Respect for nursing professional: Silence must be heard

Abstract

The value of care giving seems to be at an all-time low. whether it is clinical (bedside) or for children and elderly at home (homemakers). Currently, individuals who pass away any opportunity (for themselves) to care for another individual instead are considered weak and/or unmotivated. Thus, it is not surprising that modern society often fails to respect the nursing professionals to the extent of underplaying their strengths, skills, and even clinical abilities. While qualities such as kindness, team spirit, and willingness to get their hands dirty are the core of this profession, nursing professionals have a complex variety of set duties, involving drug dosage, trouble-shooting, ongoing patient monitoring, and providing holistic comfort and support to the sick and needy. Beyond classical role, the nursing professional has currently ventured into other roles as well, as a nurse practitioner, administrator, researcher, or even an educator. Thus, considering the wide spectrum of duties performed by nursing professionals, they do deserve more status and power rather than be treated like “ward housewives.”

1. History of nursing as a profession

Nursing is also a “profession” like doctors, engineers, or IT. Its origins as a distinct and secular profession can be traced to a school founded by legendary nurse, Florence Nightingale in England in 1860. This position as a profession was further cemented by “Nightingale Pledge,” (quite like Hippocratic Oath for physicians) developed in 1893. Further, the code of conduct for nursing professionals was also not unlike the physicians, i.e. of not only promoting health and preventing illness but in addition also caring for the patient who is experiencing varying degree of physical, psychological even spiritual suffering. Interestingly, before 1960, the focus of the nursing code was on nurses’ obedience to physicians, but since then till date, patient care has remained the corner stone of their activity. Thus, wholeness of character, which involves integrity, knowing the value of nursing profession and one's own moral values, is central to the value system of this profession. Currently health care system is plagued with numerous constraints, politics, vested corporations, and even self-serving individuals/groups. Often nursing professional is pressurized to do something that conflicts their professional values, such as to deceive patients, falsify records, or simply face and/or accept verbal abuse from physicians, administrators, even patients. However, in light of these pressures, maintaining integrity and do what is right and ethical is the crux of modern nursing code.¹

2. The occupational status of nursing professionals

At first, the nursing profession was forced into ancillary activity of physicians, as an appendage of physician's work, directed towards administration of “broom and poultice” and characterized by passive sub-ordinance to physician in charge of the case. In Western society, in pre-modern age, the care of sick or infirm when not entrusted to servants was the duty of nuns, “Sisters”, and subsequently nursing professional (Sister!) took over this secular role. Over a course of time, the role of a nursing professional has evolved from a sub-ordinate to an independent stakeholder in health care delivery. The journey has taken them from the role of a drug dispenser to trained professional in cath lab, but at the same time, they still specialize in TLC (tender loving care). However, old mindsets still persist and there is certainly poor public perception of nursing profession, and as such, they are grossly undervalued as a professional. Further, even within the confines of health care system, they become easy targets for the location of guilt and blame for poor practice by a failing and dysfunctional system. Further, hard physical and emotional work environment coupled with inadequate financial rewards now makes the nursing profession as one of the most unattractive of all professions.² As a result, few motivated and caring individuals are attracted into this profession. Consequently, the health care system, whether be it government or particularly private, is faced by a serious crunch of nursing professionals, and nursing has become one profession where there is a “steady hemorrhage of experienced nurses” from all health care facilities. Not only India but also countries around the world are facing critical nursing shortages, and globally, communities are challenged with growing health care needs but diminishing numbers of nursing professionals. It is projected that by the year 2020 the shortage of nursing professionals will be a staggering 20 percent below requirements.³

3. Threats and challenges to nursing profession

Currently, the nursing profession is faced with several challenges including low prestige, poor public perception, financial issues, heavy workload, stressful conditions, and lack of professional gratification coupled with shortage of nursing personnel and poor quality of training and education.

• 1.Obstacles to improving prestige of nursing profession. The most obvious factors responsible for this sorry state of affairs range from rigid hospital traditions and shackles of privilege and prestige, which even a balanced physician, administrator, or lay public can succumb to. In a hierarchical system of power within the practice environment, currently, the position of nursing professional is intermediate. Although they truly belong to the intellectual class, but being insecure of status and at risk of being pushed to the working class status, they are forced to display an excessively professional attitude, devoid of any emotional content, which paradoxically stunts both their professional and emotional growth. Thus, nursing remains a profession where extreme discipline remains almost like a religious order and its practitioners “starch the façade of their professionalism even more than they starch their uniform.”
• 2.
  Poor public perception of the profession. The reason for poor image may be multi-factorial:

  • (i)
    Poor media representation, which is not truly reflective of current practice. This contributes to lack of public confidence and perception of nursing professionals.
  • (ii)
    Perceived apathy and poor delivery of care in some instances may contribute significantly to poor perception.
• 3.
  Financial constraints.

  • (i)
    The material compensations of the profession are often meager.
  • (ii)
    Financial constraints within the health care system also limit the resources available for achieving standards of care and increasing the pressure to cut costs.
  • (iii)
    These constraints may also limit the opportunities for nurses’ training and development.
• 4.Lack of professional gratification. This may be even more important. The nursing professional may be actively conditioned towards blind compliance of orders and actively discouraged from displaying foresight, initiative, imagination, and feelings, thus relegating them to a position of sub-professional rather than a professional on equal footing.
• 5.
  Workload. A major challenge is also ever-increasing workload, both clinical and administrative.

