Evolution of Nursing as a Profession

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Dr. K. Prabakar

CEO, Apollo Knowledge, Chennai

Abstract 

The article traces the evolution of nursing as a globally recognized profession from an intuitive art in the homes. The historical development of nursing by Egyptians, Greeks, Romans, Chinese, Hindus, Christians, and Arabs is discussed. Nursing in the modern era, with its low and high points, and the contribution of Florence Nightingale as the turning point in the development and recognition of nursing are also examined in the article. The professional characteristics of nursing, the personal qualities needed for a professional nurse, code of ethics, and professional accountability are the other key components of the article.

Nursing evolved as an intuitive response to the desire to keep people healthy as well as to provide comfort and assurance to the sick. The essence of this desire was reflected in the caring, comforting, nourishing and cleansing the patients by the care givers. Simple procedures for the care of the sick were adopted, skills in practising these remedies were improved, and knowledge of the efficient system was passed on from one generation to another. Beginning as an "art" in the homes where a member of the family cared for the sick, it has today developed as a highly skilled service to meet the health needs of the community and society, and a professional service to prevent illness as well as to care for the sick.

Historical Background

It is extremely difficult to trace how prehistoric society dealt with their sick. One of the earliest evidences of compassion for the sick comes from the Neanderthal stage of human evolution (about 1,00,000 years back). From one of the burials of an old man, it is seen that the old man has suffered a bone deformation crippling him. Palaeontologists say that the old man lived long after he was crippled and his death was not due to this deformity. Obviously he could not have survived without being a good hunter. With the deformity he could not have hunted. He must have been looked after by others of his group.

The study of various civilizations provides an insight into the concept of health and health care practised in different societies. The civilization of Mesopotamia believed that health care was religion-oriented. The practitioners were herb doctors, knife doctors and spell doctors equivalent to the present day intensivists, surgeons and psychiatrists. 

The Egyptians believed that medicine was divine and the person in-charge was the priest physician. The priest was elevated to the rank of God, temples were built in his name and the sick people were taken to the site for healing. The Egyptians developed the art of embalming the body after the death for preserving the same in the pyramids. 

The Greeks also considered medicine as divine. Apollo, the Sun God, was considered the God of medicine. The dynasties of curative medicine and preventive medicine came into existence. Priest physicians were in-charge of the temples and the sick people were brought to the temples and kept for relief. The greatest Greek physician Hypocrites studied and classified diseases based on observation and reasoning. He challenged the tradition of magic in medicine and initiated a new approach by applying clinical methods in medicine. Greeks rejected the supernatural theory of disease and looked upon disease as a natural process. 

The contribution of Romans was mainly in the field of comparative anatomy and experimental physiology. The greatest Roman medical teacher Galen felt that health preceded disease and hence it was important to preserve health first, before working on the factor of cure.

The Chinese medicine is acclaimed to be the world's first organized body of medical knowledge dating back to 2700 BC. This is based on two principles: The Yang and the Yin, Yang is the active masculine principle and the Yin is the negative feminine principle. The balance of these opposing forces meant good health (Dolon, 1973). The Chinese had great faith in their traditional medicine and it was fully integrated with modem medicine. The Chinese developed the art of acupuncture and this was considered a universal panacea.

The earliest contribution of ancient Hindu society to medicine is reflected in the vedas. Out of the four vedas, the Atharva-veda contained innumerable incantations and charms for diseases, and discourses on injuries, sanity, health and fertility. Among these compendiums of ancient knowledge was Ayur-veda (Ayur means life and Veda means knowledge) or the science of life. In ancient India, the celebrated authorities in Ayurvedic medicine were Atreya, Charaka, Susruta and Vaghbatt, The practitioners of ayurveda subscribe to the "Tridosha theory of disease". The doshas or humors are Vata (wind), Pitta (gall) and Kapha (mucus). Disease was explained as a disturbance in the equilibrium of the three humors. When there is a balance and harmony between these three, the person is said to be healthy (Park, 1996).

The contributions of the civilizations reflect a high degree of empiricism, and scientific observation in the clinical role of the doctors. However, there was no identifiable nurse or organization of nurses other than the continued role of the individual compassionate nurse figure - the mother. Though there was a significant progress in the field of medicine the contribution to the field of nursing was almost nil during this phase. 

From the moment the significance of Christ's teachings penetrated the thinking of the early Christians, special places were set aside in their homes for hospitality and the care of the sick. These were called Christrooms, showing a literal interpretation of the words of Christ. These rooms whether in the home of a bishop, deaconess or other person, were called diakonia. Xenodochia was the name given to the shelters built for the sick and poor pilgrims, and nosocomia was the name given to hospitals built by St. Zoticus in Constantinople during the reign of Emperor Constantine. The Christian Bishop St. Basil built up a Xenodochiam called "Basilias" in Caesarea in Palestine (Dolon, 1973).

