NURSING PRACTICE — REALITY OR DREAM Paper presented at the symposium Nursing in the Eighties , Rand Afrikaans University

Hier te lande is verpleegpraktyk ’n wetlike en maatskaplike werklikheid. Sommiges glo egter dat die term verpleegpraktyk net op die verpleegkundige in private praktyk betrekking het. Verpleegkundiges geniet sedert 1891 wetlike praktisyn-status. Hulle is praktisyns in eie reg, ongeag die gesondheidsopset waarin hulle werk. Verskeie faktore aan die begin van die eeu het daartoe bygedra dat die verpleegkundige 'n ondergeskikte houding teenoor die mediese praktisyn aangeneem het. Vandag is dit moeilik om sommiges te oorreed dat hulle ten voile verantwoordbaar en mede-verantwoordelik vir pasiëntsorg is. Dit is elke verpleegbestuurder se plig om te verseker dat die geregistreerde verpleegkundiges op haar personeel as professionele praktisyns, in die ware sin van die woord, funksioneer.


INTRODUCTION
F or the purpose of this article, the term nursing practice excludes m idw ifery practice.T he d eb ate as to w hether a nurse is a p ractitio n er or not centres on the nurse and n o t on the midwife.B oth legally and by custom ary practice, the midwife in South A frica has enjoyed the status of a practitio n er since 1652, whilst the nurse has only been recogni sed as a legal practitio ner since 1891.

NURSING PRACTICE A REALITY
T he thesis of this article is that nursing practice is a legal and a social reality, and is definitely not a dream.It is a p h e nom enon th a t exists as an entrenched p art of th e social structure of this coun try and is recognised in law.W hat we m ake of practice determ ines the reality of it from the view point of the com m unity.

THE CONCEPT PRACTICE
Just w hat is m ean t by practice w hen used in a professional context?W eb ste r's dictionary describes practice as follows: to p u t know ledge into practice, to w ork at, or to fo llo w a profession.
The R e a d e r's D igest illustrated D ictio nary refers to practice w hen used in a professional context as: the exercise o f an occupation or profession.N either of th ese au th o ritativ e sources define how the occupation or profession is to be practised.In o th e r w ords the concepts in h eren t in these definitions apply equally to private practice and to practice in an em p lo ym en t situation.P ri vate practice for all professionals was essentially an 18th and 19th C entury phenom enon.T o d ay , w orldw ide, m ore professionals practice w ithin an em ploy m ent situation th an o ut of it.

Some misunderstanding evident
T here appears to be a m easure of m is understan d in g ab o u t w hat is m eant by nursing practice.Som e A m erican nu rs ing literatu re views practice in the way it is done in South A frica (A .N .A ., 1973. Preface).
H ow ever, som e au th o rs ap p ear to adopt th e stan d p o in t th a t one practises nursing w hen o ne is engaged in private practice, th a t is w hen one conducts an in dep end en t nursing business.O ne treats those p atien ts and advises clients referred to th e nurse p ractitio n er by a m edical p ractitio n er, o r those who have com e w ithout referral to obtain a speci fic type of nursing care.(Jacox and N orris, 1977: pp xiii, 3: 21,22,23,25, 193,198,207).T h ere is freq u en t refer ence to the em ergence of a new ca te gory of nurse know n as a nurse practi tioner.

Need to be specific
T here is a need to be clear in o n e's w rit ings and discussions ab o u t the m eaning of nursing practice w ithin the national context.It is desirable th at th e S A N ursing Council should publish a national statem en t in w hich it is made clear th a t th e only valid definition of nursing practice fo r South A frican pur poses is th a t w hich is p rovided in the N ursing A ct. H o w ev er, it ap p ears that nurses do n ot study th e N ursing A c t so as to clarify th e ir p rac titio n e r status.

Three points of view on the topic of this paper
T he question nursing practice, dream or reality?can be view ed in th ree ways, nam ely: th e legality o f nursing practice; fulfilling a p rac titio n e r ro le, irrespec tive of th e h ealth care setting in which the nurse functions, and the reality of practice, from a care po int o f view.

THE LEGALITY OF NURSING PRACTICE
It is ad u m b rated th a t th e nursing prac tice concept in South A frica is a legally en tren ch ed on e th a t has th e sam e valid ity, and hence th e sam e reality, as the practice of th e m edical p ractitio n er.

