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As a future preventive medicine physician, one health sector profession I expect to collaborate with in most cases is nurses. Nurses are seen as people who provide care and implement orders and procedures given by doctors. My goal is not to give orders to nurses as a doctor but rather partner with them to create a realistic care plan that works for individuals. I believe that nurses are strong in the caring and relatable component of medicine, which is highly beneficial in the specific type of medicine I am aiming to practice in. Preventive medicine focuses on a patient’s lifestyle choices pertaining to their health and aims to make changes to their choices through educated and realistic goals. I expect to work with nurses to come up with goals because they will be in charge of ensuring that patients are adhering to their set goals. They will also be able to create relationships with patients and might have information provided to them that is beneficial to their care. In order for me to have an intentional and realistic partnership with nurses, it is important to understand the history, role, education, and issues that they face in the nursing field.
The development of the nursing field started in the early 19th century in England and was primarily paved by Florence Nightingale. Despite the notion that upper-class women were not to be involved with caring for the sick, Nightingale was determined to study the care and treatment of diseases. She developed the organization: Establishment for Gentle Women During Illness, which was primarily focused on training nurses (University of Pennsylvania Nursing, n.d.). Nightingale was acknowledged for her work, from 1853 to 1856, with almost obliterated the mortality rate from infections for wounded English soldiers during the Crimean War (Klainberg, 2010). Upon her return from the war, she was honored by the government of England and was given the Nightingale fund to be used at her discretion. With the funds she received, she started the Nightingale School of Nursing at St. Thomas Hospital in London. The school focused on theory along with clinical experiences in hospital wards. A set of curricula guided the students’ experiences during the program. They received training in various aspects of nursing care for patients in multiple types of specialty hospitals (Egenes, 2009).
How it works
The history of nursing in the United States looked much different than it did in England due to the fact that the nation lacked a pioneer like Florence Nightingale. The profession was filled with challenges to become recognized and the decision of the education needed. In the United States during the civil war, there were no military nurses, nursing schools, trained nurses, and/or nursing credentials in the country (Klainberg, 2010). A nurse was classified as a woman who accompanied her husband or son to war to care for them or any woman who volunteered to care for the wounded soldiers.
It was estimated that over 3000 women served as nurses during the Civil War. These women were equipped with only the most basic knowledge of nursing, derived from personal experiences caring for loved ones. They laid the foundation for professional nursing in the United States. They were instrumental in establishing the first nurse training school. Their work with the soldiers helped to change the public’s view of a woman’s role outside the home (Egenes, 2009). This led to the establishment of the first nursing school in 1872, named Nurse Training School of Women’s Hospital of Philadelphia. The school followed the Nightingale model. Nursing schools that followed the Nightingale model continued to grow in number around the nation (Egenes, 2009).
Being that nursing schools were economically dependent on the hospitals in which they were located, the needs of the hospital took precedence over the student’s educational needs. The leaders of the hospital observed that it was economically advantageous to them to use student labor rather than graduate nurses for patient care under the pretense of clinical training (Klainberg, 2010). Students worked 12-hour shifts with very little clinical supervision; some were required to sleep in hospital wards in beds adjacent to that of their patients. Classes were irregularly scheduled and canceled when students were needed to staff wards. Students were overworked and lacked supervision and access to proper instructions (Egenes, 2009). Following the completion of their training, few of them were offered positions in the hospitals, while the majority of them were employed as in-home nurses to those who could afford it. Private nurses were in demand during this time, being that the majority of health issues were cared for within the home of patients. Nurses were not only equipped with the care of their patients but also household chores (Egenes, 2009).
Graduate nurses realized in 1893 that only 10% of nurses were educated at nursing schools, and the other 90% of nurses, who got paid the same amount as they did, had little to no formal education (Egenes, 2009). In addition, there were other concerns: the irregularities in educational standards among the programs, which varied from 3 months to 3 years, the curriculum, and entrance requirements. These concerns led to the establishment of the American Society of Superintendents of Training Schools of Nursing to help evaluate the standards of nursing education. This organization later became National League for Nursing Education, now known as National League for Nursing (Egenes, 2009). Later, another organization was formed in 1896. It was named Nurses’ Associated Alumnae of the United States and Canada, later known as American Nurses Association. This raised concerns about a nurse license to distinguish between educated and uneducated nurses. This association led to the state Nurses’ association’sAssociation commitment to nurse registration (Klainberg, 2010).
By 1921, 48 states had laws that regulated the practice of professional nursing, stating that graduate nurses would be referred to as registered nurses. The weakness of this law was that only educated and licensed nurses would use the title registered nurse. Untrained nurses were not prohibited from practicing nursing as long they were not titled registered nurses (Egenes, 2009). This weakness caused hardships for registered nurses during the Great Depression because they had to compete for employment with uneducated nurses for a few available positions. Mandatory licensure laws were passed in the late 1940s, making it unlawful for any person to practice nursing without a nursing license (Egenes, 2009).
