Professional Roles for the Advanced Practice Nurse
1
In Part 1 of this book, we will consider therole of the advanced practice nurse fromhistorical, present-day, and future perspec-tives. This content is intended to serve as ageneral introduction to select issues in pro-fessional role development for the ad-vanced practice of nursing. As studentsprogress in the educational process and de-velop greater knowledge and expertise, roleissues and role transition should be inte-grated throughout the entire program.
In Chapter 1, Wolf presents a brief his-tory of nursing and its progress towardprofessional practice. Although not spe-cific to the role of the advanced practicenurse, the information presented in thischapter will assist the advanced practicenurse to gain a broader perspective onnursing and healthcare organizations andtheir future. This discussion lays the foun-dation for a deeper understanding of thehistorical development, current practice,and future opportunities for advancedpractice in nursing.
In Chapter 2, Pulcini defines advancedpractice nursing from a traditional per-spective and traces the history of the roles.Traditionally, and as discussed by Pulcini,advanced practice has been limited to clin-ical roles and includes the clinical nursespecialist, nurse practitioner, certifiednurse–midwife, and certified registerednurse anesthetist; the last three roles re-quire a license beyond the basic RN licenseto practice. This book, however, uses an ex-panded definition of the advanced practicenursing that reflects current thinking. Asyou read this chapter, keep in mind this ex-panded definition and at the same time ap-preciate the development of the advancedclinical roles for nursing practice.
Since Pulcini’s work in 2004, much hastranspired related to the role and educa-tion of nurses for advanced practice. Mostrevolutionary is the mandate to have theclinical doctorate as the requirement foradvanced clinical practice nursing by 2015(American Association of Colleges of
Nursing, 2007). With this change, many mas-ter’s programs for advanced practice nurses willtransition to the doctoral level. The rationalefor this position by the American Association ofColleges of Nursing (AACN) was based on sev-eral factors:
n The reality that current master’s degreeprograms often require credit loads equiva-lent to doctoral degrees in other healthcareprofessions
n The changing complexity of the healthcareenvironment
n The need for the highest level of scientificknowledge and practice expertise to assurehigh-quality patient outcomes
In an effort to clarify the standards, titling, andoutcomes of clinical doctorates, the Com-mission on Collegiate Nursing Education(CCNE)—the accreditation arm of AACN—hasdecided that only practice doctoral degreesawarding a doctorate of nursing practice (DNP)will be eligible for accreditation. In addition,the AACN has published The Essentials of DoctoralEducation for Advanced Nursing Practice, whichsets forth the standards for the development,implementation and program outcomes forDNP programs.
Needless to say, this recommendation hasnot been fully supported by the entire profes-sion. For instance, the American Organizationof Nurse Executives (AONE, 2007) does notsupport requiring a doctorate for managerialor executive practice based on expense, timecommitment, and the cost benefit of the de-gree. It also suggests nurses may migrate towarda master’s degree in business, social sciences,and public health in lieu of nursing. Further,AONE suggests there is a lack of evidence tosupport the need for doctoral education acrossall aspects of the care continuum. In contrast,doctoral and master’s education for nurse man-agers and executives is encouraged.
For other advanced practice roles, includingthose of the clinical nurse leader, nurse educator,
and nurse researcher, a different set of educa-tional requirements exists. The clinical nurseleader as a generalist will remain as a master’sprogram. For nurse educators, the position ofAACN, although not universally accepted withinthe profession (as demonstrated by the existenceof master’s programs in nursing education), isthat didactic knowledge and practical experiencein pedagogy is additive to advanced clinicalknowledge. Nurse researchers will continue to beprepared in PhD programs. Thus there will onlybe two doctoral programs in nursing, the DNPand the PhD. It will be important for readers tokeep abreast of this movement as the professionfurther develops and debates this issue for impli-cations for their own practice and professionaldevelopment and within their own specialty. Thebest resource for this is the AACN website andthe websites of specialty organizations.
The last three chapters of Part 1 discuss thefuture of advanced practice nursing and theevolution of doctoral education—in particular,the practice doctorate. Within today’s rapidlychanging and complex healthcare environment,members of the nursing profession are chal-lenging themselves to expand the role of ad-vanced practice nursing to include highlyskilled practitioners, leaders, educators, re-searchers, and policymakers.
In Chapter 3, Carter reviews the historicaldevelopment of doctoral programs, which pro-vides important background information re-garding how the profession has arrived at theaforementioned decisions. Of particular note ishis discussion of the controversy surroundingthe development of the clinical doctoral pro-grams. Carter traces the roots of the PhD for re-search and clinical doctorate for practice. Asdoctorates in nursing developed in the latterpart of the last century, the emerging diversityin titling and role expectations called for clarityand direction for the profession.
In Chapter 4, Chism defines the DNP de-gree and compares and contrasts the researchdoctorate and the practice doctorate. The focus
2 n Part 1 Professional Roles for the Advanced Practice Nurse
of the DNP degree is expertise in clinical prac-tice. Additional foci include the Essentials ofDoctoral Education for Advanced Nursing Practiceas outlined by the AACN (2007), which includeleadership, health policy and advocacy, and in-formation technology. Role transitions for ad-vanced practice nurses prepared at the doctorallevel will call for an integration of roles focusedon the provision of high-quality, patient-centered care.
Lastly, in Chapter 5, the authors discussemerging roles of DNP graduates as nurse edu-cators, nurse executives, and nurse entrepre-
neurs, along with advanced practice nurses’ in-creased involvement in public health program-ming and integrative and complementaryhealth modalities.
REFERENCESAmerican Association of Colleges of Nursing. (2007).
Doctor of Nursing Practice. Retrieved fromhttp://www.aacn.nche.edu/DNP/DNPPositionStatement.htm
American Organization of Nurse Executives. (2007).Consideration of the Doctorate of NursingPractice. Retrieved from http://www.aone.org/aone/docs/PositionStatement060607.doc
INTRODUCTIONNursing’s quest for professionalism hasshaped nursing education and practice,past and present, in the United States andabroad. The emergence of professionalpractice models over the past quarter cen-tury represents the latest in professionaliz-ing trends. This effort by nurses andhealthcare managers to restructure theworkplace and nursing work highlights the evolution of nursing from a simplematter of tasks to the complexity of knowledge-based practice in rapidly chang-ing healthcare organizations. The currenthealthcare environment is faced with awide range of regulatory and financial
pressures. These include demands to jus-tify healthcare service outcomes, the driveto maintain biomedical and technologicalcurrency, and a recurrent nursing shortage.Looking back through nursing history, onecan see that crises in the healthcare systemcreate opportunities for nursing. Toooften, nursing’s responses to crises havenot created outcomes that serve both theinterests of the profession and the public.Today, as nurses once again find them-selves in the midst of a crisis, there is an op-portunity to renegotiate the organizationalrealities of health care and to advance thecontribution of professional nursing tohealthcare outcomes.
