Challenges for the Nursing Profession: Today and Tomorrow, Term Paper Example

Abstract

Few professions are as complex, demanding, and subject to scrutiny than that of professional nursing.  Moreover, the field has undergone radical transformations in regard to how it is viewed both by the public and by working nurses, as the traditional, typically female “support system” long in place has given way to the modern, highly skilled, healthcare professional.  It is likely that the role of the nurse will further evolve to meet the demands of shifting societies and restructurings of healthcare itself.  Nonetheless, the job must reflect, always, the integrity, caring, and training which has rendered it unique from its recognized beginnings.  No challenge can effectively thwart the dedicated nurse, as challenge itself is a component in the calling.

Introduction

In a very real sense, nursing retains an aspect which has, ironically, hampered its status from the start: it is more of a calling and a true vocation than a career.  The motivations that influence a nurse are unlike any other, even within the vast expanse of healthcare; they are deeply internal, and born from an innate desire, if not need, to be of service to the ill.  That this sense of service is not directed to acquiring the rank of physician, and is typically more content to provide a pervasive, all-encompassing care, has of itself created difficulties for nurses, even as it has ennobled the profession.

The impediments lie, as they historically have, in a public perception that the nurse is a “lesser” entity in care.  The education and training required are not at the level of the doctor or the specialist, and this contributes to a general lessening of esteem.  Then, the simple fact that caring is built into the role diffuses its stature.  People tend to equate the nurse with a maternal presence, or they actually seek to do so; the nurse is viewed, ideally and commonly, as someone there, attentive, moderately knowledgeable, and only minimally effective in addressing real illness.  The job is respected, but only to a point, and there is a widespread feeling, abetted by centuries of nurses maintained in subservient positions, that the functions of the work are those which any relatively capable person could do, were they so inclined to be in a fully supportive role.

Some of these perceptions are not unfounded.  As noted, caring and support are integral to the profession.  Nonetheless, an extraordinary amount of skill is required to properly administer these services, and modern life and current health care issues are expanding the role of the nurse in necessary and constructive ways.  In a surprising irony, today’s world has generated a great deal of suspicion regarding top healthcare professionals and the organizations which they inhabit.  Doctors, once venerated and deemed somewhat infallible, have suffered extensive losses of prestige and trust.  The nurse, conversely, has risen in public estimation, chiefly due to a consistent application of professionalism and concern.  Moreover, today’s nurses are no longer content to occupy passive roles, and the advanced training they receive translates into a more vocal and more pronounced presence in the healthcare industry.  As the field of healthcare itself continues to evolve, it is probable that the nurse, long an insufficiently appreciated component within it, will surface as the crucial foundation to the industry and service that he or she has always been.

Calling and Career: Historical Overview

No proper understanding of how nurses are perceived today can be had without a sense of the varied and unusual historical circumstances which gave rise to the actual career.  That a great deal of even the most modern perceptions still rely, at least somewhat, on these traditional foundations goes in large measure to the emotional, cultural, and psychological factors which have always served to define the work.

If, for example, certain modern notions see the nurse as lacking in exacting medical training, it is likely a residual – and inaccurately persistent – belief carried on from the earliest manifestations of the work.  The earliest American institutions for healthcare were, naturally enough, devised from European models, both before and after the Revolutionary War.  As religious life vastly informed the European cultures for many centuries, so too did it reflect how the treating of the sick was understood and performed, and monasteries were, in essence, the first “hospitals”.  Interestingly, in these days before the advent of the Reformation of the sixteenth century, “nursing’ was largely the work of men and women equally.  That is to say, monks tended to the sick as frequently as did nuns, for the religious orders were expected to do so  (Judd, Sitzman, Davis, 2009,  p. 12).

The destruction of the European monasteries in the wake of the reformation shattered the societies of virtually every nation, and in more ways than one.  As the free and charitable work of the monks and nuns was no longer in place, the foundation of ethical principle guiding those institutions was gone as well, and the “almshouse”, or primitive hospital, was born.  The work became menial as these hospitals were poorly funded and disgracefully managed, and the drudgery of the nursing work was, in accordance with the gender expectations of the era, now allotted to laywomen.  In these years, and lasting well into the nineteenth century,  the image and role of the nurse underwent vast changes, and none for the good.  These were ordinarily very poor women with no regard for patient welfare, or worse: “Judges in the legal system began giving prostitutes, publicly intoxicated women, or poverty-stricken women the option of going to jail…or working in the hospitals” (Judd, et al., 13).  These centuries were very likely the “dark ages” of what was, and would be again, a noble and essential profession.