In 1923, Goldmark Report was released by Committee for the Study of Nursing Education. It recommended that nursing schools should have a primary focus on education and not on patients, stating that the schools be moved to universities and nurse educators receive the advanced education required for their roles. Hospital administrators resisted these changes because they would eliminate the free labor that was provided by students (Egenes, 2009). Another report was released in 1928 by the Committee on the Grading of Nursing Schools; the report recommended the same as the Goldmark Report in addition to creating admission criteria for applicants to nursing schools and suggested hospitals stop funding their schools with funds made from caring for the sick. These recommendations were also ignored by the hospitals (Egenes, 2009). A third evaluation called the Brown, Report, funded by the Carnegie Foundation, recommended the same suggestions as the previous two reports did and advocated the employment of married women and recruitment of men; it was recommended that the nursing principles be based on physical and social sciences (University of Pennsylvania Nursing, n.d.). It was this report that allowed for changes in the nursing education programs (University of Pennsylvania Nursing, n.d.).
After World War II, the United States had a drastic shortage of nurses. This was caused by several factors. First, nurses who worked in hospitals were expected to resign when they got married. Many nurses who returned from the war sought the role of a wife and mother. In addition, autonomy was given to military nurses, and most were reluctant to return to subservient roles in the hospital. Plus, nurses were paid a very low wage (Klainberg, 2010). A study in 1946 conducted by California Nurses Association confirmed that nurses were paid slightly more than hotel maids and seamstresses (Egenes, 2009). In 1946, Shirley Titus, Executive Director of California Nurses, successfully argued for nurses’ rights to economic security through collective bargaining, insurance plans, benefits packages, and access to consultation from state nurse associations (Egenes, 2009).
In response to the nursing shortage following world war II, an associate degree in nursing was created in 1951 to generate a large number of nurses in a relatively short time period. This program was two years long. It also provided a pathway to nursing for men, married women, and other groups that had been excluded from admission to the program (Klainberg, 2010). In the late 20th century, patients’ needs became increasingly complex, and studies suggested that nurses with a baccalaureate degree improved patient outcomes. It was not until the 1950s that hospitals started to hire full-time nurses who had completed their degrees to become staff nurses (Egenes, 2009).In the 1960s, programs developed that trained nurses to deliver a variety of primary care services according to different hospital settings such as intensive care units, surgery, nurse practitioners, and more increased (Klainberg, 2010).
In order to be recognized as a nurse in the twenty-first century, there are several pathways that can be taken to receive a license to work in the nursing field. Nursing assistants help with bedside hygiene of patients, such as dressing, feeding, bathing, toilet needs, and keeping patients mobile. They also help with the documentation of patients (Nurse Journal, 2018). Nursing assistants commonly work in long-term care facilities but can also work in most healthcare facilities. Educational programs range between a few weeks to a few months, depending on one’s school of choice. The training involves a mixture of classroom and hands-on clinical. A certification test is required after the training, and the requirements and details of the test vary by state (Nurse Journal, 2018). A licensed practical nurse (LPN) is one who is able to assist a registered nurse (RN) with their duties. Their scope of practice is limited; they help with documentation of patients’ vital signs, patient care such as wound dressing, insertion of catheters, administration of injections, and much more. LPNs are under the supervision of R.N.s and physicians. Licensed practical nurses mostly work in long-term care facilities and rehabilitation centers (Lafer & Moss, 2007).
According to the American Federation of State, County, and Municipal Employees, the percentage of LPNs that currently work in a hospital setting is 20 percent, which is about 47 percent, down from what was observed between the years 1984 and 2005 (Lafer & Moss, 2007). LPN training schools range between 9 months to 18 months long with a mixture of lecture-based and clinical training. After completion of training, a state licensure test is required called NCLEX-PN (Nurse Journal, 2018). A registered nurse (RN) is one who has a full range of patient care responsibilities and duties based on specialization. R.N.s can work in any medical facility where patient care is needed (American Nurse Association, n.d.). There are two ways one can become an R.N., either through a two-year associate’s degree program at a community or vocational college or a bachelor’s degree in nursing (BSN) at a 4-year university program.
