The history of nursing, a segment of the white collar service sector, reflects the general trends in the transformation of work that gave rise to the new, dependent, salaried, white collar workforce, in conflict over the construct of professionalism. Nursing has evolved from the days of Florence Nightingale to a highly respected and educated profession(Melosh 32). However, nowadays, disproportionate nurse to patient ratios continue to escalate. Increased occupational stress, job dissatisfaction, and burnout are contributing factors to increased attrition rates within the nursing profession.
A fine line separated the 19th-century nurse from the domestic servant, as both were expected to perform household chores. By 1868, however, they were more clearly differentiated by salary; the nurse earned $1.00 to $2.00 a day whereas the servant earned only $2.22 per week (Reverby 9). Because of the close association with dirty domestic work, few middle-class women entered nursing. Until the Civil War, nursing remained an occupation performed by poor, older, single women with no formal education or training.
The post-Civil War years, characterized by remarkable economic growth, the rise of industrial corporations, the decline of small entrepreneurs, and the emergence of urban America, engendered the expansion of relief organizations and the development of new charity organizations. (Lubove 4-5). One of the first training schools for nurses emerged in 1889 at the Johns Hopkins Hospital as a joint effort between the women reformers and the hospital trustees. They sought applications from Episcopalian and Presbyterian daughters of the clergy and the professions (James 214). The reformers argued that only women with proper, virtuous backgrounds could enhance the moral atmosphere of the hospital(Reverby 37).
During the 1930s and into the 1940s the private duty market collapsed altogether (Melosh 197). The new array of hospital techniques for both patients and nurses fostered a new role for some nurses, however: that of hospital foreman, supervising a new hierarchy of subsidiary nurses. The nursing professionalizers urged hospital administrators to hire educated graduate nurses of middle-class origins for these positions. Administrators were not hard to persuade on this point since they were able to hire nurses with more education and experience for the same wage as the student nurse, given depression-era unemployment. At first, grateful for work, graduate nurses accepted this condition. In time, however, graduate nurses responded to this situation with unrest, high rates of absenteeism, and turnover. Conflicts between adherents of the more elitist, human capital interpretation of professionalism and proponents of the need to work continue to resonate from staff and head nurses today. Many staff nurses claim that besides taking care of patients, they’re working to put shoes on their children’s feet and nursing administrators just don’t see that they work to support their life outside the hospital too. Such a comment was just as appropriate in the 1880s as it was in 1995. The same debates still rage on.
Obviously, until the 20th century, hospital nursing was less prevalent than household nursing since most births, deaths, and illnesses occurred in the home. The majority of Americans did not see the inside of a hospital until the turn of the century. Hospitals were barely hospitals as we now know them. They were charitable institutions built by philanthropists at the end of the 18th century for the poor, the socially marginal, or the unemployed. Indeed, many hospitals evolved out of public almshouses. Patients in both public and voluntary hospitals were incarcerated for dependence as much as for disease in the 1870s (Vogel 105), and their hospital stay was often for weeks or months, not days. Impermeable walls and guarded gates surrounded the institutions, enabling hospitals to assert some control over the working class, immigrant, or destitute patient.
In the contemporary context, the shortage of qualified nursing workforce represents one of the most acute problems in American healthcare industry, and although the specialists emphasize many reasons underlying this dilemma, the fact remains that nursing shortages have been progressing back from the late 1980s till the present moment and are likely to increase in the nearest future because of the lack of innovative programs aiming to resolve the situation. Aiken et al. (2001) explained the situation with nursing shortages by reviewing several contributing factors, namely overall dissatisfaction with nursing practices, fewer students are enrolled in schools of nursing, and general aging of nursing workforce. From the critical viewpoint, although Aiken et al. (2001) indicates the major determinants of nursing shortage problem, core reasons underlying this are more diverse and complex.