Legal practioner status -1891
The legal p rac titio n e r status of the nurse in South A frica dates back to 1891, w hen th e provisions of the M edi cal and Pharm acy A c t N o 34 o f 1891 provided for th e reg istratio n of medical p ractitioners, d en tists, ap oth ecaries (in cluding chem ists an d druggists), mid wives and nurses on th e sam e register, though in d ifferen t sections there-of.Section 47 of this A ct specifically p ro vided th at reg istered persons who were found guilty o f infam ous or disgraceful conduct in any professional or o th e r re spect, after due enquiry by the Council, were to have th eir nam es rem oved from the reg ister, subject to approval by the governor.O nce this had been done they w ere n o t en titled to practise their pro fes sion.
In h eren t in every section of this first A ct w hich p rovided fo r the registration of these five categories of health p racti tio n er was the principle th a t the person observes the law and its regulations to retain th e right to practise his/her pro fession.
The M edical and Pharm acy A c t o f 1891 clearly show ed th a t registered health professionals w ere d ep e n d en t on observance o f the law to rem ain in prac tice.N ow here was th e re any reference that th e nurse was dep en d en t on the orders of th e d o cto r to practice her p ro fession.P ersonal responsibility and ac countability, w hich lies at the core of professional practice, was inherent in every aspect o f th e A ct and its regula tions.
Section 31 of this A ct specifically pro vided for th e w ithdraw al or cancellation of a certificate of registration granted to a train ed n urse if it was proved th a t the holder was grossly incom petent, o r had been guilty of such u n p ro p er conduct as in th e opinion of the Council ren d ered it inadvisable th a t she should continue to practise as a trained nurse.
N ow here in th e regulations gazetted u nder this act did it ap p e ar th a t the nurse could only practise h er profession in an em ploym ent situation, o r u nder the supervision of a doctor.T he regula tions trea ted h er as an indep en d en t p ractition er on th e sam e lines as the.o th e r four categories of persons reg istered in 1891.

PRIVATE PRACTICE
It could n o t be otherw ise.T here were very few hospitals at th a t tim e.The m ajor p art of the health care was pro vided by nurses in the hom es of the patients.T hese w ere self-em ployed nurses or nurses in private practice.W herever m edical assistance was avail able they w orked in close collaboration with th e fam ily m edical p ractitioner in the sam e way as they w orked closely with the doctor in the hospital situation.M utual interd ep en d en ce was well en trenched.
U p to th e beginning of the S A W ar 1899-1902, the m ajority of registered nurses w ere in private practice.Some had room s in th eir hom es from which they provided a service, others u n d er took private nursing, and som e estab lished small private nursing hom es.This group of nurses established a netw ork of small hospitals and of hom e care faci lities which becam e th e foundation of the health services which exist today.The practice o f these private nursing practitioners helped to b roaden the scope and range o f m edical practice.

Independent functions
A t the same tim e institutional nursing practice was en trenching itself.A study of letters, docum ents, diaries, and books w ritten by m edical practioners in dicate th a t by the end of the 19th cen tury, the trained nurse in S outhern A frica was established as a registered practitioner with a w hole range of inde pendent functions.T hese w ere: -supervision of th e patien t and his im m ediate environm ent -observation of th e signs, sym ptom s and reactions experienced by the patient -recording o f sym ptom s, signs, re actions and trea tm e n t and care given -supervision and direction of subordi nate personnel serving the p atien t

Legislation in the other colonies
Legislation enacted in N atal in 1899 was similar to th a t en acted in the C ape.It is interesting to n o te th at when N atal com m enced the first training of nurses in 1890, the regulations of the hospital provided that the p ro b atio n er nurses had to give an undertaking th at they would follow m eticulously the orders of the doctors, and be subject to them at all times.This provision was not en trenched in the first law and regulations which authorised state registraion of nurses and midwives in N atal.N ever theless we may presum e th at this con cept was carried forw ard into the 20th Century.
A fter the S A W ar 1899-1902, the T ransvaal and O range R iver Colonies enacted legislation sim ilar to the M edi cal and Pharmacy A c t o f 1891.It is inte resting to note th at the w ord medical was considered a generic w ord which in cluded m edical practitioners, dentists, nurses and midwives.
It is clear th erefo re th a t by the begin ning of the 20th C entury, all registered nurses in the colonies now constituting the Republic of South A frica w ere prac titioners in their own right -no m atter where they w orked, in private practice, in hospitals, in the m ilitary services, or in doctor's consulting room .O n the grounds of professional practitioner status the qualified nurses w ere given officer status during th e South A frican w ar 1899-1902.
If this was th e status of th e nurse at the turn of th e C entury w hat w ent wrong?This question is asked because for many years during the tw entieth century nurses subjected them selves to a situation w here they negated their legal rights as practitioners.Y et legally they were involved in a co-operative practice situation, w ith both doctor and nurse, jointly and separately responsi ble for their patient.
The nurse practised h er profession within the am bit of statu to ry laws and regulations, th e com m on law, and the unw ritten code o f h er profession -yet she abrogated h e r status as a practi tioner.
V A t the sam e tim e successive eco nomic recessions is cause nurses to seek large scale em ploym ent in hospitals w here the b ureaucratic m achine and fear of job losses during a tim e of great financial hardship sm othered ideas of ind ependent professional practice.
A t the sam e tim e nursing education developed as a by-product of hospitali sation.N ursing education was geared to the req u irem en ts of the bureaucratic system and th e ord ers of the doctor.
L ectures in th e theory of nursing am ounted to a study of the basic sci ences and of diseases.T hese lectures were given by doctors.T he m atrons and sisters gave dem onstrations of the pro cedures used in nursing.T here was no tru e p rep aratio n of a professional prac titioner.
Q ualified nurse tu tors w ere in tro duced in th e early tw enties, b u t they had received th eir education overseas in a m ilieu w here the philosophy of doctor suprem acy in th e nurse-doctor relation ship was ram p an t.A s a result of all this, the education o f several generations of South A frican nurses reflected the con cept th a t the nurse had a dependent function on the doctor, and th a t the nurse (as opposed to the m idw ife) was not a practitioner.Y et, as late as 1944, the certificate issued by the S A M edical Council to a registered nurse clearly stated that she was com petent to practise as a m edical and surgical nurse.
T he concept o f th e nurse as a practi tioner and th e principle of professional practice are securely en tren ch ed in the Nursing A c t N o 50 o f 1978, and in the N ursing A cts preceding this.
D espite these legal provisions it has been a dispiriting task to m ake som e nurses realise th a t th ey are legal practi tioners, fully accountable for th eir own acts and om issions, w ith a joint resp o n sibility w ith the d o cto r for patien t care.

