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To the Editors:

In "Challenges to Professionalism: Work Integrity and the Call to Renew and Strengthen the Social Contract of the Professions" (January 2005:78–80,84), nurses and physicians are urged to become active, visible players in the political process regarding healthcare. Apparently, the book by William Sullivan relates how this can be achieved.

If the article is a sample of the book’s content, I will never read it. Dr Sullivan and Dr Benner are undoubtedly worthy intellects. However, their points could have been made in sentences of less than 51 words.

The article is a striking example of the way in which the leaders and scholars in nursing fail to clearly state ways for nurses at the bedside to survive their workdays. Nurses at the bedside of members of the public work every day to provide safe conduct for these people. They do this in the midst of a shadowy limbo made up of the professional world of art and science and the business world of budgets and high demand for services.

Nurses need more information on how to be positive in the workplace in the face of short staffing, dangerous assignments, and colleagues who take delight in destroying the confidence of new nurses. Nurses will not be able to contribute to the public value if they continue to be victims of the evolving struggle between healthcare and business.

Surely nursing scholars can do more than study the professions. They must go to the state legislatures and to Washington, DC, to state what must be done in the evolutionary process between healthcare and business. Nurses at the bedside are counting on them.

Mary Wolf, RN, CCRN
Endicott, NY

The Author Replies

I regret that our column did not speak to you more directly and clearly. And I appreciate the passion and concern for patients in your letter. The thesis of the column I wrote with Dr Sullivan is that the commercialism in healthcare and the standardization of work based upon the business model of healthcare impedes the capacity of institutions to provide professional staff the resources and time that they need to ensure the "safe conduct" of patients. In order to demand more than a market-driven view of healthcare, we need more than a technical view of the work of practicing nurses, physicians, and professional managers. Central to professionalism are civic responsibilities to the patient and to society. Society needs to provide healthcare institutions designed to facilitate and support good practice, and not impede it. Institutions need to be fit for good practice, avoiding unreasonable work demands that endanger the lives of patients.

I agree that leaders and scholars need to be politically active, just as every practicing nurse also needs to be politically active. But scholars and researchers need to arm lobbyists and activists with the most intelligent approaches to solving the complex problems that professionals face in working with integrity—the very possibility of acting on their best judgment and concerns for the patient’s well-being. Increasingly, hospitals operate in very competitive environments with runaway healthcare costs. Often, efficiency takes precedence over effectiveness and safety. As Mary Wolf so strongly points out, nurses, against all odds, must find a way to "be more positive in the work environment in the face of short staffing and dangerous work assignments and colleagues who take delight in destroying the confidence of new nurses." I believe that professional nurses must unite to set limits on the "demands to be positive" against all odds and in the face of dangerous assignments. The goal is not necessarily to be "more positive" but rather more demanding of the institution, for the sake of our patients and good practice...not in the name of "customer satisfaction" but in the name of safety and integrity of patients and families.

If we continue to design our healthcare institutions in ways that frustrate good practice, then we will further erode the possibility of good practice and civic professionalism. Professionals must have the opportunity to continually improve practice, not to be in the position of practicing against all odds.

Patricia Benner, RN, PhD

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