Nursing as Profession
A Pugilistic Journey
A Pugilistic Journey
In Chapter 1, we examined the theories of social contract and their critiques. That chapter looked at social contracts in relation to professions, specifically the professions of medicine and nursing. Since the focus of the social contract is its relationship with professions, this chapter turns to the topic of professions and asks “What is a profession?” We will need to address the more basic concepts of occupation, vocation, and calling, as well as the historic emergence of professions before actually turning to how professions are defined or identified. There are a number of approaches to identifying or defining professions and we will look at six. The chapter will close with a discussion of the forms of control of occupational labor, profession being one form of occupational control, and perspectives on the role of professions in society.
Nursing as an Occupation, Vocation, Calling, and Profession
Nursing’s history has been something of a roller-coaster ride. In the West, its early days as an occupation were most frequently associated with nursing religious orders. It was considered a “high calling” to care for the sick. In England, hospitals were established in the 1100s (St. Bartholomew’s, 1123) and 1200s, and staffed by religious nursing orders. Religious orders, too, suffered their own woes with the dissolution of the monasteries in 1539.1 At that point, religious support for hospitals ended and care of the sick, “no longer transformed by the devotion of religious enthusiasm, appeared a sordid duty, only fit for the lowest class in the community.”2 Into the 1800s, nursing remained in bad straights, as can be seen by Charles Dickens’s infamous caricature of a nurse, Sarah “Sairy” Gamp in his picaresque novel The Life and Adventures of Martin Chuzzlewit (1843). Mrs. Gamp is a drunken, dissolute, dissipated, disgusting, opportunistic, and incompetent nurse and midwife. Elizabeth Fry, Florence Nightingale, and others brought about a drastic reform in nursing education and practice. English authors Carr-Saunders and Wilson, early sociologists of professions, write this about nursing:
The ancient vocation of nursing has passed through vicissitudes without parallel in any other vocation which comes under review [in this book]. This may be traced to the fact that until recently the only nursing worthy of the name was inspired by religious or at least philanthropic motives. Nurses were ‘called’ to a life devoted to the alleviation of suffering, and when the ‘call’ was not given or not heard the task was left undone or was abandoned to persons to whom the honorable title of nurse was not appropriate.3
Carr-Saunders and Wilson’s book The Professions (1933) is one of the earliest thorough works on professions and professionalism. In their brief treatment of nursing, surprising for its inclusion at all, they are warmly sympathetic toward nursing. After discussing the development and transformation of nursing in Britain, they write that
nursing has thus undergone a transformation. …The dignity of the vocation has been enhanced…all working towards the conception of the building up of a skilled and responsible vocation. …Until lately, however, the nurse worked under the direction of the doctor, and there was little element of co-operation. While the nurse must continue to work under direction, the tendency is towards co-operation which is made possible by the higher training…the vocation of nursing has become professionalized. …We must look for the explanation… in the fact that a skilled and dignified profession may also be in [Nightingale’s] sense a ‘calling.’4
Nursing is an occupation, vocation, calling, and profession. To understand nursing’s journey, hard-fought, to the standing of a profession, it is necessary to unpack these terms.
THINKING ABOUT HENRY, WHO WANTS A SON…
Who knew that Henry VIII’s determination to produce a male heir would affect nursing history? English school children learn the rhyme to remember the fate of Henry’s wives: “Divorced, Beheaded, Died; Divorced, Beheaded, Survived.” England was Catholic and Henry’s wife Catherine of Aragon produced only a daughter, Mary. The Pope would not grant Henry a divorce so that he could marry another in an attempt to produce a male heir, so Henry severed the church relationship with Rome and created the Church of England. The Catholic monasteries were wealthy and powerful. By the dissolution of the monasteries Henry would, and did, gain money, lands, more power and at the same time could remove a large source of papist influence. The dissolution of the monasteries, which began in 1536, ended the Roman Catholic religious orders, including the religious nursing orders, and support for religious hospitals. Carr writes that “in England, nursing was no longer a religious vocation and, being poorly paid, it came to be regarded as menial service and attracted only paupers, drunken [sic] and the inefficient.” (Carr, 1915; p. 187.) Where is Florence Nightingale when we need her? Oh, 284 years away.