What becomes evident in an overview of these periods is, in fact, not so much that nursing suffered under enormous burdens and limitations, but that it had not actually yet been defined by any reasonable standard of professionalism.  Once the philosophical and moral guidance of the church’s role in tending to the sick was removed, the “nurse” essentially ceased to exist.  The calling of the nun or monk had translated to that of the nurse; as the first was eliminated in the society, the second disappeared.  Then, as the work was corrupted, so too was its designation, and nursing was, basically, anything that could be had in terms of a physical presence in a sick room.  No better illustration of this can be found than that of the character of Sarah Gamp in Charles Dickens’s Martin Chuzzlewitt.  Dickens was a highly astute social commentator, and his Mrs. Gamp is a hired “nurse” who will take no job unless a bottle of alcohol is provided for her.  It is probable that Dickens modeled the lady on well-known, living examples of the type.

In the United States, as in much of Europe, the situation began to alter in the nineteenth century.  As with the growth of America itself, the changes were also of a somewhat rapid nature, dictated by the enormous spurts of growth occurring in the Northeast.  Cities were quickly expanding, social policies were not keeping pace with them, and public hospitals were as yet raw and undesirable places, usually gone to only for surgery.  Consequently,  in the middle years of the century, nursing was largely a home affair: “Home, irrespective of one’s place in the class, ethnic, and racial ordering of the city, still represented the best, safest, and most comforting site for treatment and care…” (D’Antonio, 2010,  p. 3).  Women, not unexpectedly, took on these burdens, as the men of the day were the providers.

If this early nursing was not, technically, an occupation, it must nonetheless be given the immense due it merits, for here was a returning to the ethical considerations which first informed the work as practiced by nuns and monks.  As will be noted, this traditional aspect has created dilemmas in modern nursing, in regard to its inherent reflection of a subservient role accorded to women.  The issue of gender roles has long plagued the nursing profession; it remains, in fact, something of a matter of debate, despite the modern proliferation of male nurses in the field.  What is essential to note, however, is that, in regard to the basic ideological foundations of nursing, gender may be viewed as irrelevant.  That is to say, it matters little that women were almost exclusively the initial forces in the transition of nursing into its recognizable form; what is important is that the crucial elements of empathy, caring, and diligence were established as necessary to it.

Arguably, nothing was more influential in promoting the first, organized, national efforts to transform nursing, or even create it as a viable occupation, than the American Civil War.  At that point, as noted, hospitals were reserved only for desperate circumstances of surgery, and there were no real provisions extant for the enormous numbers of wounded requiring care in both the North and the South.  Responding to need, President Lincoln set in place the United States Sanitary Commission and appointed a woman named Dorothy Dix to oversee it.  Her title was Superintendent of Women Nurses of the Army, and it was something of an enigmatic one, at best; there were no nurses to supervise.  Dix decided to act on her instincts and she began training programs, fortunately filled by female volunteers wishing to aid in the crisis, which concentrated on values, rather than medical skill.  Commitment to hygiene and evidence of good moral character were what she sought, and thousands of American women enlisted as nurses (Chitty, 2005, p. 5).

It is interesting to observe how these basic origins of what would evolve into modern nursing practice bear striking similarities to the ancient European models.  While Dix was not overly preoccupied with strictly religious backgrounds in her nurses, she nevertheless insisted on ethical and moral standards not dissimilar to those that guided the earlier nuns and monks.  Nursing was, in a sense, being reborn in the United States, but the philosophical basis for it reflected the same principles of service, caring, self-sacrifice, and duty.

By the 1870s, professional nursing schools were in place in the major metropolitan areas.  What would become a vital branch of modern healthcare was being refined, with each change reflecting the advances in medical knowledge occurring.  Moreover, something else was at play; for the first time in history, nursing was a respected occupation, or career, and no longer either an ancillary aspect of a religious life, an extension of home responsibilities, or a last resort for desperate women.  Women nurses would be, and for quite some time, seen as “second-class” practitioners in health care, denied the respects the profession inherently demands.  They now at least had, however, a profession.

