Public Health Nursing Vol. 8 No. 2 , pp. 74-80 0737- I209/9 I /$5.00 0 1991 Blackwell Scientific Publications, Inc.

Holistic Concepts and the Professionalization of Public Health Nursing Carol Easley Men, Ph.D., R.N.

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Abstract The sociology of knowledge provided the conceptual and methodologic basis for this study of the relationship between the philosophic concept of holism and the professionalization of public health nursing. Set in the context of the history of ideas, the discussion examines the various meanings of holism and the circumstances surrounding their adoption, modification, and use in public health nursing. The nursing literature from the late 1800s to the 1980s was analyzed to explicate the pragmatic consequences of holism for public health nursing, and to examine holism’s moral value and its part in establishing and extending public health nursing’s professional domain.

The relationship between a theoretical concept, holism, and the professionalization of an area of specialization in nursing, public health, forms a motif in the larger pattern of the history of ideas in nursing, a study that is in its infancy. This discussion, framed within the structure of philosophic inquiry in nursing, finds its methodologic and conceptual basis in the sociology of knowledge. The sociology of knowledge is a discipline that seeks to investigate the relationship between knowledge and society, based on the assumption that reality is a social construction. It seeks to explicate the dialectical relationship between knowledge and the social position of the knower. A reciprocal interaction is postulated between the body of knowledge specific to a group in society, such as public health nurses, and the nature of the group itself. The group produces the meanings embodied in the knowledge structure and provides them with

Carol Easley Allen is Associate Professor, Graduate School of Nursing, College of Nursing, Northeastern University, Boston, Massachusetts. Address correspondence to Carol Easley Allen, P h . D . . 36 Dartmouth Street, #1010, Malden, M A 02148.

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objective reality. Reflexively, the body of knowledge acts on the producing group (Berger & Luckmann, 1966; Mannheim, 1936; Wanderer, 1969). The analysis of this relationship as it specifically involves the professionalization of public health nursing and the concept of holism takes the form of social epistemology; that is, an investigation of the social meaning and usefulness of knowledge for the particular social group. The question of wholeness has fascinated philosophers since the inception of the philosophical enterprise with the Pre-Socratics. The first Greek philosophers framed their concern in the metaphysical question, what is the nature of reality? Realizing that there was, at least potentially, a difference between reality and appearance, and assuming a basic material that constituted the oneness or unity of the universe, they sought to understand how, from this oneness, the multiplicity of appearances arose. Since their day, the sixth century B.c., the questions regarding oneness or unity have persistently intrigued philosophers because of the importance of such questions for the world view. Is reality, or being, a unity or a multiplicity, is it holistic or pluralistic, one or many? One’s view of reality is based on an implicit acceptance of one of these two claims. The philosophic positions based on one or the other of these views are very dissimilar, and “almost every other fundamental conception--of God and men, of the mind and knowledge, of matter and motion, of cause and necessity-seems also to be altered” (One and many . . . , 1952, p. 284). While the debate over holism versus pluralism, or individualism, is significant in biology, history and the social sciences, psychology, and ecology, nursing has not evaluated the concept as a philosophic issue. Instead, we have taken it more or less as given. In view of this, three assertions are necessary to the discussion that follows. First, the concept of holism holds important

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moral connotations for nursing in terms of its self-image and its idealized model of patient care. Second, in spite of the concept’s value and significance, its assumptions and implications are troubling and problematic in many respects. It deserves a critique in nursing that it has not yet received. Third, although the value of a holistic perspective for the patient care model is fairly obvious, we must recognize that in nursing it serves professionalizing goals as well. Such a multiple use of an element of knowledge is not unique to holism or nursing. Phillips (1976) presented three general notions of holism that may explain and summarize the various concepts that characterize this view of reality. He named these concepts Holisms 1, 2, and 3. Holism 1 is a set of five interrelated theses derived from the nineteenth-century study of organic wholes. The root idea is that the scientific method typically used in chemistry and physics is inadequate when applied to biologic organisms, society, or reality as a whole. Holism 1 also includes ideas of wholeness embraced by many nurses, that the whole is greater than the sum of its parts; the parts are determined by the whole and cannot be understood in isolation from it; they are dynamically interrelated. Holism 2 holds that the properties of organic wholes cannot be explained with reference to the nature of their parts. The familiar illustration of the impossibility of predicting the properties of sodium chloride (NaCI) from the individual characteristics of sodium (Na) and chloride (Cl) is often used to press this point. Thus Holism 2 is an antireductionist position, i.e., the position that a system of dynamically interrelated parts, such as a human being, cannot be explained by reduction to some theory developed initially to explain the parts of that system. Holism 3 argues the need for terms referring to wholes and their properties. It calls for the development of methods of inquiry appropriate to the study of wholes. This is a less exclusive position than Holisms 1 and 2, and, in fact, could be held by those who agree or disagree with either one. Nursing theorists, as well as most other nurses, generally adhere to some combination of the concepts of Holism 1, and possibly the antireductionism of Holism 2. Nursing’s basic view of holism is sometimes supplemented with a few additional notions, such as humanenvironment interaction. The rather flexible position outlined in Holism 3 has not received much attention in nursing, although it holds the potential of reconciling the profession’s essentially holistic philosophy with its strongly empirical, and therefore reductionistic, method of inquiry.