The early Christian period (till 500 AD) created a base to nurture nursing. Charity and love in action based on the teachings of Christ were apparent in nursing which took root during this period. The first organized visiting the sick began with the establishment of the order of Deaconesses and they endeavoured to practise corporal works of mercy. This work included the basic human needs such as to feed the hungry, to give water to the thirsty, to clothe the naked, to visit the imprisoned, to shelter the homeless, to care for the sick, and to bury the dead. Charity was considered as the greatest social reform during that period. 

After the order of Deaconess, a group of noble Roman matrons distinguished themselves in the field of nursing. They were women of wealth, intelligence and social leadership. They founded hospitals, convents and monasteries and worked for the good of others. These nurses were not just comforters, but they were also nurturers, observers, listeners, counsellors, and teachers, and gave care to the patient and the family. These intellectually and socially skilled leaders identified the basic ingredients of nursing care through careful assessment of needs. They realized the dependency of the acutely ill patients upon their nurse for vital life processes. 

The nurse's role of healer as well as builder of health was achieved by cleaning up the filth and squalor, and by rectifying human indignities and degradation. Nurses, in effect, were early social reformers. The site of health delivery occurred where the need existed - in the community, in the hospital, in the home, in the hostel of a pilgrim, and in a home for the elderly. The nurses during this period were motivated by a strong spiritual force and were independent practitioners. 

With the fall of the Roman Empire the medical schools established during that period disappeared. Europe was devastated by various diseases like plague, smallpox, leprosy, and TB. The practice of medicine reverted back to the primitive medicine dominated by superstitions and dogma. Glorification of spirits became the accepted pattern of behaviour. Dissection of the human body for medical research was prohibited. There was no progress of medicine in this period. This period is therefore called the "Dark ages" of medicine (Park, 1996).

During the middle ages religious institutions helped in preserving the ancient knowledge, at the same time rendered active medical and nursing care. The middle age was quite turbulent and the world changed politically to a great extent. During the medieval times there was a rise and fall of feudalism in Europe and this had a great effect on the common man. It was a time of famine accompanied by miseries and serious illness. Though medical care and nursing care were needed these were not available to them. However, feudalism gradually disappeared in the 13th century. 

This period also saw the establishment of hospitals. The first hospital on record in England was built in York in 937 AD and a chain of hospitals came up from Persia to Spain. Early medieval hospitals rarely specialised in the treatment of the sick; On the contrary, the sick were received for catering to their bodily wants and spiritual needs. The monasteries during this period gave opportunities for women to pursue a career in which they could satisfy their intellectual and spiritual aspirations, and develop nursing skills (Park, 1996). At the close of the middle ages there were hospitals all over Europe. 

When Europe was passing through the 'Dark Age', the Arabs took over the rest of the civilization, They translated the Graeco - Roman medical literature into Arabic. They developed their own system of medicine by borrowing largely from Greeks and Romans, and the new system they developed was called the Unani system of medicine, They founded schools of medicine and hospitals in Baghdad, Demascus, Cairo and other cities. Leaders in arabic medicine were the Persians. The greatest contribution of Arabs was in the field of Pharmacology as they introduced a large number of drugs both herbal and chemical. They invented the art of writing prescriptions and introduced a wide range of syrups, oils, pills, powders, and aromatic waters. The Golden age of Arabic medicine was between 800 -1300 AD (Park, 1996).

During the renaissance many medical and nursing schools were started. The period witnessed nurses, both women and men, providing nursing care to people of all ages in a variety of settings. Nurses expanded their role while continuing to use intellectual skills and judgments in the execution of physical as well as psychological nursing care (Dolon, 1973). 

Nursing sank to its lowest level in the countries in which Catholic organizations were banned. The state closed churches and there was little provision for the institutional care of the sick. When the demand became great, lay persons were made to run the hospitals because of social necessity. There was no honour to work in a hospital. Nursing lost its social standing. Nurses at that time were mostly recruited from lower classes. The low status of women in the social structure also contributed to this situation. The Catholic Church gave women more freedom and opportunity to move about in the world. The Protestant church did not think much of freedom for women and the nursing services. Many women were assigned nursing duties in lieu of serving jail sentences (Rao, 1996). This "Dark Period of Nursing" between 1550 - 1850 saw nursing conditions at their worst. Nursing was of a very poor standard due to the poor salary and miserable living conditions of the nurses. The work places also contributed to the depressing situation and nursing work was considered to be the most menial. These poor conditions made women feel that there was no future for them as nurses. Due to these factors there was a rapid deterioration in the care of the sick. After the counter reformation (Catholic revival) through the "Society of Jesuits" founded by Ignatius Loyala, a Spanish noblemen, religious orders were reopened and they tried to bring back some of the traditions. Some humanitarians like St. Vincent De Paul, John Howard, and Charles Dickens did much to relieve the depressing situation during that time (Rao, 1996). 

Eighteenth century also witnessed notable achievements in conquering certain diseases, devising diagnostic equipments, developing humane treatment for the mentally ill and expanding the basis for chemistry and physics (Dolon, 1973). 