These early roots are pivotal in regard to higher education for nursing.  Competency, of course, can only be enhanced by further training and acquired knowledge, but no good nurse may be unmindful of these foundations.  Technical ability is increasingly valued in nursing, as it must be.  To fail to keep pace with the array of innovations in healthcare produced by technologies is a disastrous course for even the most caring, dedicated nurse.  Conversely, however, no amount of proficiency can compensate for a lack of commitment, and at the most profound levels.  Nursing is, as stated, a calling, and never merely a career.  The early nurses of the American nineteenth century may have lacked education, but their services saved many lives and eased much pain.  The reality for nursing, as the field evolves, must always be one that pairs the advantages of education with a visceral and potent desire, or need, to do the work.

An Adage Reexamined

Be it a residue of folklore or otherwise, the saying that, “a nurse is a nurse is a nurse”, somehow persists, and virtually globally.  As with most maxims, there is an intrinsic duality to it; interpretation may be made both favorably or of a derogatory nature, depending upon the attitude of the speaker of it.

The most obvious question to be asked is: is this true?  It is.  Moreover, when peered at intently, the duality itself tends to fade from the meaning.  On first examination, for instance, there is something dismaying in the saying.  The words themselves, merely a triple repetition of a simple statement, seem to convey a flatness.  There is no horizon to this statement, but only a dull fact, and this serves to convey a limited, unattractive, and disparaging impression of the role.  It says, plainly, that a nurse can never be anything but a nurse, and this intrinsic confinement does not generate much in the way of “promise”,  or of great things coming.

Another look, however, reveals something far more substantial, for the sentence is, in fact, a tribute.  This tribute, moreover, is due solely to the occupation mentioned.  By way of clarification, to assert that, “a genius is a genius is a genius”, is hardly an uncomplimentary statement.  All it avers is that, in certain cases, a person is defined by what he or she does, or is, and the real meaning is consequently wholly derived from that thing.  A genius is a genius because, it is implied, he or she cannot be anything other than that.  It is the essence of the person, and the thing that establishes real worth and the core of the individual.

To say the same, then, of a nurse is to admit to a similarly inescapable element of self.  A nurse is a nurse, etc., because there is within that person something which must always be a nurse.  To take a more contrary stance, an office manager is an office manager, yet an office manager may be, and very likely is, defined by more fundamental criteria.  An office manager is a good person or a bad person, and office managers do not merit such adages because the role referred to can never express what a person is.  With a nurse, it is different.  With a nurse, that irrefutable  component of the occupation as a true vocation, or calling, predominates, as it should.

A nurse may well be many things other than a nurse, but the work is and should be the most exact representation of his or her’s essence as a human being.  Ultimately, then, the adage, if clumsy and not especially clever, is correct.  It assesses the person and the role as one, which is as it should be for so important and humane an occupation.

Image Issues

In addressing how nursing is perceived by the public, the media, and by other fields, one factor invariably takes precedence, that of gender expectation.  Linked to this are other, culturally-imposed stereotypes, but they rely upon the widespread and still conventionally maintained image of the nurse as, before anything else, a woman.  This is as well something the occupation itself has engendered: “The image of itself that the nursing profession has presented and promoted is in ideological construct of white femininity that deeply pervades all levels of the profession” (Hallam, 2000, p. 124).  It is, in fact, somewhat remarkable that, in an age when the male nurse no longer raises eyebrows as an oddity, this image remains largely in place.

To begin to understand the reasoning behind this, it must first be understood that there is no real dichotomy in regard to public and media perception.  Even other disciplines may not be effectively removed from the other influences, regarding the image held of nursing.  Each plays into the other, as media portrayals reflect and reinforce public and commercial ideas.  If the image of the nurse is subject to bias, it is occurring on every playing field because they are all removed from nursing itself, and consequently prone to share, and promulgate, similar notions related to it.

In very general terms, the public esteems nurses as honorable and valuable professionals.  Beyond this, unfortunately, is no clearer persona or image, save for that of the white-capped female.  This image also fails to convey any of the levels within nursing, many of which even educated people are not aware.  In media presentations and/or as referred to in public forums, the licensed practical nurse, the registered nurse, and the advanced practice nurse are one and the same, and typically never more defined than as an“RN”, or registered nurse (Masters, 2005, p. 112).  It is reasonable to conclude that, for the public at large, what actually comprises registration is usually unknown, as well.

