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ursing as a profession faces important problems, as can be seen by the conflicting S

s attached to the current situation, in which nurses are better-educated than ever a
still expected to ''serve at the bedside''. An overview of the future of nursing is v
with input from health professionals in administrative, research, and academic e
Nurses, in general, prefer to work in more personalized settings than the large, 21st- d
spital is likely to offer. The pressures in such institutions are discussed. In coming P
es will face a variety of non-hospital job choices, including peer review organizations,
surance companies, outpatient and home care, rehabilitative care, hospice work, and
administration. Rural areas, which have experienced even more nursing shortages
attract nurses with nursing diplomas or associate degrees, rather than academic
s rural hospitals close, the numbers of these nurses, who are dedicated to hospital
windles. Nurses are badly needed in nursing homes, where they currently make up
rcent of the total patient care staff. Military and community health nursing are also
A key question for the nursing profession of tomorrow is the degree of independence
attain. Some specialists within nursing, such as nurse anesthetists, have moved in
on, but are still largely excluded from affluent, urban communities. At issue are legal
and reimbursement. Physicians, as can be imagined, resist such trends. The worst
ould be erosion of the public trust in both professions. Nursing shortages are ...
, and the movement of licensed practical nurses, licensed vocational nurses, men, Cult
ies into the ranks of registered nurses is occurring very slowly. The reasons for this ure
sed. The nursing profession remains stratified by class and income; the modern care
on of these attributes are differences in educational levels. Basic issues concerning theo
entities as people who care, and people who are professionals, further complicate the ry
ursing. (Consumer Summary produced by Reliance Medical Information, Inc.) ca...
===================================================== leini

OPYRIGHT American Medical Association 1990

reaking the Bonds? IN SPITE OF nursing's historic ability to beat the odds, and its
rd of accomplishment and growing power, the profession's future is uncertain. It is, 1
f health care, facing restricted funding, work force shortages, rationing, and political 6
nursing faces specific dilemmas that have plagued it for more than 100 years: what
who should practice it, with what preparation, and in what setting. The profession has
wered these questions to its own satisfaction, much less to the satisfaction of anyone
e nursing whatever it is is so essential to health care, its problems can easily become
ms of health care as a whole. That has been demonstrated by the domino effect of the
sing shortage on other providers. It therefore seems likely that as nursing seeks to
ed stand about its own future, a great many other interests will want to be involved.

estion is what the pratice of nursing will consist of in the 21st century. Nurses work in
ng in health care and have been educated in a plethora of ways. Furthermore, two of
ctories in the 1980s were a significant increase in the average pay of a registered
, and a massive increase in the proportion of nurses who hold some type of academic
anwhile, the practice of nursing, especially in institutions, continues to include both
e and nonclinical tasks, much to the nurse's discomfiture.

question arises of whether the better-paid, better-educated nurses of tomorrow will

vide patient care "at the bedside" and whether health care will be able to afford their
To Carolyn Roberts, MBA, a nurse who is president and chief executive officer of
morial Hospital, Morrisville, Vt, this is a key issue of nursing identity: "In most
many nurses want very much to be independent practitioners and decision makers;
t to be old-fashioned nurses providing bedside care. That causes us as many internal
s any physician-nurse comflict."
e are those individuals who believe that nurses will want to stay in direct patient care.
EdD, president of the American Nurses' Association, says: "People go into nursing to
rectly to the sick; they don't want to move away from that unless they see a real
r have a real affinity for another role."

dnash, PhD, executive director of the American Association of Colleges of Nursing

ds: "There is research documenting the benefit of having individuals prepared at even
s level providing care in the acute and other setting. The benefits of increased quality
care provided by advanced clinicians will become more obvious, and there will be a
ment to bring these nurses into direct care in institutions."

er hand, says Marjorie Meehan, RN, operations division director of the Denver (Colo)
t of Health and Hospitals, "there is no way to keep highly educated nurses at the
ose who think we can afford it will die deluded. Hospital administrators still want
er their thumbs. But if nurses get the money they deserve, there will be fewer of
e patient's bedside."

ds that new technology could make it easier for nurses to work in hospitals: "With
performing more technical tasks, there could be only one nurse on every ward to
monitors but will people go into nursing to do that?"