Nineteenth century was marked by the demand for liberation of women who were forced to live a life without educational and career opportunities. However, leadership of great women like Susan B Anthony, Elizabeth Blackwell and Florence Nightingale was remarkable. They created history in their areas of operation. Susan Anthony fought for the rights of women for higher education and an opportunity to practice profession. Elizabeth Blackwell struggled to gain admission to medical school and finally she gained the degree of doctor of medicine. She was responsible for founding the Women's Medical College of the New York Infirmary for Women and Children (Dolon, 1973).

The social reformers of the early nineteenth century had focused attention on the plight of the poor and on the needs for reform in prisons, hospitals and nursing. Leadership in the social aspects of living and in nursing was needed. The person who responded to this exigency was Florence Nightingale who cannot be considered as the product of her time but rather must be regarded as one of those rare and gifted people who transcend the period of their own existence, and whose plans and accomplishments represent the thinking of a much later period of history (Dolon, 1973).

Florence Nightingale was born on 12th May 1820 at Florence in Italy. After her education, she became interested in politics and the social conditions of the people. She felt she had a special purpose for her life. She decided to take up nursing. In this journey, she became familiar with the nursing of Roman Catholic sisterhood and American missionaries. She felt the need for systematic training for nursing. She took up a nursing programme in 1847 in Kaiserworth and completed it. She considered it as her spiritual home and once again studied nursing under the "Sisters of Charity" at Maisondela providence. After returning to London, Nightingale's first position was the Superintendent of the Establishment for Gentle Women during illness. She planned for the patients and the doctors with great skill, and was successful. Within a short time she was asked to become the superintendent of nurses at King's College Hospital where she began her work. She was called to go to Crimea with a mission of mercy to help the wounded soldiers of the Crimean war. 

At that time when schools of nursing were unknown she assembled her staff in less than a week. She had in her group 38 nurses. Nightingale and her 38 nurses were given charge of 1500 patients at the Barrack hospital. The hospital conditions were extremely poor. The death rate was 42%. In two months, she had transformed the hospital into an efficiently managed institution. In six months she had reduced the death rate to 2% and had won the respect of most surgeons. She utilised scientific methods of gathering data and was skilled as a statistician presenting the factual evidence in the most graphic way. Doctor Winslow referred to her as the "Lady with the Slide Rule" as well as a "Lady with the Lamp" of compassion (Dolon, 1973).

It should be noted that Florence Nightingale made very clear the distinction between persons professionally qualified for the practice of nursing, and the knowledge essential for every woman who can be called at any time to render nursing service in some form. Students today marvel at the current pertinence of these basic principles of good nursing care and how clearly Nightingale delineated the role of identification for nurses. Florence Nightingale was not interested in simply keeping people alive; she stressed that "Nursing is helping people to live."

The Nightingale Training School for Nurses, which opened in 1860, was a completely independent educational institution. The size of the classes was small which permitted a high degree of selectivity with only 15 to 30 students. In 1865 Florence Nightingale contributed two books on nursing in a community setting. Nightingale helped in founding the first Community Nursing Association in Liverpool. 

There were two major components to nursing in her thinking : "sick nursing" and "health nursing". This involved the preservation of "wellness" as well as the care of illness. She said that "nursing proper is therefore to help the patients suffering from disease to live, just as health nursing is to keep or to put the constitution of a healthy human being in such a state as to have no disease". The Community Health Home Care Services have continued under this aegis of nursing to the present. She defined nursing as that care which put a person in the best possible condition or nature to restore or to preserve health, to prevent or to cure disease or injury. Nightingale stressed that the sick person must be treated and not the disease. She identified a "nurse the sick and not the sickness" philosophy many years before Dr. Osler pronounced his famous statement: "it is better to know the patient who has the disease than the disease the patient has" (Dolon 1973).

After Florence Nightingale, other nursing professionals like Mary Adelaide Nutting, Isabel Hampton, Lavania L Dock and Fredericka Fliedner contributed much to the development of nursing.

Certain hospitals for many years accepted men to a short course in nursing. The men were called "attendants" but not "nurses". In 1888, at Bellevue Hospital in New York, the Mills School was established with a two year course; its graduates were also called as attendants, following the custom of the time. In 1943 there were four schools of nursing for men only; the Mills School, New York, the Pennsylvania Hospital School of Nursing for Men and the two Alexian Brothers' hospitals in Chicago and St. Louis. Many more men opted for nursing programmes and by 1948 the number of male student nurses increased.

The period that followed World War I saw a greater demand for nurses. It opened up new fields of specialisation, accelerated the educational process to create public consciousness with regard to the importance of good nursing. The World War taxed the medical and nursing resources of the world to the maximum. Two catastrophic episodes of World War I-the epidemic of pneumonia in 1917 and the pandemic outbreak of influenzea in 1978-emphasized the need for well-prepared nurses.

World War II also had a profound influence on nursing. In the United States almost revolutionary changes came about as a direct result of it. Many nurses were needed for the great army camps established throughout the country, and many responded to the government's appeal. In 1940, the nursing leaders had comprehended the potential need and had formed the Nursing Council of National Defence, composed of representatives from all the national nursing bodies. In 1942 this body became the National Nursing Council for War Service.

