THE FUTURE NURSING VOICE

Based on some articles in the journal Nursing Ethics, the author outlines some of the areas of major importance for nursing in the future. These areas – the care of elderly people, long-term home-based care, genetics, international research and conflict and war – demand a new voice of nursing, which is a political voice. The rationale for a political voice is the ICN Code of ethics for nurses and the fourfold responsibilities laid on nurses: to promote health, to prevent illness, to restore health, and to alleviate suffering. Some indications are given on how nurses can engage in political work.


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Based on some articles in the journal Nursing Ethics, the author outlines some of the areas of major importance for nursing in the future.These areas -the care of elderly people, long-term home-based care, genetics, international research and conflict and war -demand a new voice of nursing, which is a political voice.The rationale for a political voice is the ICN Code of ethics for nurses and the fourfold responsibilities laid on nurses: to promote health, to prevent illness, to restore health, and to alleviate suffering.Some indications are given on how nurses can engage in political work.

INTRODUCTION
Nurses have long complained that their collective voice is not heard.It may be retorted that nurses do not sufficiently use the voice they do have at present.In recent years a nursing voice has become evident, but it is not necessarily the voice that nurses themselves thought they had.This 'new' voice is a political voice.
As editor of the international journal Nursing Ethics I am in a privileged position.Most articles written for journals are of the kind that lead the field in their subject.
New thinking is developed in articles, new research uncovers trends and shapes practice.This present article is based on some of the trends that I have noticed in the articles I receive or have commissioned for the journal.
The future for nursing lies in some distinctive areas: 1) the care of the increasing population of older people (1) .
2) Care will be in the home for people with long-term illness (2) .3) Issues of genetics will play a major part in health care (3) .4) Medical and nursing research will guide practice, but that research is international and multicultural (4) , putting into practice the slogan 'think globally, act locally'.Research is also a delicate subject, therefore needs to be carried out with great care.5) Nurses world wide are caring for people who are suffering the consequences of conflict and disasters, leading them to foster non-violent ways of resolution (5)   .The ICN Code of Ethics for Nurses (6) imparts on nurses the four-fold responsibility to 'promote health, to prevent illness, to restore health and to alleviate suffering'.All these issues and concern can and must be seen in a wider perspective of global health and well being.This is where the political nursing voice is increasingly needed to be heard.

THE CARE OF OLDER PEOPLE
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In all industrialised countries, people are living longer.It is estimated that in Japan, 26% of people will be aged 65 or over by 2025 (8) and in the USA the number of people over 65 will increase by 35% by the year 2020 (9) .A significant factor in western countries is the degree of isolation in the older population.In Great Britain in 2000, in the 65-74 age group, 19% of men and 37% of women lived alone, and 33% of men and 60% of women aged 75 and over lived alone (10) .
Living alone is often a choice, but it increases the morbidity and possible misery of growing older.Older people may be happier to live alone where they can continue with routines and habits of a lifetime.Leila Shotton (1) gives a good example of this.She describes how in some homes for elderly people the residents were forced to get up at 04.30 h to suit the routines of the staff, and were then left to sit in chairs for hours, even though this exacerbated their medical conditions.'In the rural village of my birth, the elderly people resident in the local nursing home, however, complained because they were not allowed to rise at [04.30 h], as they had done all their lives in order to attend to their cattle in the fields' (p 14).
The independence of older people is a well known factor in their well being.With more people living at home into late old age, more nurses will be visiting them at home to tend to their health needs.Nurses are therefore important advocates for individuals and groups at various levels of social and health care.It is possible that care of elderly people will become one of the main areas of work for nurses in the future.A cynic pointed out that much of nursing care will change -fewer in-patient stays, better surgical techniques, more technology and less hands-on carebut care of elderly people will always be there, guaranteeing job security.Working with older people, however, is more than 'just a job'; it is demanding work.Older people have to be understood and in order to be their effective advocates, nurses have to use imagination and ingenuity.Since care of older people will be a major aspect of nursing in the future, nurses need to learn to care for this group of people and not see this work as less valuable, as is often the case at present.
Lou Ellen Barnes et al (8) had studied the role of public health nurses' perceptions and concerns about the implications of Japan's long-term insurance law concerning the care provision for elderly people and their families.They found that there were problems concerning the lack of funding of the programme, funds being directed to groups of people rather than to individuals, a lack of diverse care facilities, and patients and families not seeking the care services to which they were entitled.These types of problems are recognised in most industrialised countries.
What the public health nurses learned from the study and

