The World Health Organization (WHO) has declared 2020 as the International Year of the Nurse and Midwife.1 In 2020, Nursing Now will conclude its 3-year global campaign to improve health by raising the profile and status of nursing worldwide.2 This year also marks the bicentennial of Florence Nightingale’s birthday on May 12.3 Accompanying these celebrations of nurses’ contributions to health are efforts aimed at empowering nurses, advocating for expanded roles for nurses, and increasing investments in the nursing workforce.
Nurses are essential members of the health care team, and nursing care underpins every aspect of health care. Globally, half of all health care workers are nurses, and in many instances, nurses are the only health care professionals available to communities. WHO Director-General Dr Tedros Adhanom Ghebreyesus recognized this when he said, “Nurses and midwives are the backbone of every health system: in 2020 we’re calling on all countries to invest in nurses and midwives as part of their commitment to health for all.”1
Nursing Now began in 2018 with a focus on 5 core areas: (1) ensuring that nurses and midwives have a more prominent voice in health policy-making; (2) encouraging greater investment in the nursing workforce; (3) recruiting more nurses into leadership positions; (4) conducting research that helps determine where nurses can have the greatest impact; and (5) sharing of best nursing practice.2 As the formal campaign concludes in 2020, progress has been made in each of these areas, but additional work remains to continue to build on the foundation laid by Nursing Now to improve the status of nursing globally.
Nursing has a rich history of independent professional practice built on distinct disciplinary knowledge. Nursing’s scope of practice is rooted in disciplinary education and training. The American Nurses Association (ANA) defines scope of practice for registered nurses and advanced practice registered nurses (APRNs) thusly: “Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations.”4 This scope of practice delineates nursing as an autonomous profession with unique contributions to patients’ well-being across health care settings and patient populations.
However, despite the crucial role of nursing in achieving successful patient outcomes, the independent contributions of nursing have been poorly recognized. In Notes on Nursing,5 Florence Nightingale said,
I use the word nursing for want of a better. It has been limited to signify little more than the administration of medicines and the application of poultices. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet—all at the least expense of vital power to the patient.
“Continued advocacy is necessary to ensure that the public’s view of nurses and health care systems’ workflows reflect nursing autonomy.”
Nurses support other members of the health care team and are central in carrying out complex interdisciplinary treatment plans (including administration of medicines, but now only rarely the application of poultices). Nurses provide connections among the health care team and are central in effective coordination of care. A conception of nurses as members of the clinical team whose primary utility is to carry out physicians’ orders is a limited, incorrect, and misleading characterization. Too often, health systems implement nursing workflows from this anachronistic viewpoint. Nurses are educated to make independent contributions to patient care, and continued advocacy is necessary to ensure that the public’s view of nurses and health care systems’ workflows reflect nursing autonomy.
Creating an environment that facilitates healing is an essential purpose for all nurses. In the intensive care unit, the critical care nurse must embrace this healing call in a highly specialized and highly technological environment where the focus on physical care may come at the cost of the potential dehumanization of the patient and their loved ones. Skilled nurses translate advanced technology into therapeutic benefit for patients while remaining cognizant of the need to balance “high tech” with “high touch” in meeting the needs of patients and families. Nurses pay attention to the holistic needs of patients, including but not limited to fresh air, light, warmth, cleanliness, quiet, and nutrition. Nurses are usually the team members who spend the most time in direct interaction with patients, and nurses often have unique relationships with patients and with families that inform both nursing care and the care provided by the interdisciplinary team.
As both technology and patient acuity have increased, so too have nurses increased their knowledge and skills. Critical care nursing has provided a blueprint for how acquisition of enhanced knowledge and skills can lead to expanded roles for nurses that result in improved patient care and outcomes. At the inception of the American Association of Critical-Care Nurses (AACN), critical care nurses sought to know more and to do more.6 In the establishment of critical care units, physicians were early supporters of expanded roles for nurses with specialized education and training, and physicians actively contributed to the development of critical care nursing. Well-functioning critical care units can also serve as models for true collaboration among disciplines that is built on mutual respect. Critical care nurses and physicians have remained important allies for each other and for all team members.
Every professional in critical care should be empowered and encouraged to use their knowledge, skills, and judgment to practice to the full extent of their education and training. This is the essence of full practice authority and should be the norm. Physician education has changed over time, and nursing education has changed as well. As the education and training for APRNs has advanced, and the positive effects on patient outcomes have been demonstrated, legislation and regulation should support appropriate use of these highly capable APRNs. We would be well advised to facilitate having registered nurses, APRNs, and others contribute their full capabilities in working together to provide care for critically ill patients. The discourse about scope of practice for APRNs could be improved by less emphasis on the perceived overlap between APRN and physician practice and by more emphasis on the real and synergistic contributions of each.
Investing in and empowering nursing can yield tangible benefits. A 2016 report issued by the All-Party Parliamentary Group (APPG) on Global Health in the United Kingdom proposed that developing the nursing profession has a triple impact.7 First, and perhaps most obvious, strengthening nursing improves health outcomes. Second, the report points out that elevating the status of nursing promotes gender equality. Access to health care for women in many regions of the world depends on nurses as frontline providers, and nurses provide care that is crucial to improving women’s health and permits women to have greater, more equal participation in society. Third, the report argues that strengthening nursing will contribute to worldwide economic growth. This is true in part because better health of a population contributes to economic growth, educational attainment, and productivity. Additionally, nursing employment and job creation make direct positive contributions to the economy. The report’s authors state plainly that strengthening nursing is “partly about increasing the number of nurses, but also crucially about making sure their contribution is properly understood and enabling them to work to their full potential.”7
“We must continue to challenge how nurses are perceived and the limits placed on nursing practice.”
Florence Nightingale challenged her society’s perceptions of what nursing was and was not and opened the door for a new era of nursing. In 2020, as we celebrate Nightingale’s bicentennial and the Year of the Nurse, we must continue to challenge how nurses are perceived and the limits placed on nursing practice. Issues related to full practice authority, appropriate staffing, and healthy work environments remain unresolved. Critical care offers immense opportunity for nurses to excel, and advances in nursing benefit our colleagues, our patients, and the public. The world deserves no less.
The statements and opinions contained in this editorial are solely those of the coeditors in chief.
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