C H A P T E R 1
The Slow March to Professional PracticeKaren A. Wolf
CHAPTER OBJECTIVES
1. Define professionalism.
2. Discuss the development of nursing as a profession over thelast century.
3. Consider future trends in nursing that have the potential topositively affect the profession of nursing.
NURSING AS A PROFESSION: KEY IDEAS FOR INTEGRATION
What makes work professional work? Nursinghas struggled with this question throughout itshistory. For most of the 20th century, nursingwas considered a semiprofession or a professionin progress by sociologists (Bucher & Strauss,1961; Etzioni, 1969). The attention that nurs-ing leaders have given to professional develop-ment is manifest in the push for control overeducational standards, efforts to develop a the-ory base for nursing practice, the growth of pro-fessional organizations and journals, and, morerecently, the reorganization of nursing workwithin professional nursing practice models.The nature of professional nursing work differstoday from what it did for the sacred three pro-fessions of medicine, law, and the clergy in1900. The autonomous solo professional ser-ving the public with expert knowledge and skillis now a rare phenomenon. Few occupationscan claim pure professional autonomy, becausethe reach of corporate and institutional controlnow dominates most sectors of the economy.
Autonomy, a hallmark of professionalism,can be differentiated into autonomy of decisionmaking relative to the client and/or patientcare and autonomy from the employing insti-tution (Manthey, 1991). Autonomous practi-tioners are those who have direct lines of accessto clients, who are responsible for their ownpractice decisions, and who are accountable toclients, peers, and professional organizations,as well as to the courts, for their conduct(Marram, Schlegel, & Bevis, 1974). The nursingprofession has struggled with the idea of au-tonomy because most nurses are employed andsubordinated to the authority of organizationssuch as hospitals (Ashley, 1976; Reverby, 1987;Wolf, 1993). The claim to autonomy with re-gard to the freedom to make decisions aboutpatient care has advanced over the past fewdecades, fueled by the development of primarynursing models (Hegyvary, 1982). More re-
cently, health services research studies have in-tegrated the concept of nursing autonomy. Forexample, a recent study by Aiken, Clarke,Sloane, Sochalski, and Silber (2002) suggestedthat increasing nursing autonomy and controlover the practice setting was associated withimproved patient care outcomes.
Nursing can no longer be viewed as a sub-sidiary function of medicine that is proscribedby doctors’ orders; nursing care now reflects apatient-centered approach based on nursingtheory and shaped by a nursing process of rea-soning. Current legal and professional regula-tions legitimate this nurse-driven process ofpractice. The body of statutory and case lawthat governs nursing practice holds nurses ac-countable to a definition of practice that rec-ognizes and codifies practice in accordancewith current nursing knowledge and clinicalpractice standards. Accountability is inherentto autonomy. By definition, accountabilitycalls for professionals to accept responsibilityor to account for their actions (Merriam-Webster’s Collegiate Dictionary, 2006). The de-mand for professional accountability has beenspurred on by the health-outcomes movementand patient safety concerns.
Professionalism should and does benefit thepublic. However, professionalism also arises outof self-interest and provides a means by whichoccupational groups exert influence to advancetheir own interests in society. The interest mayreflect a desire for greater societal power and/oran increase of rewards or benefits for the group.As such, the quest for professional status bynursing reflects an attempt to access andachieve mobility. Professionalism, by reflectingthe underlying meritocratic values of our soci-ety, offers a rational system for distributing sta-tus and rewards.
Professionalization provides access to socialmobility. According to Hughes (1971), thereare two types of mobility. The first is the rise ofthe individual by entering an occupation ofhigh prestige or by achieving special success in
6 n Chapter 1 The Slow March to Professional Practice
his or her profession. The second is the collec-tive effort of an organized occupation to im-prove its place and increase its power inrelation to other occupational groups. In thecase of nursing, mobility has traditionally beenmeasured against or referenced to other groups,such as physicians.
Since the 1970s, interest in professionalizingnursing work has emerged in healthcare organi-zations as a means to provide a substitute moti-vation for workers with blocked access tostructures of mobility. The ideological draw ofprofessionalism is that it offers the promise ofhigher status and control. A crucial issue thatarises out of the trend to professionalize work isthe struggle of workers, including nurses, to ex-ercise control over the context (environment)and content of their work. The ability to exer-cise control, however tentative, appears to me-diate individual and collective tensions thatarise from the heightened expectations of amore educated nursing workforce. By profes-sionalizing the workplace, management seeksto counter more traditional collective action,such as unionism. Educated to be professionalsin colleges and universities, nurses now expectto exercise their knowledge and skills withoutorganizational or bureaucratic constraint. Theheightened expectations of nurses represent adouble-edged sword, offering a challenge to tra-ditional hierarchical controls and opportunityfor institutional enhancement.
As hospitals and other healthcare institu-tions confront the increasing complexity inhealth care, the application of professionalknowledge and skills becomes essential to insti-tutional functioning. That professional knowl-edge and skills serve institutional goals to solveinstitutional problems is now embraced byhealthcare administrators as an asset, ratherthan a threat to traditional authority. Perrow(1972) observed in his classic treatise on bureau-cracy that professionals, far from antithetical toinstitutional bureaucracy, are in fact readily har-nessed to serve the needs and problems of orga-
nizations. Nurses have historically highlightedthis phenomenon. More recently, other tradi-tional professions (physicians, lawyers) have be-come organizational professions. Yet, despitenurses’ central role in healthcare services, theyhave struggled to develop, assert, and be recog-nized for their professional expertise. Imbuedwith managerialism, nursing work in hospitalshas evidenced a professional paradox (Fourcher& Howard, 1981). The application of nursingknowledge and skill in managing patient care inhospitals has a long history of being subjugatedto nursing and hospital administration.Nursing expertise has more often than not beeninvisible and undervalued, and autonomy ofpractice has been absent.
