Registered Nurses - Changing the face of a profession

Great Debates
1

It takes at least 3 years more likely 4 years at a junior college. A nurse has a licence issued by the state which has some pretty hefty personal rules attached to it to avoid supensions[sup]1[/sup] Most start on day one at just shy of $50,000 a year and top out in the $100,000 range[sup]2[/sup]. An RN is not just a cog in the medical machinery, They are quite often the “team leader” for a small team of LVN’s and CNA’s/PCA’s taking care of many patients. The more difficult and serious patients are cared for directly by RN’s often because lower levels are not allowed to perform the procedures needed to help a patient in a precarious medical position. They are required to participate in continuing education to keep current on medical issues and maintain their licences.

Despite the educational, personal, and professional demands of this profession many people see Registered Nurses as little more than glorified housekeepers. One of the most common gripes from patients in a hospital is “When am I going to see my doctor?” Half of the time the doctor is asking your nurse what her reccommendation and going with it. on many other occasions they call the doctor basically to approve a course of action like “patient is still complaining of pain at a 6 [sup]3[/sup] on Tylenol 3, PO Q4[sup]4[/sup] since patient X has no contraindications can I bump her up to Xmg of Percocet to try and control their pain.” Doctor quite often replies with a simple approval or approval after a couple quick questions are answered to verify that the nurse in question has ruled out certain contraindications that may not have been considered.

Many things happen and are dealt with with little if any intervention from a doctor via standing orders and or protocols.

Granted, a few decades ago nurses were glorified houskeepers, thorough medical training and licensure was almost non existent. This is no longer the case.

Despite the potential income and scheduling flexibility the nursing world is horribly understaffed. Nursing programs are unable to fill the need and some schools have even dropped them due to low enrollment or poor pass rates.

The debate:
Why do so many people tend to look down on the nursing profession as a whole when they are actually a key part of the medical world that makes many if not most of the care decisions in most forms of medical care. They make solid money, have very flexible schedules, and can pretty much write their own ticket as far as where they want to work.

My stance is that its mostly just a lack of education on the part of society. People really don’t know what nurses do and our media tends to glorify the MD’s while relagating RN’s to little more than a trusty sidekick at best, porn fantasy fodder at the worst. Nursing education needs to be expanded dramatically even at the expense of some serious tax dollars. The infrastructure to create the nurses our country needs does not exist. As it stands even some of the most poorly skilled unmotivated nurses keep their jobs or easily find other employment because of high demand and legal requirements to reduce patient load. The public also needs to be educated, maybe in the form of documentaries, public service announcements, recruiting drives, and more specific scholarship programs for nursing students.

1 DUI is one of the most common reasons for RN licence suspension/revocation.
2 Some exotic specialties higher
3 Scale of 1-10
4 By mouth every 4 hours

2

Hell, I never thought that about nurses. And especially after a 2-week hospital stay, I have a huge appreciation for the difference in skill level between an RN and, say, a CNA, even for something as seemingly basic as moving an injured person while causing minimum pain, or having the sense to know when to get authorization for more pain meds for a patient. There’s just no comparison.

I wish they’d require the equivalent of a B.S. for RNs because then I could get H-1B work visas for them, if nothing else. Right now they aren’t generally eligible because it’s not considered a “specialty occupation,” as most nursing positions don’t require the equivalent of a U.S. bachelor’s degree, no matter how strict the other licensing requirements are.

Most allied health professionals aren’t nearly as appreciated as they should be. A physical therapist once probably saved my life by paying attention to what I was saying, and it turned out she caught something my doctor hadn’t – a honking huge deep vein thrombosis. Once it was confirmed (thankfully my surgeon had the sense to believe us, even if my stupid primary care doc didn’t, that it needed to be checked out), I was readmitted to the hospital for another week of IV anticoagulants. If it weren’t for the sharp eyes of an allied health professional, I could be dead now.

3

I think it’s a “holdover” from the old days. My grandmother and her sister were nurses (not aides), back in the 30’s - no formal education required. They were quite limited in their medical knowledge; in fact, my great-aunt swore to her dying day that “cigarette smoking is good for you” and “coffee stunts kids’ growth”, among many other canards. I have a good friend in her 60’s who is an RN (just retired), but did not go to college - she says she was “grandfathered in” when the law started requiring a degree, since she’d already been working in the field. These are just a few examples, but my point is that attitudes take a longer time to change than reality does, at least in this case.

