How to regulate nursing? Professional self regulation is being challenged by many factors within and outside nursing. At an international conference on regulation, held before the recent International Council of Nurses' Congress in Taiwan, NZNO's chief executive put the case for a new model of professional regulation, which draws on nursing's innate strengths and, in turn, strengthens the profession.

Professional self-regulation is commonly understood to be an essential element of professionalism. As nurses in New Zealand, we generally accept without quesiton the notion that this element if provided for by the establishment and activity of the Nursing Council. But is it? A review of this operational model of professional regulations shows that a number of other factors are at least as significant in their importance in determining the quality and safety of nursing practice. Such review is essential because the real test of regulation is not in its theoretical conceptualisation but in its operation. What matters to nurses and to the public is how regulation works in practice. And in practice nurses have experienced real and substantila problems with regulation. Those problems impact on the public both in terms of safety and public confident in nursing.

When I refer to professional self regulation, I mean in essence regulation by a body of nurses, established under statute, for the purpose of regulating scope of practice, establishing title, setting educational standards for entry to practice and assuring ongoing quality of practice. I am not referring to those more comprehensive conceptual models, which have been well articulated by Margretta Styles and Fadwa Affara in the International Council of Nurses' publication, International Council of Nurses On Regulation: Towards 21st Century Models. (1) This contains a thorough, intelligent and comprehensive exposition of the issues of regulation. The traditional model of professional self-regulation rests on the ethic of service to the public. Self-regulation enables the profession to embrace this ethic voluntarily and freely, with all the elements of regulatory process under its authority.

The ideal expression of the model is where members of the profession voluntarily establish the standards and processes required to ensure its members practise safely and effectively. The profession establishes a regulatory body comprising selected members. It gives that body authority over all members of the profession on matters pertaining to education and practice standards. The regulatory body is fully of the profession and answerable to it. The regulatory body looks to the profession to inform it on professional ethics, standards of practice and for refreshment of its underpinning philosophy and knowledge. Thus in the ideal expression of the traditional model, regulatory authorities are set apart by the profession to do the work of regulation, but are fully of and informed by the profession in their work. The forms of nursing regulation found in practice depart from this ideal to varying degrees. Commonly found departures include:

* Regulation is imposed from outside the profession rather than being voluntary.

* The members of the regulatory body are not chosen by the profession at large.

* The regulatory body has limits placed on its authority to determine all aspects of regulation.

* Regulatory bodies act as if they were the profession itself.

These departures challenge the notion of professional self-regulation to varying degrees. More significant are challenges posed by factors operating in the world of nursing practise that act to prevent nurses practising according to the standards of their profession. These factors can be of such importance as to render the actions of the formal regulatory body more or less irrelevant.

External factors affecting regulation

The first and most obvious group of such external factors are general regulations and practices governing the employment of nurses. These often are of greater significance in determining the nature and quality of professional practice than are the actions of the legislated regulator. Two examples are where:

* Nurses are employed in insufficient numbers to enable them individually or collectively to meet professional standards of care.

* Nurses have insufficient authority over their own work to ensure they can always practise to the standards of their profession. The second group of external factors constraining the effectiveness of nurse regulatory bodies are those arising from the regulation of markets and trade. Some examples are:

* The price paid for nurses' labour is artificially constrained, effectively reducing the supply of nurses. The resulting nursing shortage, in turn, becomes a powerful influence for reducing professional standards, opening scopes of professional practice to non-professionals and for the liberalisation of statutory regulation.

* The economic policy of free trade and the proliferation of free trade agreements--bilateral, multi lateral and potentially global--treat nursing and nurses as services for trade. Trade negotiations in pursuit of economic objectives typically regard the actions of national regulatory bodies as barriers to free trade. An important action in trade liberalisation is the dismantling of professional regulation both nationally and globally. The prospect of a "globally recognised, culture-free nurse", available at Low cost in large numbers is, from a global trade perspective, a desirable and realistic solution to the problem of a nursing labour shortage.

