurses organiz- NOT FOR SALE OR DISTRIBUTIONlong-standing paternalism was NOTno longer FOR an ef- SALE OR DISTRIBUTION ing for collective bargaining began to increase in fective means of controlling nurses. the 1960s, but it was not until 1974, with the addition of amendments to the federal Taft- NURSING IS NOT ALONE: Hartley Act, that the potential impact of THE NATIONAL CRISIS IN © Jonescollective & Bartlett bargaining Learning, was realized LLC(Foley, 1993). © Jones & Bartlett Learning, LLC NOT FORThese SALEamendments OR providedDISTRIBUTION federal protection THE QUALITYNOT OF FOR WORK SALE LIFE OR DISTRIBUTION to nurses and other healthcare employees of By the late 1970s, professionalism, long viewed nonprofit healthcare institutions with regard to as an unnecessary extravagance, was to become a the right to organize. The operational structure mantra for nursing management. The growing of the amendments emphasized that nurses were belief that creating a more professional work cli- © Jones & Bartlett toLearning, be a separate LLCand distinct bargaining unit. © Jonesmate could & Bartlett mitigate the Learning, potential for LLC workplace NOT FOR SALE OR DISTRIBUTIONThe potential of the nursing labor force toNOTmilit FORancy SALE shaped efORforts DISTRIBUTION to restructure nursing be a catalyst for the unionization of the entire work in hospitals. As hospital administrators hospital labor force was clearly recognized by and nursing grappled with what was perceived hospital administrators and union busting con- to be an issue of militancy versus professional- sultants. This, in turn, resulted in the idea of re- ization, the issue was reflected in broader dis- quiring hospital© Jones employees & Bartlett to organize Learning, into cussionsLLC of an emerging national© Jones crisis &in Bartlett Learning, LLC separate NOTbargaining FOR groups. SALE NursesOR DISTRIBUTION were workplace relations. Nationally, NOTas concerns FOR over SALE OR DISTRIBUTION courted initially by professional nursing organi- decreases in worker productivity grew, labor ex- zations, such as the ANA-affiliated state nurs- perts debated the origins and solutions to ing organizations. Within a few years, more worker discontent across a wide range of occu- traditional industrial and trade unions, such as pations and professions. The U.S. Department © Jonesthe &United Bartlett Auto Learning, Workers (UAW) LLC and the of Health, ©Education, Jones &and Bartlett Welfare Learning,(1973) LLC NOT FORAmerican SALE Federation OR DISTRIBUTION of Teachers (AFT) joined funded a study—“WorkNOT FOR in America”—that SALE OR DISTRIBUTIONasked efforts to organize nurses and other healthcare the question, “What do workers want?” The

Patient-Centered Care and the Emergence of Primary Nursing I 13

study yielded© Jones the following & Bartlett answers: Learning, interesting LLCand a more equitable and open© Jones system of& re-Bartlett Learning, LLC work, enough help and equipment to get the job source allocation and rewards. Control in- done, enoughNOT information FOR SALE to get OR the DISTRIBUTIONjob done, volved complex problems ofNOT achieving FOR and SALE OR DISTRIBUTION enough authority to get the job done, good pay, sustaining authority and ensuring accountabil- opportunities to develop special abilities, job se- ity for nursing practice. The potential scope of curity, and the ability to see the results of one’s control ranged from specific day-to-day patient © Joneswork. & BartlettNational labor Learning, and management LLC experts care decision© makingJones to & participation Bartlett Learning,in orga- LLC debated innovations such as worker control pro- nizational governance, such as goal setting and NOT FORgrams SALE and work OR restructuring. DISTRIBUTION However, the finance (Siriani,NOT 1984; FOR Witte, SALE 1972). OR