Once upon a time, the ranks of new nurses graduating from training programs in Arkansas were made up of white, unmarried young ladies, prim in their long skirts and starched white pinafores and caps, prepared to go out into the world and follow male doctors’ orders unquestioningly.
That time, fortunately for nurses and patients alike, is long gone. Today’s nurses are trained and empowered to take on a much larger role in patient care. Nursing school graduates include men, single mothers, and minorities — many of whom are coming to nursing as a second career. As two major Arkansas institutions — Arkansas Children’s Hospital and the Arkansas Nurses Association — celebrate their 100-year anniversaries in 2012, it’s a good time to look back, but also forward. In this year’s Nursing Guide, we’ll follow the evolution of the nursing profession from the early 20th Century to the early 21st Century, and take a look at the forces driving the changes of tomorrow.
Watching the hustle and bustle at any hospital today, it’s hard to imagine how different everything used to be.
When what is now called Baptist Health Schools Little Rock graduated its first class of five students in 1921, nursing students could not be married, and they were required to live in the school’s dormitory. Nursing education itself consisted solely of on-the job training.
“At that time, there was no curriculum for student nurses,” said Rose Willshire, historian and retired faculty member for Baptist Health Schools. “You moved in one day, and the next day you were sent to work.”
There were also no disposable supplies, Willshire said. One former nurse wrote about her memories of attending the school around 1930 and getting one glass syringe, one needle, and a piece of sandpaper to use for sharpening the needle. Between patients, the nurses would pour one tablespoon of boiling water in the syringe and push it out through the needle to sterilize both.
Antibiotics hadn’t been developed then, or immunizations, said Dr. Angela Green, director of nursing research for Arkansas Children’s Hospital.
Nurses’ relationship with doctors was much different as well. Nurses followed orders unquestioningly, and treated doctors with extreme deference.
“If the doctor came in to see a patient, you certainly didn’t keep sitting there,” said veteran nurse Rebecca Rills, RN, the service manager for ophthalmology and surgical services at the University of Arkansas for Medical Sciences’ Jones Eye Institute. “You hopped up, gave them the chart, and gave them your chair. It was a very respectful thing to do. Now it’s like every man for himself.”
Skirt hemlines were higher by the 1960s — just below the knee instead of mid-calf or ankle — but nurses’ uniforms were still very formal. Skirts finally gave way to more practical pantsuits beginning in the mid-1970s, and it was a welcome change, said Baptist Health Schools Little Rock faculty member Georgia Seward.
“I worked in intensive care, and let me tell you that you have never seen a sight such as a nurse wearing a uniform that was a little bit too short and performing CPR,” she said.
When Dr. Ralph Vogel got his bachelor’s degree in nursing in 1976, information was much more difficult to come by. Lab reports were handwritten, with no computer reports to explain what they meant — nurses had to rely on physicians to explain.
“Back then if you had a topic you were interested in, you had to go to the library,” he said. “If the book was checked out, you were out of luck.”
Dr. Vogel remembered getting his first computer when he finished his master’s degree in nursing in 1987. It cost $2,700 for 30MB of memory, and came with a 5.25-inch floppy disc drive.
Nursing was also simply less complicated before computers, Dr. Vogel said. “When I started as a staff nurse, it took a physician order to get a pump for an IV. Now with computer-controlled machines in nursing care, you can do a lot more. It’s become more complicated with medications, blood — there are many more things going on than there used to be.”
Vogel, who was a medic in the Vietnam War, was part of the first wave of men to enter nursing in the civilian world. When he became a pediatric nurse practitioner in 1979, he said, he was only the 22nd male certified in that area in the country.
“I got a lot of flak at the time — people saying ‘You just want to be a doctor,’” he said.
The nurses of yesteryear would probably not recognize today’s nurses — because of their uniforms, because of how they interact with doctors and other health care professionals, and — especially in the last decade — because of how much time they spend on computers. Nursing is still very much a hands-on career, but hospitals and doctors’ offices continue to move toward electronic medical records. Because EMRs can theoretically be accessed from anywhere, they can bring together all the care a patient receives, regardless of location — outpatient or inpatient hospital visits, doctor’s office visits, etc.
“It certainly puts together a global picture of the patient that we haven’t had in the past,” said Amy Hester, RN, director of clinical informatics and innovation at UAMS. “Now we have created a record that really is a living document, a living story of that patient’s journey through their health care. That’s a big advantage, I think.”
Nurses spend less time flipping through paper charts or making handwritten notations. And younger nurses grew up taking access to the Internet for granted — they’re comfortable with and reliant on technology that lets them immediately look up the answer to any question they might have.
Today’s nursing graduates absolutely must have computer skills, said Leah Wright, RN, director of clinical informatics for Jefferson Regional Medical Center in Pine Bluff. The use of electronic medical records and other informatics tools has completely changed the practice of nursing, she said: Nurses now have all of a patient’s information, updated in real time, at their fingertips — no more chasing down lab reports on a printer in another department or tracking down a patient care tech who has a patient’s latest vitals jotted down on a piece of paper on her clipboard.
