Perspectives: European Academy of Nursing Science debate 2016: Are there any aspects unique to nursing?

Pashalina Lialiou

We believe that there are no aspects of knowledge, research and practice that are completely unique to nursing. We still do not have a clear definition of nursing. This was recently highlighted in the Journal of Advanced Nursing by Pang et al. (2004), who argued that nursing is cultural, and therefore differs across the world. Over time, nurses have tried to define themselves as a unique profession, distancing themselves from other health professions. Since the 1950s and 1960s, nursing theorists and philosophers have discussed and debated what is the uniqueness of nursing? And what is the general definition of nursing?

According to Clarke (2006), we have not yet reached consensus on this debate.

If we cannot define nursing, how can we claim that any specific aspects of the profession are unique? Nursing is an occupation comprised of a range of skills and activities that differ greatly depending on your clinical area or specialisation.

Everyone in this room is a nurse, yet the educational journey that we have undertaken to get to this point differs greatly across all the European countries. Even the International Council of Nurses acknowledges that there is great variability in the definition of nursing and in the educational level of nurses across countries (Currie and Carr-Hill, 2013). To be proficient at our jobs, nurses need to utilise knowledge from a wide range of disciplines. We cannot rely solely on knowledge gained from our lived experience. Nurses use knowledge from a wide range of sources and we cannot claim that it is unique to our profession. There is no nurse who has not used knowledge from another health discipline to inform and improve their nursing practice. Nurses use knowledge from a variety of different disciplines such as biology, medicine, psychology and sociology. This is not to say that nurses cannot generate knowledge. However, this knowledge would also be essential for other disciplines, in which caring relationships with patients form the foundation of their practice (Lewis, 2003). Therefore, defining particular aspects of nursing as unique could limit the impact of nursing knowledge on other disciplines.

It would be impossible to define nursing by a specific set of skills or tasks. Nursing roles differ so greatly across our countries, where some nurses are even beginning to undertake skills that we would normally associate with the medical profession, such as nurse prescribing. Nursing is characterised by its multidisciplinary approach to care, where its strengths lie in its ability to bridge the gap between these different health professions.

To move forward as a profession, we really need to stop debating whether nursing is unique or not. Instead, we need to start focussing on the patient, and how we can deliver the safest and effective care. To optimise care for our patients, we need to utilise the best available knowledge, practice and research, regardless of what discipline this comes from.

To summarise: We believe that there are no aspects of knowledge, research and practice that are completely unique to nursing.

Ashleigh Ward

To be able to debate this statement, we must first understand exactly what we are debating. Firstly, we are asked to consider ‘aspects’ of nursing. The Oxford English Dictionary defines an aspect as ‘a particular part of a feature of something’ such as the ‘way in which something may be considered’ or ‘a particular appearance or quality’ (Oxford University Press, 2016). Secondly, we are asked to consider whether something is ‘unique’. Unique is defined by the Oxford Dictionary as being ‘particularly remarkable, special or unusual’. To debate the question, we must prove that nursing has one feature that can be remarkable, special or unusual. The knowledge, theory and fundamentals can all be considered as unique in some way, but nursing also has an essence that both transcends and informs these, and it is in this essence that nursing is truly unique.

If we go all the way back in time to 100 BCE, good healthcare was said to require four things: a patient, a physician, a nurse and medicine (translation of 100 BCE text by Sharma, 2014). In this text, it was said that nurses should be knowledgeable, skilled at preparing formulations, sympathetic towards everyone and clean. These are principles that have stayed with this profession to the present day. If we move forward in time, we see that nursing played a part in early Christian and Muslim history (DeWit and O’Neill, 2013). In the 7th century, it was said that nursing was a way to manifest love for Allah, and where in addition to developing clinical skills, the first Muslim nurse sought to tackle social problems leading to illness (Kasule Sr, 2012). If we move forward again to 1836, we see that it is fitting to be having this debate in Halle (Saale). In 1836, we find the birth of modern nursing, originated in Germany (Fliedner, 1911). Within 50 years more than 5000 ‘deaconesses’ had been trained within Europe. At that time, with transport, communication and ideas travelling so slowly, it evidences the need for nursing, for some aspect of care that could not be filled by another profession. If we move forward again, in the WWII, in the British army, some nurses held ranks as high as Brigadier (British Military History, 2011).

