Continuing to look at the Nurse Manifesto

As summer progresses, I continue to think about the demand for change in the healthcare profession and nursing. The Manifesto provides us with a unique tool to begin the change process, and a foundation for the call to change.

Here is another quote from the document that may be of interest to examine with some depth:

The situation we find ourselves in has been created from an array of forces. While economic issues have helped create a situation in which nurses cannot practice nursing, we, as nurses, have participated by remaining silent. Our professional sovereignty is threatened. The health of global humankind is at risk. It is now time to ask ourselves, who benefits from the situation as it now exists? As long as we know that the current situation inhibits the fullest expression of nursing’s highest values, and that people who need our care are not receiving the best we can offer, we know that we, and those we serve, are not benefiting. If nurses are to significantly contribute to a mission of caring for people and communities, we must find our voice, acting now to create situations in which our values come to the center and from which we can realize our best intentions.  (Cowling, Chinn, & Hagedorn, 2000, paragraph 3).

I have to agree that healthcare is big business here in the USA, a place where democracy, free enterprise, and capitalism have created a healthcare system which profits in the billions of dollars every year. For more information on the profit status of insurance companies, I found this link helpful and easy to follow:

As nurses we have in many aspects blindly given over our practice to the regulating agencies and facilities where we work. Instead of as a profession deciding the services we can and will provide, which includes enacting our core values of caring and presence for those on a healing journey, we have chosen to allow our practices to be largely dictated to us. I believe that the high rate of burn out among nurses, and the great professional exodus of many new nurse graduates, is related to the inability to enact a caring-healing presence at the bedside.

So how is that we find our voice in order to create the type of transformative change that is so desperately needed in our healthcare system? While I believe joining a professional nursing organization is a place to start, I think we have found that having over one hundred specialty organizations in nursing has in some ways defeated our ability to come together and create a single strong voice. The American Nurses Association also has it challenges with membership and creating true, meaningful action. As the largest number of healthcare providers in the USA, a clear strong united voice and resultant action that demonstrates how our values can be realized in the healthcare system.

I think partnering with patients offers the profession a lot of hope for the future. As patients demand more access to complimentary and alternative modalities, nurses are the ones who could be enacting these interventions. Patients also know the importance of a caring presence at the bedside as they journey through suffering and the healing process. Patients are also some of our greatest teachers, as they remind us over and over again of the importance of nursing and the urgency of the need for loving kindness and caring in our professional actions. The rewards of nursing are indeed encapsulated within the patient-nurse transpersonal experience, and we have failed on many levels to support one another in explicating, teaching, supporting, and enacting the intricacies of this process.

I also believe that there is great hope for the future: each of us has the power to enact and create the kind of nursing practices we envision. Many of my students have found that by changing their views of themselves and the world, and begin to take action in creating change in how they practice nursing. With an emphasis on self-care and holism, the students often find themselves empowered to begin to solve workplace issues. They begin to return to the sacredness of their work, and enact their own healing journeys.

I suppose the questions remains in how to continue to reach the many, many nurses who are suffering in oppressive work situations. How can we best support and empower these nurses to take back their practices, and accordingly allow for our true nursing values of caring, compassion, empowerment, and patient advocacy to emerge?


Cowling, R., Chinn, P.L., & Hagedorn, S. (2000). The Nurse Manifesto.
Retrieved June 27, 2011 from

6 thoughts on “Continuing to look at the Nurse Manifesto

  1. At the great risk of being redundant, we no longer live in an age when we nurses can fruitfully ignore the financial environment in which we practice.

    Continued failure to understand the broader economic and financial context of nursing practice leads to inaccurate and unworkable solutions. To the degree to which nurses work, within our organizations, without understanding the constraints imposed by how health care is financed, how each patient arrives with unique and different clinical, spiritual, healing needs and very different financial entitlements to care, we will be advocating solutions at bedside that simply cannot work in our organizations.

    To change the environment within which we practice we need to understand and change the fact that no two patients, even with identical needs profiles, can be treated the same because each patient’s health benefit entitlements are different: covering different levels of costs for care, restricting access to care in different ways, and the imperatives of this system necessarily become moving patients though, and out, of our care as rapidly as possible.

    Any facility that bucks this trend, without a fundamental change in the the external economic and financial environment within which nursing care is delivered, will fail financially, whether or not it succeeds clinically, spiritually, and in its manifestation of healing intent.

    Failed health care facilities are not in the best interests of patients or nurses. Health facilities that can operate without the burdens imposed by our current system of operating as their patient’s inefficient insurers is the first step toward reclaiming the sacred ground of nursing.

    To wage this particular battle, nurses need to understand the implications of capitation financing, the Prospective Payment Systems, the Diagnosis Related Groups system of reimbursement and how it impacts physicians, nurses, and patients at every level of caregiving. As the largest workforce in nursing, nurses have a unique opportunity to collaborate across facilities, across political jurisdictions, and to affect contracting, the political and financial environment – but we cannot do that if we, as a profession, do not understand the environment within which we work.