With the inception of Nursing Section of the World Health Organisation in 1949, Oliver Baggallay was appointed chief and she continued in this office until 1954. Miss Baggallay graduated from St. Thomas' in London and had been secretary of the Florence Nightingale International Foundation from 1934 to 1949. In July 1954, Lyle Creelmana, graduate of Vancouver General Hospital School of Nursing, became the chief of the Nursing Section of the World Health Organisation. She had been public health nursing administrator in the Nursing Section of WHO since 1949. Her guidance and counsel had been extended in the area of public health nursing to all, throughout the world.

Nursing a Profession

Over the years people doubted whether nursing is a profession or is it a semi-profession. The doubts are not centered whether or not the nurses have professional attitude or professional organizations but on whether the nurses meet the criteria of professionalism. Then what is Nursing? Is Nursing an art or a science? Is the Nurse a professional? If nursing is to be a profession, what are the criteria for it to be a profession? To understand these and related issues there is a need to first study the definitions of Nursing.

Beginning with the simplest definition, a nurse is a person who nourishes, fosters and protects - a person who is prepared to care for the sick, injured and aged. In this sense "Nurse" is used as a noun and is derived from the Latin word "Nutrix" which means "nursing mother". Dictionary meaning of a nurse includes "suckles or nourishes", to take care of. In this way "nurse" is used as verb, deriving from the Latin word "nutrix" meaning to "suckle or nourish". According to Schulman (1972) nursing's long historical orientation has been based on a concept of "mother- surrogate", a role "characterised by affection, intimacy and physical proximity with an orientation for meeting the needs of the dependent ward", providing for protection and identification.

Florence Nightingale's (1859) Notes on Nursing describe the nurse's role as one that would "put the patient in the best conditions for nature to act upon him." Nursing in its broadest sense may be defined as an art and science which involves the whole patient - body, mind and spirit ; promotes his spiritual, mental and physical health by teaching and by example ; stresses health education and health preservation as well as ministration to the sick; involves the care of the patient's environment - social and spiritual as well as physical; and gives health service to the family and the community as well as to the individual. 

A classic definition used by nurses internationally is that of Virginia Henderson (1966), distinguished American Nursing educator and writer : The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this, in such a way, as to help him gain independence as rapidly as possible. She is the master of this part of her function as she initiates and controls it. In addition, she helps the patient to carry out therapeutic plan as initiated by the physician. She also, as a member of the medical team, helps other members, as they in turn help her, plan and carry out the total programme whether it be for the improvement of health or the recovery from illness or support in death.

Schlotfeldt (1978) states that Nursing is an essential service to all of mankind. That service can be succinctly described in terms of its focus, goal, jurisdiction and outcome as that of assessing and enhancing the general health status, health assets and health potentials of all human beings. It is a service provided for persons who are essentially well, those who are infirm, ill, or disabled, those who are developing and those who are declining. Nurses serve all people- sometimes individuals and sometimes collectives. They appropriately provide primary and long term care and as professionals are independently accountable for the execution and consequences of all nursing services

Fagin (1978) maintains that primary care has been the academic discipline of nursing, since its public health evolution in the early days of nursing. Nursing is defined as including the promotion and maintenance of health, prevention of illness, care of patients during acute phases of illness and rehabilitation and restoration of health.

The ANA (1973) standards of practice states, "Nursing practice is a direct service, goal directed and adaptable to the needs of the individual, family and community during health and illness. Professional practitioners of nursing bear primary responsibility and accountability for the nursing care clients/ patients receive." 

Nursing is the process of recognising, understanding and meeting the health needs of any person or society and it is based upon constantly changing body of scientific knowledge (Zwemer, 1996).

According to the American Nursing Association, nursing means the performance for compensation of any act in the observation of care and counsel of the ill, injured and infirm or in the maintenance of health or prevention of illness of others or in the supervision and teaching of other personnel, or the administration of medications and treatments as prescribed by a licensed physician or dentist; requiring substantial specialised judgment and skill, and based on knowledge and application of the principles of biological, physical and social sciences.

From a period of time lasting approximately from the 1950s through the 1970s or mid 1980s nursing periodically was reviewed against the characteristics of a profession that had been established in the sociological literature. The activities for which nurses were responsible, the legal ramifications of practice, and particularly the education of future nurses were subjected to the scrutiny of sociologists and nursing leaders found it challenging to examine nursing against established standards. The characteristics of a profession have been discussed by many scholars. According to them generally a profession will: 

• Possess a well defined and well organized body of knowledge that is on an intellectual level and can be applied to the activities of the group; 

• Enlarge a systematic body of knowledge and improve education and service through use of the scientific method; 

• Educate its practitioners in institutions of higher education; 

• Function autonomously in the formulation of professional policy and in the control of professional activity; 

• Develop within the group a code of ethics;

• Attract to the profession individuals who recognize this occupation as their life work and who desire to contribute to the good of society through service to others;

• Strive to compensate its practitioners by providing autonomy, continuous professional development, and economic security (Bixler and Bixler, 1945, Pavalko 1971).