In a recent study about patient-centred care, one patient stated ‘the caring contrasted with the culture of the doctors’ (Luxford et al., 2011). When we look at healthcare, there is no other role designed specifically to care about the person above the disease. For nurses, a person is a whole person, physiologically, psychologically, from within their culture and context. This unique role allows for us to care for our patients as a person, in their entirety within that context, whether that is in a ward or a community, whether that is for five minutes or 20 years. We are situated closest to the patient, and use everything that is available to us to care for the patient in the way that they want to be cared for. We support them in advocating for them, we advocate for them when they are unable to do so, and we support them in navigating their care through all the treatments and specialities in an increasingly multidisciplinary world.

When I trained as a nurse, I was whatever my patient needed me to be. And in that, I was a little bit of everything. In a study, a patient said that nurses ‘help with everything from paint chips to policy’ (Cleary et al., 2012), and we do. Many professions have adopted our principles and our approach to care and we should welcome that. Nursing is new to academia, and so we take knowledge from many disciplines and we are criticised for this, for not reinventing the wheel. But why should we reinvent the wheel, when we can instead add to the design or use that wheel for new applications?

I was asked today to debate whether one aspect of nursing is unique; whether one ‘feature' of nursing was remarkable, special or unusual. And I believe that there are many features of nursing that are remarkable, special and unusual. But the essence of nursing is in that unique, pluralistic knowledge-base that we both draw from and add to. The magic of nursing is in our mix.

Lotte Verweij

The uniqueness of nursing knowledge has been a topic of debate for a long time. Patients are at the centre of our care system. But how do they experience nursing care and do they think it is unique? As a matter of fact, patients are not able to distinguish nurses from other healthcare professionals. A survey by the American Medical Association in 2011 showed that patients were confused about the qualification of different professionals caring for them. More than half of the patients could not separate a specialised nurse from a medical doctor.

You would be wrong to presume that this situation is different in paediatric settings. Jensen and colleagues found that many of the children they surveyed did not differentiate between healthcare professionals who cared for them (Jensen, 2010). In another study on patients’ opinions, Calman (2006) found that the nurses’ technical skills were amongst the most important nursing competencies. Besides technical skills, Wysong and Driver (2009) found that patients think that nurses above all should be friendly, caring, compassionate, kind, good listeners, cheerful, happy and smiling. However, being friendly and compassionate are common human qualities and not unique to nurses. Neither are technical skills like drawing blood or hanging IVs. These procedures might well be performed by other healthcare professionals than nurses.

Risjord and colleagues stated that it is striking that most research by nurses is not nursing research – we rarely see nursing theories in use by nursing researchers (Risjord, 2011). Nursing researchers today use theories and frameworks from many other disciplines to develop and explain interventions. For example, in a study on Early Warning Score Systems to prevent potentially avoidable hospital deaths, Bunkenborg and colleagues (2014) borrowed theory from medical disciplines to reduce mortality rates for patients although this is a study by nurses and aimed at nurses. This is a key example of research which has tested and used theory from other disciplines. Risjord concluded that nursing research will be even weaker if nursing is perceived as a unique practice and does not use theories from other disciplines (Risjord, 2011).

The increased incidence of complex health problems has led to a multidisciplinary organisation of healthcare. Our universities have factored this into educational programmes for both nurses and other healthcare professionals. Thistlethwaite and colleagues (2014) identified a multidisciplinary competency framework for multidisciplinary purposes and had trouble in identifying the profession specific competencies. If the trend in our educational systems is to focus on similarities in competencies between disciplines rather than uniqueness, we could question what is unique to nursing. Besides generic competencies, nursing education is based on a mixture of concepts, for example, biology, psychology, sociology to name but a few. Even at the doctoral level, the European Academy of Nursing Science bases the development of complex nursing interventions on the medical MRC framework (Craig et al., 2008). It proves that the international nursing community is open to research methodologies and frameworks which are rooted in other disciplines. So, do we not share a common aim?

We have strongly argued against the complete uniqueness in nursing from a patient, research and educational perspective. The nursing profession cannot isolate itself. We need to appreciate the value of other disciplines for the benefit of patients, rather than striving for irrelevant uniqueness.

