PROFESSIONALISM IN NURSING

A decade ago in a large New York City hospital, a small group of nursing students whispered the latest news. The director of our school had been asked to step aside and make way for a new woman who had a Master's degree in Nursing Administration. Receiving our training in a 3-year diploma program, we had difficulty imagining what such a degree entails. What else must a nurse know? Our hospital, a fortress in the midst of Spanish Harlem, exposed us to the wonders and tragedies of humans trying to survive in the ghetto. We were learning both about medicine and the world, it seemed, simply by breathing the hospital atmosphere. Yet other types of nursing education were gaining ground in the field.

Historically rooted in a tradition of education achieved through experience, nursing as a discipline was beginning to blossom. One could enter a baccalaureate program and earn a college degree "rounded out" by a liberal arts background. A nurse could become a practitioner, a clinician, or a clinical specialist if she pursued further study. To our bewilderment, a nurse could even study for years, write a thesis, and obtain a doctorate! Our class was the last of our school's diploma program; the next year would be ushered in by a full-fledged baccalaureate program connected with City College of New York. Word was out: a nurse needn't waste her time bathing patients when she could become a professional.

In nursing school we had been taught to behave "professionally," which usually meant to act with discretion and a sense of dignity in providing patient care. It meant utilizing our theoretical knowledge humanely, sensitively, and wisely. We were told that the American Nurses' Association (ANA), since its birth in 1911, has had as its main purpose the development of a respected, prestigious profession. Yet in the last decade the term "professional” has accumulated other meanings as a result of the Association's efforts to elevate the socioeconomic positions of registered nurses. Recently the Boston Nurses' Group published an article, "The False Premise: Professionalism in Nursing," which addressed this

issue:

To the majority of nurses professionalism stands for qualities we all respect, such as taking responsibility for our work and caring about our patients.... We have found that there are other sides to professionalism. For example, many professionals start to feel that they are the only ones who possess the good qualities....Professionalism teaches us to see ourselves as unique and better than other health care workers.... Professionalism in nursing is being used as both a carrot and a stick. As we try to become more 'professional' our eyes are glued on the 'carrot' of increased respect, rewards, and supposed improvement-and we do not see that behind our backs, professionalism is providing a 'stick' that is used to control and manipulate us.

For a considerable period of time, the elite of the nursing field-those in the top positions of the ANA, large hospitals, and university baccalaureate programs-applied the term "professional" to registered nurses as a coherent group and implied that others beneath us on the hierarchical structure in medicine lacked this quality. We were encouraged to see Licensed Practical Nurses, dietary workers, paraprofessionals and housekeepers as less educated workers who needed our guidance and supervision. Within the last decade, however, the nursing elite has turned its collective eye-on-registered nurses and has

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begun to lobby for distinctions of professional abilities among this group.

Historically the diploma program, a 3-year education based for the most part on clinical experience, appealed both to the hospital and the nursing student. The former could staff its floors with training nurses who were not paid. The latter, many of whom came from the working class, learned a highly developed skill at a modest tuition. In the early 1960's, 84 percent of all registered nurses had been trained in a diploma program. Between 1968 and 1972, the number of diploma schools dropped by 25 percent, down to 513, whereas baccalaureate programs increased to 293. The trend continues into the 1970's.

Another category of nursing education, the Associate Degree of Nursing, has also expanded. The number of schools offering this 2-year community college-based program has doubled during the cited years. The relatively inexpensive Associate Degree education has the greatest proportion of black students, while the baccalaureate program tends to attract only those who can affort it-white, middleclass students.

Instead of allowing these diverse programs to flourish as they meet individual concerns of time, income and academic preparation, the powerful ANA decided in 1974 to endorse the baccalaureate education (BSN) as a requirement for licensure and to lobby actively for such measures to be introduced in state legislatures. The New York State affiliate of ANA has sponsored a “1985 proposal," making the BSN degree a requirement for licensure by that year. Although a "grandfather" clause would protect diploma and Associate Degree graduates who had obtained their education before 1985, their ability to find employment and to receive competitive salaries will certainly be affected. As these nurses are lumped

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together with Licensed Practical Nurses (graduates of a one-year program) and labelled "technical nurses,'' the "professional" BSN graduate will become a leader delegating work to other hospital workers.

The nursing field has been strongly influenced by 'the women's movement and feminist values. Whereas we students were taught to follow physicians on grand rounds with heads beht and hands folded, the BSN student has received a different

orientation. She is learning to become an assertive, independent practitioner, capable of detailed health teaching and preventive instructions. The "new nurse" has a place in higher education. She can challenge the physician's judgment, conduct family therapy, and start a private practice. She has a sense of her own worth and can demand respect from others.

Yet there is another side to this image of the "new nurse" so attractively promoted in nursing journals. and displayed in advertisements for hospital employment. In last month's issue of What She Wants, Beth Cagan described the powerful illusion of the "new woman" marketed by commercial culture as a pale shadow of the critical, progressive feminist of the '60's and '70's. Similarly, the "new nurse" created by the nursing elite is encouraged to think only of herself as an individual, particularly in terms of her economic needs and financial gains which benefit from an individualist ethic of competition. As the "new nurse" climbs the professional ladder of success, the majority of nurses inevitably must be left scrambling at the bottom. This employment stratification is typical of how capitalism operates. When nurses are so busy thinking of themselves as professional status seekers, the concerns and working conditions of all nurses will be ignored. Moreover, patriarchal values of individualism, competition and materialism are consequently reinforced.

Who will actually benefit from the internal division of the nursing profession? In an article, "Professional 'Upgrading' Hits Nursing," we find that individual nurses do not really gain more than token status and power. They also acquire only a superficial image of themselves as liberated from an older, passive female model of behavior:

The ANA will be able to maintain its power over the profession, and the universities can look forward to new students in a time of lagging enrollment. But it is the hospitals who will benefit most. Hospitals are run like any other business and businesses like to cut wage costs. An increase in the sheer number of nursing graduates over the past few years has helped administrators keep wages down, but the nursing hierarchy has always allowed hospitals to hire some nurses at a cheaper rate, though they all perform the same job. The same will hold true for this new wave of hierarchy: nurses will be required to have more education, but they won't be paid for it. Instead, nurses who don't have the education will be paid less. Finally, increasing divisions within nursing could also help to stave off the hospitals greatest fear-unionization.

Approximately 13 percent of all nurses working in the U.S. belong to some form of organization which offers collective bargaining. The majority have ehosen membership in a state affiliate of ANA because this organization has a "professional" image and lacks the "Teamster-like" association with union membership, as for example, in the 1199 Nursing Division of the AFL-CIO. Some of the state branches of ANA have even become militant, supporting strikes when necessary. The future of nurses as a collective group remains unclear, depending on the way the economy affects their overall potential for further education, job selection, and salaries.

Professionalism in a career setting has great appeal, particularly to women in fields which traditionally have espoused values that reinforce submissive, passive behavior. Yet the woman in a "professional" position still needs to analyze what this

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