In search of our collective voice
2018; Wiley; Volume: 25; Issue: 4 Linguagem: Inglês
10.1111/nin.12266
ISSN1440-1800
Autores Tópico(s)Geriatric Care and Nursing Homes
ResumoNursing InquiryVolume 25, Issue 4 e12266 EDITORIALFree Access In search of our collective voice Sally Thorne, Sally Thorne Editor-in-Chief orcid.org/0000-0002-1156-9425 Search for more papers by this author Sally Thorne, Sally Thorne Editor-in-Chief orcid.org/0000-0002-1156-9425 Search for more papers by this author First published: 16 October 2018 https://doi.org/10.1111/nin.12266Citations: 4AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat When we reflect on the strong social and policy advocates within nursing's history, we often lionize them as particularly wise and forceful individuals, as exceptions within generations comprised of a more docile sort of practitioners. In the masculine historical narrative form of which we are all so accustomed, one tends to locate greatness within individual public figures rather than in the collective strength that brought them to leadership and galvanized their courage to lead. In contrast, the human affection for self-aggrandizement aside, I suspect that most of our historical nursing icons would have attributed their confidence in the nursing claims they put forth to a sense of grounded certainty that they were reflecting the will of the collective whose perspective they sought to make publicly visible. I think an argument can be made, therefore, that it was nursing that made these individuals great rather than the converse. But what is this collective? How is its will formed? What is its relationship to the individual nurse? And how is it given voice? In wrestling with some of these questions, I try to build a brief case for recognizing how easily it can become obscured in today's world if we are not vigilant, and why we must ensure that it is never lost. The profound contribution that nursing makes to the world is derived not from the specific task functions it assumes but rather from what has been variously termed its unique and distinctive "gaze" (Kim, 2015) or "lens" (Disch, Keller, & Weber, 2015). This "angle of vision" (Thorne, 2015) depicts a particular stance toward the universe of interest, shaped by certain ways of knowing and perceiving. It is an aspect that the nursing theorists of the 1970s and 80s tried to operationally define (sometimes quite awkwardly) in the form of conceptual models for nursing. Although the ideal theory proved elusive, largely due to nursing's diversity, dynamism, and complexity (Bender, 2017), the philosophizing that characterized the model builders' best efforts remains a solid legacy of the kinds of ideas we came to understand as central to that professional gaze. These include, for example, a fundamental respect for the dignity of all persons, regardless of behavior or context, and an attitude of holism toward that person, in the sense of appreciating that any aspect of their life or circumstance or physiology might potentially be relevant to concern of the moment, and that all aspects operated in mutual interaction. A related notion central to nursing is that it is particularized, with the skill to interpret and strategically act upon the uniqueness of each patient's health situation and life circumstance (Thorne & Sawatzky, 2014). Nursing's service orientation is yet another core idea, in the sense of privileging the social contract we hold, one that justifies the high-level public trust that is cherished by our profession (Fowler, 2016). And a final theme within the fundamental structure of nursing is that it considers itself to hold responsibility for ensuring a system of action, in the sense of being much less concerned with individual prominence, reputation, or credibility as it is with the overall creation of a seamless and coordinated care within which all patients can be safely held (Rudge, 2011). Despite our incapacity to define it, one can argue with a certainty that nursing exists, that a shared conceptualization of it exists, and that it has been sustained, despite numerous variations in the practice context and scientific understandings, since the profession began (Thorne et al., 1998). As with all of the truly important abstract concepts with which we structure our human experience, nursing can be seen within a wide variety of ideas, attitudes, and actions, each representing particular instantiations which participate in the universal concept of nursing (Henderson, 1978/2006). While that earlier era of nurse theorists had been limited by assumptions of what theory ought to look like, a more philosophically sophisticated generation of disciplinary scholars came to appreciate that complex processes require an ongoing wrestling with the implications of ideas within a world that is itself evolving. Although nursing may defy formal definition, it is most certainly the case that it is being enacted every day in all parts of the world, and that it is being taught, led, regulated, and advanced by a highly evolved and skilled "community" of professional actors who truly understand its essence. While we accept that no two nurses will do nursing in precisely the same manner, and that each nursing situation has its unique features, we can still recognize in those actions that which represents the expertise of a highly distinctive profession. It is interesting to reflect on how one comes to take up something that is both definitionally amorphous and also intellectually coherent. In the 4 years (give or take) that is required to transform an ordinary citizen into a nurse, each learner is surrounded by ideas and, in this immersive context, gradually integrates the aspirational ideals, skillsets, values, and knowledge of the profession into a robust and personalized commitment. The nursing education experience involves being repeatedly tested as a person and as an emerging professional. It is notoriously difficult work—intellectually, physically, psychically, and spiritually—and yet it succeeds because learners are powerfully supported throughout that process by curriculum, pedagogy, and intense relational engagement with those in possession of various forms of that expertise. On graduation, however, they are let loose into a workforce where the challenges of contemporary practice can test the professionalism of the neophyte nurse even further. Although health care is inherently complex work, the work itself is rarely the problem. Among the most difficult of the contemporary workplace dynamics is the reality that the "interprofessional practice" train has long since left the track (Freshwater, Cahill, & Essen, 2013), allowing for a dominant corporatized model of care delivery that in many institutions means that nursing-specific leadership systems have become politically incorrect or structurally improbable. At the front lines, in so many settings we have lost the entity that used to be called the "head nurse" or "matron"—that senior nurse charged with a close mentoring, monitoring, and guiding function for the point-of-care nurse, and the individual charged with advocacy to senior levels of administration to ensure the appropriate conditions for nursing practice. Latterly, in my own context at least, we began to lose the clinical nurse specialist—those