What's in a title?

In many countries around the world there has been a long and often difficult struggle to get the title Nurse or Registered Nurse protected through legislation. Governments have supported the profession in taking this step to provide a means of standardizing practice and ensuring its quality for the citizens of that country. For nurses this has helped in providing recognition of the profession as well as a means of setting standards of education, a code of practice and often a much stronger voice when seeking to influence health and educational reform. In the United Kingdom (UK) at this time, new pay arrangements are being introduced for nurses and other health workers (Department of Health 2004). The new arrangements provide for both job evaluation and the introduction of a knowledge and skills framework that can be used to support life-long learning and continuous professional development. As a Nurse Director of a large health service in the north-east of Scotland, employing in excess of 7000 nurses, this is a major exercise. Scrutiny of job descriptions has driven home the shear magnitude of diversity of job titles that are now used by our profession. This is not a phenomenon unique to the UK. Examination of the biographical details of those publishing papers in international nursing journals reinforces the fact that such diversity is a global issue. Nursing is not alone in this drive towards using highly differentiated titles for the work done by healthcare professionals. Medical staff have used specialist titles for a long time and we as a profession could be accused, again, of following on the heels of medical colleagues. The use of medical classification of disease using nomenclature such as diabetes or asthma is, it could be argued, far too common nowadays in the job title of the nurse! Is this diversity of titles a problem? Why is it happening and should we do something about it? These are questions the profession should debate and take action upon rather than drift into a position where confusion is created unintentionally within the profession, across related health disciplines, and for the wider public. Talking to patients and members of both the nursing profession and colleague disciplines, it is clear that the use of titles such as ‘emergency practitioner’, ‘first responder’ and ‘practice educator’ can cause confusion. Patients are not sure about the root qualification or level of practice that is being offered by the people ascribed with these titles. Are they nurses, paramedics, pharmacists or doctors? With no common and easily understood frame of reference, the patient is often uncertain about what to expect or whether the individual is properly qualified to meet their particular needs. Amongst professionals there is also confusion. Colleagues can be taken aback when someone introduces themselves by one of the myriad titles that now abound, often stimulating responses such as ‘What do you actually do?’ or ‘How does your role fit with the rest of the team?’ With health service redesign and modernization being at the top of policy agendas in so many countries, it is not surprising that roles are changing and new ones being introduced, and the number and complexity of new titles are ever-increasing. Although the use of disease classification coupled with the adjunct ‘specialist nurse’ or ‘nurse specialist’ does not create the same degree of confusion, it does however raise a different set of issues. In a society where increasingly many of those patients seeking care are elderly with multiple pathologies, what can the patient with three or four diagnoses expect from a nurse with a single disease-label title? Can they expect to have all their needs met or only those relating to the singular focus indicated on nurse's name badge? Nursing has always prided itself on its ability to meet the holistic needs of the individual, so should we be worried about the accelerating development of specialization? If the nursing profession is to avoid developing in a fragmented manner then there is a need for a clear and coherent career structure that has genuine meaning for the public as well as the profession. So perhaps there is more in a title than we would at first think. Being clear about who we are and what we do is at the heart of professional accountability. Enabling others to judge us from an informed position is not only important in terms of empowering patients, but also should be seen as a mark of a vibrant and confident profession. Yes, there is more than we think in a title. Perhaps the time has come to agree a coherent career framework that can guide our profession's future evolution.