Hospital DISTRIBUTION long-standing dominance of industrial labor decision making is typically viewed as hierar- skewed the perspective of labor experts who chical, with organizational control at the top were slow to recognize the power and problems and bedside or patient-care issues at the bot- © Jones & Bartlett Learning,of the emerging LLC service sector, and specifically© Jonestom. But& Bartlett in reality, theLearning, arenas of decision LLC mak- the healthcare labor force. ing are overlapping and interconnected within NOT FOR SALE OR DISTRIBUTIONBy the mid-1970s, the nursing profession wasNOT hospitalFOR SALE organizations. OR DISTRIBUTION in the midst of a collective feminist conscious- ness raising (Wolf, 1993). Nursing’s perspective PATIENT-CENTERED CARE AND THE on nurses’ discontent with their work held that EMERGENCE OF PRIMARY NURSING the conditions© Jones nurses & facedBartlett were uniqueLearning, and LLCAs the workplace reforms movement© Jones moved & Bartlett Learning, LLC were oftenNOT viewed FOR within SALE the context OR DISTRIBUTIONof gender forward in the 1970s, the desireNOT for control FOR over SALE OR DISTRIBUTION and professionalism. Jo Ann Ashley (1996), a patient care took precedence in most organiza- feminist nursing historian, offered the most tions. This reflected the growing necessity for vocal of the feminist perspectives. She described greater nursing decision making given the nurses’ perceived powerlessness to change their rapidly increasing complexity of the patient © Jonessituations & Bartlett as a consequence Learning, of LLC their unique care. The most© Jones influential & development Bartlett Learning, was pri- LLC NOT FORsocialization SALE ORas a female-genderedDISTRIBUTION occupation mary nursing.NOT According FOR SALEto Marram, OR Schlegel, DISTRIBUTION and a result of the cultural barriers to the exer- and Bevis (1974), primary nursing was a devel- cise of the power of nursing within paternalistic opmental step in professional practice develop- institutions. ment that supported “the distribution of Caught in a rapid current of cultural nursing so that the total care of an individual © Jones & Bartlett Learning,change, nursing LLC and hospital administrators© Jonespatient & isBartlett the responsibility Learning, of one LLC nurse, not NOT FOR SALE ORwere DISTRIBUTION pushed by nurses and pulled by larger so-NOT manFORy nurses” SALE (p. OR 1). Man DISTRIBUTIONy of the ideas inherent cial, economic, and political currents to face in primary nursing were previously noted by change in healthcare organizations. Collegiate Lydia Hall (1969) at the Loeb Center. In- nursing education, which had begun to em- fluenced by the wave of quality in work life ideas brace the notion of nurses as change agents, in the contemporary management literature, contributed© Jones to a new & professional Bartlett Learning,conscious- LLCprimary nursing was invented ©as anJones approach & toBartlett Learning, LLC ness. TheNOT power FOR to change SALE nursing OR realities DISTRIBUTION was job redesign. This job-redesignNOT approach FOR had SALE OR DISTRIBUTION slowly unleashed. been applied successfully in industrial manage- The unfreezing of hospital nursing to ment in Europe and Japan. The primary nursing change was rapidly catalyzed as the potential model offered hospital management a way to threat of collective bargaining became evident counter worker complaints about deskilling. © Jonesto &nursing Bartlett and hospital Learning, industr LLCy management. The work of© nursingJones was & restructuredBartlett Learning, and en- LLC NOT FORNurses, SALE like workersOR DISTRIBUTION in other industries and larged to makeNOT nurses FOR accountable SALE forOR the DISTRIBUTION whole service sectors, wanted control over their work of patient care rather than just for specific tasks.