FULFILLING THE ROLE OF A PRACTITIONER IRRESPEC TIVE OF THE HEALTH CARE SETTING
T he law em pow ers th e nurse to practise her profession in any type of health care situation.T he p ara m ete rs of such p ro fessional practice are com petence, authority , responsibility, accountabil ity, in d ep en d en t decision m aking, colla boration , facilitation, advocacy, nursing diagnosis, planning o f nursing care and recording of actions on behalf of the patient/client.
O ne o f th e con strain ts in nursing practice in the hospital situation is the fact th a t we nam e th e division responsi ble for nursing care as th e nursing ser vice departm ent.E m phasis falls heavily on the concept service, in a bureaucratic sense.It is an in teg ral aspect of a b u reaucratic hierarchial organisation.This constitutes a th re a t to professional res ponsibilities and professional practice concepts.T ak e a close look at the nurs ing service concept as evinced in m any of o u r hospitals.
It is n ot service to th e p atien t b u t ser vice to the service organisation th a t lies at the centre of nursing practice in many of o u r large institutions.It is the duty of every nurse m an ag er to ensure th at the registered nurses on h er p ersonnel are tru e practitioners.T h ey m ust be freed from th e excessive bureaucratic re straints th a t m ake th em service au to m a tons, and they m ust be helped to act as fully accountable p ractitioners.
It is ironical th a t th e only tim e at w hich the h ealth care au th o rities stress the professional accountability o f the nurse is w hen a claim for dam ages is lodged by a p atien t.Is it not tim e th at we label th e existing nursing service d i visions, as nursing care divisions so as to ensure th a t th e em phasis falls on the professional practice aspects of the nurses' co n trib u tio n to p atien t care, and the centrality o f th e care to th e p atien t is em phasised.
T he concept of nursing practice and of a nurse p rac titio n e r was underm ined by m atrons in th e organisational hier archy.O nly th e n u rse m an ag er can now lift nursing p ractice to its rightful status in the h ealth care in stitu tio n s.T he qual ity of the nurse m anagers and th eir in sight into th e m an ag em en t of profess ionals can resolve this co n ten tio u s pro blem.This is a vitally im p o rta n t problem .N urse leaders have a d uty to ensure that their professional nursing personnel practice as professionals.This is the w hole justification for th e nurse m an ager being a professional nurse for, pre sum ably, she know s w hat th e profess ional p ractice o f a n u rse entails.If she continues to n eg ate this vitally im por tant dim ension of h er w ork the end result will be th a t it will n o t be neces sary fo r a professional nurse to hold the post of nurse m an ag er -fo r nurses will not be con cern ed w ith professional practice, b ut only w ith carrying o ut the rules of the in stitu tio n and the orders of the doctor.T he choice is ours.Will we m ake professional p ractice a reality, or will we live in a d rea m w orld an d con tinue to pay lip service to the concept of professional practice and practitioner status?

THE REALITY OF NURSING PRACTICE
W hilst th e legality o f nursing practice is very m uch a reality , can w e say the sam e of the reality o f nursing practice?H ow nursing practice is carried o ut con stitutes an ex perience for th e patient and his fam ily.Is th e reality o f nursing practice w hat th e p a tie n t expects?W e all know th a t som e neglect of patients occurs daily an d th a t slovenly, indifferent and even ig n o ran t practice exists at tim es.W e see u n tidy nurses in th e w ards and on th e streets.A re we facing facts and ad m itting th a t o u r nurs ing practice is n ot all it should be in all centres?
Is th e profession aw are o f th e num ber of nurses w ho annually face disciplinary action by th e S A N ursing C ouncil?A re all of us p rep a re d to w alk the extra mile w hen th e need is g reat?H ow m any of us share in th e w ork o f o u r professional as sociation?A re we really professional p ractitio n ers if we disregard this vital elem en t in o u r professional life?Continued on p,. 12 Prof Dr C. Searle, BA (SocSc) (Unisa), MA(UP), DPhil(UP), RN, RM, CHN, NEduc, NAdmin.Head, Department of Nursing, Uni versity of South Africa.

contributing to a sub servient attitude
O L 7 N O 4 CURATIONISFactors