Journal of Advanced Nursing, 1978, 3, 419-426

The rights of nurses* Mary E. Patten B.A.(Hons.). F.C.N.A. Federal Secretary, Royal Australian Nursing Federation, Melbourne

Accepted for publication 'i June 1977

PATTEN M . E . (1978) Journal of Advanced Nursing 3, 419-426

The rights of nurses The rights of nurses are those of all individuals in society. This paper examines some of the fundamental issues imderlying the 'rights of nurses' in the context of the declaration of a belief in the inalienable rights of all members of society.

INTRODUCTION In 1948, the General Assembly of the United Nations adopted the Universal Declaration ofHuman Rights, which states that: 'Recognition of the inherent dignity and of the equal and inalienable rights of all members of society is the foundation of human freedom, justice and peace in the world' (United Nations 1948). The International Council of Nurses (ICN) incorporated the declaration as a preamble to its constitution in 1973 and in so doing declared that the rights of nurses are those of all individuals. As each year passes, individuals become increasingly conscious of the fact of their interdependence—wherever they live they are part of the human family. In many instances, this feeling of being part of the whole stems from factors which are interpreted as pressures on continued existence—the ubiquitous growth of technology, the rapid increase in population, and the effects of increasingly sophisticated commvinication. Teilhard de Chardin (1971) maintains that the present period is part of the evolutionary process of man and, far from evolution having come to a halt, man is on the threshold of a totally new era in mankind's growth and development. He uses an analogy of an imaginary globe of the world, man's development having begun at the South Pole. The transformation, which most of us fear now because 'we may lose the precious spark of thought, so painfully lit after millions of years of effort', has arisen because the wave of expansion of mankind has reached the equator and inevitably, having passed the diameter of the globe, we are experiencing 'a *Based on a paper read at the i6th Quadrennial Congress of the International Council of Nurses, Tokyo, Japan, on 3 June 1977. 0309-2402/78/0900-0419 $02.00 © 1978 Blackwell Scientific Publications 419

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transition from expansion to compression, we are moving from a universe in which the divergence of the containing lines still seemed the most important featiure, into another type of universe which is rapidly folding in upon itself. At the equator, not long passed, 'we have the extreme point of separation, which means independence, between the highly differentiated element, to be found in the expansion of civilization', but now we are being transformed to a stage of compression in which man is beginning to pursue a 'single concerted direction, seeking not simply to enjoy more or to know more, but to be more'.

To be or not to be This concept of the compression of mankind releasing energy which is directed to a further stage in the evolutionary process, and specifically in a direction where there is a seeking 'to be more', appears to provide a strange contrast to much psychological and sociological theory. Taking Teilhard de Chardin's point that mankind has passed the period of expansion with its consequent opportunities for the divergent and opportunities for getting away from it all by the discovery of new continents, the increasing pressures of population would seem to mitigate against increasing opportunity for people 'to be' much less 'to be more'. For example, Freud (1963) states that 'the ethical demand of the cultural super-ego does not trouble itself enough about the mental constitution of human beings. It issues a command and does not ask whether it is possible for people to obey it'. Merton (1959) puts the same thesis in a somewhat different way in his book Social Theory and Social Structure, in which he develops his paradigm of anomie. The basis of this paradigm is that the goals of society are set, but whether or not people can fulfil them is quite another question. While Freud is concerned with the effect assimilation of the cultural goals has on the individual psyche, and Merton's concern is ultimately with the breakdown of society arising from stress on cultural goals and means of achieving those goals, they are both saying that the culture is powerful and imply little chance for the individual 'to be'. If one reads the daily press and listens to the conversations of people of many ages, there seems to be a good deal of agreement with Freud and Merton that the individual has not got much chance other than to conform with the dominant cultural values and norms or be labelled and treated as deviant. Theories such as those of Freud and Merton deal with the process of socialization and consequential problems which arise when individuals fail to live up to expectations of society. Inherent in this concept is the concept of behavioiu: as a conditioned response, which seems to be very similar to the famous experiments of Pavlov (1928) and which Skinner (1963) develops to the point where he maintains that 'novel forms of behaviour are selected or discarded through reinforcement'.