14 I Chapter 1 The Slow March to Professional Practice

Primary nursing© Jones was also & Bartlettideologically Learning, imbued LLCucators faced pressure to produce© Jones a product & Bartlett Learning, LLC with professionalism. nurse that met the hospital labor market needs The associationNOT FOR between SALE primary OR DISTRIBUTIONnursing in terms of skill as well as price.NOT FOR SALE OR DISTRIBUTION and enhanced professional orientation was As legal and regulatory pressures for greater noted in many studies beginning in the 1970s accountability mounted, new demands for (Marram, Schlegel, & Bevis, 1974). Manthey documentation shaped the day of hospital © Jones(1980), & Bartlettan early proponent Learning, of primary LLC nursing, nurses. Nurses© Jones expressed & Bartletta sense of Learning,being LLC noted that primary nursing reflected a philo- pushed into documentation at the expense of NOT FORsophical SALE commitment OR DISTRIBUTION to decision making at being pulledNOT away fromFOR patient SALE care. OR As DISTRIBUTION one the level of action. Primary nursing, drawing on primary nurse noted, “Make sure your patient professionalism, sought increased accountabil- care is your priority, but don’t forget your pa- ity by the nurse for patient care, a rational sys- perwork” (Wolf, 1993, p. 115). The strain of © Jones & Bartlett temLearning, of care provided LLC by the nurse who is most© Jonescompeting & Bartlett demands betweenLearning, the work LLC of nurs- knowledgeable about the patient, individual- ing and the documentation of the work NOT FOR SALE ORized DISTRIBUTION and personalized patient care, and in-NOTemerged FOR asSALE a recurring OR themeDISTRIBUTION underlying alien- creased equality among nursing staff (Marram, ation and nurse dissatisfaction. As nurses grap- Schlegel, & Bevis, 1974). To support the initia- pled with the potential of primary nursing to tion of primary nursing, registered nurses had provide rewards, the reality of the system’s con- to be reskilled,© Jones and hospitals & Bartlett sought toLearning, increase straintsLLC and the contextual issues© Jonesof organiza- & Bartlett Learning, LLC the staffing levels of registered nurses while de- tional control became more apparent. creasing theNOT employment FOR SALE and roles OR of DISTRIBUTIONlicensed NOT FOR SALE OR DISTRIBUTION practical nurses and nursing assistants. In most instances, this necessitated increased funding THE MISSING LINKS: SHARED or significant reallocation of funds, made possi- GOVERNANCE AND RECOGNITION © Jonesble in& the Bartlett late 1970s Learning, by government LLC and private The initiation© of Jones shared governance& Bartlett in Learning,health- LLC support to hospitals. care institutions in the 1980s highlighted an NOT FORPrimary SALE nursing OR DISTRIBUTION provided a process by attempt to easeNOT the FORtensions SALE between OR adminis- DISTRIBUTION which patient-centered care could be individu- trative controls and professional work. Primary alized yet applied within a standardized nursing nursing, while restructuring nursing work, was process. However unique each patient-care situ- quickly found to be limited in its scope. The ation might be, the process of nursing judg- work of nurses was embedded in the organiza- © Jones & Bartlett mentLearning, and discretion LLC became predictable. The© Jonestional context & Bartlett and was Learning, shaped by decisions LLC that NOT FOR SALE ORapplication DISTRIBUTION of the nursing process as a methodNOTw ereFOR often SALE removed OR from DISTRIBUTION their sphere of action. of solving nursing care problems became cen- From staffing to equipment choice, these deci- tral to nursing education and practice in the sions often impacted patient care, leaving nurses 1970s. The development of professional nurs- frustrated, which compounded problems of ing standar©ds Jones for care by& theBartlett ANA further Learning, codi- turnoLLCver and militancy. Just as American© Jones indus- & Bartlett Learning, LLC fied this process orientation. However, the try struggled