ROOTS OF NURSINGCONTRADICTIONSThe concept and actual practice of nursingwork has evolved dramatically over the past 100years. But like many evolutionary paths, old oroutdated conceptions of nursing persist. As aresult, both popular and professional concep-tions of nursing are riddled with contradictoryviews. Prior to Florence Nightingale’s reformsin England, nursing was largely women’s work.Nursing was viewed as an extension of mother-hood, midwifery, or religious duty. By the late19th century, women working as nurses beganto fill a role in the administration of poverty.Because health care and nursing care of the sickwere intertwined with poverty, caring for thesick was largely caring for the poor. Nursingwas commonly carried out by impoverishedwomen who worked as nurses in almshousescaring for the poor, the sick, and the destitute.These untrained, able-bodied paupers workedfor room and board. The harsh reality was thatthese nurses were viewed as part of the chaoticenvironments in which they worked. TheDickinsonian image of Sairey Gamp, a low-classdrunkard and disheveled woman, was reflectiveof the persistent stigma that Nightingale
sought to escape with the formal education of ahigher class of women (Dean & Bolton, 1980;Williams, 1980).
Although some few nurses saw their work asa religious service, the role of religious valueswaned with the disintegration of church-basednursing orders with the rise of Protestantism inEngland. Hospitals, lacking the support of reli-gious nursing orders, struggled to providenursing care that was haphazard at best.Nurses lacked a systematic set of skills, a knowl-edge base, or training. Nightingale sought tomodernize nursing by developing a trainednursing labor force composed of a higher classof women.
Nightingale also sought to link nursing edu-cation with the more formalized developmentof hospitals. Influenced by her experiences inthe Crimea, Nightingale recognized that nurs-ing care was the major determinant of hospitaloutcomes. A brilliant and politically astutewoman, she took on nursing reformation witha passion born of her religious beliefs and desireto reform social expectations for women.Nightingale advanced her case for trainingnurses based on data. Nightingale contributedsome of the earliest biostatistical data of hospi-tal conditions and outcomes, drawing connec-tions between the environments of care and thecontribution of nurses (Dossey, 1999).
Despite Nightingale’s innovative ideas tosystematize the education of nurses, the originsof modern nursing were seeded with social con-straints. Nightingale (1866) wrote to a friendthat “the whole reform in nursing both at homeand abroad has consisted of this: to take allpower over the nursing out of the hands of menand put into the hands of one female trainedhead and making her responsible for every-thing. . .” (p. 25). Nightingale and her contem-poraries purposely overlooked the traditions ofmen in nursing, such as the work of the KnightsTemplar (Bullough & Bullough, 1984). Theconcept of nursing discipline projected byNightingale, as well as by nursing leaders in the
20th century, held nursing to conventionalstandards of female subservience within a hier-archy of a moral female authority. Nursing wasembraced as a feminine endeavor that was to bethe singular focus of the nurse’s life. Imbuedwith inherent religious values, nursing wasviewed as a selfless act, and the reward for nurs-ing work was deemed intrinsic to the work it-self. Nightingale, although a feminist andsupporter of women’s suffrage, struggled withcontradictions of class and gender as she ad-vanced her campaigns for nursing and health.Despite Nightingale’s political opinions, mod-ern nursing was reconceptualized as a woman’scalling, and hence doubly subordinated to thepaternalism of society.
NURSING TAKES ROOT IN THEUNITED STATESThe universal traditions and nursing functionsof caring for the sick have existed for centuries.The power of Nightingale’s reforms to formal-ize and reshape nursing has been evident intheir global reach. In the United States, as inmany other countries, the importation of theNightingale schools of nursing legitimatednursing work as an occupation for women.Hospital-based schools of nursing offeredwomen access to education and the potentialfor employment, creating an option for a sus-tainable livelihood. Employment as a headnurse or private duty nurse was a welcome al-ternative to agrarian domesticity or mill work.
The demand for nursing grew in response tohospital growth. As industrialization spurredthe growth of larger communities, hospitalsproliferated and became a central feature ofcommunity life (Rosenberg, 1989). Social re-formism was a major force because it spurredthe development of both public health andhospital-based services to provide health care tothe growing industrial labor force (Rosenberg,1989; Starr, 1982). From 1875 to 1924, thenumber of hospitals grew from just over 170 to
8 n Chapter 1 The Slow March to Professional Practice
more than 7,000 (Rosner, 1989). However, asnoted by Stevens (1989), the central role thathealth care would take in American society wasbeing shaped by the growing power of medi-cine. A benevolent paternalism pervaded thestructure of healthcare services and harnessedthe potential of nursing to support the role ofmedicine and hospitals (Ashley, 1976). By theearly 1900s, the growth of hospitals in theUnited States generated an unprecedented de-mand for nurses. The growth of technologyfrom basic advances such as X-rays and anes-thesia fueled excitement in hospital investment.Physicians invested their money and technol-ogy into hospitals, securing power in their com-munities as well. Hospitals became a focal pointof community life, and hospitals became both asymbol of the prosperity of a community and afocus for social reformism.
The thirst for a cheap and rapidly producedlabor supply overshadowed concerns over stan-dards of quality education. From 1900 to 1920,the nursing profession grew “from one in whichthere were more than 10 times as many physi-cians as nurses, to one in which there was lessthan one physician for every nurse” (Burgess,1928, p. 43). As hospitals grew, schools of nurs-ing were created to provide a labor force for thehospitals, often at the expense of adequate edu-cation (Ashley, 1976). As Dock and Stewart(1938) noted in their history of nursing, “the ex-cess of poor schools and poorly prepared nurseswas attributed in large measure to the appren-ticeship system that prevailed, with its overem-phasis on practice service at the expense ofeducation” (p. 183). Formal studies of nursingeducation, such as the Goldmark report (1923)and the grading committee report of theNational League for Nursing Education (1926),addressed the issue of raising standards for nurs-ing education. Dock and Stewart (1938) sug-gested that despite the many recommendationsfor reform, “the system was too deeply rootedand the funds for putting nursing schools on asound economic and education basis were sim-
ply not generally available” (p. 183). Despite for-ward movement with the establishment of uni-versity schools of nursing at Columbia, Yale, andWestern Reserve, the push to establish college en-trance as a requirement for practice was eclipsedby the hospital training schools. The fundamen-tal professional goal to control the entry into theprofession was overridden by hospitals’ needs fora cheap labor supply.
