Definitions clarify purposes and functions

Nursing is a complex enterprise that is often confusing to its own practitioners, as well as to the public. Defining nursing assists people to grasp its nuances, many of which are not readily observable. Nursing benefits when journalists, public policy makers, insurers, other health care professionals, and the public, among others, understand what it is that nurses do.

Definitions differentiate nursing from other health occupations

Five million allied health care providers in more than 80 different occupations represent approximately 60% of all health care providers (ExploreHealthCareers.org, 2012). Advances in technology are often accompanied by a new technician or other provider who needs to be educated, hired, oriented, and paid with limited health care dollars. These resulting costs figured greatly into the redesign of the health care system over the past decade and required the redefining of roles within the system. Defining nursing amid these new providers became even more important to avoid losing the core identity of nursing. Nurses have had to name and claim for their own what it is that nurses do. Furthermore, with health care reform being implemented incrementally over the next few years, nursing must be clearly defined and its importance within the health care system unmistakable. It is no secret among nurses that nurses possess the capabilities to address a wide variety of health issues; keeping nurses in key positions of influence as health care reform takes shape in the next few years is crucial to fulfilling nursing’s social contract with the public, which you read about in previous chapters. The ANA’s Nursing’s Social Policy Statement: The Essence of the Profession, updated in 2010, explicates this contract.

Definitions influence health policy at local, state, and national levels

Policy makers, such as legislators and regulators, need a clear understanding of the role and scope of nursing. Without that understanding, they cannot institute good health care policy that maximizes use of nurses’ particular skills to improve the health of the public.

A key reason to define nursing is that nursing practice is regulated at the state level. Nurse practice acts of each state need to reflect the widening expertise and autonomy of nurses. When the roles of professional registered nurses (RNs), advanced practice nurses, licensed practical/vocational nurses, and nursing assistants are well defined, legislators can pass progressive laws regulating and expanding nursing practice. Otherwise, nurse practice acts that are legislated by state governing bodies may restrict nursing practice and inhibit professional growth.

Definitions focus educational curricula and research agendas

When nursing faculty plan the curriculum of a school of nursing, one of the major determinants of the design is their definition of nursing. A definition of nursing provides a good starting point for curriculum development. Without the foundation of a clear definition, deciding what to include in a nursing curriculum and how to prioritize educational needs would be very difficult and unwieldy. In much the same way, nurse researchers cannot easily determine phenomena of interest for nursing unless they are clear about the boundaries and purposes of nursing actions that a definition of nursing sets in place.

Nightingale defines nursing

Florence Nightingale was the first person to recognize the complexities of nursing that led to difficulty in defining it. Considering how relatively undeveloped nursing was during her time, Nightingale’s definitions contain surprisingly contemporary concepts. Remember that during Nightingale’s day, formal schooling in nursing was just beginning. In Notes on Nursing: What It Is and What It Is Not (originally published in 1859), she became the first person to attempt a written definition of nursing, stating, “And what nursing has to do. . . is put the patient in the best condition for nature to act upon him” (Nightingale, 1946, p. 75). She also wrote:

Although Nightingale lived in a time when little was known about disease processes and available treatments were extremely limited, these definitions foreshadowed contemporary nursing’s focus on the therapeutic milieu (environment), as well as the modern emphasis on health promotion and health maintenance. She accurately observed that although simply possessing observational skills does not make someone a good nurse, without these skills a nurse is ineffective. Indeed, informed observation has always been an integral part of the process of nursing. Nightingale was also the first person to differentiate between nursing provided by a professional nurse using a unique body of knowledge and nursing care provided by a layperson such as a mother caring for a sick child.

Early twentieth-century definitions

Fifty years after Nightingale wrote Notes on Nursing, the search for a definition began in earnest. Following the English model, many schools of nursing had been established in the United States, and many “trained nurses” were in practice. These nurses sought to develop a professional identity for their rapidly expanding discipline. Shaw’s Textbook of Nursing (1907) defined nursing as an art: “It properly includes, as well as the execution of specific orders, the administration of food and medicine, the personal care of the patient” (pp. 1–2). Harmer’s Textbook of the Principles and Practice of Nursing (1922) elaborated on Shaw’s bare-bones definition: “The object of nursing is not only to cure the sick . . . but to bring health and ease, rest and comfort to mind and body. Its object is to prevent disease and to preserve health” (p. 3). The fourth edition of the Harmer text, which showed the influence of coauthor and visionary Virginia Henderson, redefined nursing: “Nursing may be defined as that service to an individual that helps him to attain or maintain a healthy state of mind or body” (Harmer and Henderson, 1939, p. 2). Henderson’s perceptions represented the emergence of contemporary nursing and were so inclusive that they remained useful for many years. We will see her influence again in the next section.

Post–world war ii definitions

World War II helped advance the technologies available to treat people, which, in turn, influenced nursing. The war also made nurses aware of the influential role emotions play in health, illness, and nursing care. Hildegard Peplau (1952), widely regarded as a pioneer among contemporary nursing theorists and herself a psychiatric nurse, defined nursing in interpersonal terms: “Nursing is a significant, therapeutic, interpersonal process . . . . Nursing is an educative instrument . . . that aims to promote forward movement of personality in the direction of creative, constructive, productive, personal, and community living” (p. 16). Peplau reinforced the idea of the patient as an active collaborator in his or her own care.

During the late 1950s and early 1960s, the number of master’s programs in nursing rapidly increased. As more nurses were educated at the graduate level and learned about the research process, they were eager to test new ideas about nursing. Nursing theory was born. (See Chapter 13 for an in-depth discussion of nursing theory.)

Dorothea Orem was one of the important theorists who began work during this early period of theory development. Her 1959 definition captures the flavor of her later, more completely elaborated self-care theory of nursing: “Nursing is perhaps best described as the giving of direct assistance to a person, as required, because of the person’s specific inabilities in self-care resulting from a situation of personal health” (Orem, 1959, p. 5). Orem’s belief that nurses should do for a person only those things the person cannot do without assistance emphasized the patient’s active role.

By 1960, Henderson’s earlier definition had evolved into a statement that had such universal appeal that it was adopted by the ICN:

This definition of nursing was widely accepted both in the United States and across the world. Many believe it is still the most comprehensive and appropriate definition of nursing in existence.

Another pioneer nursing theorist, Martha Rogers, included the concept of the nursing process in her definition: “Nursing aims to assist people in achieving their maximum health potential. Maintenance and promotion of health, prevention of disease, nursing diagnosis, intervention, and rehabilitation encompass the scope of nursing’s goals” (Rogers, 1961, p. 86).

Professional association definitions

Nursing organizations worldwide have also struggled with defining nursing. Definitions to be reviewed here include those of the ANA, the RCN, and the ICN. As you read these definitions, notice that some new concepts and terms are introduced in the more recent American definitions. In the United States, nursing has defined itself as the health discipline that “cares,” although recent discussion suggests that limiting nursing to “caring” only overlooks the significant role that nurses have in the curative processes of health care (Gordon, 2005).