    Absent insight into the real problems that impact the quality of nursing care, the quality of the experience of being a dedicated, caring, and compassionate nurse, we will, sadly, continue to practice in a manner that is both off target, and outside the feasible domain of the solution, rather than addressing the heart of the problem.


  2. Thomas, I have to absolutely agree with you. I have taught healthcare policy and economics at the graduate and undergraduate levels for 6 years, and most nurses have minimal knowledge of the healthcare system and the driving economic and political forces behind it. It is always empowering though to see nurses grow in this area. Sadly, most nurses do not gain knowledge in this area around policy, politics, and economics unless they enroll in graduate level work. Clearly this deficit in knowledge also his reflects on the realm of pre-licensure nursing education, the NCLEX exam process, and the governing boards such as the BRNs and the accrediting bodies of nursing education programs.


  3. 🙂

    I used to teach a nursing economics class in a BSN program, but the sad truth was that the students were just not prepared to understand the implications of health care provider insurance risk assumption.

    Most students were having trouble with drug calculations and completely unprepared for even modest statistics.

    But, throwing nurses into practice environments without an understanding of the financial implications of patient care is as dangerous to their patients and their facilities as an incorrectly calculated does of regular insulin. If a nurse misjudges the patient’s entitlement to care, plans care on a model that assumes that the patient will be in the facility for 3 days, and the patient is discharged after 2 days to meet the imperatives of cost reduction, the care planned will never be delivered.

    The saddest aspect is that we may deliver compassionate, spiritually enriching, and healing care for those 2 days, but leave our patients’ needs for core nursing care unmet because we simply did not front load their care to fit the time they would be with us.

    I’d agree that if the NCLEX is the regulated standard of competence – then we better start asking questions on orchestrating care in its financial and economic context, or the NCLEX simply will not distinguish between those with the ability to work in this strange new world from those who cannot.

    I’d be interested in any thoughts you might have with regard to how one might go about encouraging nursing study groups.


  4. Sovereignity

    I hear and respect your commentary on the current state of nursing education, practice and healthcare economics-policy.

    The concept of sovereignty in nursing is fascinating to explore. Sovereignty involves both the legal right and the ability to exercise power. From a legal rights perspective, we have to power to practice within the state defined scope of practice under our independant licensure.

    Do we have the ability to exercise our power as nurses?

    You both raise valid points and bring great ideas for facilitating power:

    * Educating nurses about political action, healthcare policy and economics.
    * Encouraging nurses to join and become involved in state and national organizations that lobby
    for nurses at state and national legislative venues.

    We all know there are limits to the education that can be achieved in formal academic settings. But, nurses are life-long learners. How can we educate them to these very powerful and liberating concepts outside of academia? What is the best way to deliver this information and spark a fire for change so that nurses can get the ability to exercise power?

    I remember the 1960’s and 70’s and the power of the people speaking out during the civil and women’s rights movements at public and government rallies…What about the power of nurses speaking out?


  5. Wendy and Thomas, I appreciate your thoughts here. One thing that occurred to me this morning is of course how we educate pre-licensure nurses at the ADN level. Originally the ADN level of education was designed to move nursing education out of the hospital-diploma based system and toward academia, as well as to address the nursing shortage. As an ADN educated nurse, I appreciate the amount of clinical experience I gained, though I also wonder about its relevance to my true practice as an RN. This brings to mind questions of how we measure entry level competency and how we support nurses to be lifelong learners.

    Meanwhile, professions such as pharmacy and physical therapy are requiring ever greater entry into practice, at the “doctoral” level. I do believe that if we require ADN nurses to get their BSN or MSN within 5-10 years post licensure, we would see a level of nurses that are more empowered to address the current healthcare economic situation (or perhaps crisis is a better term here) and to create emancipated practices. We also know that as nursing education increases, patient mortality decreases.

    So what would it take to make this a reality? I know Canada has some success in this area as do Australia and New Zealand. I also feel like this is one of those “strange loop” issues I wrote about in my nursing shortage article in ANS; we just keep going around and around and never creating any real change to the entry into practice. Would it help if ANA/ NLN took a clear stance and stated that by the year 2025 BSN would be the entry level? Do we need national legislation to address this? Should there be an NCLEX-RNII exam, which nurses take upon completing the BSN to become recognized as a “professional” nurse?


  6. Interesting points and suggestions. I have considered that there is strength in our educational process and maybe we do have it right; with varying entry levels, mulitple certification specialites, and terminating in doctoral degrees. Is educational diversity really detrimental to us? Or is it our inability to form a large cohesive political group that exerts its power (communicative energy for action) to advocate for socio-economic and healthcare policy change that can advance our profession?


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