4

My mother became an RN in 1965. She was graduated from a four-year nursing program sponsored by a hospital. While she does not have a Bachelor’s degree, she is highly skilled from all the hands-on, closely supervised clinical experience.

Now she works in a nursing home and constantly complains about the new nurses she has to hire these days. Many LPNs can get through a six or nine month program, have no clinicals and zero patient care experience and get a job making almost as much as she does after nearly 40 years of nursing! Her biggest gripe is the lack of clinical experience. Even RNs with degrees are somewhat clueless about many of the things she has to do. For example, she’s the only RN in the entire facility who can deal with IV therapies. I understand there’s a specialty for that now, but smaller facilities cannot afford to contract with nor hire specialist nurses. Another example is simply passing meds several times per shift. Newer nurses have trouble getting a handle on the documentation and understanding why charting is so important, legally and medically. It seems there’s a lot that just isn’t covered where these kids are getting their nursing education. Perhaps that’s a function of geography: she’s in a small town with the nearest major 4-year university at least 90 minutes away. People go away to college and do not come back because they can find better jobs in the bigger cities.

The local hospital in Tallahassee uses almost exclusively contract nurses. I don’t believe this compromises care much. I think if a nurse is a good nurse, then she’s (or he’s) a good nurse – regardless of who’s paying her (or him) how, or what degree she does or doesn’t have. The fact of the matter is, much like teachers, some people do not have the bedside manner and have no business in nursing. But some OJT programs are shorter and easier to get into than say, a four year university with an accredited nursing program.

In short, I think there’s a lot of idiots out there, making all the good, highly skilled, well trained, educated nurses out there look really really bad. (Like many other professions.) I also think nurses are highly undervalued, much like teachers. My belief on why both professions are so seriously underappreciated, undervalued, overworked and underpaid: because both professions are dominated by women.

Do with that what you will.

5

But aren’t there many nursing jobs were bedside manner is not a neccessary requirement? Surgical nurses come to mind.

6

I find this fascinating considering it is a high demand occupation in the US. The hospital my wife works at sometimes has over 50 openings for RN’s. They are hardly unique in this shortage. Time for a little lobbying I guess.

7

I will agree with the overworked but they are generally pretty well paid. IIRC the avg starting pay nationwide is around $20/hour. My wife started at $21-$22/hr. This is to start right out of school, zero experience. Many places even offer signing bonuses. There is also massive potential for promotion/advancement related specialites in nurse education, or unit/floor managers and other adminitrative functions.

I guess the issue is, how do you get them into school, what would it take to get our society to see nurses as the medical professionals they are and aspire to the goal of becoming one.

8

As Pashnish Ewing pointed out this is not a critical issue and maybe part of the problem is this mindset. A nurse can be flawlessly skilled and have little “bedside manner” from most peoples point of view. They are part of your medical care team, not personal servants. Most people don’t recognize when a nurse has made a mistake but they remember it took 2 hours before someone got them an extra pillow. Your treatments were administered flawlessly, they hit your IV site and blood draws in one shot with little discomfort but a not so fluffy pillow can be percieved as “poor nursing”.

I would trade a mountain of good bedside manner for one technically gifted ICU nurse if it came down to my kids life on the line.

9

I think the word it out about getting them into school. The problem now, as I understand it, is there is a shortage of teachers for the nursing schools. My wife is finishing her prerequisites for nursing school and the competition for available spots in nursing school is very tough. She already has her BA (1992), but has to replace the few B grades from her transcript with A grades in order to be considered for nursing school (sorry, no cite about the teacher shortage).

Pash

10

Traditionally female occupations have always been marginalized, no matter how important they may be. How many people know or care that flight attendents are very important to safety and their role is more about taking care of emergencies than looking cute and pouring drinks? We all know about the respect that teachers get…

People are picking up to the fact that nursing is a hot profession right now. I know several people in nursing school- most of them college graduates that realized that their BA still can’t get them a job better than waitressing. Nursing requires relitively little education for very high pay and readily availible work (not to mention benefits like easy immigration just about anywhere).