HOLISTIC REFERENCES While considerable controversy surrounds the concept of holism in many disciplines, nursing has not yet en-

tered the debate. Therefore, we must not expect to find an approach to the related conceptual issues when we examine the nursing literature. Rather, we must identify implicit and explicit references to ideas and concepts of wholeness in an attempt to relate such references to professionalizing trends in public health nursing. To trace holistic concepts in the historical development of nursing, we must identify statements in the literature that embody the following types of notions: the unified nature of the human being, such as statements that imply facets of his or her being (e.g., physical, mental, emotional, spiritual, social, cultural, and sexual aspects); the integral nature of the individual’s role in family or community as a part-whole relationship; the family, community, or larger social group as a unified whole; the professional group as a social whole; the unified or integral relationship between mankind and environment; and the idea of synergy, that the whole is greater than the sum of its parts. Notions and concepts specific to nursing that reflect holistic themes, such as comprehensive care and total care must also be identified. In tracing the relationship between holistic ideas and public health nursing, we must note the specific goals, values, and practice prescriptions with which holism is identified. An examination of the historical data reveals numerous holistic statements between the 1890s and the late 1930s. Such references then dwindle significantly in number and scope. 189Os-1930s

It is in reference to district nursing, and its later appellations of instructive visiting nursing and public health nursing, that we see many holistic ideas in the literature between the late 1800s and 1919. With the early emphasis on nursing the whole person, the prevention of illness, and the provision of health teaching and social service, there was a challenge to extend nursing care beyond the purely physical. It was recognized that the patient’s personal contacts, family, friends, and neighbors, as well as the environment, had to be accounted for if health were to be restored and disease prevented. In the spirit of the great sanitary and philanthropic movements of the time, the idea arose quickly of expanding nursing responsibility to the total family and community. The ideas of wholeness implicit in the public health nursing movement were important in providing its direction, significant in the notion that it was a type of nursing somehow set apart and above other specialties, and crucial to the movement of nursing education into the university and nursing’s recognition as a profession. As early as 1889, Mrs. Dacre Craven, the British author of A guide to district nursing, was sounding two themes that American district nurses were quick to espouse:

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ing for the collegiate woman was supposed to rest in part on its holistic focus. The “something else” that public health nursing required was bound up in the holistic demands of its scope of practice, “a broad outlook on society as a whole” (Lent, 1909, p. 973). It is of interest that among the early references to this linkage, the application was usually made to service for the poor, with no such extensions made in reference to private duty practice among the upper classes. Perhaps the public health nurse pioneers were more innovative aim must be not only to aid in curing disease and alleviating pain, but also through the illness of any one member of a fam- and community minded than private duty nurses as a ily to gain an influence for good so as to raise the whole family. group. An alternative explanation may lie in the greater openness and vulnerability of the poor to official inter(P. 2) vention as compared with the middle and upper classes. That the elevated, in short the professional, nature of Because the homes of the poor were considered “illpublic health nursing was recognized by those outside regulated.” nursing saw a need to expand its services of nursing is evident when we examine Flexner’s (1915) and broaden its educational base, that is, to adopt a hocomparison of this specialty with nursing as a whole. listic perspective in addressing the problematic aspects The “trained nurse” at the bedside seemed to fall short of rendering care to the poor. The interconnectedness of his professional criteria in that her responsibility was of their health problems and the social concerns of neither original nor final, and her function in relation- housing, unemployment, lack of sanitation, and so on ship to the physician was at best collaborative, if not spurred the interest in social knowledge and the emphainstrumental. On the other hand, Flexner presented the sis on philanthropic methods of investigation. case of the public health nurse: Holistic conceptions of care of the individual were The public health nurse is a sanitary official, busy in the field quickly replaced with the concept of the total family and largely on her own responsibility rather than in the sick-room community as the object of public health nursing conunder orders. Whether the term nurse is properly applicable cern. In fact, the collective interest was given priority to her, whether a differentiation in training and technology is over individual needs in some instances. Wald ( 1904), in not likely to occur as public health work comes into its own, discussing the potentially disruptive effects on the famI need not undertake to decide. (p. 906) ily of the hospitalization of an ill mother, recommended In 1902 Lillian Wald advised the district nurse to have home care instead, stating, “sometimes her [the mothknowledge of “the housing conditions, the educational er’s] medical need must be subordinated to these conprovisions, and the social life of the neighborhood in siderations” (p. 515). which she lives and works” (p. 573). This was the first The social, political, and economic upheavals from allusion to the interest in nursing education that became 1920 to 1939 were mirrored by and related to changes in an overwhelming concern to the public health nursing the nursing profession that drastically altered major asmovement of this era. The vital linkage of holistic ideas pects of practice and education. Faced during this peof nursing care to the education impetus of the time was riod with undersupply, oversupply, maldistribution, and readily apparent in the literature. Indeed, the major major attacks on its educational system, nursing and thrust of holistic statements in the literature between others interested in the profession, in a pattern that was 1900 and 1919, the period when the rudiments of to prove predictive, undertook several studies of the sitthe professionalization-holism connection were estab- uation. In December 1918 the Rockefeller Foundation lished, served to cement and support the relationship initiated a study of the status of and education for public among professionalization, public health nursing, and health nursing that was quickly expanded to “include higher education in nursing, with holism providing the the entire subject of nursing education” (Committee for rationale. The 1901 expansion of the course in Hospital the Study of Nursing Education, 1923, pp. 1-2; ComEconomics at Columbia University Teachers College mittee on Nursing Education, 1922, p. 882). The resultinto a new department of Nursing Education and Social ing document is commonly known as the Goldmark ReHygiene is significant in that visiting nursing was the port. An examination of the discussion presented only clinical area of nursing among the three postgrad- reveals extensive use of holistic justifications. While uate courses offered (The new course . . . , 1910). Lil- many of the recommendations were ignored, one of the lian Wald was instrumental in securing the gift that most significant outcomes of the Goldmark Report was funded this educational advance (Large endowment the founding of the nursing school at Yale University. . . . , 1910). The supposed appeal of public health nurs- Its curriculum was based on the conclusions of the rethe superiority of district nurses, and a commitment to holistic care. She wrote, “For district nurses a higher education and higher grade of women are required than for the hospital nurse or even hospital superintendent” (p. 1). In this she echoes Florence Nightingale’s (1867) dictum, “On the whole, it would seem to require a higher class of woman to be District Nurse than even to be Hospital Nurse” (p. 19). Craven continued with the idea that the district nurses’s

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port, especially with regard to the public health nursing emphasis. An idea prevalent in the literature of the time was that nursing’s subscription to holistic aims and practices was what conferred professional status. The statements and illustrations that support this contention were flavored strongly with allusions to the nature and scope of public health nursing practice. Although the notion that public health nursing demanded a superior person with special educational preparation continued to hold sway in the early 1920s, it was beginning to be challenged by the contention that all nurses should have public health concepts in their basic education. The tension between these two ideas reflected in the literature of the early 1920s gave way to adherence to the latter view, which eventually became dominant. Holistic ideas were used to justify this shift. Isabel Stewart, taking a historical view in 1925, noted that “good nursing in the sense in which Florence Nightingale understood and practiced it, contains all the essential elements that go into public health nursing” (p. 214). Somehow these elements of consideration for the whole person, the human and social side of nursing with reference to mental as well as physical aspects, had been lost along the way. It was urged that these elements appear in the required curriculum. Again, a holistic appeal was made to support the proposed change. Public health aspects were to be emphasized in all courses, since “no longer can nursing care of a patient be confined to his immediate physical needs. Nursing must be based upon the whole need of the patient” (Grant, 1934, pp. 169, 170). The root of this effort was the realization that consideration of the whole person, family, and community was essential to the comprehensive, professional level of care that all nurses purported to give. If the progression from 1900 to 1939 is considered as a whole, we can see that the same appeal to holism was employed, first to set public health nursing apart from and to some extent above other clinical specialty areas in nursing, and later in an attempt to reverse this by bringing public health nursing’s essential content within the scope of nursing in general. Such widespread and sometimes contradictory use of the holistic appeal speaks to its potency among the nursing public. A number of holistic statements were embedded in a popular concept of the times, the “public health point of view.” This was an attempt to crystallize into one definition the “something” that public health nursing experience added to basic nursing preparation that was reflected in an understanding of the patient and his or her illness with reference to the family and social circumstances. Several versions were offered (Frost, 1933; Hay, 1937; Hubbard, 1935). Frost (1933) summed up the

