nursing care today Sister Rosemary Donley, P1i.D.. R.N. School of Nursin!!, First Vice President, Signla Theki Tat:.

Assistant Professor of Nursing, University of Pit!sburgh

The theme nursing care today is diffi- cult to write about. Initially, the particu- lar frame of reference of :he author seems more limiting than the time frame of to- day. Closer scrutiny reveals, however, that the topic encompasses a universe of experience about which many words have been written. The volume and variety of words gives support to the view that the topic, wide ranged and value laden as it is, needs to be defined for purposes of discus- sion. Ironically, this very limitation nec- essary for clarity and logic, results in a dis- cussion which represents not nursing care today but a slice of life phenomena - a generalization about practice - which can be confounded or rendered less meaning- ful by another equally real and valid ex- position of the same subject. The person who writes on this topic must face the complex construct nursing; the bias of a personal frame of reference; and the limi- tations imposed by logic. Is i t perhaps that a writer in exploring this subject, only reflects the confusion which exists?

Nursing care today is a complex issue. Consideration of it invites immediately the question of definition and its corollary question: who gives nursing. I t probes into the status of the recipient of care an5 simultaneously shifts the focus from either nurse or client to the interaction which occurs between them. This interaction i s of a loose dynamic quality, undefinable in the sense that it i s always growing. To look at it, as of today, is to freeze it and divorce it from past and future. Yet this limitation, as the restriction of author bias and subject definition is the very nature of this paper.

Basic to any discussion is a definition or point o f view about nursing care today. Although most nurses practice their craft with acutely ill and/or hospitalized people, present-day definitions underscore a more global sphere of activity. The idea con-

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veyed in currerit discussions is that the goal or end object of nursing care is the maintenance and/or restoration of health. Care of the sick is subsumed within this health centered orientation. In her paper, Doctor Mauksch alludes to health care and illness care. This is another way of ex- pressing the goal of nursing.

Today’s definition expands the hori- zon of care. Cbrrent practice seeks to cperationalize how i t i s that nursing care is offered and received by people who are individually and collectively healthy, a t risk, acutely or chronically ill, or con- valescing.

Many nurses define their practice and caring activities within the framework of the nursing process - the assessment, planning, implementation and evaluation of nursing care. Historically nurses have been implementors of care - planned and directed in many instances by our col- leagues the physicians. Today the broad outlook which nursing has taken toward i t s end point or goal has also been directed towards the means. There has been in- creased effort and awareness a t all stages of the nursing process. This has resulted in the refinement of techniques in obtain- ing a base of data about and around the client and his experience. This informa- tion has enabled nurses to proceed with confidence in their practice.

This is an interesting side effect of col- lection and analysis of data. Doctor Mauksch refers to the lack of self confi- dence and respect for nurse-colleagues which plagues the profession. She men- tions how nurses turn to physicians or a bureaucratic hierarchy for support and Val- iciation of themselves and their practice. I t is painful to trace how these behaviors came to be the modus operandi. Yet, since nurses were dependent on medical histories and diagnoses, hospital and/or nursing service procedures and policies as

the starting points for their activity, i t seems only logical that these groups wouid come to constitute nursing's reference points.

As nurses collect their own data base, however, they experience and exert an i r i - creasing sense of their own identity and a greater appreciation for what i t is that they do. Their relationship with clients begins now with the collection of informa- tion rather than somewhere down the stream when a nurse was called in to pick up and carry out medical orders. Interest- ingly too, if the literature on data analysis i s examined, evidence is found to support the concern and caring, and other-center- edness which is nursing's historical and unique contribution to health care.

The planning phase of the process in- cludes the client and significant others. It i s geared toward optimal utilization of al l resources and a thorough sifting of the data base. The fluidity of the data and the changing sphere of action within and around the client gives rise to the necessity of establishing priorities of care.

Essential to nursing care today is the notion of experiencing the client where he is and recognizing and planning around the important a1.d significant realities which have assumed ascendancy or prior- ity in his situation. Consequently, assess- ment and planning are intersecting opera- tions expressed by the sentence. The nurse plans to assess and assesses to plan nursing care.

Given this perspective the implementa- tion phase of the nursing process is the delivery of nursing care, not medical ord- ers nor treatment nor hospital routines.

I ne ciieni is boih recipieiii aiid coopera- tor so that the intervention which occurs is congruent with his time and space and life goals.

Evaluation is also conceived within the global framework of health. The nurse i s accountable to the client so that her re- lationship ends where it began.

This insight - that the nurse i s respon- sible to the client - has helped clarify in the mind of nurses some o f the institu- tional mores that imply that the nurse is responsible to the physician or to the hos- pital or the nursing office. It has in some

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instances caused nurses to seek and offer peer review of their practice.

Evaluation of the nursing process deals with the nature or essence nf the nursing contract which i s made between client and nurse. I t i s not a check list of things done or omitted but a realistic appraisal of process toward health-oriented and re- lated goals. Given our history this move- ment toward accountability to the client and review by other nurses is remarkable. It is perhaps another indicator of the sen- sitivity of our profession and its value orientation.

I t would seem logical given such a scope of practice that the responsibility of rendering care or applying the nursing pro- cess would be clearly fixed. We find, how- ever, that the question who i s a nurse i s less easily answered than what i s nursing. The conflict about nursing education is a mere illustration of the in-group fighting which dissipates energies, refuels original fires, keeps nurses immobilized and de- fensive and distracts them as others con- tinue to assume and maintain leadership and power in the health care field.

One of the most striking chords in Dr. Mauksch's remarks was her discussion of power. NLrses have become embroiled in power plays among themselves; they have allowed concerns about the nature of pro- fessional education to intensify self preoc- cupation to the point that they have be- come divided over an issue that i s not sig- nificant!y related to the goals of the pro- fession. Has this happened in the heat of battle and resulted in a loss of a sense of purpose, the delivery of nursing care to people? Or i s this an expression of power- lessness and minority group activity which causes its members to shy away from the ~::CP. nf sigr?ificance? ! t simultaneously renders i t s main contenders unable to com- pete in the world of policy because their attention is divarted to internal operations or cross-fires.

Nurses who practice today are in a sense a t the crossroads. At times they seem very much as the two brothers men- tioned in the biblical parable. Armed with the fruits and riches of labor and urged on by good will, they stumble alone without a vibrant sense o f purpose: afraid perhaps to face themselves and each other; hesitant to move forward together and as- sume leadership roles in health care.

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