Two specific image issues are consequently raised by, and/or reinforce, the iconic image of the female nurse.  The first reflects expectation of behavior, and of a decidedly noble kind.  Nurses are viewed by the public and the media very much as police officers and firefighters are; that is, they are respected as servants of the society who voluntarily dedicate themselves to disagreeable, and sometimes dangerous, work to ensure the public good.  The nurse who is known to be one by his or her community will likely receive expressions of consideration and respect in daily life, and when not in uniform.  The image is, simply, an exalted one.  It is also more accessible; doctors command respect but, unlike the nurse, it is usually felt that they are not as in touch with ordinary people and ordinary living.  The nurse, to the public mind, is the healthcare worker who remains “one of the people”.

As may be expected, this sort of admiration must have its drawbacks.  More exactly, if people ordinarily do not anticipate overt caring from doctors because they are committed to more rigorous disciplines, the same warmth within the public regard for nurses carries with it expectations of them being, always, “on duty”.  The respect accorded to the nurse actually works against him or her, as the feeling that the profession is motivated by innate caring translates to a demand for that caring to be perpetually at the ready.  Empathy and dedication, ironically, stigmatize the nurse, for few allowances are made for the normal, human, sometimes unhelpful behaviors all people at times manifest.

This dilemma notwithstanding, there is a great deal to be said for the existing stereotype, for at least it acknowledges the essential worth of the profession.  The public and the media are notoriously adept at holding onto fixed conceptions of roles and performance in any known occupation.  Given the checkered history of the nursing profession, it is both remarkable and valid that its reputation remains one of high ethical standards and humane commitment; no matter past issues, this could only be the case if the majority of nurses actually evinced these qualities.

The other image issue relates to gender, and this is even more of a contradictory scenario.  That men are nurses is, as noted, a well known fact of modern living.  However, the same image expectation that nurses are, or should be, invariably female, creates a different stereotype here.  Male nurses have not weakened the gender stereotype, as might be anticipated.  On the contrary, they themselves suffer from it.  In basic terms, the phrase “male nurse” usually conjures in the average mind the image of a gay man.  There is absolutely no evidence that reveals a higher proportion of gay men within the profession, but the orientation label is widely attached nonetheless: “The general stereotype is that men who choose nursing must be gay and effeminate since they have chosen a career in so-called ‘women’s work’” (O’Lynn, Tranbarger, 2007, p. 257). It is to be hoped that only more time, and a continued infusion of men within the profession, will finally dispel the random and unjustified characterization.

This particular image issue, however, demands closer scrutiny.  Moreover, it goes to an element not especially in favor in modern culture, but which must be addressed as it relates to the very essence of nursing.  That is to say, the question becomes: why are nurses so insistently viewed as female, or feminine?  The obvious answer is that society, both in the past and currently, associates certain characteristics with female behavior, and these invariably tend toward nurturing, caring, and providing needed service.  It is difficult to set aside prevailing ideologies that view such assessments as sexist, but this must be done because, at least in terms of recorded human history, women generally do manifest these qualities to a far greater extent than do men.  As has been exhaustively studied, there is some substantial biology behind this as well, in regard to oxytocin output, etc.  This alone, coupled with the rather inescapable fact that women reproduce, validates any supposition that inclinations to care for others are more dominant in females.

What is, in fact, most interesting about the general perception of nurse gender is that something of a greater onus is then placed upon the nurse.  Not only is the female nurse expected to be always at the ready to be of assistance by virtue of her calling, her sex itself exponentially enhances the expectation.  Few other professions carry this degree of responsibility, and that it can be overbearing is evidenced in studies on nursing stress.  Naturally enough, the work itself provides a wide array of stress factors for nurses, including insufficient resources, emotional involvement with patients, and struggles with healthcare bureaucracies.  Added to this, however, is the substantial component of how the image of the nurse actually influences the working nurse, consciously or otherwise.  In other words, nurses are as vulnerable to public opinion as anyone, and many enter into the profession with a desire to be as consistently helpful as the image or stereotype presents.  This is a form of idealism not necessarily incorrect, but it can cripple a nursing career as unrealistic ideals confront the reality of the work (Thomas, 2009, p. 25).