o leave the bedside, says the American Medical Association's senior vice president M.
rz, MD, someone will replace them. "Nurses will go into administration and other
will move far away from the bedside, instead supervising those who do provide
are; but there will be people providing that care."
entury Hospital

st majority of nurses still working in hospitals, this question is pivotal to the future of
are. And the larger issue is how many nurses will want to work in 21st-century
any capacity.

ugh, PhD, director, Center for the Study of the History of Nursing, University of
ia, Philadelphia, says: "It seems perfectly obvious that new nurses will not work in
ms if they have a choice; hospital nursing will simply have to be reformed."

n, JD, RN, executive director of the American Organization of Nurse Executives, an

he American Hospital Association, fears that "the hospital may not have provided the
atisfaction for its professional nursing staff that other settings peer review
ns, ambulatory care clinics, home health services can provide. The hospital must
it has strategies in place that can meet the needs of registered nurses."

se strategies, she says, must be a top-level recognition by hospital leaders that "a
t a nurse is not a nurse. The future of hopital nursing, in my opinion, lies in better
on of RN roles that matches the competence, education, and experience of nurses to
le roles. The goal should be to use the right RN for the right work in the right way.
not widgets that can be shuffled around indiscriminately."

ker, RN, vice president for nursing of Queen's Medical Center, Honolulu, Hawaii, is
"Hospital nursing has a good future, I think. Nurses will continue to find satisfaction
hin an organized structure. they will involve the patient and family more in decision
wever and they will have more autonomy in making decisions and policy."

es underscore the issue of greater autonomy within the hospital organization.

fact, goes so far as to envision "in my dreams, a 'nurses' hospital,' where we would
rals to physicians. I have often thought that patients come to hospitals, basically,
ey need nursing care. "

ospital nursing survives in anything resembling its current form will depend on more
s. Roberts says: "The onus rests very strongly with the executive leadership and the
ard. If they really support good quality of life for hospital staff, and if physicians and
icipate in the organization then a good relationship can develop."

Meehan, hospital nursing could deteriorate into " a kind of purgatory for entry-level
which it would be obligatory that they spend 3 to 5 years before they can move on to
and more prestigios work."

rses forsake hospitals, says Andrew Jameton, PhD, associate professor of medical
ce and humanities, University of Nebraska Medical Center, Omaha, hospital nursing
to resemble what he calls "the K Mark model." As has been done with salespeople in
ores, he says, hospitals could "take as many nurses off the floor as possible, so the
main are well recompensed and professional, but are never available."

ld nurses go? Opportunities are multiplying; the situation is a far cry from the late
ry, when private-duty nursing was virtually the only choice. Connie Curran, EdD, RN,
researcher and principal with the Curran Group, Chicago, Ill, says: "Experienced
being heavily recruited by insurance companies, peer review organizations,
tical firms, and other employers. And the nurses are so thrilled to have regular, 9-to-
at they don't even ask for much money."

ure opportunities will be more outpatient care, says Cheryl Easley, PhD, chair,
t of Community Health Nursing, Rush University, Chicago, Ill. "As more patients want
me, care outside the hospital will increase. If nothing else, there will be a continuing
yers to force as much care as possible out of institutions."

e, RN, a US Army colonel and chief of the nursing division, Fort Sam Houston, San
ex, says: "More opportunities will open up in fields such as rehabilitation, nursing
d hospice. And as the population ages, there will be more need for geriatric care,
outstanding field for nursing."

Ferguson, RN, deputy assistant chief medical director for nursing programs of the US
t of Veterans Affairs, geriatric care is the future of nursing: "We should seize the
to provide elegant services to the elderly and those with chronic illness."

here is pessimism among nurses who are also hospital administrators that nurses will
ministration. That would end a long tradition; between 1909 and 1920, an estimated
spital administrators were nurses, according to Susan Reverby, PhD, director of
udies at Wellesley (Mass) College.
C.J. Parnell, superintendent of the University Hospital in Ann Arbor, Mich, who in
lained that most physicians who went into hospital administration were "medical
whereas "the reason for the almost univeral employment of trained nurses as hospital
has been simply that a higher quality of intelligence could be purchased for the
n could be secured in the service of men in the positions" (Reverby S. Ordered to
York, NY: Cambridge University Press; 1987:106).

