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: AS070-12 April 5, 2001 16:3 1 Char Count= 0 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 , transdiscipli nary caring-healing, values The crisis of modern medicine lies in the lack of a suit able philosop hy of prac tice , wher eby non-measurable . . . valu es can be tr eate d with the same att ent ion as cli nic al indicator s of disease. 1(p. xi) I N RECENT times there has been an increasin g int erest in thi ngs that are nonphysical, often nonvisible and non- meas urabl e; thos e sile nt unkn owns, lyin g behind the out er world of us ual rea lit y . These things may manifest in more spiri- tual awareness as we ev ol ve as a cul tur e 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- spa ce, inter gal act ic spa ce, and be yon d. The y may 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 sustainabili ty? One con seq uen ce of thi s shi fti ng rea lit y is a call for nursing to reconsider the very con- cept of our profession and whether we are gro und ed eno ugh to survi ve as a distinct dis- cipline in this new reality. Global concerns and diversity of human experiences across cultures, 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, F AAN,  is Dis tin- guished Professor of Nursing and Endowed Chair in Caring Science at the University of Colorado Health SciencesCenter , Schoo l of Nursi ng, Den ver , Color ado.  Nurs Admin Q, 2001, 25(3):77–82 c 2001 Aspen Publishers, Inc. 77

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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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