Nursing leaders believe that nursing is an unique profession as it has borrowed various concepts and skills from biologic sciences, social sciences, and medical sciences. Nursing researchers are working towards developing an organized body of knowledge which is unique to nursing. There are nursing professionals who are working to advance the standing of nursing through the development of code of ethics, standards of practice and peer review. As a result of all this nursing has emerged as a profession. 

A profession should have the ability to grow and change according to the requirements in this dynamic world. The growth is expected to be systematic over a period duly supported by scientific methods. Provision of nursing care is a problem solving process. The nurse first gathers data about her patient, then identifies the problem. An approach to the problem is selected and carried out. Finally, the result of this approach, in terms of consequences for the patient are evaluated. By using this process, the nurse can individualize her care and be accountable by providing a scientifically based service. Nursing diagnosis is the title given to the stage of identifying the problem.

Research activities in nursing have added value to the established body of knowledge in this discipline. Tangible proof for this growth is the added literature in the nursing textbooks. All this reflects the continued growth of the body of knowledge in nursing.

Nursing's heritage, like that of medicine, was founded in an apprenticeship beginning. Students were assigned to experienced practitioners who taught the skills with which they were familiar. Once those skills were acquired, the student moved into the world of employment. The earliest programmes of education were located in hospitals rather than in universities. Today by far the majority of nursing programmes preparing registered nurses are located in school or collegiate settings affiliated to medical universities.

Critics review professions against standards for professions. They place emphasis on the ability of any group to develop its own policy and to function fairly autonomously. This has always been a problem for nursing. Traditionally the nurse works under the direction of the patient's physician, often in a hospital setting. The physician writes the orders for medical care that are to be implemented by the nurse, and the agency or hospital sets the policies under which that care is delivered. Only in the last 50 years has nursing made significant inroads in defining the unique role of the nurse in "care" as opposed to "cure" of the patient. Today nurses are responsible for planning and implementing the nursing care patients are to receive and are also accountable for the care provided. Nursing diagnosis, once challenged as an inappropriate responsibility for nurses, has become a standard of good nursing care. Although nurses continue to carry out the medical instructions by physicians, a more collaborative relationship is beginning to occur and the contribution of the nurse is receiving more recognition. 

The general standard for professional behavior of nurses in the United States is the American Nursing Association Code for Nurses. This document was developed by the ANA and is periodically revised to address current issues in practice. The International Council of Nurses, housed in Geneva, Switzerland, has also developed a code for nurses that reiterates many of the behaviours outlined in the ANA code. The international code sets the standards for ethical practice by nurses throughout the world. 

Bixler and Bixler (1945) emphasize in their listing of criteria for professions that a profession should attract people of intellectual and personal qualities who place service above personal gain and who recognize their chosen occupation as a lifework. Pavalko (1971) also identifies as a significant criterion the sense of commitment the members have toward work as a lifetime or at least a long-term pursuit rather than as a stepping stone to another profession. Studies of nursing indicate that most individuals gaining educational preparation for nursing remain within the profession although concern has been voiced regarding the "burnout" that occurs from stress. Today there is a tendency for individuals to enter the profession of nursing at one educational level and to continue to advance in practice and education by pursuing additional degrees and experience. 

The criteria of professions includes concepts like altruism, service to the public and dedication, and these must be the motivating force for the individual to take to the profession of nursing care. The image of nursing as a profession had a strong religious heritage supported by the concept of giving of self to the profession. 

The heritage of nursing is a rich one. The history of nursing has given us a complete picture regarding the growth and the development of the profession and the contributions of various nursing leaders. The vision of the great nurses of the past has to develop nursing practice with ethical standards for the good of the society. Quality nursing care has become a very important factor for the survival of a health care institution. Today's nurse is required to possess all round personality, necessary general education, professional education, and a high degree of commitment and maturity to work as a nurse. 

Nursing Practice

The important personal qualities needed for a professional nurse are a caring attitude, a willingness to put service before personal gain, poise, self discipline, honesty, courage, a pleasant and neat personal appearance, and good health.

A caring attitude usually comes with being able to express a sense of spiritual love to the fellow human being. Professionally it includes concern and empathy. Putting service first rather than personal gain is extremely important in spite of the changes in ethics and values, which are taking place in the nurse's professional work and relationships with patients. A well balanced and a stable personality is a requirement for the nursing profession as nurses will have to take full control of the emotions, mental activities and actions under pressure. It is important for an individual nurse to be self disciplined to develop into a good quality professional nurse. Self discipline supported by being truthful, sincere and fair will not only make a good nurse but also a good individual. A nurse will have to be courageous in handling difficult times while treating a patient. A neat clean pleasant appearance with good health and a well balanced life will help a nurse to be good and effective in a profession (Ann, 1996).