Anna Anåker

To vote against the motion, the only thing we need to prove is that one aspect of nursing is unique. As already stated, nursing is unique. If you could find one single thing in your practice or in nursing research that you think makes nursing unique, then you must vote against the motion. There are many examples but the following arguments against the motion are focused on two important issues.

First, nursing is unique in its ways of promoting patient advocacy. The role of patient advocate has been mandated by a recommendation in some North American states and is supported by the American Nurses Association (2016) and by nursing theorists (Corley, 2002; Watson, 1999).

As practising nurse professionals in any society, we not only have a responsibility to know what we need to know to practise nursing but also a responsibility to act as advocates for those who cannot speak for themselves, our patients. As professional nurses, we carry a commitment and responsibility to all people in the community in which we practise. That’s what makes our profession unique.

Second, nurses are different from other healthcare providers by our approach to patient care. Nursing stands apart from all other healthcare professions because of the healing relationships nurses can cultivate with their patients. Nursing is about the intensity in the relation to the person that they care for. The person-centredness is there, but the uniqueness of nursing is the intenseness in person-centred care. We are constantly present. We are the only professionals that are present with the unique human being from birth to the very ending of life, like no other profession in our healthcare services. We are the navigator through health and wellbeing.

To return to the beginning of this speech, to vote against the motion, you need to believe that only one aspect of nursing is unique. We believe that there are many aspects of nursing that are unique. Ashleigh Ward has argued that the uniqueness of nursing is in our role to care for the person as a whole, in their own context before anything else. I have given two further examples of patient advocacy and the intenseness of nursing. Most of the real work of nursing is intangible. Our profession involves much more than just the ability to perform practical tasks. We help people to find the quality of life amid life as it happens; the skill and finesse by which we do this exposes the beauty of our profession. And that is the art of nursing and the very heart of nursing.

Katie Louise McGoohan

Before the main argument is presented, we would like to re-instate an important point that is at the crux of this debate. On Twitter one of the EANS students posted a quote from Virginia Henderson about the uniqueness of nursing. The quote starts as follows: ‘The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery’ (1964). We would like to take this opportunity to point out that we are not arguing that the nurses' function or the nursing profession as a whole is not unique. What we are meant to be arguing, is that there are no particular aspects of nursing knowledge, nursing research, or nursing practice, which are unique. Quotes such as these, however appealing, can neither prove nor disprove this motion.

As my colleagues have discussed, nursing is a dynamic, evolving and relatively new profession, which makes it somewhat difficult to define. The desire to attain a professional status has been particularly acute in nursing, which has sought to establish an identity that is distinct from medicine, while simultaneously striving for recognition as an academic discipline. Some nursing scholars believed that to attain this professional status, it was necessary to establish a unique knowledge base, a perception that clearly remains to this day (Nolan et al., 1998). However, we will argue that, although we do not believe that there are any aspects of knowledge, research or practice that are truly unique to nursing, this does not actually matter. In fact, it is one of the many strengths of this profession.

Limitations of a unique knowledge base must first be acknowledged. To search for a unique knowledge base is not the best way forward. It may disempower patients, and hinder multidisciplinary communication. As stated by Lützén and Tishelman: ‘In whose interest is it that professional caregivers all speak different disciplinary languages?’ (1996: 197). It is impossible and unnecessary to reduce nursing to a specific and unique set of knowledge and skills. The fundamental requirement for effective nursing is to understand the human condition. It is, therefore, essential that we, as nurses, draw on a rich reservoir of available knowledge. Many nurse leaders believe that nursing is a profession, made up of concepts from a multitude of other health and science disciplines (Parse, 2015). The nursing discipline needs this broad scope, where multidisciplinary knowledge is necessary to handle the complex theoretical and practical problems faced by nurses today and is paramount for the care of the patient.

The whole of science is a patchwork quilt of theories, concepts, methods and interventions, where nursing science simply lies within one of these areas of overlap (Risjord, 2011). However, this is a strength for nursing – whose capacity lies in its ability to make connections and bridge the gap between the different knowledge and skills from across the other disciplines. This ‘borrowing’ of knowledge and skills will not make the discipline of nursing less independent. Knowledge and skills, no matter which discipline they come from, should be adopted when they are the most coherent and effective.