CARE IN THE HOME FOR PEOPLE WITH LONG-TERM ILLNESS
Many conditions combine to create the situation where in the future most people will be cared for at home, and much of that care will be long-term.People living longer means that some of them will be ill longer.Hospitals will be used increasingly for shorter stays where treatments are quicker and less invasive.Recovery from operations or treatments will be in the home.The increasing morbidity from chronic illnesses, such as diabetes, heart disease, obesity and other diseases caused mainly by lifestyle, require care in the home in the first instance.In most parts of the world, infectious diseases are still not controlled, and therefore beyond the scope of organised or planned care, demanding families to care for each other.
Hirschfeld (2) says that '[t]he burden of long-term caregiving is borne primarily by women who generally have very little access to, or control of, the resources needed to assume this responsibility' (p.103).Nurses may not visit homes very often where someone is cared for, but they may need to act as sources of information and support, especially for women carers.
While nursing is increasingly a specialised task, there is a strong point to be made for 'generalist' nurses (11) .
Such nurses may work from bases in the community, much as family practitioners do now (12) .They may need simply to be available, as much as doing practical work.Such nurses may truly serve a community and be spokespersons for the community.Given that long-term care in the home mostly falls on women, the role of women nurses may be crucial in keeping families and communities functioning through networks of friends and supporters of carers.

ISSUES OF GENETICS
Genetics, the science of heredity, has been known and used for many centuries, but it is only in recent decades that it has become possible to manipulate the genetic code of all living things, seemingly endlessly, and to various uses.While few nurses in the foreseeable future will be directly involved with either the science or the techniques of genetics, many will be (or are already) caring for people receiving some type of therapy based on genetics.
Genetics will affect nursing indirectly, possibly in drastic ways.
Nurses need to understand the scientific basis of genetics for any care to be valid.They need to be familiar with ethical and legal issues surrounding the technologies.
Many nurses will be approached by patients and clients for explanations, teaching, and possibly with decisions surrounding issues of their care.Social issues will be more widely debated and perhaps be more controversial, especially in the area of health insurance and prospects for jobs and work (14) .This is such a rapidly changing field In these roles, nurses may be called upon to help parents and patients in decision making of many kinds, thus directly and indirectly guiding the values of society (3) .
They may be called upon to advise ethics committees and give evidence to parliamentary and police investigations, and be members of workgroups and forums where opinions are shaped and formed.At present it is still the scientists who dominate such committees, but as always, it is the nurses who have most of the actual contact with the people involved, therefore it is becoming increasingly necessary that nurses see their work extending into the policyformation area.The four responsibilities are clearly evident here: promoting health, preventing illness, restoring health and alleviating suffering are all part of this work.It is through the work with individuals that the implications for the whole of society become evident, and it is in reaching the wider society that nurses can better care for individuals.