Occupation and Vocation, Livelihood and Calling
Occupation
Surnames make a fascinating and complex study. They take different structures, order, and modes of acquisition in different languages and cultures. In a number of languages they indicate lineage through a patronymic formed from the father’s name; for example, in Welsh, John, son of Owen would be John ap Owen (later John Bowen), Richard ap Evan (becoming Bevan), or William ap David (becoming William Davies or Davis). In Scandinavian languages, the construction Thorsen indicates a son of Thor, or Knuteson a son of Knute; in Spanish, Fernandez would be a son of Fernando, or Rodrigues, a son of Rodrigo. In Icelandic, Jóhanna Sigurðardóttir is Jóhanna, daughter of Sigurð[ur], and in Russian, Svetlana Ivanovna is Svetlana, daughter of Ivan. Other surnames are descriptive of the person, such as Tom Swift, William Lovejoy, or Samuel Long (indicating tall). The names Franklin and Fry refer to one who is free-born. Some surnames are locative, indicating the place of origin of the person, such as Meadows, Wood, Lane, and Fields. Still others, and more to the point here, were occupational surnames such as Fletcher (maker of arrow feathers), Fowler (bird keeper), Tinker (itinerant mender of metal utensils), Taylor, Saylor, Cooper (barrel maker), Fuller (one who fulls cloth), Chandler (candlemaker), and Wainwright (wagon builder). Is there a surname indicating a nurse? The French surname Nurse
is an occupational name for a wet nurse or foster mother, deriving from the Old French “nurice, norrice”. …Early examples of the surname include: Matilda Nutrix and Maria le Noreyse (Cambridgeshire, 1273); Alice la Norisse and Agnes le Norice… dated 1310 to 1337; and Joan Nurys, recorded with Magota Nuris in the 1379 Poll Tax Returns of Yorkshire. Recordings of the surname from London Church Registers include: …Margery Nourse… and the christening of Elizabeth, daughter of Peter Nurse…1601. An early settler in the New World was Robert Nurse. …A Coat of Arms [was] granted to the Nurse family of England. …The first recorded spelling of the family name is shown to be that of Roberta la Norice, which was dated 1273, in the “Hundred Rolls of Bedfordshire”, during the reign of King Edward 1…1272-1307.5
Occupational surnames once indicated the type of work that one could do, and more often indicated the livelihood that occupied one’s time in earning a living. Surnames can seem amusing but, historically speaking, they signal a coalescing public recognition of divisions of labor that had emerged as specific— and paid—occupations. From the early 1300s onward, then, the occupation of nurse finds its way into surnames. In the past, there might have been
only one tanner, smith, sawyer, and cooper in a town, but as population density increased, so did the number of people involved in the same occupation.
only one tanner, smith, sawyer, and cooper in a town, but as population density increased, so did the number of people involved in the same occupation.
Eventually members of an occupation living in close proximity to one another would form an associative group such as a guild, confraternity, secret society, or association. These were largely (though not exclusively) men’s groups, as the majority of women did not work outside the home and caring functions such as nursing remained “hidden” within homes. Guilds were of two types—artisans and craftsmen or merchants—and they controlled the exercise of their respective trades within a specific town or city. Rousseau was a strong critic of the guild system as he supported laissez-faire market system. Guilds failed with the advent of industrialization and modernization and the advent of free-trade laws. Safartti Larson believes that modern medicine’s professional association initially had a guild-like structure.6 However, these groups of workers did not yet constitute professions as we understand professions today, though they could be vocations.
Vocation and Calling
The term vocation comes from the Latin vocatio, a call or summons. Historically it has been a reference to a divine calling to serve God, the Church, or humanity with the specific abilities that one has been given. Thomas Aquinas (1225-1274) saw vocation as a social office that is only a vocation insofar as it serves the common good and does not harm. He created a hierarchy of vocations including judges, military, farmers, artisans, and merchants. He ranked farmers highest and merchants lowest, though all secular vocations were lower than explicitly religious vocations.7 In the Protestant Reformation, vocation included all or any occupational labor that was specifically secular in nature, as long as the individual was called to the exercise of that specific occupation.8 The Reformers refuted any notion of a hierarchy of occupational labor. Reformer John Calvin’s (1509-1564) vocational idea was that “there would be no employment so mean and sordid (provided we follow our vocation) as not to appear truly respectable, and be deemed highly important in the sight of God.”9 So, whether lofty or humble, philosopher or chimney sweep, all occupations were equally worthy. It must be noted that some current usages of vocation, as in vocational education, signify not a calling, but a form of education for manual trades such as automobile repair, welding, and tool and die makers. Vocation is not used in that sense in this book.