  • (i)
    Clinical: This is mainly a result of increased number of patients who are acutely ill and also having more aged population with higher level of dependency.
  • (ii)
    Administrative: In the prevailing culture of blaming and fear of litigation, there is an ever-increasing need for documentation, the burden of which primarily falls on the nursing professional. The problem is compounded by a lack of appropriate clerical support.
• 6.
  Nursing shortage

  • (i)
    Acute shortage of nursing professional paradoxically puts even more workload on the existing ones. Nursing professional often has to spend “more time trying to give good care or finish a task already ongoing even while I may like to go home where my family is waiting.”
  • (ii)
    Moreover, because nursing profession is now less attractive to new entrants, the remaining nurse's population gets more aged.
  • (iii)
    Poor staff retention also results in areas of care with poor leadership around quality care. In other words, there is no proper guidance available to the newly qualified workforce if at all they join the profession.
• 7.
  Inadequate education, training, and professional development opportunities

  • (i)
    Low entry standards: The reason for these low standards could be failure to attract higher caliber individuals.
  • (ii)
    The continuation of diploma's instead of focus on degree qualification.
  • (iii)
    Attempts by higher caliber nursing professional to migrate into teaching or research roles leaving the traditional TLC to less endowed nursing professionals.
  • (iv)
    Lack of guidance on career progression.
  • (v)
    Language barriers or poor communication skills: This may be especially relevant in the context of South Indian nurses working elsewhere in India. Despite abundance of caring attitude, the inability to properly communicate in native language with patients may lead to frustration at both ends.
• 8.
  Stressful working conditions. At present, nursing may be among the most stressful jobs for several reasons:

  • (i)
    Constant need to update knowledge and skills to meet demands of new and complex treatment modalities and procedures.
  • (ii)
    Lack of adequate leadership and management deficiencies. Increasingly, hospital administrators are now management professionals without a clinical background, and as such, are unable to understand clinical requirements and needs of the nursing professional and they rather become unsupportive and get to “bullying to get jobs done” rather than being nurturing and developing.
  • (iii)
    Violence against medical staff is another factor contributing to stress.
  • (iv)
    Increased patient expectations in the era of increasingly knowledgeable patients/relatives who are willing to challenge the nurses’ rationale. Thus, nursing professional need to be more up-to-date and ready with all the answers. Along with this, the patients/relatives are also aware of their so-called “rights” and demand and expect more.

4. What needs to be done?

The society can no longer afford to turn a blind eye towards this problem. Unless there is an urgent revision in status of nursing professional, unless the physicians, administrators, and society in general systematically take cognizance of need of nursing professional for emotional security and well-defined status, there will be no meaningful TLC or a meaningful nursing profession. The following steps are mandated to achieve that:

• 1.
  Better projection of nursing profession. This is the first essential step, i.e. to emphasize the positive contributions to the society.

  • (i)
    Engaging media to improve public perception by focusing on positive achievements in response to negative allegations or representations.
  • (ii)
    Improving image, emphasizing aspects like dress code and professional attitude (punctuality), so that they look like a professional and not “cleaning attendant” at a local railway station.
  • (iii)
    Improving their own self-image by valuing the essence of work they do themselves.
• 2.
  Increased individual and professional funding. Provide funds for things considered important.

  • (i)
    Better treatment and facilities.
  • (ii)
    Provision for staff training and development.
  • (iii)
    Better pay and emoluments.
  • (iv)
    Social support: understand the needs pertaining to family, decent housing, or even counseling, “not to wait till something happens at work or home,” i.e. proactive rather than reactive approach.
  • (v)
    Support for patients, so that nursing professional does not feel helpless.
• 3.Employing more qualified nurses. This would reduce the pressure on nursing professional's time and allow for “capping of caseload.”
• 4.
  Increase administrative support. This will also free up nursing professional's time for providing quality care. This can be achieved through:

  • (i)
    Providing more/better clerks.
  • (ii)
    Using IT tools to reduce workloads.
• 5.
  Improving the education.

  • (i)
    Education campaigns to attract bright young people.
  • (ii)
    Review education of nursing professional, narrowing the gap between theory and practice.
• 6.
  Raising standards. Setting high benchmarks for recruitment and subsequent development.

  • (i)
    Appreciating and awarding the role models, “employee of the month/week.” Encouraging them to take new initiatives beyond the more established professional standards (dress code, punctuality, etc.).
  • (ii)
    Continuous professional and social skill development opportunities, such as communication skills, good manner, empowering patient, care planning, clinical leadership, management skills, and also coping mechanisms.
  • (iii)
    Taking out time for education and delivery of education, i.e. they have enough time to undertake training and train within their clinic hours.
  • (iv)
    Provide greater access to evidence-based practice.
• 7.
  Improving working conditions.

  • (i)
    Setting realistic targets and workloads.
  • (ii)
    Better administrative support. Senior administrators need to support and respect staff, listen to their opinions and contributions, and thus be in close contact with them.
  • (iii)
    Nomination of nurse managers on the hospital board/committees, so that they also become an important stakeholder of health care delivery.
• 8.Focusing on the patient. The nursing professional on their own should focus on patients, “Patient First.” They should encourage and value hands-on care and provide psychological support to the patient. They should involve patients in decision-making.

5. Summary

The nursing profession is at crossroads. The prestige of this profession has not kept up to its growth, and as a result, fewer individuals are joining this profession. There are several factors for the inability to grow, but the problems within the profession could be addressed not only by improved projection of the profession, better funding, and education but also by providing support to its practitioners.

Look into the others eyes, many frustrations

Read between the lines, no words just vibrations

Don’t ignore hidden desires

Pay attention, you’re playing with fire

Conflicts of interest

The author has none to declare.