NURSING RESEARCH
Any nursing action has increasingly to be seen and understood to be accountable and also evidencebased.This involves nurses in research of their own, and as participants with other health care professionals.Of its very nature, research has an international dimension, even when carried out very locally.Sources of literature, methods, and findings are shared world wide, and most research participants (subjects) are from various cultural and ethnic backgrounds.Many research projects are carried out in many countries at the same time (15) .
Much nursing research is of a qualitative nature.
Quantitative and scientific or technical research will always need to be balanced by qualitative research.Any study about human physiology needs the personal story of the person concerned to interpret the context.Research participants give away aspects of themselves, their lives, feelings, experiences, and crucially their time and goodwill, in an effort to help others.This altruism must be respected and seen as something entrusted to researchers as a gift (16) .Researchers therefore have professional, ethical and legal obligations to keep to standards that enhance the persons with whom they research, as well as their own profession.In particular, the aspects specifically concerned with research -but especially international nursing research -are '1) respect for persons; 2) beneficence; 3) justice; 4) respect for community; and 5) contextual caring' (2) , p. 125).The first three principles are part of the canon of western bioethics.It is the fourth and fifth principles that need more attention.The fourth principle asks of '[r]esearchers and research ethics committees [to] consider the effects of possible results on a community's self-conception, altered perceptions outside the community, changes to health care delivery methods by implementing results of potential problems with implementing results, as well as any effects on the entire community arising from individual participation' (2) (p.126).
The differences in cultural understanding of ethics depend largely on the basic interpretation of the self: in American-European cultures the self is an individual self; in most other cultures it is largely a relational self (17)  nurses played a large part, such as the (in)famous Tuskegee study (18) .Despite tighter controls and scrutiny, it is still easy enough for investigators to use studies for their own ends eventually.Nurses have particular duties to see that their patients and clients do not come to harm, and in the area of research, they have a significant role as protectors of and gatekeepers for often vulnerable groups of people.
This dimension is addressed in the fifth principle mentioned: that of contextual caring.This involves more than beneficence in that it specifically draws upon the researcher's personal values.This 'principle of caring concern encourages the consideration of what good can and may be done for another to whom one feels responsible beyond the obligatory dictates of what must and must not be done' (2) (p.126).An understanding of the international, cultural and ethnic dimensions of research are significant parts of the four-fold responsibilities laid on nurses, to promote health, to prevent illness, to restore health and to alleviate suffering, and to do this consciously, willingly, and with respect for the needs of individuals and communities.Being informed on issues concerning one's work and specialty is a professional duty.Reading is therefore an important part of nursing and caring.Wide and eclectic reading is a necessary part of being a 'skilled companion'.

CONFLICT AND DISASTERS
This article is being written while the debates world wide are increasingly agonising if there should be a war on According to Kofi Annan, the Secretary-General of the United Nations, '[w]e must make conflict prevention the cornerstone of collective security in the twenty-first century.
That will not be achieved by grand gestures, or by shortterm thinking.It requires us to change deeply ingrained attitudes' (19) (p.xix).The agony over a possible war on Iraq is that the 'deeply ingrained attitudes' are hard to shift and that the non-violent ways of conflict resolution have not yet been recognised as good enough examples for dealing with 'terror'.Churchill's famous phrase 'To jaw-jaw is better than to war-war' (20) (meaning: talking is better than making war) is quoted but not yet applied frequently.
Nurses are daily caring for people who have suffered some form of violence or conflict, be this in the home, the work place, as soldiers, refugees and migrants, and many other possibilities.Many nurses in mental health know all too well the emotional, psychological and spiritual scars left on people, perhaps for the rest of their lives.In many of these settings nurses use every skill they have to restore health and alleviate suffering.What nurses need to do increasingly, in the face of conflict, war and violence, is to promote health and prevent illness.This means deliberately taking on the advocacy role that is relevant to one's sphere of influence.This sphere is much wider than most people believe possible, and a group of people can be even more effective than a single individual.It will need an understanding of the dynamics of the situation.This, however, is what the political voice of nursing is about, and this is how changes of attitudes come about.
Vibeke Sjøgreen and colleagues (21) make the important point that the mere assumption that nursing staff must be able to 'control' conflict can lead to conflict.A better approach is to focus on how conflict can be used constructively as an opportunity for development for both patients and staff.They argue that working with conflict and prevention of violence is a collective responsibility.In this area in particular, the collective nursing voice is urgent, effective, and important for the global future.The public trusts nurses, and nurses need to continue and enhance this trust by speaking for the public they serve.

