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8/13/2019 PostHospital Nursing Shortage Shifts and ScriptsPostHospital Nursing Shortage Shifts and Scripts
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Post-Hospital Nursing: Shortage, Shifts,and Scripts
Jean Watson
This article offers a critique of nursing’s focus during this critical turn in post-hospital nursing with evolv-
ing, nonmedical, nonclinical notions of human health. It raises some seminal questions about nursing’s
ground-of-being in relation to its survival for a new and different human health script. The call is not for
more —old script nursing and nurses, but less and different —transformed nursing and nurses, grounded
in mature disciplinary, philosophical values, knowledge, and skills that converge with evolving public
and system realities: real, surreal, virtual, and timeless. The fewer, different, transformed nurses will need
to be grounded in nursing, while simultaneously transdisciplinary and, paradoxically, beyond nursing .
Key words: nursing shortage, philosophy, post-hospital, transdisciplinary caring-healing, values
The crisis of modern medicine lies in the lack
of a suitable philosophy of practice, whereby
non-measurable . . .values can be treated with
the same attention as clinical indicators of
disease.1(p. xi)
I
N RECENT times there has been an
increasing interest in things that are
nonphysical, often nonvisible and non-
measurable; those silent unknowns, lyingbehind the outer world of usual reality.
These things may manifest in more spiri-
tual awareness as we evolve as a culture
and civilization, moving into a new epoch
in human history. They may manifest as ad-
vancements in modern science and technol-
ogy, where attention is given to such non-
physical phenomena as laser surgery, virtual
caring, mind-altering techniques, and non-
invasive procedures. These shifts manifest
as quantum jumps into cyberspace, hyper-
space, intergalactic space, and beyond. Theymay manifest as increasing attention to val-
ues and beliefs.
What are we to make of this cultural shift
between centuries and millennia, whereby
the nonphysical becomes the real, and the
actual becomes virtual or surreal? What are
we to make of these changing times and re-
alities for nursing’s sustainability?
One consequence of this shifting reality is
a call for nursing to reconsider the very con-
cept of our profession and whether we are
grounded enough to survive as a distinct dis-
cipline in this new reality. Global concerns
and diversity of human experiences acrosscultures, generations, and geography raise
the ante as to how, and how well, nursing
is located within these evolving shifts. New
models of health care and new reforms and
forms of professional practice and leader-
ship are upon us. The Millennium Futurist
Project, for example, points out some of the
global changes and new skill sets that are
necessary for a new era in human history.2
Jean Watson, PhD, RN, HNC, FAAN, is Distin-
guished Professor of Nursing and Endowed Chair in
Caring Science at the University of Colorado Health
SciencesCenter, School of Nursing, Denver, Colorado.
Nurs Admin Q, 2001, 25(3):77–82c 2001 Aspen Publishers, Inc.
77
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78 NURSING ADMINISTRATION QUARTERLY / SPRING 2001
Recently Porter-O’Grady reminded us
that changes in the past two decades have
accelerated to a level that is untenable in
the present time, requiring a new script.3 He
named these transformative changes as:• technological innovations affecting
quality and quantity of person’s life• economic and value foundation changes
seeking to assure the right balance be-
tween resource use, service, and sus-
tainable outcomes• reconfiguration of delivery of health
care, from hospital-centric (cure-centric) to health (and relational caring-
inner healing) based script—leading
to a post-hospital turn, low intensity,
minimally invasive, chemically based
treatments (and self-generated, selfcar-
ing, self-healing modalities) (author’s
parentheses)
These changes, facing us all on a moment-
by-moment, daily basis, are compounded by
yet another crisis of all crises—a profound
nursing shortage. These changes, however,
are yet to be fully realized, comprehended,faced, or admitted, privately or out loud. Be-
cause we either do not comprehend these
new realities/surrealities or do not wish to
face them, we see mainstream nursing still
trying to conform, or at least catch up, with
the past era of hospital-centric, cure-centric
approaches, which have already dissolved.