The most important goal of a hospital organization is to provide the best and the immediate medical treatment to the patients. In a modem hospital the health team providing treatment to the patients consists of doctors and nurses. The doctor focuses on the curative aspects and the nurse focuses on the care process. The nurse is the key figure to articulate the therapeutic process and shares the responsibility of acting as a mediator between the patient and the doctor. She infuses confidence in the doctor, in the patients and in the treatment process. By virtue of playing complex and delicate roles, the nurse has become indispensable in the modern therapeutic system. The central values of health care are a responsibility of the nurses and the doctors. The real inspiration and hope for progress is given by the nurses among other health professionals. Ethics play a very important part in determining the values of the nursing profession. The moral and ethical dimensions in health care are reflected by the performance of the individuals concerned. The nature of nursing practice is an important factor in the genesis of issues in relation to the moral and ethical problems connected with people or institutions. 

Moral and ethical problems in a hospital can be divided into three categories: moral uncertainty, moral dilemmas and moral distress. Moral uncertainty arises when one is unsure of what moral principles or values to apply. Moral dilemma arises when two or more moral principles apply but they support mutually inconsistent courses of action. Moral distress arises when one knows the right thing to do but institutional constraints make it impossible to pursue the right course of action. These problems are symptoms of crisis of rapid change in the health care delivery system. Nurses play a central and varied role in patient care and the management of health care delivery. They are educated in different levels with a variety of academic qualifications and they practice many specialities. They perform many different jobs in patient care and administration. Nurses face many ethical conflicts in relation to their job. 

The practice of nursing means the performance for compensation of professional services requiring substantial specialised knowledge of the biological, physical, behavioural, psychological and sociological sciences and of nursing theory. It is the basis for assessment, diagnosis, planning, intervention and evaluation in the promotion and maintenance of health, the case finding and management of illness, injury or infirmity, the restoration of optimum function, or the achievement of dignified death. Nursing practice includes administration of medication and treatment prescribed by persons authorised by law apart from ward administration, teaching, counselling, supervision, delegation and evaluation of practice. These services are performed under the supervision of a registered nurse and utilise standardised procedures leading to predictable outcomes in the observation and care of the ill, injured and infirm, to safeguard and maintain life and health of the patients. Each registered nurse is directly accountable and responsible to the patient for the quality of nursing care rendered. 

Nursing functions can be classified as maintaining or restoring normal life functions, observing and reporting science of actual or potential change in a patient's status, assessing his/her physical and emotional state and immediate environment, formulating and carrying out a plan for the provision of nursing care based on medical regimen including administration of medications and treatment, interpretation of treatment and rehabilitative regimens, counselling families in relation to other health related services and teaching. 

In one study, nursing educators project the evolving functions of nursing as data gathering, including history taking and assessment; nursing diagnosis (and some aspects of medical diagnosis); nursing intervention; evaluation, including evaluation of nursing team performance, evaluation of community resources; and administration, including carrying 24 hour responsibility for nursing care (Torres, 1975).

Yura and Walsh (1973) state that the term nursing process was not prevalent in the nursing literature until the mid 1960s, with limited mention in the 1950s. In 1967, a faculty group at the Catholic University of America specifically identified the phases of nursing process as assessing, planning, implementing and evaluating of the services. The nursing process is described as an orderly systematic manner of determining the client's problems, making plans to solve them, initiating the plan or assigning others to implement it and evaluating the extent to which the plan was effective in resolving the problems identified.

The focus of clinical practice, clinical research and nursing education depends heavily on the systematic and orderly arrangement of the nursing process. A major thrust in nursing today is identification and the use of conceptual frame work. The "Nursing Process" was a forerunner in the presentation of theories that guide and support nursing (Yura and Walsh, 1973). From the mid-1960s to the early 1970s, there was much discussion about the nursing process which emphasized on the assessment phase of the process. Nurses were so enamoured with the systematic way of performing nursing, but they became bogged down in data collection. A number of assessment tools were developed. The concept of health was assumed to be subjective, relative and dynamic, it is a state that is subject to the modification by invasion of pathogens by the functional ability, adaptability and reserve capacity of a person (Yura & Walsh, 1973). Four factors were used as a basic frame work, essential to the concept of health in long term clients: demographic characteristics, physical status, psychological status, and self care practices. Extensive testing for reliability and validity produces an instrument that can assist the nurse in classifying clients according to the types of the care they need.

Professional Ethics

To become a nurse is not just a matter of learning particular knowledge and skills, or adopting forms of behaviour appropriate to the context. It is also a matter of assimilating the attitudes and values of the nursing profession in a way, which can influence the thinking, the personality and the lifestyle of the individual concerned. There is a combination of knowledge, skill and acquired moral responsibility, which is a part of the process of nursing education. Those entering the nursing profession may fail to realize the difficult decisions one has to take which can question one's own personal convictions and values. Doctors are highly specialized and skilled, and they are often seen to be dealing with the matters of life and death of a patient. As nursing sometimes is carried out by lay people in a family apart from professionally qualified nurses it makes it difficult for new corners to the profession to appreciate the responsibilities and complexities involved in the nursing process and therefore encounter moral conflicts. The risk of conflict between the personal and the professional values are at its peak during the early years of professional life as the incumbent has to get adapted to the values of the profession. The socialization process helps the individual to build personal moral convictions and values which are required to balance the emotional responses when they enter into the nursing profession. Professional nursing within an organization relies on the notion of roles rather than individuals (Kath & Boyd, 1995).