* Health reforms based on economic rationalism have similar detrimental effects on nursing because they, too, treat professional authority, professional autonomy and professional standards as barriers to the operation of a free market in health services. The invisibility or even the absence of professions in the workplace is desirable from this narrow economic perspective.

The effect of these external factors on the practice of nurses and on the nursing profession is a mismatch between the work and purpose of self-regulation (public safety through professional autonomy) and the reality of the world in which nurses practise. Nursing sets its own standards but is unable to enforce the means by which those standards are achieved.

The inevitable result of this mismatch is a raft of outcomes with serious consequences for nurses and the public. These include:

* poor patient outcomes;

* dissatisfied and burned out nurses;

* nurses disciplined by their regulatory authority for failing to uphold professional standards;

* public disenchantment with professional self-regulation; and

* actions to still further constrain professional self-regulation.

Of course, the imposition of further constraints on self regulation simply worsens the mismatch between the work of regulatory bodies and standards of practice. In this way, a cycle of deteriorating regulatory effectiveness is set in motion. The challenge to professional self-regulation and the challenge to nursing is to break this cycle and restore the assurance of safe and effective nursing practice.

A new conception of professional regulation is required that responds to the realities faced by practitioners and is built on the natural strengths of nursing. What might be the key elements required in such a model of professional regulation?

An effective model of regulation will have three underpinning elements: (i) it will be founded on the fundamental professional ethic of public service; (ii) it will be centred upon the realities of nursing practice; and (iii) it will recognise and strengthen nursing as a whole.

Foundation in public service: The ethic of public good must be the foundation of an effective model of nursing regulation. By very deliberately focusing all professional activity on achievement of the public good, the power of the public will be naturally aligned with building the power of nursing to do that good. If nursing fails to maintain this focus, then it foregoes both its inherent power base and its authority.

Primacy of practice: Nursing only meets social needs when it is applied in practice. Because practice is the primary function of nursing, an effective model of regulation will take this as its second key element. Nursing research, nursing policy, nursing education and so on are essential professional activities but if nursing practice is poor, all these activities are worthless. Whenever nursing practice is rendered less visible, then claiming authority over regulation is problematic. An effective model of nursing regulation will honour nursing practice as the focus of all professional activity.

Strengthening the whole profession: The third key element of an effective model of nursing regulation is that it will treat nursing as a fully integrated whole. Nursing is a profession of many parts and its strength lies in the integration of those parts. Conversely, weakness comes from fragmentation, yet as a profession we often attend more to differences that fragment us, than the shared values and objectives that unite us.

The work of nursing regulatory bodies, nursing labour organisations and nursing professional associations are often seen as naturally opposed to each other. However, the reality is there is more in common among us than there is in contention.

Labour issues make no sense unless they are informed by professional and regulatory thinking and requirements. Professional issues are left adrift if they are not connected to workplace and regulatory realities. Regulatory issues are empty noise if they are not composed with professional and workplace understanding.

Debate will and should arise when considering issues from these different perspectives and it is in resolving those differences that fully practical and useful professional advancement will occur.

The challenges to professional self-regulation are real and they are powerful. The effect of those challenges is so great as to render traditional regulatory processes more or less irrelevant to nursing practice and to the achievement of the public good. The traditional model of nursing regulation is a failing model and efforts to mitigate the signs of that failure tend to intensify the cycle of failure, rather than correct it. A new model of professional regulation is required. The key features of that new model lie in recognising the inherent strengths within the nature of nursing itself.

Such a model may require a substantial redesign of the systems and processes, not only of nursing regulation but also of nursing structures as a whole. However, the risk of not embarking upon such redesign is that the profession of nursing may become irrelevant.

This article is from a presentation Geoff Annals gave to an international conference on regulation held immediately before the International Council of Nurses' quadrennial congress in Taipei in late May.

Reference

(1) Styles, M. and Affara, F. (1997) ICN on Regulation: Towards 21st Century Models. The third in a series on regulation. Geneva: International Council of Nurses.