Although it is not a direct response to a particular JAN paper, this contribution to JAN Forum focuses on a continuing and major worldwide issue – nursing shortages. Indeed, virtually every nurse leader and every nursing organization worldwide claims that there is an unprecedented shortage of nurses (Watson 2006). No one, to my knowledge, has claimed that there is not a nursing shortage. Noteworthy is that discussions of past, current and projected future nursing shortages do not take into account the knowledge needed to be a professional nurse, nor do those discussions consider a work environment in which nursing practice is based on unique nursing knowledge.
I am sceptical about shortages of nurses. Indeed, I am not convinced that there even would be nursing shortages if what Watson (1997) calls nursing qua nursing were the focus of nursing practice. However, I do agree that there are global shortages of nurses for the practice of what Watson (1996) calls nursing qua medicine. Nurses are, as most of us realize, ‘the largest single group of healthcare providers, and they oversee and deliver nursing care, which encompasses a significant portion of the care prescribed by physicians’ (Jones & Mark 2005, p. 271). As Registered Nurses perform so many medical activities, nursing qua medicine extends from those activities driven by physician orders for vital signs, dressing changes and medications to nurse practitioners substituting ‘for a physician in a range of predefined, protocol-driven clinical tasks’ (Halcomb et al. 2006, p. 377).
We reward the medical activities performed by nurses even though we must know that, as Sandelowski (1999) pointed out, at least in the United States of America, such work relieves the deliberately controlled shortage of physicians, which preserves their market value. Noteworthy is Rayner's (2003) report that, in the United Kingdom, ‘nurses are regarded as a key solution to meet new legal requirements to cut junior doctors’ hours’ (p. 10) rather than increasing the number of physicians.
Furthermore, Registered Nurses perform activities that I believe only pharmacists should perform, namely administering medications. Nurse practitioners venture even farther into the knowledge territory of pharmacists when they prescribe drugs. Why do nurses insist on administering medications when pharmacists could do so? Why do advanced practice nurses fight so hard for prescriptive privileges when pharmacists are the only healthcare team members with sufficient knowledge to prescribe drugs? Research findings indicate that nurse prescribing is acceptable to patients and is perhaps more patient-centred than physician prescribing, but some questions have been raised about the adequacy of nurses’ knowledge of pharmacology (Latter & Courtenay 2004).
What, I must ask, are the implications for nursing shortages of Graham's (2006) comment that we are ‘slotted [into the paternalistic healthcare system] as medical technician[s] or handmaiden[s]’ (p. 381) to physicians? What are the implications for nursing shortages of Salvage's (2006) declaration that ‘nurses in every continent and from many different cultures complain that their work is trivialized and undervalued’ (p. 260)? What are the implications for nursing shortages of Gordon's (2005) reports of the dreadful and punitive conditions nurses endure as they practise against the odds? Although Gordon pointed out that nursing practice is undermined by healthcare cost cutting, medical stereotypes and medical hubris, nurses rarely rebel. Why do nurses continue to work in such oppressive situations? Are nurses, as Anderson (2000) speculated, ‘a culture that values or at least tolerates being oppressed’ (p. 53)?
What are the implications for nursing shortages of Thorne's (2005) statement that ‘the relationship between the practice of nursing and the conceptual knowledge that is supposed to drive it remains ambiguous and confusing’ (p. 107)? What, especially, are the implications for nursing shortages of Mason and Whitehead's (2003) book, Thinking Nursing, in which not one chapter was devoted to unique nursing knowledge, because, as they claimed, ‘As nursing does not appear to have a unique theoretical body of knowledge specific to itself, it has traditionally drawn upon many other fields of study to provide the basis of nursing education’ (p. xiii)? Instead, the chapters of their book focus on thinking psychology, sociology, anthropology, public health, philosophy, economics, politics and science – but not nursing science.
What are the implications for nursing shortages of the lack of unity within nursing about roles and the future? Salvage (2006) maintained that ‘Some factions wish to include under the nursing umbrella anyone who does anything that could remotely be described as nursing…, and want to be all things to all people, while others see the way forward in a high-powered portrayal of the advanced practitioner who can, and increasingly does, replace junior doctors’ (p. 260).
If we do not want to continue to practise nursing qua medicine, what can we do? What would happen if we declared that there was no shortage of nurses and maintained or decreased enrollment in nursing education programmes? I have thought for a very long time that our continual quest for additional students in our programmes, as a response to the periodic nursing qua medicine shortages, has resulted in undervaluing nursing in the market place. We rush to graduate as many nurses as we possibly can from the shortest and least professionally focused programmes to flood the market and then wonder why working conditions and pay do not improve. Do we really think our cries of a global shortage of nurses greater than ever before is the way to improve our future? What would happen if we insisted on practising nursing qua nursing?
What, you may ask, is nursing qua nursing? The answer is that nursing qua nursing practice is based on unique nursing knowledge rather than knowledge developed by members of other disciplines. Unique nursing knowledge is evident in the many conceptual models of nursing, the more than 50 middle-range theories derived from just seven of those conceptual models, and many other middle-range theories developed by nurses (Fawcett & Garity, in press). Unique nursing knowledge also encompasses all patterns of knowing – which can be regarded as types of middle-range theories – including empirical theories, aesthetic theories, ethical theories, theories of personal knowing and socio-political theories (Carper 1978, White 1995). Think about what would happen if nurses did not perform activities that are driven by physician orders. If those activities actually are legitimate nursing activities – assessments and interventions – why do physicians write the orders? If the activities really are medical activities, why do nurses perform them? What would happen if nurses practised nursing conceptual model-based, nursing theory-guided nursing and collaborated with the people who seek our services to write orders for nursing care?
Graham (2006) called for nurses to ‘find their voice and participate in the debate on what professionalism… is all about to influence and stop the creation of medical somethingness’ (p. 381). Will you find your voice and stop practising nursing qua medicine? Will you begin to practise and support nursing qua nursing? Will you join Milton (2007) in declaring, ‘[T]he practice of nursing ought to be guided by discipline-specific schools of thought that include nursing theoretical frameworks, principles and concepts. Members of the discipline should be expected to demonstrate knowledge of the theory in practice when providing nursing and complementary healthcare services to people’ (p. 33)?
Will you join me in questioning whether there is a real shortage of nurses? Will you help me try to find out how much more time we would have and how fewer nurses would be needed if nursing practice were based only on unique nursing knowledge, so that only nursing qua nursing would be practised by nurses? In conclusion, as long as we continue to practise nursing qua medicine, we will have nursing shortages. But, if we practise nursing qua nursing, we may have enough nurses for all people who seek and deserve our services. Clearly, our future lies in nursing qua nursing.