Nursing schools are still struggling to
deal with the nursing shortage of students,
lamenting the decline of undergraduate (and
graduate) students. Hospitalsare trying to fill
beds with patients and create more positionsto serve those beds.3
As we revisit these crises and changes,
and review the new, real/virtual/surreal re-
alities, we are called upon to acknowledge
that old-set patterns of response that seek to
patch up and perpetuate the old realities that
no longer serve. As Porter-O’Grady put it:
The interesting thing about today’s nursing
shortage is what it is saying to nursing leader-
ship that they have not yet discerned. . . . Those
with sufficient vision already recognize how see-
ing nursing’s current circumstance as a shortage
is inadequate. It is, instead, a necessary reconfig-
uration of services.3(p. 33)
Awakening to these new realities, whetheractual or virtual, invites or requires a recon-
sideration of nursing’s ground of being-in-
the-world. Some, rightfully so, applaud the
success and state of nursing science to date.4
Others raise the realities we do not wish to
admit, such as another state of the science
and professional standing.5
For example, Fawcett’s review of 20th
century hallmarks of success in nursing the-
ory development resulted in her lament: “I
have seen nothing that might qualify as a
new hallmark of success in nursing theorydevelopment, nursing research, or nursing
practice . . . reflecting a very real concern for
the continued existence of the discipline of
nursing.5(p. 312)
From a social-political lens, nursing re-
mains invisible, and externally controlled, in
spite of the scientific facts and evidence that
nursing care and caring are crucial variables
that make a positive difference in patients’
(and nurses’) outcomes of health and well-
being.6 From another lens, concerns about
the continued existence of the disciplinecome from concerns associated with nursing
knowledge and the need for continuing frag-
mentation of nursing without a converging
structure that might address these concerns.7
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Post-Hospital Nursing: Shortage, Shifts, and Scripts 79
Old-Script Nursing
These concerns are compounded by a
contemporary trend to paradoxically ac-
knowledge and then disregard nursing’s
philosophical-theoretical heritage and his-
tory in our old-script models. These
old scripts are reluctant to acknowledge
the importance of nursing’s philosophical-
theoretical ground as the basis for transform-
ing the profession for a new human health
script. The old-script thinking of nursing
continues to cling to the passing demand for:• A more pragmatic, advanced nurse-
practitioner-management role in the
community [The result: some nursing
roles are beginning to look more like
physician roles and more contemporary
medical practices (which are rapidly
shifting to holistic models, spiritual care
practices, mind-body-spirit medicine,
and so on) are beginning to look like
advanced nursing practices.]• More nurses for more hospital beds, to
fill positions for the specialized techni-cal demands in the current, yet dramat-
ically shifting, systems. [The result: a
short-lived, obsolete approach, as newer
perspectives take the place of bed-based
approaches to care.]• More undergraduate nursing students,
when the new practice demands require
additional education, with graduate
preparation as minimal level for profes-
sional challenges of this new paradigm
of post-hospital care. This preoccupa-
tion of nurse educators with undergrad-uate education continues when most
other health professional education
models are at the masters or doctoral
level (for example, physiotherapists,
occupational therapists, pharmacists,
and clinical psychologists). [The re-
sult: usurping creative energies and eco-
nomics of faculty and systems by cling-
ing to nursing educational programs for
the declining entry hospital role, rather
than realizing that major schools of
nursing need to prepare mature, career
professionals, while offering creative,
flexible, advanced professional devel-
opment models of continuous, perpet-
ual learning for current nurses in the
field. These mature nursing practition-ers and students, like other health pro-
fessionals who are prepared within their
discipline, will need to be grounded
in nursing’s disciplinary, philosophical-
theoretical foundations to guide and in-
form their new-script nursing practices.]
While these past efforts and old scripts
have offered, and may still offer, a greater
sense of stability, predictability, control, and
esteem, they may even succeed within the
more conventional script of the external
world of institutional, medical practices.However, these approaches for hitching our
stars to the moon flee quickly and become
meaningless, if nursing itself is not informed
by its professional caring ethos and ethical
covenant with the public. This new script re-
quires that nursing and nurses be guided by
their own values, disciplinary perspective,
and clarity of vision for a new and differ-
ent script that is already being written by the
public.
Thus the current, old-script mind-set
seems to be more: more in numbers of nurses or nursing students, or more in terms
of conventional approaches to hospital and
orthodox medical care management. This
emphasis on more, whether in numbers or
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80 NURSING ADMINISTRATION QUARTERLY / SPRING 2001
regular kind of nurses, fails to recognize
that more of the same does not address
the changing shift and script to less and
different .
New-Script Nursing
The less, and different, nurse and nurs-
ing I am referring to in this instance, is less
in numbers of overall nurses being available
and less in number of future generation of
students, especially traditional undergradu-
ate students. The “different ” I am referringto is Different Ways of Being, Doing, and
Knowing Nursing. This difference includes
preparing and reconfiguring ourselves, our
services, and our systems for having less of
the physical numbers of nurses and more
about preparing both new and conventional
nurses to engage in different, more mature
caring-healing and health practices as trans-
disciplinary professionals.
These less (in numbers) but different ,
newly reconfigured, transdisciplinary
professional nurses will be required to bemore grounded in who they are and who
and what they bring to their practices.
They will be required to bring to their
practices and teaching, and perhaps even
their research, a different consciousness and
a mindful intentionality about their values,
theories, and fundamental philosophy for
caring-healing work. In addition, the differ-
ent , newly reconfigured, transdisciplinary
nurses will have to be more present and
more authentically available to self and
others, have more advanced caring-healingarts and skills that offer self as sojourner,
helping others to gain more self-knowledge,
self-control, self-healing knowledge and
information.
These different and newly reconfigured
nurses and nursing will have to know
how to gain access to information and
engage in purposeful caring relationships
that facilitate meaning-making out of the
information obtained. The new, different-
script, transdisciplinary nurses will be more
grounded in relationship, community, per-
sonhood, meaning-making, with respect to
birthing, living, aging, changing, growing,
and dying.