Social determinants of behaviour This concept of behaviour as a direct response to rewards and punishments is developed in a variety of ways by a number of sociologists who see deviant behaviour arising from a process of social typing or labelling—in general these

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writers equate deviant behaviour with some form of criminal or otherwise disruptive behaviour. At the risk of over-simplifying the views of these sociologists, one quotation will help to clarify this perspective: 'In dealing with the delinquent, the criminal, therefore, the important thing to remember is that we are dealing with a human being who is responding normally to the demands, stimuli, approval, expectancy of the group with whom he is associated (Tannenbaum 1968). It is this concept of the action of individuals being determined on the basis of a response to the demands of others, be it the demands of other individuals or of society, which highlights a fundamental issue when one is speaking about the rights of all members of the human family, or, more specifically, the rights of nurses. How can we talk about the rights of individuals if we believe behaviour is almost totally determined by others? RIGHTS AND POLITICAL ACTIVITY It is always interesting to talk with nurses from other countries and exchange information about the problems being faced—so often, while the detail of the problems varies, it seems to me that a fundamental similarity exists. I shall use three examples of recent experiences in Australia to illustrate. Some 2 years ago, Australian nurses had a dispute with the government about the rates of pay for the nurses they employed. The nurses at one of the government hospitals decided that they would not admit any more patients until the dispute at least came luider negotiation. At that time there were strict rules operating in the country as a whole about the conditions under which pay rises could be won, apart from rises which went to all wage earners based on cost of living increases. The nurses lifted their ban on admission of patients as soon as guarantees were given that negotiations would start without further delay. However, because of the wage disparity existing between that and other hospitals in the state, which came under a different wage tribvinal, a major problem existed in terms of staff shortages. Nurses and the staff of the Royal Australian Nursing Federation. (RANF) worked out how niany patients the nurses could in fact look after in each of the wards and notified the authorities accordingly. An incredible amount of opposition was raised to the ceiling, placed on patient numbers, and the events which followed, including a halt to wage negotiations, were exasperating to say the least. In the end, as a result of RANF and nursing staff meetings with senior representatives of government departments and of government ministers, the position was resolved and pay negotiations went ahead to a successful conclusion. However, quite apart from the pay rises, the staff now have a recognized role in determining the number of patients for whom they believe they can provide appropriate care. The successful resolution of this issue was dependent on two factors: leadership on the part of some members of the nursing staff and RANF, and the willingness and ability of all concerned to cope with what can only be called abuse on the part of a number of non-nursing personnel. The most severe test was applied by senior medical consultants who put

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enormous pressure on individual nurses. The medical staff were accustomed to telling the nurses how many new patients they wished to admit and the nurses were expected not to respond in any way other than by doing what they were told. When the nurses in charge of wards started saying 'No, we cannot look after any more patients', that is, when the nurses in charge of the wards responded on the basis of their own values, beliefs and knowledge they were acting responsibly, but the other person in the situation often became angry and abusive and accused the nurses of being irresponsible.

Postponing change The second example is rather different in character and, in 1977 (at the time of writing this paper), was still unresolved. The nurses in one part of Australia have developed and are continuing to develop a band of community health nurses who are changing their approach to their work because they believe that traditional ways of working have not necessarily been effective. They were faced with a proposal for administrative changes which had been determined by the government department involved. The nurses were concerned because they felt that the proposal was so unclear that it could be used in a way which could destroy much of the work they had been doing and which they believed to be worthwhile. They maintained the proposed new system was to be introduced fairly soon and asked RNAF to intervene. The system in Australia is such that in this situation nurses were able to notify the appropriate authorities that they believed, if the proposal was introduced, the nurses would refuse to follow the rules laid down by the new system. As a result of a conference attended by RANF and representatives of the appropriate authorities, the introduction of the new system was stopped and a specific period of time was given for the nurses in the situation to negotiate with the local authorities. It could be that once the nurses and the authorities reach agreement on what certain terms of the proposal mean, the proposal will be seen as reasonable and be introduced, but that remains to be seen. The nurses involved in this situation have acted according to their own values, beliefs and knowledge and have not been prepared simply to base their actions on the expectations of others.

Changing patterns of nursing education. The third and final example concerns changes proposed for nursing education in Australia. Until 1974, all nurses were trained in hospital schools of nursing in an apprenticeship-type system and even now the number of students in programmes conducted by educational institutions is very small indeed. As a result of a process in which nurses throughout the country had an opportunity to express their views, the nursing profession has decided that the education of all professional nurses should be conducted by educational institutions as tertiary level studies, that is studies which require the student to have completed secondary schooling. This change will be complete by 1985.