The rapid expansion of a nursing labor forceoccurred with little regard for educational qual-ity. Hospital administrators recognized the eco-nomic benefit of using student labor, andphysicians began to appreciate the good nursingcare offered by graduates of such training. Butby the 1930s, concerns about overproduction ofnurses emerged and were underscored by theGreat Depression. A third of all hospital schoolsof nursing closed between 1929 and 1939.Nurses, no longer able to secure private dutywork, sought employment in hospital wards forhourly or group nursing work. But as Reverby(1979) noted, hospitals were slow to hire gradu-ates as staff nurses, despite admonishments bythe nursing leaders and the American NursesAssociation. Modified grouped private dutynursing efforts served as a transition to the de-velopment to staff nursing. The dire economicconditions of the Depression reshaped nursingwork and healthcare services. Nursing shiftedaway from private freelance work to organizednursing services in hospitals and public health.As nursing became embedded in hospitals, theprimacy of the nurse–patient relationship—acharacteristic of private duty nursing—eroded,and the nurse became subordinated to the pa-ternalism of the hospital (Ashley, 1976; Dock &Stewart, 1938).
THE CHANGING ORGANIZATION OF WORKThe organizational culture of hospitals, charac-terized by strong gender-based roles and a hier-archical authority structure, was fertile ground
for the application of industrial managementmethods. The ideas of scientific managementmade an easy leap from factory floor to hospi-tals in the first half of the 20th century.Frederick Taylor, the architect of many scien-tific management ideas, was of a new breed ofindustrial engineers. His primary concerns were enhancing worker productivity and limit-ing the threats of unions so as to increase theprofits from capitalism. Scientific methods were intended to extract labor from workers atthe shop-floor level by dividing work into dis-crete tasks to be done by individual workers.“Taylorism” spread to hospitals and was em-braced by nursing leaders, and the quest for effi-ciency in hospital operations mirrored thefactory push toward mechanistic functioning.The application of Taylor’s scientific manage-ment methods to hospitals included division oflabor, the task orientation of functional nurs-ing, and standardized and proscriptive proce-dure manuals. Hospitals were in a uniqueposition to maximize the control and the exe-cution of nursing work, because they were oftenboth the diploma schools for training nursesand the employer. The hospital culture was ableto secure the loyalty of nurses through bothschool ties and training (Wolf, 1993).
Management in hospitals emerged largely atthe ward level. Mobility in nursing became tiedto the management structure. Nursing leader-ship embraced managerialism, because it of-fered the potential for mobility and statusrecognition for women. Subordinated to physi-cians, nurses were unable to gain control overaccess to patients, use of technology, or applica-tion of knowledge. Nursing leader IsabelStewart attempted to advance scientific nurs-ing, which she thought could be employed inconjunction with industrial methods for stan-dardization and efficiency of hospital care towrest control from hospitals. However, her aca-demic approach to building a scientific basis forpractice was viewed skeptically by nurses andnever gained sufficient financial support(Reverby, 1987). Nurses continued to follow or-
ders under a system where work conception wasclearly separate from execution.
That the adage “a nurse is a nurse is a nurse”was born in this period reflects the view thatnurses were considered an interchangeable partof the hospital machine. Although many nursespreferred to work as private duty nurses, thechanging economics of the Great Depressionmade this an unstable option by the 1930s(Reverby, 1999). As a result of application of sci-entific management methods to nursing, pa-tient care became fragmented, task oriented,and management focused. Case-based nursing,rooted in the tradition of private duty nursing,fell victim to what was viewed as progress. Newmodels of care, such as group nursing and func-tional nursing, reflected the pooling of scarcenursing labor resources to meet the needs of theorganization, not the patient.
Following World War II, team nursing be-came the common model of nursing care or-ganization. The team nursing concept wasinfluenced by wartime experiences and theemerging human relations school of manage-ment. The goal was to create a team of nursingcare providers led by a professional nurse.Emphasis was placed on effective communica-tion and delegation to enhance team function-ing. However, nursing shortages often resultedin team leaders struggling to provide care withinadequately trained staff. The result of theteam approach was more a functional approachto care, with emphasis on task completionrather than patient care (Hegyvary, 1982).Because of tradition and nursing shortages,remnants of mechanistic task performance con-tinued to permeate the work culture of hospitalsand counter professionalization attempts.
Nursing leader Lydia Hall, a fierce opponentof team nursing, challenged nursing to put itsrhetoric of professionalism to the test of prac-tice. In 1963, she instituted a system of profes-sional nursing practice at the Loeb Center,Montefiore Medical Center, in New York City.The Loeb model of care emphasized nursing au-tonomy and accountability, giving the nurse
10 n Chapter 1 The Slow March to Professional Practice
responsibility for providing care and makingcare decisions for his or her patients during thefull duration of their hospital stay (Hall, 1969).Her visionary efforts planted ideas for change;however, few hospitals adopted her model.
INSTABILITY IN THE NURSING LABOR FORCEDespite the emphasis on efficiency and ratio-nality in hospital management, the nursinglabor force continued to be wracked by instabil-ity. Recurrent nursing shortages during the1940s and 1960s led to the policies that in-creased the production of more nurses—short-training nurses in particular. These nursingshortages set the pattern for subsequent policyinitiatives dominated by hospital interests(Grando, 1998). Hospital administrators andnursing leaders first encouraged licensed practi-cal nurses and then associate degree nurses. Inthe midst of the shortages, attempts to fill nurs-ing positions were like filling a leaking bucket.Nurses were clearly unhappy with work condi-tions and compensation. Shortages of nursesleft team nurse leaders working alone as cap-tains of understaffed nursing teams. While hos-pital nursing administrators struggled with theoutflow of nurses, nursing educators struggledwith the quest to professionalize nursing. Thedevelopment of nursing knowledge and skillstook on renewed urgency at mid-century.Nursing scholars such as Virginia Henderson(1966) sought to reclaim the primacy of thenurse–patient relationship and expand thefocus of nursing care beyond efficiency to aprocess-oriented effectiveness.
The post–World War II period led to in-creased federal funding for nursing and healthcare. Along with the funding came a new closerscrutiny of hospital costs. As the federal govern-ment became more involved with funding hos-pital care, the drive to disentangle educationalcosts from nursing care costs took force.
By the late 1960s, funding of nursing educa-tion began to move away from the hospital
training schools to colleges and universities.Early doctoral programs developed as hybriddegrees, between nursing and fields such as ed-ucation, sociology, psychology, and biology.These graduate programs had as their primaryfocus the development of a pool of nursing ed-ucators. But within a few years, collegiate nurs-ing education institutions expanded programsin nursing administration and clinical special-ization. Graduate education became the pri-mary incubator for nursing theory and thegrowth of professional knowledge and values.
