Preparation of community health nursing leaders for social action.

Indiana University School of Nursing graduate Department of Community Health Nursing has been preparing community health nurses for primary health care practice, as defined by the World Health Organization since 1978. The faculty are committed to preparing community health nursing leaders for social action aimed at improving the health of the community in both the Department's major in the master's programme and its new major in the doctoral programme. The core curricula for these majors in both programmes are presented. The master's curricula is based on integrating public health principles with those of community development. The doctoral major builds on this base of primary health care practice with a curriculum focused on the contribution of community health nursing to public and health policy. The graduates of the master's programme are prepared to work with community groups as a social force in promoting the health of the community. The graduates of the new doctoral major entitled "Health Policy and the Health of the Community" are being prepared as community health nursing leaders with expertise in health care policy and the legislative process with a focus on issues related to nursing and community health. These graduates will be able to function within the broader community, including national and international settings. Based on experiences in graduate education in community health nursing recommendations are made for the response graduate nursing education must make in order to prepare appropriate leaders who can work toward the goal of improving the community's health.

Strains in the nurse-doctor relationship.

Many problems and conflicts between nurses and doctors in the hospital stem from the organizational structure of the hospital rather than from the personalities of the individuals involved. Nurses often assert the latter. Understanding these conflicts requires that they be examined in terms of the organizational context within which they occur. To understand the modern American hospital it is useful to view its development. Private practitioners who at one time had cared for patients in their homes shifted the locus of care to the hospital as medical care became more complex in the latter half of the nineteenth century. Three selected aspects of hospital structure that are seen as sources of strain for nurses in their relationship with doctors are: (1) Doctors do not see themselves as full-fledged members of the hospital organization. While nurses, who do, feel bound by the operating rules of the hospital, doctors tend to operate as free agents. There is probably little that nurses can do to reduce this source of strain. (2) The hospital has two lines of authority, administrative and medical, unlike most large-scale organizations which have only one. Nurses are in the former while doctors are in the latter hierarchy. The "influence relationship" between nurses and doctors is largely unarticulated; informally "negotiated" patterns prevail. Nurses can be more aggressive in attempting to develop institutional patterns that are mutually satisfactory to themselves and to doctors and that meet the needs of the hospital as a whole. (3) In the absence of a functioning health team nurses have assumed responsibility, without the requisite authority, for the coordination of patient care. Although this action is for the immediate benefit of patients nurses should realize that it also tends to retard the development of needed organizational changes in the hospital. Nurses generally accept the possibility of changing the personality structure of an individual. They should be aware that in an analogous fashion organizations can change their structure. There is a dire need for hospital nurses to participate more actively and creatively in activities that can alter the existing hospital structures so that health personnel can more effectively bring the benefits of modern medical science and technology to their patients.