NURSING MODELS FOR THE FUTURE: ACKNOWLEDGING THE POLITICAL NATURE OF NURSING

What are models of care? Why do they matter? And what models do we need for the future? I think it is important for nurses to consider these questions on at least 3 levels: the individual practitioner at point of care, the employment context in which that care is provided, and the sociopolitical environment that influences both health and health care delivery. At all 3 levels, I would argue that the practice of nursing is inherently political.

At the point of care, common issues requiring nursing advocacy include the imperative for human-centered caring and the right to work to full scope of practice.

I am a strong believer in the need for strong and well-articulated nursing models of care that are useful in guiding nursing practice and in helping to define the scope of that practice. Although, legally, nursing is a self-regulating profession in many jurisdictions, in reality, the scope of nursing practice is most often defined by employers and underutilizes the full potential of nurses. A nursing model can provide both the language and a theoretical basis that enables nurses to advocate clearly, confidently, and credibly both for optimal patient care and for healing environments. For example, a nursing model can assist nurses in communicating the nature, scope, and value of nursing's contribution to the multidisciplinary team and serve as an educative tool in nurses' advocacy for full scope of practice. At the point of care, situation- and/or setting-specific models need to be made accessible to nurses, for example, as apps on smartphones. Models of the future need to be researchable so that evidence of their effectiveness can be linked to positive patient outcomes. It will be important for nurses at point of service to be involved in developing nursing practice models if they are to be embraced as relevant and helpful practice tools.

Nurses work in environments of competing paradigms, most prominently the biomedical and corporate models. A nursing model can make visible to nurses themselves, the unique contribution, and value of nursing care and thus provide a reference point from which to recognize and evaluate competing paradigms. While conducting research for my dissertation in the mid-1990s, I spoke to a number of public health nurses who told me that many programs that traditionally had been their responsibility, for example, prenatal classes, were no longer considered appropriate because they were secondary prevention whereas the new direction for public health was focused on primary prevention. Notwithstanding the questionable administrative interpretations of the levels of prevention, I asked these study participants the origins of these terms. The common perception was that they came from government directives; not one participant recognized them as concepts from a medical model of health promotion. A nursing model can serve as a reference point against which to critically evaluate the congruence of new and emerging trends, often based on dominant models that may be incongruent with nursing values and may compromise patient care. The uncritical acceptance and unwitting assimilation of such models may lead nurses into inadvertently becoming complicit in devaluing and limiting their own scope of practice.

Nursing care is strongly influenced by the employment environment in which nurses work. Models of care delivery determine how nursing care is assigned and may facilitate or create barriers to a human-centered, relational approach to care. Likewise, the mission and philosophy of a health care agency are important for communicating its values and priorities. An agency's philosophy may or may not be informed by a nursing conceptual framework/philosophy creating an environment that supports excellence in nursing care. Furthermore, inconsistencies may exist between an agency's published mission/philosophy statements and workplace realities. Dominant paradigms, such as the biomedical and business models, may play a much more significant role than an organization's public statements acknowledge. For example, in practice, medical diagnosis and treatment may be a much higher priority than human-centered patient care. When that is the case, the aspects of nursing practice that overlap or directly support medical practice become more highly valued than relational caring actions. Provision of excellent nursing care may also be compromised by an organizational priority of meeting profit-margin goals to satisfy investors. Furthermore, meeting those goals commonly earns bonuses for already highly paid chief executive officers. Both these realities may compete with patient care resources and result in fewer nurses per patient and/or reductions in services and/or supplies. Working in such realities, it is important for nurses not to assimilate the dominant paradigms, for example, that optimal nursing care is not affordable. A nursing model that grounds nurses in nursing ideals can provide a basis for resisting trends that compromise patient care.

The third level to examine in considering models of care for the future is the sociopolitical context in which we live and in which care is provided. It has been more than 35 years since representatives from countries around the world gathered in Alma-Ata, USSR, and concurred that health was about more than health care. The Alma-Ata conference formed the basis for identifying social, economic, and political factors that influenced health, factors that became widely known as social determinants of health. The Declaration of Alma-Ata, which emerged from this conference, the numerous others that have followed from the World Health Organization, and a vast body of subsequent research, have shaped an understanding of what it means to be healthy and identified which socioeconomic factors influence health. Addressing those factors, such as income, equity, shelter, food, and education, occurs through the enactment of public policies. Examples include policies related to the provision of affordable housing, a fair minimum wage, equitable employment, affordable education, and universal health care. And yet governments continue to vary in their willingness to adopt such policies. An analysis of political traditions on health outcomes indicates that countries such as Sweden, Denmark, and Norway, whose governments have adopted social policies focused on reducing social inequities, fare better on health outcomes, particularly infant mortality rates and life expectancy, than countries whose governments do not such as Canada, the United States, and the United Kingdom.1 Government policy decisions thus have implications not only for nursing practice in terms of the focus of health promotion efforts but also for funding of nursing services to vulnerable populations that are more likely to become ill and less likely to be able to afford health care.

Future models of care must consider all 3 levels. To assist nurses to value and make visible nursing knowledge and practice, they must be grounded solidly in the nursing discipline. Yet, to serve nurses as a tool of resistance to policies that damage health or limit the public's access to nursing services, I believe they must also be informed by critical social theories.

Conceptual models and grand theories will continue to be important for providing a philosophical basis for practice and may also serve as frameworks for health care and academic settings, for example, to guide development of institutional standards for patient care or curriculum development. Furthermore, they provide a solid nursing anchor from which situation- and setting-specific models can be developed, models that may also be based on congruent theories from other disciplines and that can be used by nurses and other health care professionals.

What models we need depends on our values and vision for a preferred future, not only for nursing but also for humanity! To support a vision that nurses play a critical role in promoting health and healing for all, nursing models must move beyond the premise that health is an individual responsibility, acknowledge the important role played by socioeconomic determinants, and include political activism as a means to redress them.

-Adeline Falk-Rafael, PhD, RN, FAAN

ANS Advisory Board

Senior Scholar

School of Nursing

York University

Toronto, Ontario, Canada

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