By the 1970s, a culture of professionalismemerged in nursing, fueled by the growth ofnursing scholarship. This resulted in a gap be-tween nurses’ expectations and the experientialreality of nursing work. This gap, or realityshock (Kramer, 1974), was evidenced by therapid turnover in staff nursing and nurses’growing discontent. Despite the move to amore efficient hospital functioning, the nurs-ing labor force continued to be wracked by in-stability. Once again, nursing shortages led tothe increased production of nurses, in particu-lar short-training nurses. Hospital administra-tors and nursing leaders encouraged theaddition of associate degree nurse productionas a solution.
Nursing education, long tied to hospitalsthrough the tradition of hospital diplomaschools, began to break free in the 1960s. Thefederal government took up more of the finan-cial burden for nursing education. But as nurs-ing education moved into colleges, the trade-offwas the loss of nurses’ loyalty to hospitals, acentral characteristic of hospital-diploma-school nurses. While hospital administratorsstruggled with the outflow of nurses, thegrowth of college-based programs at the bac-calaureate and associate degree levels infusednursing with a new drive for professional status.As the development of nursing knowledge andskills took on more status and legitimacy, thepredominance of nursing management as theprimary means of career mobility came to anend (Wolf, 1993).
MILITANCY ROCKS THE HOSPITAL BOATDiscontent with the reality of nursing work re-flected the changing values and expectations ofnurses. With rising expectations of profession-alism, nurses’ desires for control over their workwere influenced by the new social realities ofwomen’s employment. Nursing was no longerviewed as a transient occupation for women tokeep them busy until they married. The grow-ing careerism sharpened nurses’ lenses to work-place realities. Turnover rates in hospitalsreflected the discontent with working condi-tions and benefits. Nurses, college educated andempowered by the emerging women’s move-ment, were no longer willing to bow to the pa-ternalism of hospital administrators.
At various points in nursing history, nurseshad discussed or attempted the use of collectiveaction or unionism. The rate of nurses organiz-ing for collective bargaining began to increase inthe 1960s, but it was not until 1974, with the ad-dition of amendments to the federal Taft-Hartley Act, that the potential impact ofcollective bargaining was realized (Foley, 1993).These amendments provided federal protectionto nurses and other healthcare employees ofnonprofit healthcare institutions with regard tothe right to organize. The operational structureof the amendments emphasized that nurses wereto be a separate and distinct bargaining unit.
The potential of the nursing labor force tobe a catalyst for the unionization of the entirehospital labor force was clearly recognized byhospital administrators and union busting con-sultants. This, in turn, resulted in the idea of re-quiring hospital employees to organize intoseparate bargaining groups. Nurses werecourted initially by professional nursing organi-zations, such as the ANA-affiliated state nurs-ing organizations. Within a few years, moretraditional industrial and trade unions, such asthe United Auto Workers (UAW) and theAmerican Federation of Teachers (AFT) joinedefforts to organize nurses and other healthcare
workers. The ANA-associated state nursing or-ganizations were viewed as the lesser of two evilsbecause the professionalism inherent in thenursing leadership tempered the militancy.
Hospital administrators explored a varietyof means to fight the spread of hospital union-ism (Kohles, 1994). Treating various types ofhospital workers as contract workers was com-mon, but this approach was neither cost- noroutcome-effective for nursing. Another ap-proach was to create a new work culture andstructure that would divide nurses from otherhospital employees. This served a double pur-pose. First, it helped to insulate other hospitalworkers from nursing collective action.Second, it held the potential to curb the mili-tancy. To effectively bridge the reality gap thathad led to nurse militancy, nursing and hospi-tal administrators needed to realistically grap-ple with the roots of nurses’ frustration. Thelong-standing paternalism was no longer an ef-fective means of controlling nurses.
NURSING IS NOT ALONE: THE NATIONAL CRISIS IN THE QUALITY OF WORK LIFEBy the late 1970s, professionalism, long viewedas an unnecessary extravagance, was to become amantra for nursing management. The growingbelief that creating a more professional work cli-mate could mitigate the potential for workplacemilitancy shaped efforts to restructure nursingwork in hospitals. As hospital administratorsand nursing grappled with what was perceivedto be an issue of militancy versus professional-ization, the issue was reflected in broader dis-cussions of an emerging national crisis inworkplace relations. Nationally, as concerns overdecreases in worker productivity grew, labor ex-perts debated the origins and solutions toworker discontent across a wide range of occu-pations and professions. The U.S. Departmentof Health, Education, and Welfare (1973)funded a study—“Work in America”—that askedthe question, “What do workers want?” The
12 n Chapter 1 The Slow March to Professional Practice
study yielded the following answers: interestingwork, enough help and equipment to get the jobdone, enough information to get the job done,enough authority to get the job done, good pay,opportunities to develop special abilities, job se-curity, and the ability to see the results of one’swork. National labor and management expertsdebated innovations such as worker control pro-grams and work restructuring. However, thelong-standing dominance of industrial laborskewed the perspective of labor experts whowere slow to recognize the power and problemsof the emerging service sector, and specificallythe healthcare labor force.
By the mid-1970s, the nursing profession wasin the midst of a collective feminist conscious-ness raising (Wolf, 1993). Nursing’s perspectiveon nurses’ discontent with their work held thatthe conditions nurses faced were unique andwere often viewed within the context of genderand professionalism. Jo Ann Ashley (1996), afeminist nursing historian, offered the mostvocal of the feminist perspectives. She describednurses’ perceived powerlessness to change theirsituations as a consequence of their uniquesocialization as a female-gendered occupationand a result of the cultural barriers to the exer-cise of the power of nursing within paternalisticinstitutions.
Caught in a rapid current of culturalchange, nursing and hospital administratorswere pushed by nurses and pulled by larger so-cial, economic, and political currents to facechange in healthcare organizations. Collegiatenursing education, which had begun to em-brace the notion of nurses as change agents,contributed to a new professional conscious-ness. The power to change nursing realities wasslowly unleashed.
The unfreezing of hospital nursing tochange was rapidly catalyzed as the potentialthreat of collective bargaining became evidentto nursing and hospital industry management.Nurses, like workers in other industries andservice sectors, wanted control over their work
and a more equitable and open system of re-source allocation and rewards. Control in-volved complex problems of achieving andsustaining authority and ensuring accountabil-ity for nursing practice. The potential scope ofcontrol ranged from specific day-to-day patientcare decision making to participation in orga-nizational governance, such as goal setting andfinance (Siriani, 1984; Witte, 1972). Hospitaldecision making is typically viewed as hierar-chical, with organizational control at the topand bedside or patient-care issues at the bot-tom. But in reality, the arenas of decision mak-ing are overlapping and interconnected withinhospital organizations.