“The computer has really become a tool just like the stethoscope,” Wright said.
It’s made nursing safer, Wright said, because information doesn’t get lost in the shuffle or forgotten. One system Jefferson Regional has implemented is having nurses scan all medications they give patients at the bedside, Wright said, so the medication, dose, and time given are all recorded instantly. It slows nurses down a little, she said, but that inconvenience is nothing compared to the improvement in safety.
Still, technology can only do so much, say nurses who have watched their profession evolve over the last 20 to 30 years. It can’t teach a nurse how to comfort a patient or family member, or how to make a decision in a crisis.
“In nursing programs, we have to make sure in the curriculums that we preserve the skill of interpersonal relationships between nurses and patients, and the skill of critical thinking and decision making,” Hester said. “We can’t assume the right decision is going to be made just from getting the electronic medical record.”
Critical thinking skills are also at the top of the list for Dr. Ann Schlumberger, chair of the Department of Nursing at the University of Arkansas at Little Rock — but only if they’re paired with an inborn desire to help others.
“I don’t know that you can teach caring,” she said. “People have to come to the table caring about others and wanting to provide nursing care to that individual as if they were the person you loved the most in your life.”
Cindy Hiegel, a clinical nurse analyst working with nursing informatics at Conway Regional Medical Center, said the expansion of technology has definite advantages, and has changed the culture of nursing. Conway Regional has computers in each hospital room so nurses can document the care they provide in real time.
“It’s nice to be able to be at the patient bedside documenting,” she said. “The patient can have input into their care and you document what is being done at that time. As a nurse, your focus is to be your patient, not the computer, so getting the patient involved in their care and real time documentation can help produce that. You don’t want to be nursing the computer but engaging with your patient.”
Today’s hospitals are also a lot quieter than they were in the past as texting and other silent methods of communication have become the norm, said Tammy Gillham, a charge nurse in the intensive care unit at UAMS with 31 years of experience.
“When I started, you paged everybody overhead,” she said. “Now if we get an overhead page, everybody stops in their tracks and says, ‘What was that?’ When I think about it now, that operator must have been making announcements all day long. That’s how we communicated.”
Nurses from a century ago would also be surprised at how few nurses look like them. In the early days of Baptist Health Schools Little Rock, students couldn’t be married and they had to live in a dormitory on campus. They were, of course, all women. These days, nursing is much more diverse — in gender, race, age, and family circumstance. Many have had previous careers in unrelated fields. It’s not unusual at all to come across someone like Ted Clowers, a 2007 graduate of Conway High School who’s in the final year of studying for a bachelor’s degree in nursing at UAMS. His ultimate goal is to be an advanced practice nurse, which would require a master’s degree.
Clowers said he chose nursing because he liked the idea of providing 24/7 hands-on care, and also because of the job security it offers in an uncertain economy.
“I went into it for all the same reasons female students went into it,” he said. Clowers said he’s been well accepted by patients, although a few patients have assumed that he’s a doctor or pharmacist because he’s male.
From a big-picture standpoint, the profession of nursing has really come into its own in recent years. Nurses are no longer viewed as doctors’ handmaidens, Vogel said, and are more politically active now, especially with the ranks of advanced practice nurses expanding.
“It’s considered now to be a profession, not something that’s just a job, that’s there to just supplement the physician and do whatever they say,” Vogel said. “There’s much more of an idea that we have our own niche and that it should be expanding.”
Health care today is putting an increasing emphasis on interdisciplinary teamwork — bringing together caregivers from different fields to work together to provide complete, well-rounded care for each patient.
“We’re looking at it more holistically,” Schlumberger said. “We’re looking at all the people providing care for that person knowing what’s going on, so there’s no oversight or duplication of service. … There is a lot more interacting and problem-solving between the nurse, doctor, pharmacist, social worker, and others.”
Forces Driving Change
Nursing will continue to change in response to both small and large changes in society and health care as a whole. One of the biggest of these is the passage of the Affordable Care Act, and its requirement that almost all Americans have health insurance by 2014.
“We hope those people will seek primary care they’ve denied themselves before,” said Lepaine Sharp-McHenry, assistant director of the University of Arkansas’s Eleanor Mann School of Nursing.
In addition, the Baby Boom generation continues to age, and medical advances make it possible for people to live longer with illnesses that would have been fatal in the past.
“When you look at the country as a whole, we are living longer, we have more chronic illnesses, and diseases are more complex to manage,” said Dr. Pegge Bell, director of the University of Arkansas’s Eleanor Mann School of Nursing. “There will be a need for more nurses to provide the care individuals need.”
Financial influences are also pushing hospitals to change how they provide care. For instance, Medicare will no longer reimburse hospitals for the cost of caring for patients who get an infection or a bedsore while they’re in the hospital for treatment of another condition.
“That’s created a more conscious awareness of sterile technique when inserting catheters, IVs, and it’s also made it to where a lot of nursing homes and hospitals have a routine turning schedule,” Rills said.