In addition, a state board exam known as NCLEX-RN must be passed (Nurse Journal, 2018). Nurses can further specialize their scope of practice through additional licensing classes to become certified pediatric nurses, intensive care unit nurses, certified hospice/palliative nurses, and much more (Nurse Journal, 2018). People with different degrees and career fields but desire to be in the nursing field can continue their education to receive a master’s in nursing (MSN), which ranges from two to three years of school and intensive clinical rotations. People with this degree can enter the nursing field as advanced practice nurses or in advanced positions such as nurse managers or educators (Nurse Journal, 2018). People who desire to focus on clinical practice and/or leadership can continue on to receive their Doctor of nursing practice (DNP), which is a long and intensive training (American Nurse Association, n.d.). According to the Bureau of Labor Statistics (2018), the job outlook for registered nurses is subjected to grow by 15 percent from 2016 to 2026.
With the vast history of nursing and the challenges they have overcome to be recognized as a profession, the nursing field still faces challenges that affect their career in our current society. The American Nurse Association is aware of some of the issues nurses face in the workplace and are working to shed more light on them through surveys, research, data collection, and legislative means. Inadequate staffing is one of the top reasons nurses are dissatisfied in the workplace (Spring Arbor University, 2017). According to the American Nurse Association (n.d.), staffing nurses in healthcare locations is the biggest issue being faced. This issue is viewed as a personal and professional concern. It impacts nurses’ health and safety due to the increased pressure on nurses to care for more patients, which creates fatigue, a higher injury rate, and a decreased ability to provide care in a safe and effective manner among nurses. Short-staffing nurses is a threat to patients’ health which could lead to more complex care for patients.
In 2012, Nursing Times carried out a survey to garner nurses’ opinions about issues and challenges they encounter in the nursing field. 52% of the nurses surveyed said that the cuts to the workforce were the main concern they faced. The majority of the nurses, about 70%, said that, from their point of view, staffing cuts endangered patient safety, while 59% said that staffing cuts significantly increased their workload (Ford, 2012).
AMN Healthcare conducted a survey in 2017 geared towards chief nursing officers (CNOs) named the Worsening Shortages and Growing Consequences: CNO Survey on Nurse Supply and Demand. 72% of the surveyed CNOs agreed that their healthcare organization is facing a moderate to severe nursing shortage. They also acknowledged that they believed this shortage would worsen over the next five years (Gooch, 2018). In addition, the U.S. Bureau of Labor Statistics (2018) estimates over one million registered nurses will be needed by 2022 based on the growth of the field and replacement hiring. According to the AMN Healthcare survey, 34 percent of CNOs attributed nurse shortages to be of a negative impact on patient care (Gooch, 2018). According to the Medscape RN/LPN Salary Report in 2016, 47% of registered nurses and 52% of licensed practical nurses reported working overtime regularly (Gooch, 2018). Nurses across the United States have increasingly reported the use of mandatory overtime in their workplace, which has had a negative impact on delivering of care, medical errors, and fewer bedside reports (American Nurses Association). Nursing shortages have resulted in errors, higher morbidity, and mortality rates, according to research published by the National Center for Biotechnology (Gooch, 2018).
American Nurses Association (ANA) is aware that nurses work hard on the job and should not have to do it at the expense of their health. Another major issue being faced in the nursing field is workplace abuse. ANA conducted a survey that revealed more than 62 percent of nurses have had a personal experience with physical or verbal abuse on the job. 1 in 4 nurses said they had been physically assaulted at work (Gooch, 2018). Bullying and harassment of nurses is not only done by patients but also by colleagues. RNnetwork, an employment agency 2017, found 45 percent of nurses have been verbally harassed or bullied by other nurses (Gooch, 2017). In March 2016, a report published by Government Accountability Office stated healthcare workers in inpatient facilities experienced higher rates of nonfatal injuries through hitting, kicking, and beating compared to workers in the private sector (Gooch, 2018). American Nurses Association (ANA) has created various tools and initiatives for nurses to help them approach situations such as preventing workplace violence. ANA launched its initiative #EndNurseAbuse as a way to raise awareness of the issue. The initiative aims to help fight against nurse abuse and encourage healthcare foundations to teach communication skills with respect to interacting with others (Gooch, 2018).
Learning about the nursing field has been insightful for me as a future physician. I think that learning about the history and issues that nurses face has placed me in a position to be more intentional when interacting with them and validating their experiences. I think that my idea of interaction with them will be a lot more diminished than I have previously thought. Being that the nurse shortage is a big issue in the nursing field; they might not be able to create genuine relationships with patients due to the fact that their caseload will be a lot heavier than normal. This realization is not one that I am excited about; I have envisioned partnering with nurses and patients to look at a patient’s lifestyle in detail. To help provide tools and implementation methods for change in their life and health. Based on my experience working in the hospital and observing, the interaction between doctors and nurses is not necessarily positive. I am hoping to have a better line of communication in the future with other professionals and eliminate any bias or silos I have embodied to collaborate better with nurses.
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