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common element among them: “The whole view must be visible” (p. 570). The wholeness contained in these definitions existed on three levels. First, the holistic nature of the individual was presented. Physical, mental, emotional, social, and spiritual aspects were to be considered. The second level was that of the individual in relationship to the family and community. Also, the family and the community as wholes were objects of concern. Health must be related to other social needs such as recreation, education, and religion. Service in any one of these areas involved consideration of the whole. Finally, from 1920 to 1939 there was a significant shift from viewing the poor as the domain of public health practice. Now the middle and even the upper classes became the objects of concern. With this consideration of all social classes the early public health nursing emphasis On regulation disappeared and was replaced by the concepts of prevention, health promotion, and health education. As these concepts increased in their potency to describe public health nursing’s scope of practice, they coincided with, and in some instances even replaced, holistic justifications. By the end of the 1930s holistic references in general, and with specific application to public health nursing, begin to dwindle in the nursing literature. Perhaps they had served their purpose. The professionalizing goals had been gained. Public health nursing was enjoying a solid status within the profession and was assured of a place in the basic nursing curriculum in higher education. The desired holistic scope of practice had been delineated. Now the focus in the literature could leave the abstract notions that provided foundation for the more concrete discussions of actual clinical practice, educational methodology, and organizational concerns. 1940s-1980s

Holistic references in the literature from 1940 to 1959 are few. There was a shift from the more idealistic statements to greater emphasis on the technical and managerial aspects of the nursing role. Public health nursing’s holistic focus was presented as an exemplary component in the definition of professional nursing proposed by Sister M. Olivia of Catholic University (Brown, 1948), but Esther Lucille Brown admitted in 1948 that most graduate nurses were not truly professional within this meaning. Perhaps the most significant development of this period in this area was the rise of the integrated curriculum. The goal was to provide the student with the knowledge and skills requisite to holistic practice, with total or complete patient care as the ultimate object. Public health nursing concepts, “the social and health aspects,” were to be integrated, as were concepts of

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psychiatric nursing (Fay, 1945;Integration . . . , 1950; Mitchell, 1950;Patton, 1945).This reflected a trend in the general education of the time-a departure from the traditional, fragmented approach to knowledge and a movement toward consideration of the whole phenomenon. The holistic concept of synergy was brought to bear. The goal of the integrated educative process was seen as holistic and reciprocal rather than merely summative, with the whole individual, emotionally, physically, and intellectually, engaged interactively and experientially with the subject matter (Cam, 1945; Heidgerken, 1959;Johansen, 1950). The major thrust of holistic references in the nursing literature between 1960 and the 1980s was in relationship to the need to define and protect the professional role. The number of developed holistic discussions is not large, however, the term and its related concepts, such as total, comprehensive, and patient-centered care, were popular as means of supporting a variety of nursing ideas and models of practice. It is in the context of one such professional practice model that the holistic status of public health nursing was addressed tangentially in the mid-1960s. Wolford, in 1964, introduced the idea of “complemental nursing.” The proposed nurse specialist was to enter into contractual relationships with clients that would allow her to provide care both inside and outside the hospital setting, based on a synthesis of knowledge and broad consultation and coordination with other health professionals. To function in this way, the nurse had to adopt a holistic view of the patient that was more than the aggregation of biopsychosocial factors. This complemental nurse required education in public health and psychiatric nursing, the two areas generally conceded to be holistic in scope, as well as knowledge in a clinical area. Wolford reiterated this model a few years later (1966)under the rubric of “distinctive nurse specialist practitioner,” but neither the model nor either of the proposed titles were generally adopted.