On a larger front, there’s a general push to focus more on keeping people healthy rather than simply treating them once they get sick, Schlumberger said.
“Our current model of health care tends to be heavily acute and chronic care — people get very ill and then they go seek treatment,” she said. “If you think of it as a triangle, the base is dealing with problems that have already developed, vs. putting a lot of money and energy into health promotion and risk prevention.”
The coming years will be ones of tremendous change for the nursing profession. The Institute of Medicine issued a landmark report in 2010 called “The Future of Nursing: Leading Change, Advancing Health,” that looks at how the profession of nursing needs to evolve in order to best meet the needs of a growing population of patients. That report is driving significant changes in the profession nationwide.
One of its recommendations is that nurses participate more in the process of strategic planning and decision making that will determine the future of health care.
Increasing nurses’ presence “at the table” is a major aspect of the report, said Dr. Cheryl Schmidt, interim associate dean for academic programs at UAMS’ College of Nursing. She and Dr. Claudia Beverly, director of the John A. Hartford Center of Geriatric Nursing Excellence at UAMS, are two of three nursing co-leaders of the Arkansas Action Coalition, a group that is spearheading efforts to implement the recommendations of the Institute of Medicine’s report.
“Nurses have tried to do that for years, but it’s a turf issue,” Schmidt said.
Green, of Arkansas Children’s Hospital, is co-leading the coalition’s leadership workgroup, which is focusing on increasing leadership development opportunities and participation for Arkansas nurses. Bachelor’s degree programs already include a course in leadership, she said, but it’s going to become an even more important part of every nurse’s career in the future.
“Increasingly, the job description of staff nurse has leadership as a job expectation,” she said. “It’s a bit of a paradigm shift in terms of helping everyone see themselves as a leader, and helping develop that capacity.”
One issue facing Arkansas, Schmidt said, is that state law requires nurse practitioners to have a collaborative agreement with a physician — but in some underserved or rural areas like the Delta, there may not be any physicians to collaborate with.
“We’re going to have the worst shortage of all health care professionals we’ve ever seen” with the Affordable Care Act, Schmidt said.
“We need everybody that’s available and interested, and not limited to certain professions,” she said. “There’s a huge shortage of primary care physicians, and we’ve got to fill that gap.”
Another major thrust of the “Future of Nursing” report is increasing the educational preparation of nurses.
“The Institute of Medicine’s recommendation is that by 2020, 80 percent of registered nurses be educated at the baccalaureate level, so nurses with a diploma or associate’s degree will be thinking about going back to finish their bachelor’s degree,” said Dr. Debra Jeffs, director of academic nursing education at ACH and a co-leader of the Arkansas Action Coalition’s education workgroup.
Currently, about half of RNs nationwide have at least a bachelor’s degree, according to the IOM. In Arkansas, however, only about 28 percent do. The report also recommends doubling the number of nurses with doctoral degrees.
Nursing is also shifting toward what’s called evidence-based care, ACH’s Green said. That means basing decisions about how to care for patients on what has been scientifically shown to be effective, rather than on how things have always been done.
“Even though most of us think it’s obvious, people are really bound to tradition,” she said. “It’s hard to change.”
As hospitals and doctors’ offices continue to make the move to electronic health records, the field of informatics is growing in influence within the nursing profession. Informatics deals with how you take the information from systems and databases and transform it into useful knowledge that can drive improvement in health care.
“As our technology evolves, our care evolves with that,” UAMS’ Hester said. The challenge, she said, is to build and implement information systems in a way that the system supports the work of the nurse, rather than the work of the nurse changing to meet the demands of the system. “We’ve had that backwards in the past.”
Nurses in the future will have to be comfortable navigating a computer system, Hester said, and beyond that, be able to manipulate the system to get the most out of it. “They can’t just look at it and take information from it,” she said. “They really have to be interactive participants in that record to be able to get the full advantage out of it.”
And more importantly, she said, nurses are going to need to assert themselves and be involved as their employers make future decisions about informatics and health care. “Even though we have moved into an electronic age and information systems and computers sort of rule the day, the basic foundations of nursing — we’re the only care provider who’s there 24/7, the eyes and ears of other health care providers when they go home — that hasn’t changed,” Hester said. “That is never going to change for nursing. Developing systems that support that level of dedication and involvement in patient care makes it even more imperative that nurses have a spot at the table.”
Gillham said she’s also seeing the nursing profession evolve into one that provides nurses with more opportunities for advancement, independence, and financial gains. When she graduated from nursing school in 1986, the ICU was the place to be — the top job nurses could shoot for.
“Nursing has broadened and has so many fingers now and so many directions for nurses to go,” Gillham said. “You can be an advanced practice nurse, a nurse anesthetist, a physician’s assistant. Nurses like me that have been there 30 years, we’re a rarity. What you’ll see is that nurses in hospitals will have five to 10 years of experience, and then they’re going to branch out and go in other directions. There are too many other opportunities.”