wever, says Sister Marie Madeleine, RN, president of St John's Hospital and Health
nta Monica, Calif, "I don't see nurses seeking executive positions in hospitals,
was hoping that would happen. There are too many other options that provide a more
edule for one's personal life."

rees, adding that "the correlation between having a nursing back ground and being a
ministrator is more historical than current, although nurses, if they have a leadership
e very good at it. My few years of nursing school have been very important to me in

s that are available to nurses today are not just divided among what type of work or
of patient is involved. Where one wishes to work, and for whom, is also a facotr. The
ome forms of employment for nurses seems unsettled, although there is much
mong potential employers.
rural health care, which is suffering an even greater shortage of nurses than urban
ording to Toby Turner, RN, senior staff associate at the National Rural Health
. "In rural areas, there is more of a concentration of diploma and associate degree
o, by virtue of their education and training, are geared toward hospital practice, so
to cluster around hospitals," she says. The recent decline in the number of rural
us affects the supply of nurses.

e hospitals remain, she says, many are small and therefore have difficulty staffing for
varying occupancy. As a result, many rural hospital nurses are employed part-time,
es problems for them in terms of employee benefits and quality of life.

s also have a thinner support network, she says, citing both fewer nursing assistants
ians to take referrals. As a result, "there is a need for nurses who function in
oles, such as nurse practitioners and nurse midwives. There is also a tremedous need
anagement and social services; the social side of health is simply more important in

ural health is facing enormous problems across the board; the future availability and
sing in these areas is only one of them and is unlike to be solved except in that

ea, long neglected by society, is nursing home care whose time is coming, according
ezey, EdD, professor of gerontological nursing at the University of Pennsylvania. She
the irony that in the many institutions known as nursing homes, there are, in fact,
gistered nurses.

approximately 19 000 nursing homes, with 700 000 personnel providing some type of
personal care services in them," Mezey says. "Only 7% of total employees are RNs
f total nursing staff. Most of the nursing staff are orderlies, aides, and LPNs [licensed

g home patients older and more intensely ill than they have ever been, she says, this
unacceptable. She argues that every nursing home should have "a resident
l nurse provider, who should be a specialist a geriatric nurse practitioner. Yet there
y only 1500 geriatric nurse practitioners in the country; we need between 6000 and

mes the current situation on lack of federal requirements for nurses in these
, along with social stigmas associated with longterm care. But, she adds, if nurses go
pe of work, "they enjoy it."

rsing is facing its share of problems, Burke says, but she reports "an increase in
Although there is a shortage of nurses at the moment, she says, "I envision no
the future.

he believes that an intentionally collegial environment is one draw: new military

k with a preceptor who provides support and continuing training before the new nurse
work independently.

hat RNs are commissioned officers, which is greater recognition than they are often
n civilian life. Furthermore, she says, there's one thing about military health care:
elongs to the same service. "Nurses work very closely with physicians and enjoy
and respect. Our patients are military, our physicians are military, our nurses are
e speak the same language, and we have the same mission. It is a very comfortable
hich to provide care."

he same qualities enhance the future prospects for Department of Veterans Affairs
rguson says. She points out that this system "is already the largest organized nursing
he free world, with 62 000 nursing personnel, of whom more than 36 000 are RNs."

, too, is dealing with nursing shortages, she says, "but what we have going for us is
a career-oriented service. One does not come here and get a good salary for the first
as bottomed out by the third year."

ment of Veterans Affairs also has built greater nurse autonomy into its system, she
ell as offering high administrative posts in many psychiatric and long-term care
nurses. Like most large systems, the department also offers extensive mobility within

erguson sees as its trump card in the race to recruit nurses is that her system is
ing for the patients of the future: the elderly, the frail, the chronically ill, and the
he system, therefore, offers both experience and a higher level of pay than civilian
care settings. "These are cutting-edge areas of care, and we have distinguished
n developing and providing it."

Health Nursing

m of public-sector work community health nursing may be staging a comeback after

estigious place in health care eroded earlier in this century. Easley ascribes some of
e to the omnipresent limits of public funds: "It used t be that the public health nurse
ut and visit a new mother with a baby or a family that might be at risk. Then funds
nd nurses could not go out into the community much."

says, "nurses are starting to do that outreach again." Although that promises a
ure, she says, it is always

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