The changing face of nursing

Now, as throughout history, providing the best possible patient care is the theme that tops most nurses' agendas. So, it's not surprising that practices, problems, and concerns that interfere with nurses' ability to do that work become the issues that capture their attention. Although health care trends move across the country at various rates, concerns about the changing workplace, the changing workforce and workplace safety affect most nurses at one time or another.

"First and foremost [on nurses' minds] is probably the whole issue of quality care and 'How do you assure that you are still giving patients quality care? when health care is in the middle of a revolution in terms of restructuring and redesigning,'" said Gayle Whitman, R.N., an associate professor at the University of Pittsburgh School of Nursing. "And I think the dilemma that health care administrators are facing is that we are really not sure what the right answer is."

Changes in hospital patients' acuity levels, in the lengths of most hospital stays, types of available care facilities, and health care providers' mergers and acquisitions all can affect how patients receive care. "I've been a bedside nurse by choice for 27 years, and I love touching and being with patients. That's our focus," said Teresa Stone, president of the Oregon Nurses Association and chair of the State Nurses Association Labor Coalition. "But I have watched the [health care industry] focus on the bottom line. They are interested in how they can save money, and many times it's at the expense of patient care."

As the ultimate caregivers, R.N.'s are watching hospitals metamorphasize into intensive care units, Stone said. Such changes mean that nurses deal with patients of higher acuity, have larger workloads and have fewer resources.

"One of the primary concerns right now is providing patient care when we see so many cuts in health care taking place," said Ruth Shumaker, R.N., president of the American Association of Operating Room Nurses. "That's not just a concern of perioperative nurses; that is a concern globally for all nurses. And it should be."

Adaptability

Changing roles and uncertain futures, therefore, weigh on many nurses' minds. "The dilemma is that while there is lots of chaos out there, people want to see the structure of what the future is going to be," said Whitman, who worked in hospital administration for 23 years. "And, unfortunately, we can't give them that. So they are trying to deal with issues of giving quality care in an environment that is unsettled."

As a result, nurses are distracted by worries about whether they will have jobs tomorrow and what those jobs will entail. The reality of staffing data today, however, suggests that their worries are unfounded.

"I think what the data shows is that there has clearly been an overall increase in the number of jobs in hospitals," said Whitman. Despite the uncertainty, she sees the changing scene as a good opportunity. "I think we are going to come out on the other side of this with better systems of how we deliver care."

Part of the goal to find the best way to deliver care includes determining how many R.N.'s will be needed and how they will fit into the care continuum. "I think that there is real concern about whether we have an oversupply or an under-supply of nurses," said Virginia Trotter Betts, senior advisor to the assistant secretary for health and senior advisor on nursing policy in the U.S. Department of Health and Human Services.

Betts, for one, is predicting a nursing shortage. "The shortage is not just a shortage of R.N.-licensed individuals, but a shortage of nurses prepared for what the health care system is going to look like," she said. "That means having a very broad education, a minimum of a baccalaureate degree and [the ability] to move into ambulatory and community settings because the health care delivery system is reorienting where they're delivering care."

Education

For nurses already in the workforce, changes in care settings may require them to pursue additional training or consider working in an environment different than what they had intended.

"There is a whole burgeoning industry for nurses in subacute and extended care facilities, such as nursing homes," Whitman said. She points to the new practice of hospitals discharging patients to other facilities for treatments such as physical therapy. "In those institutions, which are relatively new in the last five-to-eight years, there are a number of openings for R.N.'s to think about."

For nursing students, workplace changes may require them to pursue different education options.

"We have too many associate degree nurses and not enough baccalaureate's and master's [degrees] and doctorate's," said Patricia L. Starck, a John P. McGovern professor and dean of the school of nursing at The University of Texas-Houston Health Science Center. "Our data shows that only 15% of those people go on to earn a bachelor's degree, so it's not even a good feeder mechanism to get more of what you need."

"The associate degree programs are very highly focused on secondary hospital services, and that's not really where care is being given anymore," Betts explained. "Care is being given in highly complex tertiary centers and it's being given in more community-oriented centers, such as public health, ambulatory settings and nursing homes."

She noted that the Department of Health and Human Services' division of nursing is looking for innovative programs that will quickly give L.P.N.'s the schooling necessary to attain a baccalaureate degree, as well as other options. "I think we would like to put money into master's degrees that are very clinically oriented and/or management oriented toward the new kinds of health care systems that we are getting - not hospitals as much as maybe managed care companies, and community care nursing organizations," she said.

Age and experience

But no matter how much schooling students pursue, experience is an important part of the mix, as new nurses just out of school discover. "When I see advertisements for good [nursing] salaries, it's for experienced nurses-nurses who really know how the system works," Betts adds. "And that's a combination of education, credentials and front-line, hands-on experience."

However, an aging nursing population is a concern for many in the field. Starck noted that while the average age of nurses is in the 40s, the average age for nursing faculty members is in the 50s. At Houston, Starck noted that they encourage graduates to get some experience in the field and return to a master's or Ph.D. program - to get new blood in the faculty.

Betts agreed that the nursing workforce is aging - a fact that adds to the dilemma of envisioning the future workforce. "I think it's very hard to be a very experienced, very competent nurse in your 40s and still be expected to work a 12-hour shift, running up and down a floor where there is already a high level of emotional intensity," Betts said. "I think the aging of all of us health care professionals is an issue that hasn't been fully understood." PR

Tracy Baumann is a St.Paul, MN-based freelance writer.