If female nurses do indeed suffer from stress relating to image perceptions, as well as their own expectations of their performance, it is hardly surprising.  It is equally understandable, then, that one other stereotype of the nurse exists: that of the cold, hard, unsympathetic practitioner.   Confronted by unreasonable demands on their humane qualities and professional capacities, it is rational to assume that nurses may, for protection, fall back on a more business-like, unemotional approach to the work.  As may be evident, this image is largely negative, and seemingly at odds with what a nurse is believed to represent.  It is not as prevalent a stereotype as that of the kind, giving nurse, but the mere fact that it is exploited as such points to both unrealistic ambitions on the part of some nurses, and a lack of understanding from the public.

Nurses themselves, in fact, do not have to do a great deal to generate this stereotype, as that latter component of public feeling is more than enough to create the image.  People in hospital settings are typically at their most vulnerable, either as patient or as loved one.  In such scenarios, any failure on the nurse’s part to evince active caring may easily be interpreted as harshness, or unconcern.  For the nurse, it is very much a no-win scenario.

The nurse has one recourse, in regard to dealing with any image problem at all.  He or she must be committed to fulfilling the obligations of the job with absolutely no regard for such things.  No career of such import is served by an observance of potential reaction; nursing, especially, is too important for that.  Image, both exalting and tarnished, will attach itself to the profession regardless of efforts made to counter it, because public perception is both a removed and obstinate thing.  In place, it is not easily shaken or altered when it concerns something as vast as an entire vocation within healthcare.  It must never be the concern of the nurse.  What should be in its place is a realistic understanding of the demands of the work, paired with education and an innate desire to do it well.  By following this course, the nurse effectively eviscerates the power of image in the only sphere he or she may have impact on: their own.

Credentials and Education

As was noted, nursing has evolved from a virtually non-existent state to a regulated and honored one.  The nurse today has options unthinkable not very long ago, in regard to specific forms of practice and venue, as well as how independently he or she may wish to operate.  In basic terms, some form of licensing is necessary to practice, and state nursing boards determine the educational criteria needed to meet their own standards.  Beyond this, however, national accreditation provides both greater mobility and opportunity, and systems are in place by which state certified nurses may obtain licensure through national examinations, which permit them to practice in various states without being certified in them individually (Chitty, p. 557).

Nursing in the United States has, in a sense, grown up with the country.  That is to say, recent and major shifts in healthcare policies, both governmental and stemming from the private sectors, have greatly influenced the directions nurses may take.  “Telehealth”, for example, is the practice of nursing performed by means of information technologies, wherein the nurse is no longer restricted by physical barriers.  Then, nurses are acting upon the trends indicating a public preference for at-home, assisted care; hospitals are not equipped to maintain patients not in immediate distress, and the visiting nurse, either through actual visits or operating from within a nurse-run clinic, can provide the necessary, intermediate care.

That all nurses comply with certain standards of education and licensing is, of course, essential.  Moreover, there should be no ceiling as to educational opportunity for nurses.  The work is so varied, and so inextricably connected to all elements of healthcare, that virtually every branch of healthcare should afford the highest levels of nursing training.  What is most important in this scenario, however, is that nurses take an active role in determining both the educational needs and the avenues to achieving them.  Plainly, only a working nurse can know precisely what the job requires, if the job is to be done at its best, and this is a force which must be present, at least in some measure, in every regulatory agency.  Nursing has had to invent itself, after a fashion, going back to Dorothy Dix and her untrained volunteers.  There is great value in such a way of proceeding, despite initial drawbacks, because the realities are identified by those truly capable of doing so.  Moreover, as caring is an integral part of the vocation, it is not surprising that many nurses seek to instruct others (Chitty, p. 328).  This is a unique form of mentoring not evident in many other professions, and nursing should take full advantage of the natural impulse within it, to carry on and improve the work.

Leadership in Nursing

No name is more renowned in nursing than that of Florence Nightingale, and she merits the recognition by virtue of one single accomplishment, if by nothing else: she was responsible for the founding of the first school of nursing, in 1860.  Known as “the lady with the lamp” because of her nocturnal tours of the sleeping wounded, Barton virtually created the image of the nurse-as-ministering-angel so prevalent today.  What gets lost in this appraisal, however, was an apparent and fierce power of leadership.  When reports of how abominably the wounded were being treated in the Crimean War reached her in England, she assembled a team of nurses and crossed into the Russian territory.  This action taken by a woman of the day clearly reveals an extraordinary ability to lead, and her subsequent founding of the nursing school at St. Thomas’ Hospital was equally notable, and indicative of innate leadership abilities.

