Betz, Linda

Crissman, Susan

English

The Catholic University of America Columbus School of Law

Journal of Contemporary Health Law & Policy (1985-2015) Volume 3 Issue 1 Article 14 1987 Education and Image: Critial Issues Confronting the Nursing Profession Susan Crissman Linda Betz Follow this and additional works at: https://scholarship.law.edu/jchlp Recommended Citation Susan Crissman & Linda Betz, Education and Image: Critial Issues Confronting the Nursing Profession, 3 J. Contemp. Health L. & Pol'y 179 (1987). Available at: https://scholarship.law.edu/jchlp/vol3/iss1/14 This Article is brought to you for free and open access by CUA Law Scholarship Repository. It has been accepted for inclusion in Journal of Contemporary Health Law & Policy (1985-2015) by an authorized editor of CUA Law Scholarship Repository. For more information, please contact edinger@law.edu. EDUCATION AND IMAGE: CRITICAL ISSUESCONFRONTING THE NURSINGPROFESSIONDr. Susan Crissman*and Linda Betz**Nursing is facing a turning point; a turning point which could well affectprecarious balances which currently exist in the health care delivery system.The essence of the problem is a dwindling number of nurses. This essayexplores two critical and related issues, education and image, and furtherposits that resolution of these issues must occur if the nursing profession isto regain its balance.The decrease in the number of nurses available today is largely due to therekindling of the nursing shortage which existed most recently in the late1970's and early 1980's. 1 At that time hospitals encountered increasing diffi-culty in recruiting and retaining nurses. Journals acknowledged the struggleto obtain nurses and hospitals reported the closing of beds and intenserecruiting campaigns.2At the same time federal budget cuts for nursing education were imple-mented.3 While hospitals searched for ways to address the shortage, de-creased funding drove many potential nurses away from nursing education.By early 1982 there were thirty-two states reporting shortages totaling ap-proximately 100,000 registered nurse ("RN") vacancies nationally.4With the nursing shortage in full swing, hospitals experienced a drasticchange of events which began with the advent of the revised Medicare regu-* Vice President, Memorial Hospital, South Bend, Indiana, Presbyterian UniversityHospital School of Nursing, Pittsburgh, PA, B.S.N., University of Pittsburgh, M.N. Ed,(Nursing Administration), University of Pittsburgh.** Standards & Systems Coordinator, Memorial Hospital, South Bend, Indiana, Memo-rial Hospital School of Nursing, B.S., Western Michigan University.1. Fagin, The National Shortage of Nurses. A Nursing Perspective, in NURSING IN THE1980's-CRISIS, OPPORTUNITY CHALLENGES 21 (L.H. Aiken & J.B. Lippencott eds. 1982).2. J. GOLDSMITH, CAN HOSPITALS SURVIVE? THE NEW COMPETITIVE HEALTH CAREMARKET 184 (1981).3. Keynote Address by Doris M. Armstrong at the Conference bn A Center for NursingInnovation (Mar. 17, 1982).4. Id.180 Journal of Contemporary Health Law and Policy [Vol. 3:179lations.5 As Medicare began its prospective payment system, and as man-aged care systems gained prominence, hospitals experienced decreasedadmissions and shorter lengths of stay.6 The resulting decreased patient vol-ume lowered the demand for nurses to the point that numerous hospitalswere forced to layoff nurses.Although the change in the Medicare payment mechanism temporarilylessened the demand for nurses, it now appears that the shortage is onceagain at hand. As the dust settles in the mid-80's, it is evident that theshortage is picking up where it left off. Professional journals are again re-flecting the difficulties experienced by hospitals in obtaining nurses to fillpositions, and hospitals have again reinstituted very active and costly re-cruitment campaigns.7 Nursing leaders are becoming convinced that theshortage will escalate over the next several years.8Changes within the health care delivery system itself are also contributingto the shortage. Alternative employment opportunities available to nursespull them away from the traditional but increasingly frenetic hospital set-ting. As occupancy rates and lengths of stay have declined, new and innova-tive outpatient services have developed. Emphasis is placed on home healthcare programs, intermediate treatment centers and freestanding outpatientservices. Alternative delivery systems are expanding as a replacement for, oran adjunct to, inpatient treatment and are literally taking nurses away fromthe traditional hospital settings.Nurses who care for hospitalized patients represent a wide cross section ofeducational backgrounds. Statistics from 1974 show that nurses employedin hospitals were primarily diploma school graduates (75%) followed byBachelor of Science in Nursing graduates ("BSN") (15%), Associate Di-ploma in Nursing graduates ("ADN") (6%), and Master of Science in Nurs-ing graduates ("MSN") (3%).9 By 1984 the percentage of diploma preparednurses had decreased to forty-two percent while nurses prepared at the Bac-calaureate level increased to twenty-four percent, ADN nurses increased totwenty-five percent, and MSN graduates reached four percent.l° While thenumber of BSN graduates reflects an increase of nine percent, the expecta-5. Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. No. 97-248, § 101-11, 96Stat. 324 (codified at 42 U.S.C. § 1395 (1982)).6. Patient Census Seen Declining in Most States, 84 AM. J. NURSING 1050 (1984).7. Demand for Critical Care Nurses Keeps Soaring: Crunch is Reaching Medical-SurgicalUnits Too, 86 AM. J. NURSING 1052 (1986).8. This position is derived from personal discussions with a number of peers in the nurs-ing profession.9. H. ROWLAND, THE NURSE'S ALMANAC 57 (1978).10. RN Ranks Grow to 2 Million Says HHS: New Survey Shows 20-Percent EmploymentRise, 86 AM. J. NURSING 603 (1986).Education and Imagetion of baccalaureate preparation for management positions decreases thepercentage of BSN graduates available for direct patient care. Further, theincrease in the number of BSN graduates incorporates many diploma andADN nurses who have returned to school to acquire a baccalaureate degreerather than an overall increase in the number of graduates from generic pro-grams."1 This essay will not explore the comparative merits of the 2+2 orthe Diploma/BSN completion approach as contrasted with a generic BSNprogram, but it is an issue for future consideration.Issues related to entry level plague the profession. Over sixty years agothe Goldmark Report recommended the transition of nursing educationfrom the hospital to institutions of higher education; a transition which hasgradually occurred. 2 For a number of reasons ranging from persistentshortages of nurses to the role of women in society, the nursing professionhas been unable to reconcile the lack of clarity within the educational sys-tems. In fact, the situation has become more complex.The concept of Associate Degree preparation for nursing emerged in 1952.In originating this concept, Mildred Montag expressed the premise thatnursing care is "a continuum ranging from simple tasks to complex care."' 3Therefore, she contended, there is room for varying levels of education tocare for varying patient needs.' 4 It is distressing to note that although levelsof competency vary with educational preparation, the nursing professioncontinues to license graduates of associate, diploma, and baccalaureate pro-grams equally as RNs.In efforts to differentiate performance expectations of nurses prepared atthe ADN and BSN levels, studies have been conducted which explore thecompetencies of the graduates of these programs. 5 The ADN graduate isprepared to use basic communication skills and to coordinate and organizecare. In contrast, the BSN graduate relies on complex skills in communica-tion, decision-making, and collaboration in the practice environment. A sig-nificant difference in roles, however, is in the area of patient outcomes.While the ADN graduate provides care for patients who have common,well-defined nursing diagnoses, the BSN graduate cares for patients withmultiple nursing diagnoses requiring coordination of complex situations.11. Rosenfeld, Nursing Education: Statistics You Can Use, 7 NURSING & HEALTH CARE327-29 (1986).12. E. ALEXANDER, NURSING ADMINISTRATION IN THE HOSPITAL HEALTH CARE SYS-TEM 9-13 (2d ed. C.V. Mosby eds. 1978).13. Pholman & Mosca, Should Nursing Implement the 1985 Resolution?, in CURRENTISSUES IN NURSING 150-52 (J. McCloskey & H. Grace eds. 1981).14. Id.15. MIDWEST ALLIANCE IN NURSING WORKSHOP, ADN/BSN COMPETENCIES IN THESERVICE/EDUCATION SETIING (Oct. 4, 1986).1987]182 Journal of Contemporary Health Law and Policy [Vol. 3:179Nurses prepared at the baccalaureate level have had the opportunity todevelop the required knowledge and abilities to meet the holistic needs of allpatients.' 6 In addition to expertise in the performance of tasks and use oftechnical equipment, they are able to demonstrate competence in applicationof nursing knowledge, patient teaching, and managing the psychosocial as-pects of illness. 17 Nurses prepared at the baccalaureate level should be adeptat decision-making and able to plan, organize, set priorities, and evaluatetheir own performance. Hopefully, they possess a willingness to assume re-sponsibility for their actions and the consequences of their decisions. Inshort, these nurses are outcome-oriented; they are able to identify the needsof the patient and take the necessary steps to achieve the desired goals.Today, patients who are hospitalized are acutely ill,' 8 requiring highly so-phisticated nursing intervention. Consequently, patients require a nursewho is able to analyze, synthesize, and integrate the wide array of physicaland emotional responses to illness. The nurse must collaborate with the pa-tient, physician, and others in identifying and reaching desired outcomes topromote and maintain health and wellness.While members of the nursing profession have always favored a registerednurse in the role of primary provider of bedside care, they could accept "as-sistants" caring for the less acutely ill patients who occupied their hospitalbeds ten years ago. However, the complexity of the care requirements oftoday's hospitalized patients forces the need for a registered nurse at thebedside, and in many instances, for a nurse who has been educationally pre-pared at the baccalaureate level.A bright spot in the dilemma is that experienced diploma and ADN-pre-pared nurses have developed clinical knowledge beyond their basic educa-tional preparation which enables them to skillfully care for the patient withcomplex needs. These nurses are to be commended for their insight anddiligence. Relying on individual nurses to educate themselves is, however, arisky way to ensure that patients are receiving appropriate care.The balance in nursing is becoming more precarious. Not only is there adecreasing number of