For Nursing, New Responsibilities, New Respect

▪ 1997

by Margretta Madden Styles

      In remote villages around the world—whether in southern Africa, Latin America, or southwestern Asia—the community's mobilizer for health, sanitation, and housing services may well be a nurse. In the rural or inner-city U.S., a clinic serving the entire community may well be run solely by nurses.

      The head of a national family-planning program may be a nurse. The chief executive officer of a hospital or health care system may be a nurse with additional training in economics or business administration. The attorney representing a client in high-stakes health care litigation may be a nurse with training in the law.

      In fact, all of the above-mentioned positions are presently or have been held by nurses. Adapting to current social, economic, and health-care trends, nurses today are attaining higher levels of education than in the past and are applying their newly acquired knowledge, skill, and confidence to expanded roles and in novel settings.

      Worldwide, the nursing profession is responding to myriad health care needs and challenges. These include the escalation of health care costs, the fragmentation of care resulting from growing specialization, the rampant spread of AIDS, malaria, cholera, and tuberculosis, and other infectious diseases, and the worldwide increase in the number of elderly persons, with its corresponding increase in aging-associated health problems.

      Nurses have been called upon to meet these diverse challenges for a number of reasons. First and foremost, in most countries nurses constitute the largest group of health care providers. Because nursing is defined variably around the globe, it is difficult to arrive at exact figures, but, as just one example of their significant numbers, there are more than 2.2 million registered nurses in the United States alone. Nurses are geographically more evenly distributed than other health care providers, and more of them serve in rural, remote, and poor areas.

      Changes at the grassroots of nursing have been stimulated and assisted by both governmental and nongovernmental organizations (NGOs) on all levels. The governmental system includes, in ascending order, local, state, and federal departments or ministries of health and, internationally, the World Health Organization (WHO), with its six geographic regions. The International Labour Organisation (ILO), a UN agency, specifically addresses economic and general welfare issues for workers in all occupations, including nursing. Principal among the NGOs advocating for nursing are the 114 national nurses associations constituting the International Council of Nurses (ICN). Conveniently, the ICN, WHO, and the ILO are all headquartered in Geneva, where their close proximity permits intensive communication and cooperation.

      Nursing education has had to change dramatically to prepare nurses for their expanded roles. Traditional hospital-based nursing schools do not provide community nursing experience, nor can they offer the liberal arts curriculum of the university. Moreover, traditional nursing schools have isolated students from the mainstream of higher education. To remedy this situation, nursing education is now occurring increasingly in academic rather than clinical settings. In fact, in some countries the training of nurses has moved exclusively into the universities. Despite the extension and reform of nursing education, the costs of educating a nurse remain only a fraction of those required for educating a physician.

      As nurses have become better educated and their roles have been enlarged, the legal scope of their practice has been extended accordingly. In recent years, largely through the combined efforts of the ICN and WHO, there has been an accelerated movement to expand the practice boundaries of the profession. In some countries nurses are now authorized to make diagnoses, to prescribe medication, and even to admit patients to hospitals under their care.

      The government or private, so-called third-party, health insurers pay for some or all of health care in most countries. When nurses provide "expanded" services, the health care system must provide for their reimbursement, just as it does for physician-rendered services. In nations with centralized, single-payer health care systems, such adjustments have been easily accommodated. In the United States, ongoing negotiations with the federal government, state agencies, and private insurance companies have inched forward to gain authorization for reimbursement of advanced nursing services.

      Incentives have been a major enabling factor in the advanced-practice movement. Nurses are encouraged to seek additional education and to assume roles of greater scope and responsibility when patients recognize their expertise and seek out their care and when they are appropriately compensated by employers. The profession long suffered from the "a-nurse-is-a-nurse" complex, and little motivation was provided for nurses to better themselves. Although inequities in salaries and practice privileges persist, progress has been made in establishing career ladders and salary structures that appropriately distinguish those individuals who have attained higher qualifications and assumed greater responsibilities.

      Historically a female profession, nursing has long been a natural standard-bearer for the economic and social rights of women. Battles continue to be waged on many fronts and at many levels, with nurses and nursing organizations often leading the fray. As just one example, many nurses were at the negotiating tables of the UN Fourth World Conference on Women in September 1995 in Beijing, where they spoke persuasively for the educational, economic, and health rights of women around the world.

      The emerging new roles and responsibilities of nurses have already had a dramatic impact on health care. Studies show that the expanded services provided by well-qualified nurses are different in nature from those provided by physicians. For example, nurses spend more time with patients; the treatments they provide are often more conservative and less intrusive. Most telling, so-called outcomes—cure and survival rates, cost savings—are as good or better. As sweeping changes occur in health care technology and in the structure and priorities of health care delivery systems, nurses will continue to be at the patient's side, assuring quality care, providing expertise, and offering comfort.

Margretta Madden Styles is president of the International Council of Nurses and the American Nurses Credentialing Center.

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