PATIENT-CENTERED CARE AND THEEMERGENCE OF PRIMARY NURSINGAs the workplace reforms movement movedforward in the 1970s, the desire for control overpatient care took precedence in most organiza-tions. This reflected the growing necessity forgreater nursing decision making given therapidly increasing complexity of the patientcare. The most influential development was pri-mary nursing. According to Marram, Schlegel,and Bevis (1974), primary nursing was a devel-opmental step in professional practice develop-ment that supported “the distribution ofnursing so that the total care of an individualpatient is the responsibility of one nurse, notmany nurses” (p. 1). Many of the ideas inherentin primary nursing were previously noted byLydia Hall (1969) at the Loeb Center. In-fluenced by the wave of quality in work life ideasin the contemporary management literature,primary nursing was invented as an approach tojob redesign. This job-redesign approach hadbeen applied successfully in industrial manage-ment in Europe and Japan. The primary nursingmodel offered hospital management a way tocounter worker complaints about deskilling.The work of nursing was restructured and en-larged to make nurses accountable for the wholeof patient care rather than just for specific tasks.
Patient-Centered Care and the Emergence of Primary Nursing n 13
Primary nursing was also ideologically imbuedwith professionalism.
The association between primary nursingand enhanced professional orientation wasnoted in many studies beginning in the 1970s(Marram, Schlegel, & Bevis, 1974). Manthey(1980), an early proponent of primary nursing,noted that primary nursing reflected a philo-sophical commitment to decision making atthe level of action. Primary nursing, drawing onprofessionalism, sought increased accountabil-ity by the nurse for patient care, a rational sys-tem of care provided by the nurse who is mostknowledgeable about the patient, individual-ized and personalized patient care, and in-creased equality among nursing staff (Marram,Schlegel, & Bevis, 1974). To support the initia-tion of primary nursing, registered nurses hadto be reskilled, and hospitals sought to increasethe staffing levels of registered nurses while de-creasing the employment and roles of licensedpractical nurses and nursing assistants. In mostinstances, this necessitated increased fundingor significant reallocation of funds, made possi-ble in the late 1970s by government and privatesupport to hospitals.
Primary nursing provided a process bywhich patient-centered care could be individu-alized yet applied within a standardized nursingprocess. However unique each patient-care situ-ation might be, the process of nursing judg-ment and discretion became predictable. Theapplication of the nursing process as a methodof solving nursing care problems became cen-tral to nursing education and practice in the1970s. The development of professional nurs-ing standards for care by the ANA further codi-fied this process orientation. However, thegrowing complexity of patient care and the in-creasing body of nursing theory would soonshift nursing’s emphasis to critical thinking.
Despite the shift in control over nursing edu-cation from hospitals to academic institutions,the reality was that most nursing graduates weregoing to be employed by hospitals. Nursing ed-
ucators faced pressure to produce a productnurse that met the hospital labor market needsin terms of skill as well as price.
As legal and regulatory pressures for greateraccountability mounted, new demands fordocumentation shaped the day of hospitalnurses. Nurses expressed a sense of beingpushed into documentation at the expense ofbeing pulled away from patient care. As oneprimary nurse noted, “Make sure your patientcare is your priority, but don’t forget your pa-perwork” (Wolf, 1993, p. 115). The strain ofcompeting demands between the work of nurs-ing and the documentation of the workemerged as a recurring theme underlying alien-ation and nurse dissatisfaction. As nurses grap-pled with the potential of primary nursing toprovide rewards, the reality of the system’s con-straints and the contextual issues of organiza-tional control became more apparent.
THE MISSING LINKS: SHAREDGOVERNANCE AND RECOGNITIONThe initiation of shared governance in health-care institutions in the 1980s highlighted an attempt to ease the tensions between adminis-trative controls and professional work. Primarynursing, while restructuring nursing work, wasquickly found to be limited in its scope. Thework of nurses was embedded in the organiza-tional context and was shaped by decisions thatwere often removed from their sphere of action.From staffing to equipment choice, these deci-sions often impacted patient care, leaving nursesfrustrated, which compounded problems ofturnover and militancy. Just as American indus-try struggled with the push to expand workercontrol without sacrificing managerial preroga-tives, the push for workplace participation in de-cision making grew. Genuine participation wasmade difficult by the complex hospital author-ity structure, which kept nurses trapped be-tween the dual hierarchies of medicine and thehospital administration.
14 n Chapter 1 The Slow March to Professional Practice
The climb by nurses out from between thesetwo systems of control generated both a threatand an opportunity for the reallocation of powerin hospitals. Nursing leaders such as Manthey(1991) cautioned that for the reallocation ofpower to occur, a major change was required inthe structure and operation of nursing depart-ments. Change would require a major disman-tling of the hospital hierarchy, beginning withthe nursing departments. As Porter-O’Grady(2001) noted, “Implementing an empowered format such as shared governance means thatthe relationships, decisions, structures, andprocesses will be forever changed at every level ofthe system and that all the players in the organi-zation will be different and behave differently as a result” (p. 5). The changes in patterns ofcommunication and behaviors extended acrossrelationships, not only nurse–nurse or nurse–patient, but also nurse–physician. Many physi-cians were initially ambivalent and threatened byshared governance (Wolf, 1993).
In the 1980s and 1990s, many hospitalsmoved toward flatter management structures inan effort to move toward shared governance.Work, previously viewed as a management pre-rogative, was typically distributed across theflattened structure to involve staff nurses as wellas administrators in decision-making processesat the committee level. Nurse participation wasconcentrated at the committee level. A study byJenkins (1988) observed that the expanded com-mittee structure resulted in more time spent inmeetings and an overall drop in hours per full-time employee. For example, MassachusettsGeneral Hospital provides a wide range of com-mittees in its governance structure, includingsuch foci as patient-care quality, diversity, andstaff recruitment (Erickson, 1996). Participationis based on an application; it is a selectiveprocess that draws from a pool of dedicated full-and part-time nursing staff who give generouslyof their time and expertise.