IMPLICATIONS As we have seen, nursing exhibited an early and contin-

uing acceptance of holistic ideas. Holistic justifications were useful in the elevation of public health nursing as the first truly professional specialty in nursing and later as a symbol that all of nursing was indeed professional. It is important, however, that we return to the conceptual issue. It is possible to identify three levels at which nursing may apprehend holism as a concept: as it provides a basis for practice prescriptions; as it presents a certain methodologic dilemma to our traditionally empirical, and therefore necessarily reductionistic method of inquiry; and on its relative merits as a philosophic

issue. It is at the first two levels that past, present, and future implications reside. Holism was a critical factor in public health nursing’s rise to a preeminent position among nursing specialties, and yet today the profession has declined in status and is facing a variety of problems in which holism may be partially implicated. Continuing federal cutbacks in funding, combined with fiscal problems of state and local governments, has threatened the scope and even the existence of public health nursing programs in many areas. The position of state director of public health nursing is being abolished in some states, and business managers are being placed in control of the profession in many areas, with the power to influence significantly nursing care decisions. The practice of public health nursing has been constricted or distributed among other disciplines in many localities. In some areas, public health nurses merely staff clinics or carry caseloads that are limited to single service categories, such as communicable disease. Peoples-Sheps, Efird, and Miller (1989)noted a decrease in prenatal home visiting over the past several years. A contributing factor in all of these problems may well be the generalized, global nature of the holistic goals that have historically been valued in public health nursing. A long-standing problem has been to translate such goals into measurable outcomes that lend themselves readily to evaluational research methodologies. Although in more affluent times this problem was recognized and deplored, it did not significantly affect the maintenance and retention of public health nursing programs. Now that the fiscal outlook has dimmed, it is necessary to demonstrate cost-effectiveness or risk substantial loss. Public health nursing has often been hard put to demonstrate that the holistic care it purports to give makes any real difference. This is a critical failure in such fiscally insecure times, as exemplified by such services to prenatal clients. Baldwin and Chen (1989) summarized findings regarding the effectiveness of public health nursing interventions with prenatal clients from 17 studies conducted between 1963 and 1988. “The review indicated public health nursing interventions can increase birthweight, and the use of prenatal medical services, nutritional services, and childbirth classes” (p. 80). But because of methodologic problems, Baldwin and Chen found it “difficult to conclude with certainty that such interventions make a significant difference in client outcomes” (p. 80).Public health nurses have to document and evaluate in a systematic manner the interventions and strategies that are important to delivering care. The rise of home health care in too many instances represents a turning from holistic concepts, such as family-centered care, prevention, and health promotion,

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toward more pragmatic, less optimistic curative and rehabilitative goals that are predicated on a model of care that is reimbursed by the federal government and other third-party payors. Originally, home health care referred to preventive or health maintenance services in the home delivered to all family members regardless of financial status, or financed philanthropic contributions. Today however, home health care services comprise a multimillion dollar industry. . . . Cost escalation in the industry has led to narrowly focused reimbursement policies primarily concerned with short-term skilled nursing care for the elderly, and the abandonment of long-term health maintenance and chronic illness management. (Kent & Hanley, 1990, p. 235)

The quality sought in the prospective home health nurse is “recent medical-surgical experience” rather than a family-community focus. T h e message is clear: the type of nursing increasingly rewarded in the community is not the holistic ideal of family-community care that has long been valued, but rather a more restricted focus on the curative/rehabilitative needs of the individual. In summary, we may derive several implications from the mandate that holism presents t o public health nursing. It is my belief that despite the problems it presents in some areas, nursing must continue to develop, evaluate, and maintain the full scope of its holistic practice model. T h e profession must be proactive when holistic ideals are threatened in such a way as to meet the challenges of shifting federal, state, and local programs and priorities. Such action may involve such strategies as the articulation of the value of holistic and preventive services t o policy makers and the public, a n d addressing the polic y-making process early enough to influence financial support of the full scope of practice. Demonstrating the cost-effectiveness of public health nursing services through systematic evaluation is vital in areas where such services are being constricted. In addition, holistic ideas must become influential in t h e practice philosophy of home care nursing such that it moves toward greater realization of the holistic practice model. T h u s , as we look to the future, the consideration of the concept of holism as it relates to the professionalization of public health nursing provides us no easy answers, rather only significant questions and challenges.