The new-script nursing, and nurses, will
have to be more knowledgeable in the sci-ence of unitary being8 as well as the art
and science of caring,9−12 grounded in a ba-
sic philosophical-relational ontology as the
moral and pragmatic foundation of nurs-
ing. This old/new foundation addresses ul-
timate questions of being-in-the-world and
becomes the basis for new-script approaches
and advancedpractices beyond medicineand
hospital technology and cure.
Without reconfiguring nurses and nursing
for a new world and a new script, nursing
may indeed not survive; if it is to surviveas a mature, distinct discipline and health
profession, it must be transformed. The old-
script, and continual perpetuation of educa-
tional and practice models for the old-script,
hospital nursing can no longer hold for the
new world that is upon us. This view returns
us to the starting point for this article: “The
Without reconfiguring nurses and
nursing for a new world and a new
script, nursing may indeed not survive;if it is to survive as a mature, distinct
discipline and health profession, it must
be transformed.
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Post-Hospital Nursing: Shortage, Shifts, and Scripts 81
crisis of modern medicine lies in the lack of
a suitable philosophy of practice. . . . ”1
Without mindfulness of our philos-
ophical-disciplinary ground nursing and
nurses continually will be drawn into old-
script detours. Nor will it or they be able
to engage in mature transdisciplinary prac-
tices for the emerging future. Aphilosoph-
ical, atheoretical disciplinary and profes-
sional detours can and have perpetuated
a clinicalization of human experiences, of
both nurse and patient, and have pulled
nurses and nursing toward an overempha-sis on hard physical material evidence that
yields only partial accounts of human ex-
periences. These old scripts miss the essen-
tials of human suffering, search for spiri-
tual fulfillment, wholeness, unity, relation-
ships, and inner meaning, self-knowledge,
and so on. These detours of the old script
have limited nurses’ and nursing’s develop-
ment in advancing its caring, healing arts
and practices, which are now being em-
braced by the public as well as new-script
medicine.
Without a philosophical pause and cri-
tique, which entertains a new script for a
new world, nursing is inclined to be further
consumed with more detours about learn-
ing dated technical-medical protocols and
an overreliance on outdated, old-script med-
ical science conceptions of human health
and technical-task care practices. If the de-
tours continue away from the philosophical-
theoretical roots of the profession, nursing
may indeed become extinct.
As we turn a more optimistic corner
of our common history, a reflective stanceof our philosophical grounding may be
one of the hopes for finding our way
home. It is the position here that clarify-
ing and then maturely standing in our own
philosophical-disciplinary foundation may
well help to assure that nursing not only
survives but thrives—transformed and re-
configured. Thus transformed and recon-
figured nursing and nurses can lead the
way toward a new transdisciplinary moral
community script for public health and
healing.
REFERENCES
1. E. Pellegrino and D.C. Thomasma, A Philo- sophical Basis of Medical Practice: Toward aPhilosophy and Ethic of the Healing Profes- sions (New York: Oxford University, 1981), xi.
2. D. Pesut, “Millennium Issues and NursingLeadership,” Nursing Outlook 47, no. 6(Nov./Dec. 1999): 242.
3. T. Porter O’Grady, “Visions for the 21st Cen-tury: New Horizons, New Health Care,” Nurs- ing Administrative Quarterly 25, no. 1 (Fall2000): 32–38.
4. C. Anderson, “What Is the State of the Sci-ence?” Nursing Outlook 47, no. 6 (1999): 241.
5. J. Fawcett, “The State of Nursing Science:Hallmarks of the 20th and 21st Centuries,”
Nursing Science Quarterly 12, no. 4 (1999):311–318.
6. K. Swanson “What Is Known about Caringin Nursing Science.” In Handbook of Clin- ical Nursing Research, ed. A.S. Hinshaw,S. Feetham, and J. Shaver, 31–60 (ThousandOaks, CA: Sage, 1999).
7. H.S. Kim, “Challenge of New Perspectives,”Nursing Knowledge Impact Conference Pro-ceedings (Boston: Boston College School of Nursing, 1996).
8. M. Rogers, An Introduction to the Theoreti- cal Basis of Nursing (Philadelphia: F.A. Davis,1970).
9. J. Watson, Nursing: The Philosophy and Sci-
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82 NURSING ADMINISTRATION QUARTERLY / SPRING 2001
ence of Caring (Boulder: Colorado AssociatedUniversity Press, 1985).
10. J. Watson, “Nursing’s Caring-Healing Para-digm as Exemplar for Alternative Medicine?”
Journal of Alternative Therapies in Health and Medicine 1, no. 3 (1995): 64–69.
11. J. Watson, Postmodern Nursing and Be- yond (United Kingdom/New York: Churchill-Livingstone/Harcourt-Brace, 1999).
12. M.C. Smith, “Caring and the Science of Unitary Human Beings,” Advances in Nursing Science 21, no. 4 (1999): 14–28.
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