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A sustainable nursing workforce

The Differences That Divide Us: Is talk of reconciliation in the academy only talk?
—Amy S. Lang, Associate Professor, Graduate Institute of the Liberal Arts

While the practice of nursing is as old as humanity, the discipline of nursing is quite young. The idea that women needed to be trained as nurses is most closely associated with the work and influence of Florence Nightingale, and the first U.S. schools based on her model opened in the 1870s. Nursing education moved from hospitals to universities in the mid-1920s, and the number of baccalaureate programs in nursing remained small until the 1960s. The first doctoral programs in nursing were established in the early 1920s, but they were housed in schools of education and focused on preparing nurse faculty and administrators. The first comprehensive doctoral programs were not established until the mid-1960s.

Since that time, a serious shortage of nurses has evolved into the most pressing issue the field now faces. It is the result of multiple factors—most obviously, that fewer young people are choosing a nursing career. In the past five years, 25 percent fewer students enrolled in baccalaureate nursing programs in 2000 than in 1995. That trend—combined with the fact that the average age of a nurse in practice is about forty-five and the average age of nurse faculty in higher education is close to fifty-five—points to the problem before nursing and the public.

A combination of social factors has contributed to declining enrollments. Nursing has traditionally been a female dominated profession and, at least in Western societies, young women have a much greater range of career choices than in the last half- or even quarter-century. Female enrollment in medical, law, business, and engineering schools has increased dramatically. Employ-ment opportunities for nurses outside of hospitals are expanding as community-based health care settings, pharmaceutical firms, law offices, and insurance companies seek nurses’ expertise. The salaries of nurses in traditional hospital roles have not begun to keep pace with the salaries of other professions, and unlike many other professions, nurses’ salaries tend to top out rather early in the career trajectory.

Public understanding of nursing tends to be very limited. If the average person is asked what a nurse does, he or she is most likely to respond that the nurse follows the doctor’s orders. They rarely realize that nurses assess the patient’s condition, make critical decisions, provide life-saving interventions, teach patients and families about caring for themselves, provide comfort and support, and remain with patients during some of the worst and best moments in human existence. Most people with no direct connection to health care are surprised to learn that nurses can earn advanced degrees that prepare them to provide primary care, be leaders in health care agencies, influence the formation of health care policy, and do research that can determine best health care practices.

Oddly, while the general public has a poor understanding of what nursing is, nurses are rated highly among professionals whom the public trust. It has been said that if nurses do their job well, their work is invisible. You only miss it when it’s not there. Changes in health care financing and concomitant changes in the way health care needs are met have had a tremendous impact on the working conditions for hospital nurses. Anyone with recent hospitalization experiences can usually relate some incident in which a nurse was needed but not available. Only the sickest patients are admitted to hospitals today, and those who have had surgery stay for very short periods. Consequently, hospitals resemble large intensive care units. Unfortunately, this situation contributes to burnout, fatigue, frustration, and errors. The stories that appear in the newspapers and on the evening news do little to attract young people to nursing.

The nursing shortage is just as serious in developing countries as in industrialized nations. It is no overstatement to say that the health of the world population is at risk due to the shortage of educated nurses to provide the care, teaching, and prevention needed to sustain and improve the health of people around the world. Marla Salmon, Dean of the School of Nursing, has been instrumental in partnering the school with a number of key national and international groups to sponsor an invitational international forum for government chief nursing officers, national nursing association leaders, and human resource directors and health planners to come together at the Carter Center to discuss the topic of “Global Nursing Partnerships: Strategies for a Sustainable Nursing Workforce.” Several hundred nurse leaders from every part of the world will attend the October conference.

Nursing education: more or less?

The nursing shortage has sparked major debates both within and beyond the discipline. Some suggest a quick fix, such as shorter programs or less stringent admission requirements. In the face of sicker hospital patients, impressively complex technology that enables restored health and function to those whose illness or injuries would have been fatal just a decade ago, and the potential for genetically based treatments in the near future, a lesser-prepared nurse hardly seems to be the answer. In fact, greater effort is needed to upgrade the education of nurses who currently practice with less than a baccalaureate-level education. In addition, there is a growing need for nurses with advanced-practice credentials in both primary and acute care settings and for doctorally prepared nurses to conduct clinical research and teach the next generation of nurses.

The minimum academic credential required for eligibility to write the licensure examination has been debated for at least fifty years. In 1965, the American Nurses’ Association called for the baccalaureate degree to be the basic requirement for licensure eligibility. Yet as recently as 1996, only 32 percent of registered nurses held a bachelor of science in nursing, 34 percent held associate’s degrees from community colleges, 24 percent held diplomas from hospital-based programs, 9 percent held master’s degrees, and less than 1 percent held doctoral degrees. While the number of hospital-based diploma programs has decreased over time, they are still an option. Students may also earn an associate’s degree in nursing from community colleges in two to three years or attend a senior college or university for a baccalaureate degree. The persistence of multiple levels of entry into nursing probably contributes to the public’s lack of understanding of what nurses are capable of doing.

If there is a generational debate in nursing, it focuses on educational level more than anything else. Older nurses are more likely to have a diploma or associate’s degree in nursing. They may resent the fact that new, better-educated nurses typically advance in rank beyond what they have achieved after years on the job. Nurses with advanced-practice (graduate) degrees tend to fare better due to a level of expertise that gives them both credibility and autonomy. These nurses also tend to be better able to work effectively with physicians and other health care professionals.

Emerging scholarship

Lest the reader think the picture is totally bleak, there are a number of positive trends in the discipline of nursing. Students entering nursing now have deliberately chosen to do so. It has gained respect as a legitimate field of academic inquiry. Nursing research has evolved from social science-based studies of nurses to the physiological, biological, and behavioral science-based study of how nursing affects patient care outcomes. Funding sources have expanded from primarily federal sources to include ones such as the American Heart Association, the American Cancer Society, or the Alzheimer’s Association. Nurse researchers conduct studies ranging from cellular-level explorations to animal model experiments and clinical nursing interventions designed to alleviate human suffering. Nurse researchers contribute to the body of knowledge that supports health care practice. They have improved the quality of life of patients from infancy through old age.

By its very nature, nursing is interdisciplinary. Nursing education is built on a foundation in the humanities, the social and behavioral sciences, and the physical and biological sciences. Nursing practice combines this general education with nursing theory and content to teach students to provide care to individuals, families, and communities. Nurses often have primary responsibility for coordinating care and treatment of patients, and consequently, they must be able to establish collaborative working relationships with the many different disciplines that provide necessary components of patient care.

Nursing as a practice discipline and as an academic discipline has come a long way in a relatively short time. The challenges include continuing to contribute to the evolution of the discipline, educating the public about what nursing is and what it can be, attracting bright young men and women who want to make a difference in the lives of others, and ultimately improving the health of people everywhere.