Nearly as well-known as Nightingale is Clara Barton, who founded the American Red Cross in 1881, having been inspired by the Swiss Red Cross.  As with Nightingale, the interesting fact remains that she is viewed as a model of caring, “womanly” nursing, yet she spent years in fighting for what she believed to be an essential and national organization (Crompton, 2009, p. 71).  Both of these legendary women established new parameters in nursing as an honorable and immensely valuable profession, but neither could have accomplished her ambitions without a vast degree of fortitude and a leader’s sense of forging new territory.  It appears that the accomplishment’s of each, moreover, were largely due to one characteristic: tenacity.

A nurse/leader of perhaps a different kind was Sister Elizabeth Kenny, from Australia.  Sister Kenny was not concerned with breaking ground, or even with defining the role of the nurse; she had a single enemy, polio, and she devoted her life to confronting far more powerful doctors in implementing better treatment for its victims. The prevalent wisdom was to keep infected limbs immobile, but Kenny was convinced that such inactivity further crippled the tissues.  For decades, she was ignored.  By 1941, however, when she demonstrated the physical proof of her more successful modes of treatment, she was recognized by the medical power structure of the day (Peters, 2005, p. 39).  Tenacity, here, was displayed to an extraordinary degree, and was the leadership quality that both finally gained for Kenny recognition and real help to polio sufferers.

Today, Jean Watson stands out as a pioneering nurse and leader, and what is most fascinating about this is that her Caring Theory, widely adopted in nursing communities internationally, is essentially founded on the most old-fashioned, if not stereotypical, concepts associated with nursing.  Watson evinces real leadership in holding to a conviction seemingly out of place in today’s science-driven world; that empathy is the cornerstone of nursing.  Moreover, her theory goes so far as to encompass the acceptance of miracles.  Dr. Watson currently maintains both the Watson Caring Science Institute and an honored chair at the University of Colorado, and her leadership is based on an unwavering commitment to humane values within nursing.

Conclusion

There is no escaping the regrettable reality that, as women have been traditionally minimized in regard to contributions to society, nursing, chiefly composed of the gender, has been equally viewed as an ancillary, if caring, component of healthcare.  Images persist of female nurses who are kind and committed, or harsh and unfeeling, and who invariably serve passive functions within a culture.  They are esteemed as public servants, yet abused as such as well.

What is important to note is that nursing has drastically evolved over the years.  This “passive” occupation, not so long ago a last resort for women facing jail, has been honed into a crucial and vastly influential element of living, and this is due to no one but the nurses themselves.  Called to the vocation by intense ambition and feeling, they have pursued education to achieve the goals they recognize as vital for the welfare of humanity.  Popular opinion may shift in time, either favorably or otherwise, regarding them, but the greater reality is that nurses will continue to do what they do.  Healthcare will evolve, certainly. As it does,  it is likely that the nurse, long an insufficiently appreciated component within it, will ultimately be recognized as the crucial foundation to the industry and service that he or she has always been.

References

Chitty, K. K.  (2005.)  Professional Nursing: Concepts and Challenges. St. Louis, MO:  Elsevier Health Services

Crompton, S. W. (2009.) Clara Barton: Humanitarian.  New york, NY: Chelsea House.

D’Antonio, P.  (2010.)  American Nursing: A History of Knowledge, Authority, and the Meaning of Work. Baltimore, MD: Johns Hopkins University Press.

Judd, D. M., Sitzman, K., & Davis, M. (2009.)  A History of American Nursing: Trends and Eras. Sudbury, MA: Jones and Bartlett Publishers.

Hallam, J. (2000.)  Nursing the Image: Media, Culture, and Professional Identity. New York, NY: Psychology Press.

Masters, K. (2005.)  Role Development in Professional Nursing Practice. Sudbury, MA: Jones and Bartlett Publishers.

O’Lynn, C. E., & Tranbarger, R. E. (2007.)  Men in Nursing: History, Challenges, and Opportunities. New york, NY: Springer Publishing Co., Inc.

Peters, S. T. (2005.)  The Battle Against Polio. Tarrytown, NY: Marshall Cavendish.

Thomas, S. P. (2009.)   Transforming Nurses’ Stress and Anger: Steps Toward Healing. New York, NY: Springer Publishing Company, Inc.