A parallel concern to expanded decisionmaking has been the need to recognize nurses
for their efforts (McCoy, 1999). Hospital nurs-ing is complex and difficult work. Keeping ex-perienced nurses at the bedside improves thequality of patient care and reduces recruitmentand orientation costs. The challenge has beento find a way to reward nurses for a career in di-rect care rather than management. Career lad-ders typify the development of new rewardsystems. Career ladders provide a hierarchicalsystem of rewarding professional behaviors,such as advanced education; scholarship; andcontributions to the institution, such as com-mittee work or clinical projects. This systemprovides the semblance of mobility by recogniz-ing those nurses who choose to stay at the bed-side. Given the recurrent stresses of nursingshortages, career ladders have provided anothermechanism to attract and retain clinically ex-pert nurses. The career ladder system has codi-fied the job enlargement of the professionalnurse, while stimulating nurse productivity in avariety of areas, such as quality assurance, prac-tice policy development, hospital public rela-tions, and nurse recruitment (Wolf, 1993).
However, the linking of remuneration withcareer-ladder progression historically has beenproblematic for many hospitals. The hospitalbudget process and pressures to control nursesalaries has thwarted career-ladder developmentefforts in some hospitals. Many senior nursesfind themselves hitting the glass ceiling with newhires rapidly gaining more compensation.Healthcare organizations have also adopted non-monetary systems of nurse recognition, such asthe professional nurse of the month awards.These symbolic rewards, while recognizing clini-cal excellence, divert attention away from theconcrete contextual realities of practice.
THE ATTRACTION OF MAGNET HOSPITALSIn the early 1980s, the American Academy ofNursing launched an effort to recognize hos-pitals for their ability to attract and retain nursing staff (Upenickes, 2003). The Magnet
Hospital program was launched based on astudy that identified hospitals having low staffturnover, high nurse job satisfaction, and lowstaff nurse vacancy rates. The initial recognitionwent to some 41 hospitals. The results of theearly magnet hospital studies highlighted theimportance of organizational factors, such asparticipatory structures and processes, per-ceived autonomy of nurses, and empoweringleadership (Scott, Sochalski, & Aiken, 1999).The characteristics of these hospitals paralleledmany of the recommended changes of the qual-ity of work life advocates. Policy reports by theInstitute of Medicine (1981) and the NationalCommission on Nursing (1981) report by theAmerican Hospital Association gave added le-gitimacy to the move to restructure hospitals tobetter attract and retain nursing staff. Some 20years after the initial magnet studies, a body ofresearch has been collected to justify continu-ing support for the restructuring of systems ofcare. Current efforts focus on validating out-comes of care in magnet hospital systems, but abetter understanding of the relationship be-tween outcomes and nurses’ autonomy isneeded (Havens & Aiken, 1999; Ritter-Teital,2002; Scott et al., 1999).
PROFESSIONAL NURSING ANDNURSE STAFFING: CHICKEN OR EGG?How well hospitals are able to sustain profes-sional models is dependent on the political andeconomic climate of the healthcare market. Pastnursing shortages generated greater leverage fornursing stakeholders. Yet as tensions in laborease or are overcome by greater organizationalpressure to contain or depress labor costs, thepotential for backpedaling on professionalnursing gains increases. Nursing has a greaterpotential to enhance quality outcomes by max-imizing the use of professional expertise. As hasbeen noted in recent studies, sustaining ade-quate nurse staffing may be one of the most im-portant key factors in patient care outcomes(Aiken et al., 2002; Cho, Ketefian, Barkauskas,
& Smith, 2003). Such research further under-scores the importance of continuing profes-sional models of development as they supportthe recruitment and retention of staff. For toolong the value of nursing has been hidden inhealth care by data collection and informationsystems that give primacy to medicine. Ideally,emerging advances in nursing informatics willadd to nursing’s visibility and support contin-ued vitality. A firm investment in professionalmodels will also call for healthcare organiza-tions to effectively match nursing educationand talents with the complexity of the work.The corporatization of hospitals provides a rel-ative opportunity for nursing to gain power inthe healthcare organization. It is time for nurs-ing to cease its dependence on the good will ofinstitutions and to demand full participation ininstitutional policy making.
CONCLUSIONThroughout the history of nursing, profession-alization has been a driving force for change.From the earliest innovations of Nightingale tothe most recent nursing shortage, the work cul-ture of nursing has been reshaped to meet theneeds of society or managerial interests, often inthe midst of crises. The slow march toward pro-fessional practice continues as models of nurs-ing practice offer a powerful ideological hold.Nursing has been influenced by ideas drawnfrom sociology, management, and industry, re-sulting in workplace reforms reframed within aprofessional lens. The power of professionaliza-tion has contributed significantly to the successof this reform, offering benefits to both health-care institutions and nurses. However, nursingshortages remain. Challenging questions for the future include the following: To what extentare professional models of practice sustainablein the face of economic uncertainty? Can insti-tutional control truly be ceded to nurses with-out a fundamental revolution in the overallrestructuring of healthcare financing and ser-vice structure?
16 n Chapter 1 The Slow March to Professional Practice
DISCUSSION QUESTIONS1. In this chapter, the author argues that
nursing’s role in hospitals is imbued withmanagerialism, causing a paradox (Fourcher& Howard, 1981). The application of nursingknowledge and skill in managing patient carein hospitals has a long history of being subju-gated to nursing and hospital administration.Nursing expertise has more often than notbeen invisible and undervalued, and auton-omy of practice has been absent. Reflectingon this statement, do you agree or disagree?
2. How has societal and healthcare policy af-fected the development of nursing?
3. What are the pros and cons of unionizationin nursing?
4. How will the Magnet Hospital program,shared governance, and mandated staffingratios affect nursing in the future?
REFERENCESAiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J.,
& Silber, J. H. (2002). Hospital nurse staffing andpatient mortality, nurse burnout, and job satisfac-tion. Journal of the American Medical Association, 288,1987–1993.
American Association of Colleges of Nursing. (2007).Doctor of Nursing Practice. Retrieved July 14,2007, from http://www.aacn.nche.edu/DNP/DNPPositionStatement.htm
Ashley, J. (1976). Hospitals, paternalism, and the role of thenurse. New York: Columbia University Press.
Ashley, J. (1996). This I believe about power in nurs-ing. In K. Wolf (Ed.), Selected readings of Jo AnnAshley (pp. 23–34). New York: NLN Press/Jonesand Bartlett.
Bucher, R., & Strauss, A. (1961). Professions in pro-gress. American Journal of Sociology, 66(4), 325–334.
Bullough, V., & Bullough, B. (1984). The history, trends,and politics of nursing. Norwalk, CT: AppletonCentury Crofts.