with the push to expand worker growing complexityNOT FOR of patient SALE care OR and DISTRIBUTION the in- control without sacrificing managerialNOT FORpreroga- SALE OR DISTRIBUTION creasing body of nursing theory would soon tives, the push for workplace participation in de- shift nursing’s emphasis to critical thinking. cision making grew. Genuine participation was Despite the shift in control over nursing edu- made difficult by the complex hospital author- © Jonescation & fromBartlett hospitals Learning, to academic LLC institutions, ity structure,© which Jones kept & nurses Bartlett trapped Learning, be- LLC the reality was that most nursing graduates were tween the dual hierarchies of medicine and the NOT FORgoing SALEto be employed OR DISTRIBUTION by hospitals. Nursing ed- hospital administration.NOT FOR SALE OR DISTRIBUTION

The Attraction of Magnet Hospitals I 15

The climb© Jones by nurses & outBartlett from between Learning, these LLCfor their efforts (McCoy, 1999).© HospitalJones nurs-& Bartlett Learning, LLC two systems of control generated both a threat ing is complex and difficult work. Keeping ex- and an opportunityNOT FOR for SALEthe reallocation OR DISTRIBUTION of power perienced nurses at the bedsideNOT improves FOR theSALE OR DISTRIBUTION in hospitals. Nursing leaders such as Manthey quality of patient care and reduces recruitment (1991) cautioned that for the reallocation of and orientation costs. The challenge has been power to occur, a major change was required in to find a way to reward nurses for a career in di- © Jonesthe & structure Bartlett and Learning,operation of nursingLLC depart- rect care rather© Jones than management. & Bartlett Career Learning, lad- LLC ments. Change would require a major disman- ders typify the development of new reward NOT FORtling SALEof the hospital OR DISTRIBUTION hierarchy, beginning with systems. CareerNOT ladders FOR provide SALE a ORhierarchical DISTRIBUTION the nursing departments. As Porter-O’Grady system of rewarding professional behaviors, (2001) noted, “Implementing an empowered such as advanced education; scholarship; and format such as shared governance means that contributions to the institution, such as com- © Jones & Bartlett Learning,the relationships, LLC decisions, structures, and© Jonesmittee & work Bartlett or clinical Learning, projects. ThisLLC system processes will be forever changed at every level of provides the semblance of mobility by recogniz- NOT FOR SALE ORthe DISTRIBUTION system and that all the players in the organi-NOT ingFOR those SALE nurses ORwho chooseDISTRIBUTION to stay at the bed- zation will be different and behave differently side. Given the recurrent stresses of nursing as a result” (p. 5). The changes in patterns of shortages, career ladders have provided another communication and behaviors extended across mechanism to attract and retain clinically ex- relationships,© Jones not only & nurse–nurseBartlett Learning, or nurse– LLCpert nurses. The career ladder© system Jones has codi& Bartlett- Learning, LLC patient, but also nurse–physician. Many physi- fied the job enlargement of the professional cians wereNOT initially FOR ambivalent SALE and OR threatened DISTRIBUTION by nurse, while stimulating nurseNOT productivity FOR inSALE a OR DISTRIBUTION shared governance (Wolf, 1993). variety of areas, such as quality assurance, prac- In the 1980s and 1990s, many hospitals tice policy development, hospital public rela- moved toward flatter management structures in tions, and nurse recruitment (Wolf, 1993). © Jonesan &effort Bartlett to move Learning, toward shared LLC governance. However,© the Jones linking & of Bartlett remuneration Learning, with LLC Work, previously viewed as a management pre- career-ladder progression historically has been NOT FORrogative, SALE was OR typically DISTRIBUTION distributed across the problematicNOT for many FOR hospitals. SALE TheOR hospital DISTRIBUTION flattened structure to involve staff nurses as well budget process and pressures to control nurse as administrators in decision-making