But vocation is an odd term. Is nursing a vocation? For those in nursing who are not called to nursing the answer is no. Some enter “nursing” for economic reasons, some out of a sense of obligation, or family pressure. There are any number of reasons one might enter nursing without being called. But doing so turns nursing work into toil or a job and nursing does not become a resident
part of the person’s identity. For those who are called to nursing, it is a vocation, it is something much more than a job, it becomes an abiding part of one’s identity. This is the nurse who does not simply do nursing; this is the nurse who is a nurse: it is a matter of being over doing. At some point an occupation may develop into a profession. From the earliest moments of the rise of modern nursing, its leaders understood nursing to be a true profession.
part of the person’s identity. For those who are called to nursing, it is a vocation, it is something much more than a job, it becomes an abiding part of one’s identity. This is the nurse who does not simply do nursing; this is the nurse who is a nurse: it is a matter of being over doing. At some point an occupation may develop into a profession. From the earliest moments of the rise of modern nursing, its leaders understood nursing to be a true profession.
Nightingale: Called by God but a Non-Religious Nursing School
The notion of nursing as a vocation or calling, (the terms are used interchangeably), persists in the nursing literature. Florence Nightingale (1820-1910) felt herself called by God, and more specifically called to nursing as service. However, she also came to regard nursing itself as a calling and wrote to probationers (early nursing students) and nurses that “nursing is said, most truly said, to be a high calling, an honorable calling.”10 Nightingale’s life
was lived out in service to God through her call to nursing and her embrace of nursing as a high calling in itself. As she moved into nursing education she demanded a rigorous education for women who would become nurses. Surprisingly, however, she sought a thoroughly secularized nursing education.11
Nightingale scholar Lynn Macdonald, who has compiled the complete works of Nightingale, writes:
The exacting workload, character, and devotion long required of the nurse go back to Nightingale’s conceptualization of nursing as a religious calling, a calling to patient care and health promotion. She abhorred nurses acting as missionaries to save the souls of the sick or dying, which prompted her to insist that her training school for nurses be non-sectarian.12
Nightingale wanted to accept students into her school independent of their religious commitment. Even so, while the school was to be non-sectarian, it was nevertheless Christian. Again McDonald writes,
Nightingale wanted nurses to be ordinary women, not nuns, and the profession to be open to all without any religious test. But her letters to nurses and nursing students are full of religious material, advice and prayers, for she believed that nurses needed ongoing spiritual nourishment. …While Nightingale insisted that her training school be non-sectarian, accepting students on the basis of merit regardless
of religion, there was a significant Christian (indeed Church of England) element in the daily routine.13
of religion, there was a significant Christian (indeed Church of England) element in the daily routine.13
So nursing education was secularized yet retained a strong concept of vocation as a call from God. Eventually the concept would become neutral so that it could be understood in either secular or religious terms as a vocation to which one was committed, not to do nursing, but to be a nurse. Nursing, then, was not a job or occupation, it was more than that; it was a calling and a profession in the sense of what one professes so that it was inextricably tied to one’s identity and way of being in the world.
Did Nightingale regard nursing as both a vocation and a profession? Yes… and no. When Nightingale entered nursing she undertook to elevate it from a less than reputable activity to an educated, trained, prepared, scientific, and cultivated profession.14 After returning from her work in Crimea and establishing Nightingale model schools of nursing she did in fact move nursing into a new social, educational, and occupational status. She did, however, live in that uneasy eschatological tension of something that is now, but is also yet to come. Yes, nursing was a calling or vocation, but it was also a nascent profession, beginning its growth and development under her watchful eye—and the extensive labors of her quill.