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It is recognized that there are many practical problems which will need to be overcome to achieve this change. Those who oppose the proposed change, mainly some members of the medical profession and some authorities involved in education and health, are using the practical problems as reasons for stating that the change is undesirable. However, nurses themselves, in many instances, are playing a dangerous game. Inevitably, there is a percentage of nurses who do not agree with the proposal—that is their right and they are acting on the basis of their own values, beliefs and knowledge. However, there are also a number of nurses who are supporting or opposing the proposal depending on the circumstances. Thus, if they are in a group which is known to support the proposal, they respond to the expectation and agree with their colleagues. Conversely, if they are with people who oppose the change they again respond to the expectation and agree with their colleagues. Such people are dangerous because while they may know what they think, they do not act on the basis of their own values, beliefs and knowledge— they simply respond to expectations of others. This being the case, how can they possibly value and understand the values, beliefs and knowledge of others, nursing and medical colleagues, patients, or other members of the community who utilize the health services?

Basis of actions In these three examples I have emphasized actions of individuals based on their own values, beliefs and knowledge, and from these examples my position about the rights of people should be clear; namely that I believe it is a fundamental right and, for that matter, a right and responsibility of individuals to act on the basis of what they believe and not on the basis of reacting or responding to the demands, stimuli, approval or expectations of others. The rights of nurses are transgressed daily with demands to perform procedvires with which they are unfamiliar, demands that their vision of the future conform with that of others, and constant demands to stretch available staff to cope with caring for more people than is just either for nursing personnel or the people who are their patients or clients. The rights of nurses are transgressed daily by nurses themselves who, as individuals, are content to act in response to the expectations of others rather than acting on the basis of their own values, beliefs and knowledge. 'Yes, of course I will cope'. How often have nvirses said that in a situation where they know the demands are unreal, but they are expected to cope and they say they will. Emergencies place demands on people which are often extreme and nurses have shown time and time again their ability and willingness to cope and go on coping for as long as the emergency lasts. I am not, however, referring to emergencies. I am referring to what I would call permanent emergencies of too many demands on too few people, too many unrealistic demands, and the expectation that too few people will continue to cope and continue to meet unrealistic demands. In Australia, this attitude has done a great deal of harm to nursing and, I believe, to patients and clients of nursing. It stems from the transgression of the fundamental right of human beings to act on their own initiative and to sanction

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their own actions according to their own physical, psychological, ethical, moral, intellectual and spiritual needs.

SOCIALIZATION I am not preaching anarchy. There is no question that the socialization process, whereby children learn to act as a member of a family and community, is dependent to a very large extent on rewards and punishments for acceptable and unacceptable behaviour, and that the definition of such behaviour is determined primarily by society as a whole and/or groups of people within that society. Thus, as children grow they learn how others expect them to behave and what behaviour is unacceptable and they learn a whole range of values and beliefs. However, we do not remain children all of our lives (or at least we should not remain so). Further, in this socialization process, there is one interesting phenomenon and that is the early age at which a child learns to use the word 'I'. If you think about it there is no simple explanation as to how this happens, but somehow the child learns to apply the word 1' to himself. It may be the result of chance copying with which is associated a reward, but, whatever the process, the fact remains that the child verbally expresses his or her own identity as an individual human being at a very early age. Maslow's (1970) theory of human motivation recognizes that motivation is not the single determinant of human behaviour, but he also attacks 'the current fashion to treat attitudes, tastes, interests and indeed values of any kind as if they had no determinant other than local cultural associative learning, i.e. as if they were determined wholly by arbitrary environmental forces'. Maslow in fact postulates relevance across cultures of needs which are basic to health; this hierarchy of needs (physiological, safety, belongingness, esteem and self-actualization) is well known. He makes it clear that although he has arranged these basic needs in a hierarchy, they are invariably identifiable in one way or another as a cluster. He sees basic need satisfactions as being quite impossible, or at least severely endangered, when there is a thwarting of conditions such as freedom to defend oneself, justice, honesty, and orderliness in the group. Clearly then, the rights of individuals are dependent on these pre-conditions existing in society and from this it must follow that until and unless these pre-conditions exist, it is a mockery to speak about the rights of individuals, let alone the rights of nurses. One must conclude also that the rights of nurses in such societies can hardly be met without changing those conditions which thwart freedom to speak, justice, honesty, orderliness of the group, and so on.