registered nurses available today, but it is also distres-sing to note that the number of generic BSN graduates has not increasedsignificantly since 1980. Hospitals, with a growing need for nurses preparedat the baccalaureate level, may be forced to place other nurses in positions16. AMERICAN NURSES' ASSOCIATION COMMISSION ON NURSING EDUCATION, A CASEFOR BACCALAUREATE PREPARATION IN NURSING (1979).17. Houston & Cadenhead, DRGs and BSNs: The Case for the Baccalaureate Nurse, 17NURSING MGMT. 35-36 (Feb. 1986).18. AJN Survey Shows A New RN Shortage Sprouting: Rising Acuity, Falling EnrollmentAre Blamed, 86 AM. J. NURSING 961 (1986).Education and Imagefor which they are not adequately prepared. If the nursing profession al-lows this mismatch to continue, it may compromise the level of care pro-vided to patients.A second issue which must be addressed is that of image and the underly-ing, but far more complex, issue of self-esteem. Declining interest in nursingas a career can be attributed to expanding opportunities for women in otherprofessions. It is clear that women seeking career opportunities which fosterautonomy and the opportunity for advancement are choosing professionsother than nursing. The image of nursing held by potential applicants maywell be a significant factor in their decision not to choose nursing as a career.Much of what is known about the image of nursing comes from studies byKalisch which describe society's impression of nursing as ranging from the"angel of mercy" at the turn of the century to "sex objects" since the latesixties.19 Today the media image of nursing portrays a woman standing inthe background awaiting the physician's order.2" The nurse is seldomshown interacting with patients, physicians, or other health care profession-als in any meaningful way.It is proposed that the public forms its image of nursing not simply frommedia portrayals but also from personal contacts with nurses.2 1 Unfortu-nately, many nurses do not have a strong sense of personal worth nor dothey truly value nursing. The image nurses hold of themselves and conveyto their families, friends, patients, and others, is of utmost importance. Inthis context nursing is ineffective in promoting itself as a profession whichprovides a meaningful service essential to society.22As a group, nurses continue to struggle with who they are and what theydo. Nurses must be able to define what they do beyond "baths and beds"and physician-driven tasks. Nurses must also take pride in nursing and exertdominance over their role. Nurses must treat one another as valued col-leagues. But, most importantly, nurses must communicate the role and im-portance of nursing to persons within their reach.In essence, the stability and future direction of the profession will be basedon its image. Furthermore, the image of nursing is and will continue to be19. Kalisch, Kalisch & Clinton, The World of Nursing on Prime Time Television, 1950-1980, 31 NURSING RES. 358-63 (1982).20. Andrew, Image of Nursing.: Public, Professional, and Personal Implications, in CUR-RENT ISSUES IN NURSING 587 (J. McCloskey & H. Grace eds. 1981).21. Blichfeldt, Wat is Wrong with Nursing's Image?, 11 Focus ON CRITICAL CARE 55-56 (1984).22. Young, Political Action for Professionalization, in CURRENT ISSUES IN NURSING 610(J. McCloskey & H. Grace eds. 1981).19871184 Journal of Contemporary Health Law and Policy [Vol. 3:179built upon the individual nurse's sense of self-esteem. Herein lies thechallenge.Women are hindered in developing a positive self-esteem as a result of thesocial conditioning imposed on them during their formative years. 23 Wo-men, especially nurses, tend to be so centered on others that they lose touchwith themselves.24 Women tend to look to others for self-definition andplace too much emphasis on those opinions. Women also fear that if theyexpress their true selves to others, they will be rejected.To move past these obstacles, nurses must educate themselves regardingtheir social conditioning and begin to strengthen their self-esteem. Nursesmust learn how to flourish with independence, autonomy, and self-suffi-ciency. "They must learn to savor the rewards of assertive professionalism:inner peace, satisfaction, and comfort; self-respect; honesty; self-control; in-dependence; and decision-making power and ability."25Until the self-esteem of individual nurses is improved, they will be unableto define and communicate their role, clarify the confusion in the educa-tional system, and ensure adequate numbers of appropriately preparednurses. As a result, desired patient outcomes may be compromised. Indeed,"self-image more than self-interest may well determine how nurses positionthemselves in the evolving health care constellation." 2623. Lasky, Self-esteem, Achievement, and the Female Experience, in SOCIALIZATION, SEX-ISM, AND STEREOTYPING 48 (J. Muff & C. Mosby eds. 1982).24. M. CHENEVERT, STAT SPECIAL TECHNIQUES IN ASSERTIVENESS TRAINING FORWOMEN IN THE HEALTH PROFESSIONS 31-33 (2d ed. C.V. Mosby ed. 1983).25. Kilkus, Adding Assertiveness to the Nursing Profession, 3 NURSING SUCCESS TODAY19 (1986).26. Donley, A Social Mandate for Nursing: Prescription for the Future, 1 J. CONTEMP.HEALTH L. & POL'Y 46 (1985).

Education and Image: Critial Issues Confronting the Nursing Profession

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Education and Image: Critial Issues Confronting the Nursing Profession

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