11

Part of the problem is that nurses tend to ‘eat their young’ - older, more experienced nurses tend to forget what it was like to be just out of school and how much they had to learn and give new grads hell. The great majority of nurses who leave nursing permanently do so in the first year or two after graduation. There’ve been articles in nursing magazines about this.

Because of advances and changes in medicine there’s so much more for nurses to learn in school now that it’s hard to fit everything into even a four-year program. Many nursing skills are very hands-on and require a lot of practice to learn. Hospitals are so short of staff and desperate to put working nurses on the floor quickly that they have cut orientation and mentoring programs to the bone. Except in an exceptional institution, an new RN fresh out of school is going to get the bare minimum of on-the-job training. When I started in nursing circa 1985, the standard was 4-6 weeks mentoring/orientation for new grads before they were expected to function independently . Now it’s one week, if that. And the older, more experienced RNs who should be providing the newer ones with support and help are either too swamped in their own workload to do so or downright hostile.

Nurses are leaving hospital work in droves for other segments of the profession. I worked in hospitals for 18 years before I found my current position with a disease-management company. The change in atmosphere was shocking…I found a five-week orientation with tons of educational support, colleagues who were actually interested in helping each other out, and a company that makes it clear they value RNs as more than just warm bodies.

It’s been a year, and I still love this job. I’ve moved from a hospital to a cubicle, but I’m still working with patients, helping people out, and I’ve discovered a lot of new ways I can use my talents. I spend my days providing educational help to people with diabetes and heart disease. The difference in atmosphere between the call center I work in and the hospitals I worked at before is -staggering-. I feel very lucky.

There is something very, very wrong with what the hospital system does to nurses now. What can be done to fix it? I don’t know if there’s a clear answer. Sadly.

12

An odd aspect of the immigration side of nursing is that they aren’t eligible for most temporary work visas, like the H-1B, but because they are a shortage profession they can go straight to the green card stage. Most professionals come on temporary work visas and then proceed with green card processing after they get here, but a nurse has to go through what amounts to about 2 yrs. of paperwork (after they pass all the necessary certification exams for state licensing) before they can come here. Weird, no?

13

screw the pillows, i want the nurse.

I counted up last year, I have spent 2 years, 3 months and 17 days total in hospital in 43 years. Stupid pillows I can do without, but nurses have always [with a couple of exceptions] been my favorite people in hospita. The only real exception was the stupid bint who couldn’t wrap her mind around IV 1L/hour + meds = need to whiz about every hour …and that side rails up and locked + IV 1L/hour + meds = pissing the bed because I could not wait more that 5 minutes to have someone come and unlock the side rails and let me run to the bathroom … so Denis + tool kit + siderail disassembly = not pissing the bed. [I have serious problems mentally being catheterized when I am conscious … something to do with a narrow urinary tract, urethral sounds to widen the passage and being 4 years old. I have intense memories of the pain to this day…]

14

This is misleading and may be the cause of some of the questions on this topic.

Deb has been an RN for around 25 years and has broken a $40K salary just once. Nurses at large hospitals can make a pretty good wage, but nurses at nursing homes, doctor’s offices, home health care providers, and a host of other locations are often paid peanuts. In exchange for their wages (regardless of the location) they are placed under extremely stressful conditions. Hospitals and nursing homes that used to staff one RN plus one or more LPNs and an aide or two for every 10 - 15 patients are now eliminating the LPNs and aides and telling the RN that she (still typically a she) must handle all the med passing and charting accurately (as she should) and also respond to all the bed-sitting, cleanup, hand-holding, and other duties herself, often while increasing the load to 20 beds. The technical knowledge required of RNs has increased dramatically, along with the rest of the medical profession, but they have been simultaneously required to perform more of the non-medical functions as part of smaller staffs.

15

I have no beef with RNs, NPs or BSNs. They kick much butt in doing a job that is often made thankless because of the vagaries of health in the era of managed care.

(Well, I do have a beef with them when they use childlike language for bodily functions as if profesional adults wouldn’t know what they were talking about if they asked about “urine” rather than “pee” but that’s another matter altogether.)