The Emergence of Professions
In the High Middle Ages, the late 11th through the 13th centuries, the first European universities were established for the study of theology, law, and medicine.15 For centuries these three disciplines would remain the only recognized professions. The noted essayist Joseph Addison (1672-1719) referred to them as “the three great professions divinity, law and physic.”16 These professions were referred to as learnéd professions, as entry into practice required a university education. A Bachelor of Arts was earned in the third or fourth year on the way to a Master of Arts. Students were required to become accomplished in seven liberal arts: arithmetic, geometry, astronomy, music theory, grammar, logic, and rhetoric, which was foundational learning. After completion of the Master of Arts, the student could then enter one of the higher faculties to study law, medicine, or theology. Of the three learned professions, theology remained the most prestigious for centuries; 17 it was the first profession and remained the only profession until joined by medicine and law, and later architecture, commissioned military service, and possibly teaching.18 It is important to note here the university education was required of each of the learned professions, and that entry into these professions was built upon a base of both a master’s degree and a liberal arts education.
Knowing that there were three groups that were regarded as professions does not answer the question “What is a profession?” Sociologist John Archer Jackson writes
The main issues which have been debated in the study of professions and professionalization centre around the problems of distinguishing a profession from a non-profession, and of discerning the processes of professionalization. With the former problem, the major task is usually thought to involve the isolation of sets of critical discriminating characteristics or variables. …In contrast, the professionalization approach commonly rests on a set of assumptions, often implicit, about the nature of a profession, while the main emphasis is placed upon the identification of some sort of development sequence.19
Like defining human so that it encompasses all persons no matter their condition, but without including robots and dolphins, defining profession has similar problems of inclusion and exclusion. Distinguishing between profession and craft is one such example. Though there are important outliers on either end, such as Carr-Saunders and Wilson,20 who wrote from the late 1920s into the 1930s, and Freidson,21 (a noted sociologist who studied the structure of professions), in the present who writes principally on medicine, the bulk of the writing on the rise and nature of professions takes place in the 1950s through the 1970s. This may be a consequence of the escalation of divisions of labor in society that attend the advance of science and technology. The road to defining profession has been filled with controversy, argument, and a lack of consensus that has been refractory to resolution. As a consequence, there are multiple approaches to how a profession might be defined.
Some Approaches to Defining Profession
Millerson identifies three means of defining professions that remain the major approaches.22 Cheetham and Chivers add another three approaches, all of
which are less common.23 Each of the six approaches is discussed below. The six approaches are as follows:
which are less common.23 Each of the six approaches is discussed below. The six approaches are as follows:
THINKING ABOUT GOOD AND EVIL…
Why would an occupational group want society to regard it as a profession? It’s not hard to understand why. With the status of profession, occupational groups have social prestige, authority, recognition, and financial reward. All of this gives them power. That power can be used altruistically to benefit society and be a moral force for good, or selfishly to reinforce monopolistic power elites, restrain other groups, garner excessive wealth, exploit those needing their services, and increase political power. It is important to think about how various occupational groups that have gained social power have used that power. Physicians, politicians, entertainers, attorneys, teachers, professors, artists—as groups (not as individuals), how have these occupations used their social power?
Looking for a set of characteristics or traits associated with professions.
Looking for evidence of professionalization (the process through which occupations are said to become professions).
Developing a model of professionalism based on certain sociological aspects of professional practice.
Adopting a classification system based on socioeconomic factors, e.g., Standard Occupational Classifications.
Examining the complexity of the competencies involved (which may have some relationship to the level of a qualification, as is the case with the UK National Vocational Qualifications).
Following the societal view of which jobs are seen as professions.
The Trait Approach
The first approach has been the one that predominates in the nursing literature in the defense of nursing as a profession. This approach identifies requisite traits or specific attributes of professions by which occupational groups are judged.
Trait definitions abound and form the backbone of many of the discussions of nursing as a profession.24 They often focus on a core that includes (a) a well-defined body of knowledge; (b) specialized education and expertise based in higher education; (c) provision of a practical service; (d) existence of a professional association; (e) autonomy of practice; (f) profession-determined standards or practice and education; (g) adumbration of a code of ethics; and (h) altruistic motivation.25 Within a trait definition framework, whether or not an
occupational group is to be regarded as a profession depends on its realization of the attributes specified.26
occupational group is to be regarded as a profession depends on its realization of the attributes specified.26
THINKING ABOUT BARBERS, SURGEONS AND DENTISTS…
Professions emerge and develop; they do not spring forth full-grown. Take the case of surgeons. Physicians in ancient Greece were forbidden to do surgery with the sole exception of surgery for renal calculi. Surgery was disdainful and distasteful as an occupation as it engaged in “manualism,” the use of the hands rather than the mind. In medieval Europe, barber surgeons were medical practitioners who would extract teeth, perform enemas, sell medicines, do bloodletting, lance cataracts, perform surgery—oh, and cut hair, shave beards, and perform manicures. Barbers had blades and knew how to use them. It is not until the mid-1700s that barbers and surgeons and dentists go their separate ways. (For additional insights along these lines: visit the Londons Science Museum’s History of Medicine website: http://www.sciencemuseum.org.uk/broughttolife.aspx.)