REFERENCES Baldwin, K.A., & Chen, S.C. (1989, June). The effectiveness of public health nursing services to prenatal clients: An integrated review. Public Health Nursing, 6 , 80-87. Berger, P.L., & Luckrnann, T. (1966). The social construcfion of reality: A treatise in the sociology of knowledge. Garden City, NY: Doubleday. Brown, E.L. (1948). Nursing for the future: A report prepared

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Foundation. Carn, I . (1945, March). The social and health aspects of nursing. American Journal of Nursing, 45, 223-228. Committee for the Study of Nursing Education. (1923). Nursing and nursing education in the United States. New York: Macmillan. Committee on Nursing Education. (1922, August). From the report of the Committee on Nursing Education. American Journal of Nursing, 22, 882-884. Craven, F.S. (1889). A guide to district nursing. New York: Macmillan. Fay, A.M. (1945, January). Orienting ward teachers to the social and health aspects of nursing. American Journal of Nursing, 45, 54-55. Flexner, A. (1915, June 26). Is social work a profession? School and Society, 26, 901-91 I . Frost, H. (1933, June). How to stimulate a public health point of view. American Journal of Nursing, 33, 569-572. Grant, A. (1934, February). Public health and the nursing curriculum. American Journal of Nursing, 34, 169-174. Hay, R.W. (1937, December). Preparing students for community service: How can this preparation be given in the basic course? American Journal of Nursing, 37, 1373-1379. Heidgerken, L. (1959, March). When is a course integrated? Nursing Outlook, 3 , 128-129. Hubbard, R.W. (1935, August). How shall we secure adequate experience in public health nursing? American Journal of Nursing, 35, 772-778. Integration of social and health aspects of nursing in the basic nursing curriculum. Public Health Nursing, 42, 652653. Johansen, D. (1950. February). The integrative method of teaching. American Journal of Nursing, 50, 117-199. Kent, V., & Hanley, B . (199O, May). Home health care. Nursing and Health Care, II, 234-240. Large endowment for the course in hospital economics. (1910, January). American Journal of Nursing, 10, 229-230. Lent, M.E. (1909, September). The organization of district work. American Journal of Nursing, 9, 967-977. Mannheim, K. (1936). Ideology and utopia: An introduction ro the sociology of knowledge (L. Wirth and E. Shils, Trans.). New York: Harcourt, Brace & World. Mitchell, H. (1950. March). The social sciences in nursing education. American Journal of Nursing, 50, 179-181. Nightingale, F. (1867). Suggestions for the improvement of the nursing service of hospitals and on the methods of training nurses for the sick poor. Extract from report on cubic space in metropolitan workhouses, in Blue book. No other publication information available. (Typewritten copy of 1867 original available at Andrews University Library, Berrien Springs, Michigan.) One and many. (1952). In R.M. Hutchins (Ed.), Syntopicon (Vol. 2 ) . Chicago: Encyclopaedia Britannica. Patton, E. (1945, March). Psychiatric nursing in the general hospital. American Journal of Nursing, 45, 193-195. Peoples-Sheps, M.D., Efird, C . , & Miller, C.A. (1989. June). Home visiting and prenatal care: A survey of practical wisdom. Public Health Nursing, 6 , 74-79.

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Phillips, D.C. (1976). Holistic thought in social science. Stanford: Stanford University Press. Stewart, I.M. (1925, March). Revisions of the standard curriculum. American Journal of Nursing, 25, 213-219. The new course at Teachers' College. (1910, April). American Journal of Nursing, 10, 458459. Wald, L.D. (1902, May). The nurses settlement in New York. American Journal of Nursing, 2 , 567-574. Wald, L.D. (1904, April). The treatment of families in which

there is sickness. American Journal of Nursing, 4 , 602606. Wanderer, J.J. (1%9, Winter). An empirical study in the sociology of knowledge. Sociological Inquiry, 39, 19-25. Wolford, H.G. (1964). Complementary nursing care and prdCtice. Nursing Forum, 3( I ) , 8-20. Wolford, H.G. (1966, April). The nurse of the future. Nursing Outlook, 14, 4 1 4 2 .