Need gratification The importance of Maslow's theory for the rights of nurses lies in this claim for the existence of pre-conditions of individual freedom and also in its application to what I have been saying: the right to act on the basis of one's own values, beliefs and

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knowledge is simply a fundamental right which meets a basic human need and is a prerequisite of community in the full sense of the word. While Maslow is concerned with developing his particular thesis, he does set out what to him seem to be good social effects of need gratification, listing groups of phenomena under affective, cognitive, character-traits, interpersonal and miscellaneous outcomes. I have selected six outcomes, quite arbitrarily and to suit my own purposes, out of a total of 61 phenomena cited by Maslow as being determined to a large extent by basic need gratifications. I have done this in an attempt to demonstrate that adult action, based on the person's own values, beliefs and knowledge, is part of need gratification, which in turn not only has positive effects in terms of the individual, but more than likely contributes to that person being a 'better citizen'. The six outcomes selected show a person likely to experience feelings or autonomy with less preference for the familiar and less fear of the novel and of the unfamiliar. The person is likely to be more democratic, have respect for others who are worthy of it and move towards higher values and a higher spiritual life. The person is likely to move away from win/lose, adversary, zero-cum-gain way of life. That sketch outline sounds like the person whom I would describe as a good nurse, selfish to the point of maintaining and developing his or her own character structure, with no need to fear the unfamiliar or simply respond to the expectations of others; the selfish element is crucial to the ability to work with people in the promotion of health, the prevention of illness and the care of the sick; working with people instead of doing things for them or to them. This is at least part of the picture of Teilhard de Chardin's (1971) concept of mankind seeking not simply 'to be', but 'to be more'. CONCLUSION Nurses' rights, in many countries, have been trampled on, neglected and opposed. In moving to further the rights of nurses, we have a responsibility and a right as nurses to examine some of the issues underlying our planning and action whether that planning and action is directed specifically towards improving pay, education or the social and cultural conditions in which nursing personnel work. The compression of mankind need not give rise to increasing oppression and should in fact release an enormous quantity of psychic energy where individuals seek not only to enjoy more and to know more, but to be more. The technology now at man's disposal, and in particular the advent of the computer, can be used to this end rather than contribute to the 'Big Brother' world of George Orwell's 1984 (Orwell 1966). I have attempted to outline some of the elements which happen to be part of my philosophy. The detail of a paper on this same subject in, say, i year's time, would probably be very different, but the fundamental would not. In essence, I have talked about both rights and obligations of nurses and have stated my belief that the nurse, as any other individual, can meet his or her obligations appropriately only when that person is acting in his or her own right on the basis of his or her

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own values, beliefs and knowledge and not simply responding to his or her expectation of others. Do you have a personal commitment to human rights, to the rights of nurses? 'In order to find one's place in the infinity of being, one must be able to both separate and unite . . . In life . . . there are times when a man must put himself in order. During such time he can do nothing for others, but his work is nonetheless valuable, because by enhancing his powers and abilities through inner development, he can accomplish more later on' (Wilhelm 1968). References FREUD S. (1963) Civilisation and its Discontents. Hogarth Press, London. MASLOW A . H . (1970) Motivation and Personality. Harper & Row, New York. MERTON R . K . (1959) Social Theory and Social Structure. Glencoe Free Press, Illinois. ORWELL G. (1966) Nineteen Eighty Four. Penguin Books, Harmondsworth. PAVLOV I.P. (1928) Lectures on conditioned reflexes. International Publishers Co., Inc. SKINNER B.F. (1963) Science and Human Behaviour. The Free Press, New York. TANNENBAUM F . (1968) The dramatisation of evil. In Deviance: The Interactionist Perspective, eds. Rubmgton E.S. & Weinberg M.S. MacMillan, New York. TEILHARD DE CHARDIN P. (1971) Man's Place in Nature. Fontana Books, London. UNITED NATIONS (1948) United Nations—General Assembly: Universal Declaration of Human Rights. United Nations, Office of Public Information. WILHELM R . (1968) / Ching or Book of Changes. The Richard Wilhelm translation, 3rd edn. Routledge & Kegan Paul, London.

The rights of nurses.

Journal of Advanced Nursing, 1978, 3, 419-426 The rights of nurses* Mary E. Patten B.A.(Hons.). F.C.N.A. Federal Secretary, Royal Australian Nursing...
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