processes salaries has thwarted career-ladder development at the committee level. Nurse participation was efforts in some hospitals. Many senior nurses concentrated at the committee level. A study by find themselves hitting the glass ceiling with new © Jones & Bartlett Learning,Jenkins (1988) LLC observed that the expanded com-© Joneshires &rapidly Bartlett gaining Learning, more compensation. LLC NOT FOR SALE ORmittee DISTRIBUTION structure resulted in more time spent NOTin HealthcareFOR SALE organizations OR DISTRIBUTION have also adopted non- meetings and an overall drop in hours per full- monetary systems of nurse recognition, such as time employee. For example, Massachusetts the professional nurse of the month awards. General Hospital provides a wide range of com- These symbolic rewards, while recognizing clini- mittees in© itsJones governance & Bartlett structure, Learning, including LLCcal excellence, divert attention© awayJones from & the Bartlett Learning, LLC such foci as patient-care quality, diversity, and concrete contextual realities of practice. staff recruitmentNOT FOR (Erickson, SALE 1996). OR Participation DISTRIBUTION NOT FOR SALE OR DISTRIBUTION is based on an application; it is a selective THE ATTRACTION OF process that draws from a pool of dedicated full- MAGNET HOSPITALS and part-time nursing staff who give generously In the early 1980s, the American Academy of © Jonesof &their Bartlett time and Learning,expertise. LLC Nursing launched© Jones an effort & Bartlett to recognize Learning, hos- LLC A parallel concern to expanded decision pitals for their ability to attract and retain NOT FORmaking SALE has beenOR theDISTRIBUTION need to recognize nurses nursing staffNOT (Upenickes, FOR SALE 2003). TheOR MagnetDISTRIBUTION

16 I Chapter 1 The Slow March to Professional Practice

Hospital ©program Jones was & launchedBartlett based Learning, on a LLC& Smith, 2003). Such research© further Jones under- & Bartlett Learning, LLC study that identified hospitals having low staff scores the importance of continuing profes- turnover, NOThigh nurse FOR job SALE satisfaction, OR DISTRIBUTIONand low sional models of development NOTas they FOR support SALE OR DISTRIBUTION staff nurse vacancy rates. The initial recognition the recruitment and retention of staff. For too went to some 41 hospitals. The results of the long the value of nursing has been hidden in early magnet hospital studies highlighted the health care by data collection and information © Jonesimportance & Bartlett of organizational Learning, factors, LLC such as systems that ©give Jones primacy & to Bartlett medicine. Ideally,Learning, LLC participatory structures and processes, per- emerging advances in nursing informatics will NOT FORceived SALEautonomy OR of DISTRIBUTION nurses, and empowering add to nursing’sNOT visibility FOR andSALE support OR contin- DISTRIBUTION leadership (Scott, Sochalski, & Aiken, 1999). ued vitality. A firm investment in professional The characteristics of these hospitals paralleled models will also call for healthcare organiza- many of the recommended changes of the qual- tions to effectively match nursing education © Jones & Bartlett ityLearning, of work life LLCadvocates. Policy reports by the© Jonesand talents & Bartlett with the Learning,complexity of LLC the work. Institute of Medicine (1981) and the National The corporatization of hospitals provides a rel- NOT FOR SALE ORCommission DISTRIBUTION on Nursing (1981) report by theNOTative FOR opportunity SALE ORfor nursing DISTRIBUTION to gain power in American Hospital Association gave added le- the healthcare organization. It is time for nurs- gitimacy to the move to restructure hospitals to ing to cease its dependence on the good will of better attract and retain nursing staff. Some 20 institutions and to demand full participation in years after© the Jones initial magnet & Bartlett studies, Learning,a body of institutionalLLC policy making. © Jones & Bartlett Learning, LLC research has been collected to justify continuing supportNOT for the FOR