Nursing ethics is a part and parcel of professional nursing. The applicability of a fidelity rule concerns with implicit promises. The principle of confidentiality and patients' expectations that nursing staff will promise to undertake their duties with a required degree of skill and care according to Beauchamp and Childress's framework is dependent on four moral principles. They are the principles of respect for autonomy, the principle of beneficence, the principle of nonmaleficence, and the principle of justice (Edwards, 1996).

The challenge in a health care unit is the creation of healing environment for patients. Florence Nightingale demonstrated through her work, the specific requirements, attention and aspects of patient care which promote healing. Three decades ago, Edmund Pellegrino, physician and noted medical ethicist, commented on working relationships between nurses and physicians as a major challenge in the patient care environment. The working relationship between and among nurses and patients are an ethically significant aspect in patient care environment. The compassionate patient care requires a collegial and collaborative working relationship both within nursing, and between nurses and doctors. A collegial or collaborative working relationship is defined as working together with mutual respect for the contribution and accountability of each profession to the shared goal of quality patient care (Aroskar, 1998).

Nurses who work in critical care units are confronted with ethical issues, which produces mental and moral distress. The primary challenge which confronts the nurses and the physicians are cost containment on one side and resource allocation on the other side during the course of the treatment. The other challenges which confront them are the values of individuals involved, communication pattern, trust, integrity, role responsibilities, and role conflicts.

Values are inculcated through family upbringing and training. The values which are learned are modified by education and work experience. Ethical conflicts may arise between various professional care givers as they have different work experiences and different values on issues connected with patient care such as what comprises informed consent, extent or invasiveness of treatment, when to stop treatment, or when to resuscitate. The nurses sometimes are also caught in quandary between physicians and the patients with conflicting values about termination of life sustaining treatment. 

Two important factors that affect communication between nurses and doctors are gender and prestige. Though the image of the nurse as the physician's handmaiden is fading, still this influence continues. Sometimes the nurses' opinion not valued by the doctors and the nurses are afraid to confront and challenge them. They have a fear of intimidation as the doctors are more powerful and hence nurses are not assertive particularly in the Indian context. The nurses are obedient soldiers in just following strictly the physicians orders of treatment.

Trust and integrity play a very important role in effective nurse physician relationship. Patient conditions may change rather quickly and unexpectedly. Although the nurse may know what interventions are necessary she waits for the physician's order to act beyond the standard protocols of treatment. However some of the nurses carry out certain actions required for managing a patient once she has a trust that the concerned consultant will back her actions. Nurses are torn between the loyalty to the physician and the patient as nurse - physician relationship depends on trust between each other and violating it can create an imbalance in the system. 

The major role of nurses is to carry out the doctor's orders. The knowledge base of bedside nursing care for a nurse is much more than that of a physician. The critical care nurses have a major responsibility of monitoring the patient and provide early intervention in case of an emergency. Nurses have more intense exposure to the patient and hence expect to be involved in the decision making process about the patient's care. However when physicians do not share this perspective it leads to lack of understanding between each other's responsibilities creating mental distress there by affecting the patient care. 

The ethical work environment should support a collaborative team approach by blurring professional boundaries and clarification of values, as well as the process to monitor and evaluate ethical performance. Necessary protocols and critical pathways for treatment have to be developed which can bring in consensus between doctors and nurses in the delivery of effective and efficient patient care. 

The principle of confidentiality has a long tradition amongst health care professionals, and for doctors it has its origin in the Hippocratic Oath. For nurses, respecting confidences is often seen as having two practical applications: firstly, respecting the confidences of the patient and, secondly, respecting the confidences of colleagues. Health professionals have a special duty to respect the confidences of the patient as part of their professional responsibility. This type of responsibility has been described by Hart (1994) as 'role responsibility'. Professor Hart suggests that if a person occupies a distinctive place or office within society and as a result has duties attached to this position, then that person is responsible for fulfilling whatever duties are recognised as part of that role within society. The role responsibility is not restricted to the professional roles but also to other roles like parents (Fletcher & Holt, 1995).

Rushton and Brooks-Brunn (1997) have proposed a strategy for developing environments that support ethical practice. Although they focus on end-of-life care, their recommendations are pertinent for all ethical issues in a health care environment. They identified six key points to use in assessing an organisation's structure to monitor ethical performance: (1) performance reporting that includes ethical behaviour, (2) employees considering ethical aspect part of their job, (3) recognition of employees who provide ethical leadership, (4) procedures for dealing with ethical code violations, (5) mechanisms for accountability to the public and patients, and (6) assessing frequency of use of conscientious objection (taking a stand on an ethical issue different from that of the majority). These assessment criteria can be used by the health care institutions to gauge their progress in enhancing the organizational cultures to functions at a higher ethical level (Corley, 1995).