Discussions of nursing as a profession have focused on nursing’s possession of all of these traits. In recent decades much of this discussion has centered on the possession of a well-defined body of knowledge that is distinctive from that of medicine and, more pointedly, the criterion of autonomy of practice. Much of the discussion of the metaparadigm concepts of nursing, theories of nursing, and nursing diagnoses has been historically important in sharpening the distinction between medicine and nursing, even if that distinction has not been widely known or understood outside of nursing—or by medicine. The continued development of nursing research, that is, nursing science, has pretty much dissolved this discussion: nursing possesses a distinctive body of knowledge. It is the issue of autonomy that has remained a sticking point, though less so in the past 20 years. Cheetham and Chivers, who study professional development in the UK, point out that Freidson
makes a distinction between professionals and paraprofessionals. He uses the term ‘paraprofessional’ to describe occupations such as Nursing which, whilst they possess some of the characteristics of the medical profession with which they are closely associated, are nonetheless subordinate to it. In his view, nurses are not full professionals because they, like the military, lack autonomy.27
However, in his more recent 2001 work, Professionalism: The Third Logic, Freidson writes:
If one can stretch the method a bit and create an ideal type for an impure or incomplete social form like semi-profession, one might call it an occupation that has gained jurisdiction in a division of labor, as well as a labor market shelter and control over its own training, credentialing, and supervision, but that has not established sufficient cognitive authority to dominate either the division of labor in which its jurisdiction is located or public discourse concerning its work. A crude measure of this weak economic and cultural authority is its relatively low but by no means ignominious social status.28
In his evolving schema, nursing has some of the elements of autonomy of practice, but not others. Nursing would remain one of Freidson’s semi-professions to the degree that it did not have “cognitive authority to dominate either the division of labor in which its jurisdiction is located or public discourse concerning its work.” Nursing, today, does dominate the division of its own labor. Whether it dominates the public discourse concerning its work is an open question, and whether this is a determinative criterion of professionalism is
subject to disagreement, particularly with the growth of mediative control of occupational labor (discussed below).
subject to disagreement, particularly with the growth of mediative control of occupational labor (discussed below).
Control of one’s work, which Freidson terms professionalism (or autonomy), is critical to his analysis. He writes:
Professionalism may be said to exist when an organized occupation gains the power to determine who is qualified to perform a defined set of tasks, to prevent all others from performing that work, and to control the criteria by which to evaluate performance. In the case of professionalism, neither individual buyers of labor in the market nor the managers of bureaucratic firms have the right to themselves choose workers to perform particular tasks or evaluate their work except within the limits specified by the occupation. The organized occupation creates the circumstances under which its members are free of control by those who employ them.29
If nursing did not rise to the level of professionalism that Freidson accorded professions in his early writings, it does so now. As to trait definitions of professions generally, there is a tautological problem in trait definitions. The traits are largely derived by identifying existing professions and deriving from them a set of traits that define professions. It becomes tautological because it asserts that “these are the traits of a profession because these are the traits that a profession possesses.” Trait approaches assume that there are “true” professions and that they will demonstrate all of the essential core attributes. However, the attributes themselves are often an untidy aggregation of overlapping, arbitrarily chosen, or undifferentiated elements, lacking a unifying theoretical framework that explains their interrelationship. Trait theories tend to empirically generate a definition of a profession and then ascribe to it a normative rather than a descriptive status.30 Traits, then, become a matter of seeing what one is looking for.
The Professionalization Approach
The second approach posits that there are stages that occupations go through in becoming a profession. This approach is championed by Caplow,31 Vollmer and Mills,32 and Wilensky.33 Wilensky’s stages are
Start doing full time the thing that needs doing.
Establish a training school: if the school does not start in a university it nonetheless develops standards for education, academic degrees, research, and standards.
Form a professional association.
Political agitation in order to win the support of law for the protection of the job territory and its sustaining code of ethics….
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