restructuring SALE ORof systems DISTRIBUTION of NOT FOR SALE OR DISTRIBUTION CONCLUSION care. Current efforts focus on validating outcomes of care in magnet hospital systems, but a Throughout the history of nursing, profession- better understanding of the relationship be- alization has been a driving force for change. From the earliest innovations of Nightingale to © Jonestween & Bartlettoutcomes Learning,and nurses’ autonomyLLC is © Jones & Bartlett Learning, LLC needed (Havens & Aiken, 1999; Ritter-Teital, the most recent nursing shortage, the work cul- NOT FOR2002; ScottSALE et al.,OR 1999). DISTRIBUTION ture of nursingNOT has FORbeen reshaped SALE toOR meet DISTRIBUTION the needs of society or managerial interests, often in the midst of crises. The slow march toward pro- PROFESSIONAL NURSING AND fessional practice continues as models of nurs- NURSE STAFFING: CHICKEN OR EGG? ing practice offer a powerful ideological hold. © Jones & Bartlett HowLearning, well hospitals LLC are able to sustain profes-© JonesNursing & has Bartlett been influenced Learning, by ideas LLC drawn NOT FOR SALE ORsional DISTRIBUTION models is dependent on the political andNOTfrom FOR sociology, SALE management, OR DISTRIBUTION and industry, re- economic climate of the healthcare market. Past sulting in workplace reforms reframed within a nursing shortages generated greater leverage for professional lens. The power of professionaliza- nursing stakeholders. Yet as tensions in labor tion has contributed significantly to the success ease or are overcome by greater organizational of this reform, offering benefits to both health- pressure to© contain Jones or &depress Bartlett labor Learning,costs, the careLLC institutions and nurses. Ho©w ever,Jones nursing & Bartlett Learning, LLC potential NOTfor backpedaling FOR SALE on ORprof essionalDISTRIBUTIONshortages remain. ChallengingNOT questions FOR for SALE OR DISTRIBUTION nursing gains increases. Nursing has a greater the future include the following: To what extent potential to enhance quality outcomes by max- are professional models of practice sustainable imizing the use of professional expertise. As has in the face of economic uncertainty? Can insti- been noted in recent studies, sustaining ade- tutional control truly be ceded to nurses with- © Jonesquate & nurse Bartlett staffing Learning, may be one of LLC the most im- out a fundamental© Jones revolution & Bartlett in the Learning,overall LLC NOT FORportant SALE key factors OR DISTRIBUTIONin patient care outcomes restructuringNOT of healthcare FOR SALE financing OR and DISTRIBUTION ser- (Aiken et al., 2002; Cho, Ketefian, Barkauskas, vice structure? © Jones and Bartlett Publishers. NOT FOR SALE OR DISTRIBUTION

References I 17

DISCUSSION QUESTIONS Dean, M., & Bolton, J. (1980). The administration of © Jones & Bartlett Learning, LLCpoverty and the development ©of nursingJones practice & Bartlett Learning, LLC 1. In thisNOT chapter, FOR the SALE author OR argues DISTRIBUTION that in nineteenth-century England.NOT In C. DaviesFOR (Ed.), SALE OR DISTRIBUTION nursing’s role in hospitals is imbued with Rewriting nursing history (pp. 76–101). London: managerialism, causing a paradox (Fourcher Croom Helm. & Howard, 1981). The application of nursing Dock, L., & Stewart, I. (1938). A short history of nursing. knowledge and skill in managing patient care New York: G. P. Putnam’s Sons. in hospitals has a long history of being subju- Dossey, B. (1999). Florence Nightingale: Mystic, visionary, © Jones & Bartlett Learning, LLC healer. Springhouse,© Jones PA: Springhouse& Bartlett Corporation. Learning, LLC gated to nursing and hospital administration. NOT FOR SALE OR DISTRIBUTION Erickson, J. I. NOT(1996). OurFOR professional SALE practice OR DISTRIBUTION model. Nursing expertise has more often than not MGH Patient Care Services, Caring Headlines, 2(23). been invisible and undervalued, and auton- Etzioni, A. (1969). The semi-professions and their organi- omy of practice has been absent. Reflecting zation. New York: Free Press. on this statement, do