Professional Accountability

In the health services sector the doctor, the nurse and the organization become the service provider and the patient is the purchaser. The introduction of the purchaser and provider concept has raised the issue of accountability in the health care services. The concept of accountability impinges on nurses the ways in which it does not impinge many other non-professional occupations. Nursing as a profession demands training and registered qualification in order to practice the profession. The nurses are accountable to the patients and to the hospitals for their practice and this accountability is regulated by statutory bodies (Watson, 1981).

The average nurse appears to believe that accountability is following procedure and making sure "one is covered" by having the right kind of note or record and refer back to when something goes wrong or where for whatever reason the acquisition is made. Nursing accountability is moral responsibility narrowed down to the role of a nurse. Nurse is one element of the health care unit. So the nature of accountability to the patients is moulded by the particular political, economic and administrative forms which the institution takes. 

There are two ways through which the gap between the patient and the institutional ends are reconciled. The reconciliation takes the form of self regulation otherwise called lateral accountability. The nurses keep a check on each other for the best interests of the patients. The other takes the form of upward accountability, that is, the nurses are checked by the authorities for the best interests of the patients.

The first type depends an notions of honourable, gentlemanly, lady like behaviour which underlies reputation and justifies public trust. The second rests on authority, the rule of experts and discipline (Hunt, 1994).

Nurses may be expected to account for their actions and to explain procedures on a day to day basis to the patients. Such accountability is quite informal and the nurse is not obliged to be accountable in the fullest sense to the patients and relatives. It has been argued that nurses could be viewed as being accountable 'for' rather than 'to' the patients and relatives.

Nurses are not unique in this and they share accountability of a kind involving patients and relatives with the medical profession. The situation for the medical profession is however very clear in legal terms. Doctors do not have to take account of the wishes of the relatives of an incompetent adult patient in arriving at a decision to treat the patient or not. 

The complicated nature of the accountability can be seen from the above. At one extreme nurses are fully accountable to the statutory body and on the other extreme nurses exercise visible accountability daily to the bodies very close to them professionally and within the profession for aspects of nursing which are accounted for to bodies outside nursing (Watson, 1981).

Development of Nursing in India

In the past, the progress of nursing in India was hindered due to a number of reasons such as the low status of women, purdha system among Muslim women, the caste system, illiteracy, poverty, political unrest and the image of the nursing profession. Since Independence, many changes for the betterment of nursing profession have taken place in tune with the advancement of technology and professional expertise.

Military nursing was the earliest type of nursing in India. In 1664 the East India Company started a hospital for soldiers in Madras. This was followed by a civilian hospital and the hospitals were looked after by the staff of the military hospital. In 1797, a hospital for the poor called "Lying in Hospital" was built in Madras. The government started a training school for midwifes in 1854 in this hospital. In 1871, a training school for nurses was started. The faculty for this institution came from England. Due to the efforts of Florence Nightingale in 1861, the reforms in military hospitals led to the reforms in the civilian hospitals. The government hospital for women and children at Egmore is one of the earliest and the chief midwifery training schools in Madras. In 1885, the Royal Victoria Caste and Gosha Hospital was started. The Methodist Mission Kalyani Hospital, Mylapore, and Christian Rainy Hospital, Royapuram were started by the Missionaries (Rao, 1996).

In India, there was a lot of prejudice for sending educated girls from the families of the Hindu and Muslim communities to take up nursing as a profession. Only Christian girls came forward to take up this profession. The Americans and the Britishers started many schools of nursing between 1880 and 1900, and the first two well known nursing schools were established in Madras and Bombay in 1884 and 1886, respectively. The mission hospitals played a very important part in starting short programmes in nursing so that more nurses were available for taking up the job in one of their hospitals.

Ida Scudder started her work in a small hospital in Vellore for which she raised funds in America, and it was opened in 1902. She felt the need for training nurses very early and contemplated to start a nursing school with the help of Delia Houghton who was an American nurse in 1909. The origin of the school and its development had a great influence in South India (Abraham,1996).

Scudder, along with the fellow American nurse, Delia Houghton, started a medical school in 1918 in the hospital premises. Houghton was the founder of nursing profession in India. In 1946, the nursing school got recognition by the Madras University as a College of Nursing and the first Dean of the College was Florence Tailor. In 1968, the MSc programme was started.

After World War II, the practice of nursing in India reached greater heights. The Indian nurses started preparing themselves for administrative and teaching positions which were till then handled by the English nurses. In 1943, the health survey and development committee was appointed for studying the conditions of nursing in India. The report of the committee known as 'Bhore Committee' was published in 1946 which described the nursing conditions as deplorable and stressed the importance of having educated Indian women join the profession in order to raise the standard of nursing.

The Indian Nursing Council Act was passed by an Ordinance on December 31, 1947. The council was constituted in 1949. The purpose of the council was to co-ordinate the activities of the State Registration Councils and to set standards for nursing education and practice.

In 1908, the Trained Nurses Association of India (TNAI) was formed. In 1912, the TNAI got affiliated to the Nursing Council. The Nursing Journal of India published in 1909 was the official organ of the TNAI.

Nursing as a profession in India today provides an opportunity for service. With present trends leading towards greater opportunities, supported by growing social and professional recognition, the profession of nursing is becoming more open and challenging as well.

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