Burgess, M. (1928). Nurses, patients, and pocketbooks.New York: Committee on the Grading of NursingSchools.
Cho, S. H., Ketefian, S., Barkauskas, V. H., & Smith,D. G. (2003). The effects of nurse staffing on ad-verse events, morbidity, mortality, and medicalcosts. Nursing Research, 52, 71–79.
Dean, M., & Bolton, J. (1980). The administration ofpoverty and the development of nursing practicein nineteenth-century England. In C. Davies (Ed.),Rewriting nursing history (pp. 76–101). London:Croom Helm.
Dock, L., & Stewart, I. (1938). A short history of nursing.New York: G. P. Putnam’s Sons.
Erickson, J. I. (1996). Our professional practice model.MGH Patient Care Services, Caring Headlines, 2(23).
Etzioni, A. (1969). The semi-professions and their organi-zation. New York: Free Press.
Foley, M. (1993). The politics of collective bargaining.In D. Mason, S. Talbot, & J. Leavitt (Eds.), Policyand politics for nurses (2nd ed., pp. 282–302).Philadelphia: W. B. Saunders.
Fourcher, L., & Howard, M. (1981). Nursing and themanagerial demiurge: Social science and medi-cine, Part A. Medical Sociology, 15(Pt. 3), 299–306.
Goldmark, J. (1923). Nursing and nursing education inthe U.S. Report of the Committee for the Study ofNursing Education. New York: Macmillan.
Grando, V. T. (1998). Making do with fewer nurses inthe United States, 1945–1965. Image: Journal ofNursing Scholarship, 30(2), 147–149.
Hall, L. E. (1969). The Loeb Center for Nursing andRehabilitation, Montefiore Medical Center, Bronx,New York. International Journal of Nursing Studies, 16,215–230.
Havens, D., & Aiken, L. (1999). Shaping systems topromote desired outcomes: The magnet hospitalsmodel. Journal of Nursing Administration, 29(2),14–20.
Hegyvary, S. T. (1982). The change to primary nursing. St.Louis, MO: C. V. Mosby.
Henderson, V. (1966). The nature of nursing. New York:MacMillan.
Hughes, C. E. (1971). The sociological eye. Chicago:Aldine.
Institute of Medicine. (1981). The study of nursing andnursing education. Washington, DC: NationalAcademy of Science Press.
Jenkins, J. (1988). A nursing governance and practicemodel: What are the costs? Nursing Economics, 6(6),302–311.
Kohles, M. K. (1994). Commentary on union electionactivity in the health care industry. Health CareManagement Review, 19(1), 18–27.
Kramer, M. (1974). Reality shock: Why nurses leave nurs-ing. St. Louis, MO: C. V. Mosby.
Manthey, M. (1980). The practice of primary nursing.Boston: Blackwell Scientific Publications.
National Commission on Nursing. (1981). Summaryof public hearings. Chicago, IL: The Hospital Re-search and Educational Trust.
National League for Nursing Education. (1926). Thegrading committee report of the National League forNursing Education. New York: NLNE.
Nightingale, F. (1866). Letter to Mary Jones. Cited onp. 25 in B. Abel-Smith, A history of the nursing pro-fession (1960). London: Heinmann.
Perrow, C. (1972). Complex organizations: A critical essay.Glenview, IL: Scott Foresman.
Porter-O’Grady, T. (2001). Is shared governance stillrelevant? Journal of Nursing Administration, 31(10),467–473.
Reverby, S. (1979). The search for the hospital yard-stick. In S. Reverby & D. Rosner (Eds.), Health carein America (pp. 206–225). Philadelphia: TempleUniversity Press.
Reverby, S. (1987). Ordered to care, the dilemma ofAmerican nursing, 1850–1945. Cambridge, England:Cambridge University Press.
Reverby, S. (1999). Neither for the drawing room norfor the kitchen: Private duty nursing in Boston,1873–1914. In J. Waltzer Leavitt (Ed.), Women andhealth in America (pp. 460–474). Madison: Universityof Wisconsin Press.
Ritter-Teital, J. (2002). The impact of restructuring onprofessional nursing practice. Journal of NursingAdministration, 32(1), 31–41.
Rosenberg, C. (1989). Community and communities:The evolution of the American hospital. In D. Long& J. Golden (Eds.), The American general hospital (pp.3–17). Ithaca, NY: Cornell University Press.
Rosner, D. (1989). Doing well or doing good: Theambivalent focus of hospital administration. InD. Long & J. Golden (Eds.), The American generalhospital (pp. 157–169). Ithaca, NY: CornellUniversity Press.
Scott, J. G., Sochalski, J., & Aiken, L. (1999). Review ofmagnet hospital research: Findings and implica-tions for professional nursing practice. Journal ofNursing Administration, 29(1), 9–19.
Siriani, C. (1984). Participation, opportunity, andequality: Towards a pluralist organization model.In F. Ficher & C. Siriani (Eds.), Critical studies in or-ganization and bureaucracy (pp. 482–503). Phila-delphia: Temple University Press.
Starr, P. (1982). The social transformation of Americanmedicine. New York: Basic Books.
Stevens, R. (1989). In hospitals and in wealth: American hos-pitals in the twentieth century. New York: Basic Books.
Upenickes, V. (2003). Recruitment and retentionstrategies: A magnet hospital prevention model.Nursing Economics, 21(1), 7–13, 23.
U.S. Department of Health, Education & Welfare.(1973). Work in America, HEW report. Cambridge,MA: MIT Press.
Williams, K. (1980). From Sarah Gamp to FlorenceNightingale: A critical study of hospital nursingsystems from 1840 to 1897. In C. Davies (Ed.),Rewriting nursing history (pp. 41–75). London:Croom Helm.
Witte, J. (1972). Democracy, authority and alienation inwork. Chicago: University of Chicago Press.
Wolf, K. A. (1993). The professionalization of nursing work:The case of nursing at Mill City Medical Center.Dissertation microfilms PUZ9322364. Ann Arbor:University of Michigan.
18 n Chapter 1 The Slow March to Professional Practice
![CENTERITY SERVICE PACK FOR CLOUDERA€¦ · OOZIE [roles status] • CLOUDERA ROLES SOLR [roles status] • CLOUDERA ROLES SPARK [roles status] • CLOUDERA ROLES SQOOP [roles status]](https://static.documents.pub/doc/80x56/5fc0df6d43307a59a12ae0a7/centerity-service-pack-for-cloudera-oozie-roles-status-a-cloudera-roles-solr.jpg)