advanced practice nurses whose role was the development of strong systems of care. And further, in so many settings, we have even lost the roles of chief nursing officer—shifting the mandates of nurses in the most senior leadership positions into the kinds of interdisciplinary "professional practice" leadership portfolios within which they can no longer justify speaking out on behalf of any one professional group or privileging that group by demonstrating disciplinary leadership. All of these leadership changes have contributed to an erosion of commitment to the fundamentals of care in many settings (Feo & Kitson, 2016), and they have also silenced a subset of the nursing leadership that would historically have been relied upon, by virtue of its experience and positional authority, to voice the profession's concerns in the public arena. In an increasing number of jurisdictions, nursing is also at risk of losing its formal professional association voice. While historically nursing might have combined all of what the International Council of Nursing considers "pillar" functions (i.e., regulation, professional practice and socio-economic welfare) into a single organization, the pressures of the modern world have placed these functions in sufficient conflict that those organizations that traditionally performed multiple functions have had to split and consolidate functions. As regulatory bodies and bargaining units have formalized and expanded their strength and scope in this context, the need for a strong third organizational entity—the professional association voice—has become more difficult to defend within the profession (Duncan, Thorne, & Rodney, 2015). Thus, some of the structures within which nursing's collective public contributions have historically been shaped, developed, strengthened, and clarified are being dismantled and reconfigured into entities with quite different roles and functions, often less directly informed by nursing philosophy than by workplace realities and tensions. In weakening the kinds of nursing organizations best positioned to represent the professional angle of vision in the public and healthy policy arena, we erode the infrastructure best suited to support the profession as a coherent and distinctive voice within society, one that can inherently be trusted as bringing to the table a unique and fundamentally essential set of values and perspectives on how health problems can be addressed. Taking all of these intersecting trends into consideration, it is apparent that, despite its proud history and a powerfully coherent set of core ideas that drive its distinctive understanding of the world, modern nursing is confronting difficult challenges. Its fundamental nature is such that it does not easily conform to the kind of "soundbite" definition to which we have become accustomed in our modern media universe. Although we know how to teach to these highly complex ideas, we have not yet found ways to effectively sustain them within the challenging context of everyday work the modern health care environment. That workworld is governed by managerialist ideologies designed to dismantle rather than strengthen intra-professional allegiances. Although nursing generally endorses the idea of the health care team, its manifestation in uncritically applied interprofessionalism serves to dissemble our capacity for structural oversight and conceptual leadership of the system of nursing. Further, the demands of a modern society have strengthened nursing regulators and unions to the detriment of dedicated professional associations. The confluence of these co-existing trends means that the expression of a coherent, socially conscious, collective nursing voice is becoming increasingly challenging in today's world. Despite the impediments, there is optimism to be found in considering all of these trends together such that we think about the problem of nursing and its collective will in new ways. First, I believe we need to remind ourselves that a shared voice is fundamental to our public trust. The trust within which our profession is held by society derives from a strong system of nursing care that becomes a safety net in advance of, during and following a health crisis, a support system for persons who are struggling, and a carative system for those in need. It is never the work of an individual nurse, but of each nurse as a representative of that coherent system. To keep that system strong, to ensure that each nurse remains aligned with the core values and ideals of that system, we need to nurture that collective voice that reminds us individually and collectively on an ongoing basis of that for which we stand. Strong organizations (nursing professional associations, specialty practice groups), and nursing leadership systems within our workplaces are essential. All nurses ought to know who their colleagues are, have ready access to mentorship across the career, and always understand how to turn to nursing leadership as need arises. And although we will always work hand in hand with our allies across the professional, paraprofessional, and lay sectors, the primary system of that mentorship and leadership must reside within our profession. That nursing systems are breaking down and need urgent attention is being recognized across national and international contexts. It is reflected in a number of recent calls for strengthening the collective capacity of nursing. Since 2010, following (what was then) the US Institution of Medicine's assessment of the pending challenges facing the profession, a campaign entitled The Future of Nursing1 was launched. More recently the World Health Organization and the International Council of Nursing have mounted a three year campaign entitled Nursing Now,2 with the similar aim of raising the profile and strengthening the capacity of the nursing profession to enact its distinctive contribution to the health of nations. These calls build on a solid body of evidence that makes explicit the meaningful and powerful role that nursing plays in any health care system, and the risks to society that ensue when nursing policy and advocacy voices have difficulty making themselves heard. So we are in an ideal time to take advantage of political will to work with us, and a body of solid knowledge to guide us. We must also do all in our power to ensure that nurses across the career trajectory fully appreciate the value of that collective professional voice, and play their part in endorsing, building or supporting it (Woodward, Smart, & Benavides-Vaello, 2016). Our educational programs must ensure that the core intellectual underpinnings are strongly integrated into each new nurse, and that each graduate is equipped with core skills in policy and advocacy (Fawcett, Holloway, & Rhynas, 2015). Our workplace leadership systems must ensure a nursing angle of vision on mentorship, structures and processes is accessible to each member of the profession. And our professional associations must stay vibrant, healthy, and optimally positioned to ensure that nursing perspectives on health and public policy are loudly expressed and widely heard. The world is gradually recognizing that nursing really does matter. We also have to truly believe it ourselves. 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