you agree or disagree? Foley, M. (1993). The politics of collective bargaining. In D. Mason, S. Talbot, & J. Leavitt (Eds.), Policy © Jones & Bartlett Learning,2. How has societalLLC and healthcare policy af-© Jones & Bartlett Learning, LLC and politics for nurses (2nd ed., pp. 282–302). NOT FOR SALE OR DISTRIBUTIONfected the development of nursing? NOT FORPhiladelphia: SALE W. OR B. Saunders. DISTRIBUTION 3. What are the pros and cons of unionization Fourcher, L., & Howard, M. (1981). Nursing and the in nursing? managerial demiurge: Social science and medicine, Part A. Medical Sociology, 15(Pt. 3), 299–306. 4. How will the Magnet Hospital program, Goldmark, J. (1923). Nursing and nursing education in shared governance, and mandated staffing © Jones & Bartlett Learning, LLCthe U.S. Report of the Committee© Jonesfor the Study & Bartlettof Learning, LLC ratios affect nursing in the future? Nursing Education. New York: Macmillan. NOT FOR SALE OR DISTRIBUTIONGrando, V.T. (1998). Making do withNOT few FORer nurses SALE in OR DISTRIBUTION REFERENCES the United States, 1945–1965. Image: Journal of Nursing Scholarship, 30(2), 147–149. Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., Hall, L. E. (1969). The Loeb Center for Nursing and & Silber, J. H. (2002). Hospital nurse staffing and Rehabilitation, Montefiore Medical Center, Bronx, patient mortality, nurse burnout, and job satisfac- © Jones & Bartlett Learning, LLC New York.© Int Jonesernational Journal& Bartlett of Nursing Studies,Learning, 16, LLC tion. Journal of the American Medical Association, 288, 215–230. NOT FOR1987–1993. SALE OR DISTRIBUTION Havens, D., &NOT Aiken, FOR L. (1999). SALE Shaping OR systems DISTRIBUTION to American Association of Colleges of Nursing. (2007). promote desired outcomes: The magnet hospitals Doctor of Nursing Practice. Retrieved July 14, model. Journal of Nursing Administration, 29(2), 2007, from http://www.aacn.nche.edu/DNP 14–20. /DNPPositionStatement.htm Hegyvary, S. T. (1982). The change to primary nursing. St. Ashley, J. (1976). Hospitals, paternalism, and the role of the © Jones & Bartlett Learning, LLC © JonesLouis, & BartlettMO: C. V. Mosb Learning,y. LLC nurse. New York: Columbia University Press. Henderson, V. (1966). The nature of nursing. New York: NOT FOR SALE ORAshley DISTRIBUTION, J. (1996). This I believe about power in nurs-NOT FORMacMillan. SALE OR DISTRIBUTION ing. In K. Wolf (Ed.), Selected readings of Jo Ann Hughes, C. E. (1971). The sociological eye. Chicago: Ashley (pp. 23–34). New York: NLN Press/Jones Aldine. and Bartlett. Institute of Medicine. (1981). The study of nursing and Bucher, R., & Strauss, A. (1961). Professions in pro- nursing education. Washington, DC: National gress. American© Jones Journal & of BartlettSociology, 66(4), Learning, 325–334. LLCAcademy of Science Press. © Jones & Bartlett Learning, LLC Bullough, V., & Bullough, B. (1984). The history, trends, Jenkins, J. (1988). A nursing governance and practice and politicsNOT of FORnursing. SALENorwalk, OR CT: DISTRIBUTIONAppleton model: What are the costs? NursingNOT Economics, FOR 6 (6),SALE OR DISTRIBUTION Century Crofts. 302–311. Burgess, M. (1928). Nurses, patients, and pocketbooks. Kohles, M. K. (1994). Commentary on union election New York: Committee on the Grading of Nursing activity in the health care industry. Health Care Schools. Management Review, 19(1), 18–27. © JonesCho, & S.Bartlett H., Ketefian, Learning, S., Barkauskas, LLC V. H., & Smith, Kramer, M. (1974).© Jones Reality shock:& Bartlett Why nurses Learning,leave nurs- LLC D. G. (2003). The effects of nurse staffing on ad- ing. St. Louis, MO: C. V. Mosby. NOT FORverse SALE events, OR morbidity, DISTRIBUTION mortality, and medical Manthey, M.NOT (1980). FOR The practice SALE of primary OR DISTRIBUTIONnursing. costs. Nursing Research, 52, 71–79. Boston: Blackwell Scientific Publications. © Jones and Bartlett Publishers. NOT FOR SALE OR DISTRIBUTION

18 I Chapter 1 The Slow March to Professional Practice