Nurses don’t get respect in hospitals which are perpetually understaffed in their nursing departments and fail to recruit new nurses and do what’s necessary to retain them (good pay, good benefits, flexible scheduling, etc.). These hospitals frequently have pseudo-nursing staff performing all functions save those which are legally prohibited and those pseudo nurses – due to the fact that they aren’t as rigorously trained, licensed or managed – do not always exhibit the same level of professionalism, compassion and skill that the public has come to expect.

To make matters worse, many hospitals are trying to downplay their lack of RNs/BSNs/NPs by having no mention of what certification/education level a “nursing staff” employ has on their name badge. And since it is the rare nurse these days who wears a traditional nursing uniform which would set him/her apart, there is no way to distinguish whether the person in scrubs who came into your room has a 4 year degree or graduated from a 12 week class held in the basement meeting rooms of the hospital.

Mr. TeaElle was hospitalized earlier this month with pancreatitis, a extremely painful illness. Overnights, there was one RN on his unit for every 14 patients, all of whom were in a very serious condition (pancreatitis, hepatitis, kidney failure/dialysis) and it was not unusual for him to have to wait up to 2 hours for painkillers. (There were similar problems around shift changes.) They justified this by having a number of staffers in a position they called “Patient Care Partners” who were reportedly all educated to a level equivalent to an LPN and also had training in phlebotomy. Unfortunately, these staffers were not permitted to administer medications, replace empty IV bags or make any adjustments to IVs, or do anything more “medical” than a vital sign check.

After the second night, he strategized how to request more pain meds than he really needed so that he could stay doped up enough that he’d never end up writhing in agony while the RN was stuck down the hall with another patient. Having just one more RN on the floor, one whose mandate was to “float” for quick procedures such as administering an injection of pain meds or replacing an empty IV bag, and whose working hours were not on the same shift schedule as the non-floating staff would’ve improved patient care immensely. The hospital – which was charging each patient (or their insurers) roughly $2,000 a day for care on that particular unit – couldn’t see their way clear to go to that expense. The hospital is not hiring nurses at this time.

These stupid staffing decisions, like GythaOgg mentioned, chew nurses up and spit them out, compromise patient care and destroy the reputation of nurses because patients (and their families) aren’t likely to feel kindly toward the nurse that took 2 hours to show up with that shot of Dilaudid.

I don’t think the battle, however, lay with the public. The public values nurses – they recognize that the nurses are there to help at 2 a.m. when all of the hospital service doctors (save the poor interns) are happily snoozing in their own beds. I think the battle lay with the medical establishment which has put profits and cost containment ahead of adequate staffing and retention which, in turn, means that they’ve also deprioritized patient care.

There was a time (I’d like to think, at least) when hospitals were founded and maintained out of a sense of charity and compassion. (Hence the frequent connection to churches or religious groups.) For all their lip service about care and compassion, it is quite clear that hospitals now exist just as all other corporations, to make money. The work of nurses is at counterpurposes to the interests of money-making – they don’t generate billable ‘visits’ or procedures, after all – and the current situation is the result. Nurses are caught in the middle between the purpose of their work and the indifference of their industry. I don’t envy them one bit.

16

Bolding mine. Nurse recruiting pretty much exists to try and latch onto as many of the nurses that exist as possible. Problem is, they are not out there, they have jobs already. Right now its a sellers market for nurses, they can pretty much pick where they want to work and see who will pay them the most. As Tomndebb mentioned doctors offices, clinics, and SNF’s are the bottom of the pay scale.
They also the lower end of the stress scale. They have their share of the pressure but its not saturday night at the ER or a swamped high risk labor and delivery unit.

Actually much of what a typical RN does, does involve billable procedures, administering medications, performing various little procedures etc. Usually anything they do needs a supply item like a drug, a needle, a suture/staple removal kit, IV tubing, and so on. This makes it pretty easy to bill for such a procedure. Most other things like taking vitals and assessments are factored into the baseline charge for the room.

Medicine is a business, and unfortunately many that rise in its ranks never set out to be good at running a business, only at being good doctors and nurses. Although you should keep in mind, most hospitals are still non profit organizations. Insurance companies are pretty much all for profit companies, and they determine alot of how much a hospital can charge.