We will illustrate our arguments with an example of the necessity for shared knowledge and skills from a colleague working in critical care nursing. Observing a patient’s clinical condition is an essential component of critical care and is one of the most time-consuming and important responsibilities for nurses in the department. To observe a patient's condition, a critical care nurse needs a profound understanding and appreciation of human anatomy and physiology as well as various pathological conditions. In addition, a critical care nurse must also be able to use various technical monitoring devices, be proficient in the skills relating to the clinical examination of the patient and have the ability to support and inform the patient's family members of their relative's condition. None of the examples given of the knowledge and skills required by a critical care nurse are unique to nursing. However, they are certainly necessary, and it would be impossible to provide safe and effective nursing care without them.

Therefore, it is crucial for nurses and other healthcare professionals to use knowledge, practice and research that has been done outside their profession. Using the words of Professor Risjord (2011: location 3652): ‘No discipline owns a knowledge or theory.’ Nursing does not have to compete with other disciplines, whether academic or professional, but rather, we should share knowledge to achieve our primary goal – the delivery of better patient care.

Catherine Lowenhoff

We will attempt to draw together some of the key points that have been made in this debate to persuade you to vote against the motion. There have been some really good points made on both sides of the argument.

There must be something special or unique about nursing for us all to be here at the European Academy of Nursing Science Summer Conference. We consider ourselves very fortunate to be part of the EANS family and very proud to call ourselves nurses. We believe that there are some aspects of nursing that make nursing unique. The Royal College of Nursing states in their ‘defining nursing’ document that ‘All nurses carry in their heads a personal concept of nursing – what it is, what it is for, and how we do it. The uniqueness of nursing (as of other healthcare professions) is the particular combination of its elements and the way in which they are used’ (2014).

Of course, we have many things in common with other health professions – in fact, we have more things in common than the things that divide us. Just because we have difficulties defining the uniqueness of nursing does not mean that nursing is not ‘unique’. The motion asks us to consider that there are no aspects of nursing, research or practice that are unique to nursing – we must go back to what we mean by an ‘aspect'. The arguments so far have focused on aspects that describe a task or function but an aspect can also describe a quality of something, a feature or an appearance of something, or a way in which something may be considered. Those of you who are proud to be a nurse and do not want to lose that aspect of who you are have demonstrated that you believe that there is something unique about nursing. There is something, some aspect of nursing that makes it unique. We do not need to know what that something is because an aspect can be about the overall appearance of something or the way in which that something is considered.

Remember, we only must persuade you that there is just one aspect of nursing practice that is unique to nursing for you to vote against the motion. Anna Anåker referred to the constant presence of nursing both throughout the patient journey and throughout a person's life. Let us, therefore, consider a patient in a hospital. Which profession has the overall responsibility for looking after that patient whilst he or she is in the hospital? Of course, the doctors are responsible for the medical care but are they always present in the ward ensuring that the patients receive all the help and care that they need? No, it is the nurse who takes responsibility for managing care and the nurse (and the team for whom the nurse is responsible) who is there 24/7. This is a unique aspect of nursing practice.

The European Academy of Nursing Science was formed in order ‘to sustain a forum of European nurse scientists to develop and promote knowledge in nursing science’ (EANS, 2016). This statement implies that there is something unique about ‘nursing' research. The fact that you are here at the EANS Summer Conference or at the EANS Summer School implies that you think that there is something unique about nursing research. An aspect of research that is unique to nursing could be that it is uniquely done by nurses or uniquely about nursing. We heard this morning from Walter Sermeus about the unique contribution that nurses make to patient safety (Aiken et al., 2014). We heard in the Summer School from Dr Deschodt about the pivotal role that nurses must play in the G-COACH intervention (Deschodt et al., 2016). The design and/or findings in these studies indicate that there is something about nursing that has a unique impact on patient outcomes. The research is run by nurses and is about ‘nursing’. Therefore, these are aspects of research and practice that are unique to nurses.

EANS has been in existence for 18 years. Earning PhDs is all about making a unique contribution. Surely, we are all here, as nurses, because we are hoping to make a unique contribution to the body of knowledge that relates to nursing. If all our contributions are unique then all those contributions must be regarded as aspects of research that are unique to nursing.