Manthey, M. (1991). Delivery systems and practice Rosenberg, C. (1989). Community and communities: models:© A dynamicJones balance. & Bartlett Nursing Management, Learning, LLCThe evolution of the American hospital.© Jones In D. Long & Bartlett Learning, LLC 22(1), 28–30.NOT FOR SALE OR DISTRIBUTION& J. Golden (Eds.), The American NOTgeneral hospital FOR(pp. SALE OR DISTRIBUTION Marram, G., Schlegel, M., & Bevis, E. O. (1974). 3–17). Ithaca, NY: Cornell University Press. Primary nursing: A model for individualized care. St. Rosner, D. (1989). Doing well or doing good: The Louis, MO: C. V. Mosby. ambivalent focus of hospital administration. In McCoy, J. M. (1999). Recognize, reward, retain. Nursing D. Long & J. Golden (Eds.), The American general © JonesM &anagement, Bartlett 30(2), Learning, 41–43. LLC hospital (pp.© Jones157–169). & Ithaca, Bartlett NY: CornellLearning, LLC Merriam-Webster’s Collegiate Dictionary, 4th ed. (2006). University Press. NOT FORp. 8. SALE OR DISTRIBUTION Scott, J. G., Sochalski,NOT J.,FOR & Aiken, SALE L. (1999). OR Review DISTRIBUTION of National Commission on Nursing. (1981). Summary magnet hospital research: Findings and implica- of public hearings. Chicago, IL: The Hospital Re- tions for professional nursing practice. Journal of search and Educational Trust. Nursing Administration, 29(1), 9–19. National League for Nursing Education. (1926). The Siriani, C. (1984). Participation, opportunity, and © Jones & Bartlett Learning,grading committee LLC report of the National League for© Jonesequality: & Bartlett Towards a pluralist Learning, organization LLC model. Nursing Education. New York: NLNE. In F. Ficher & C. Siriani (Eds.), Critical studies in or- NOT FOR SALE ORNightingale, DISTRIBUTION F. (1866). Letter to Mary Jones. Cited onNOT FORganization SALE and bureaucracy OR DISTRIBUTION(pp. 482–503). Phila- p. 25 in B. Abel-Smith, A history of the nursing pro- delphia: Temple University Press. fession (1960). London: Heinmann. Starr, P. (1982). The social transformation of American Perrow, C. (1972). Complex organizations: A critical essay. medicine. New York: Basic Books. Glenview, IL: Scott Foresman. Stevens, R. (1989). In hospitals and in wealth: American hos- Porter-O’Grady© Jones,T. (2001). & Is Bartlett shared governance Learning, still LLCpitals in the twentieth century. New ©Yor k:Jones Basic Books. & Bartlett Learning, LLC relevant?NOT Journal FOR of Nursing SALE Administration, OR DISTRIBUTION 31(10), Upenickes, V. (2003). RecruitmentNOT and retentionFOR SALE OR DISTRIBUTION 467–473. strategies: A magnet hospital prevention model. Reverby, S. (1979). The search for the hospital yard- Nursing Economics, 21(1), 7–13, 23. stick. In S. Reverby & D. Rosner (Eds.), Health care U.S. Department of Health, Education & Welfare. in America (pp. 206–225). Philadelphia: Temple (1973). Work in America, HEW report. Cambridge, University Press. MA: MIT Press. © JonesReverby, & Bartlett S. (1987). Learning,Ordered to care, LLC the dilemma of Williams, K. (1980).© Jones From Sarah & Bartlett Gamp to FlorenceLearning, LLC NOT FORAmerican SALE nursing, OR 1850–1945. DISTRIBUTIONCambridge, England: Nightingale:NOT A critical FOR study SALE of hospital OR nursing DISTRIBUTION Cambridge University Press. systems from 1840 to 1897. In C. Davies (Ed.), Reverby, S. (1999). Neither for the drawing room nor Rewriting nursing history (pp. 41–75). London: for the kitchen: Private duty nursing in Boston, Croom Helm. 1873–1914. In J. Waltzer Leavitt (Ed.), Women and Witte, J. (1972). Democracy, authority and alienation in health in America (pp. 460–474). Madison: University work. Chicago: University of Chicago Press. © Jones & Bartlett Learning,of Wisconsin Press.LLC © JonesWolf, K. &A. (1993).Bartlett The professionalization Learning, of nursingLLC work: NOT FOR SALE ORRitter DISTRIBUTION-Teital, J. (2002). The impact of restructuring onNOT FORThe case SALE of nursing OR at DISTRIBUTIONMill City Medical Center. professional nursing practice. Journal of Nursing Dissertation microfilms PUZ9322364. Ann Arbor: Administration, 32(1), 31–41. University of Michigan.