GAINING THE FUTURE POLITICAL VOICE OF NURSING
In the topics touched on in this article -and there are many others that will shape future nursing work -the For nurses to have a political voice, it is important that they are listened to, but they need to speak in such a way that others will want to listen to them.They need to speak with a practical as well as an ethical voice.They have this voice only because of their experience, and this needs to be available to those who have the power to influence and change a situation.However, most importantly, nurses have to believe that they themselves can and need to make the changes that lead to a future of better and more humane care.
Undergraduate education has to prepare nurses for their work, and as part of that, it has to teach effective communication.Nurses need to learn to appreciate their professional duties in the local, national and international arena.Nurses have to learn management and committee work, and how to be effective in these.They need to learn how to engage with their members of parliament, in order to make themselves heard.It is much easier to engage someone in a dialogue when there is some positive issue at hand, than when there is a problem.
The ICN is the body that speaks for nurses globally.However, the world over, people will have heard of the World Medical Association, but probably not of the International Council of Nurses, even though there are far more nurses world wide than physicians.There are numerous reasons for this that cannot be addressed here.
The need is now for nursing to become as politically effective as medicine is, because the need for nursing care will grow and change in the future.This means that individual nurses -and the whole profession of nursing -put into action in far more obvious ways the 'preventive' or 'up-stream' responsibilities laid on them by the ICN.
-Nurses need to lobby their national nursing organisations to be active on national health issues.When an issue arises, call your organisation and ask them what they are doing about it.
-Nurses need to give interviews to and write in local newspapers about local health concerns.Patient confidentiality needs always to be respected, but there are numerous other issues that need to be addressed publicly, such as local access to facilities.Ask who your local health journalist is and get to know him or her.
-Nurses need to lobby their members of parliament on national issues.Be sure to know the person's name and write to him or her; they have to reply.Sign petitions for national issues.
-Nurses need to get elected in local committees of management, ethics, buildings, resources, finances.
Unless the nursing voice is heard, it will be lost.Most relevant committees are requested to have a nurse representative; put yourself forward as a candidate.
-Student nurses need to ask for placements in different countries and cultures.In this way, new visions are created and prejudices reduced.Where friendships are established, there is a lower likelihood of conflict.
-Global issues, such as infectious diseases, poverty, malnutrition, violence against women (and nurses) and many others are present in every country.Research will often bring such issues to light.Engage in research of issues at the boundaries of tradition, the acceptable and the not yet acceptable, and what may be politically 'correct'.
-Nurses have a duty to make concerns known by reporting them the person who is capable of managing them.
Consider your actions carefully, and don't take no for an answer.
-Read and write, make your voice heard.Ask questions on behalf of others, be aware of the impact you can have.

Rev
Latino-am Enfermagem 2003 julho-agosto; 11(4):413-9 www.eerp.usp.br/rlaenfThe future... Tschudin V.their work was that they were taking on new functions, such as working with local government officials, in order to deal with resource allocations, and to establish health promotion programmes.The care of older people is not simply caring for an individual person, but necessitates political activity and knowledge.If nurses are to fulfil their four-fold responsibilities vis-à-vis older people, then they have to enhance their physical and mental well being by fostering their purpose in life and their place in the families and communities in which they live.This will involve nurses in discussions and negotiations at various levels of local, national and international government.It will often mean listening to the stories older people have to tell.When they are needed and welcomed and they have a valued place in the society in which they feel at home, older people's physical and mental health is promoted, illness is less likely, health may be restored and physical and mental suffering can be alleviated.Whenever people are respected for who and what they are, a fundamental human need is fulfilled that enhances all parties involved.
Iraq or not.Perhaps no other war has had so much said about it in advance by individuals, groups and governments, weighing every possible aspect in the balance of reason, justice, or need.Many of the comments have concentrated on the human and environmental costs that war and conflict bring in their wake.The destruction of individual lives, communities and societies is inevitable, creating refugee camps in neighbouring countries and leading vast numbers of people migrating and seeking new opportunities in distant parts of the world.Infrastructures are destroyed, reducing livelihoods to subsistence.The physical and mental health consequences affect people and communities for decades, and even for generations.Wars have become brutal in their magnitude and increasingly unjust in their reasons.
Question and understand the reasons behind rules and challenge the rules if they are not helpful for good patient care.Keep your goals in mind and pursue them.Respond to department and government documents.-All nursing care is 'up-stream' work, i.e. changing the conditions to improve the present.Political work is consciously, obviously and deliberately doing something about it.
science and technology that it is barely possible to speculate what may be involved even in the foreseeable future.Some aspects can be considered, however.
of individuals.They may be asked to care for babies or children born with severe defects whose parents may not want them and who may be shunned for having allowed such children to come to birth, thus not having conformed to some social pressures to have prenatal testing.The desire to have a child as a donor of tissue or cells to save a sibling may become more acceptable.