Researchers have questioned why an increasing number of nurses are leaving the profession and why nursing school enrollment continues to decline. It is projected that employment opportunities for Registered Nurses (RN’s) will grow faster than the average occupation up to the year 2010. This trend, in addition to an increased nurse shortage, will result in more jobs than RN’s can fill. Since 1995, enrollment in entry level nursing programs has declined by 21% and the number of graduating nurses who completed the national licensure exam decreased by 26% from 1995 to 2001. Research indicates that the total population of RN’s is growing at it’s slowest rate in twenty years (Goodin 335-337).
Multiple factors are likely contributing to the current nursing shortage and the increased exodus of those nurses planning to leave the profession within the next five years. Recent studies indicate that many nurses experience increased rates of occupational stress, job dissatisfaction, and burnout. Research has demonstrated a link between stress and elevated reports of physical complaints, depression, anxiety, hopelessness, and suicidal ideation. In addition, many nurses cite decreased autonomy, hostile work environments, lack of recognition, and high patient to staff ratios as major reasons for leaving the nursing profession (Albaugh 193-199). Research indicates that nurses perceive their job as stressful for a number of reasons. Work environment appears to play a significant role in nurses’ perception of reported stress. Work environment encompasses various external factors including, low job control, decreased autonomy, uncooperative staffer family members, decreased resources, high patient to staff ratios, concern for poor quality of care provided, and low supportive relationships (Lambert & Lambert 161-162).
Besides, there are two current health care issues facing the profession of nursing today: a misdistribution of nurses across the United States and burnout, both noted as causes for a nursing shortage. There is a misdistribution of nurses across the United States and there are at least two apparent reasons for this: geographic immobility and a lack of incentives for rural and inner-city hospitals. Nursing is a very demanding and stressful profession. Burnout is described by Annette T. Vallano in Your Career in Nursing, as a form of mental, physical, emotional, spiritual, and interpersonal exhaustion that is not easily restored by sleep or rest. Nurses experience burnout when they are overwhelmed and unable to cope with the day-to-day stress of their work over long periods of time. Burnout may also be a reason that many nurses have decided to work only part-time, thus burnout may be a contributing factor to the nursing-shortage problem.
Negative environmental factors and occupational stress frequently result in job dissatisfaction among nurses (Hayhurst et al 283-284). Inadequate staffing and lack of social support diminishes group cohesion, reduces job satisfaction, and increases employee attrition. In a recent survey, 56% of RN’s responding stated they were planning to leave the profession to seek a less stressful and more satisfying occupation. Similarly, these same respondents reported that heavy patient work loads, decreased autonomous functioning, and a nonsupportive work environment were deciding factors in their decision to leave the nursing field (Hayhurst et al 287).
Disproportionate nurse to patient ratios continue to escalate. As a result, nurses are providing care for a larger number of patients, while time spent with each patient decreases. This may result in nurses feeling overwhelmed, frustrated, and dissatisfied with the type of patient care they are providing. Similarly, as time spent with each patient decreases, negative patient outcomes and patient dissatisfaction continue to increase (Olofsson, et al 353). A 2001 survey by the American Nurses Association reported that 75% of respondents stated that the quality of nursing care had declined in their work setting over the past two years. Because of increased patient workloads and decreased time to provide patient care, 50% of those surveyed reported that they were unsatisfied with their current position. In addition, 40%-60% said they frequently skipped meals and felt pressure to work mandatory overtime, resulting in further occupational dissatisfaction.
Practically, one of the ways to mitigate nursing shortage is to introduce mandatory stress reduction program for working nurses in all hospital facilities, since research has demonstrated a link between various stress management interventions and decreased reports of subjective stress. Mindfulness Based Stress Reduction (MBSR) can become one of mandatory stress reduction programs. In its original format, MBSR is taught as an eight-week program, with sessions occurring for 2.5 hours per week. Sessions are conducted in a group format and include a combination of didactic instruction on various topics, including communications skills, stress reactivity, and self-compassion and experiential exercises to help participants incorporate these activities into daily living. Participants, nursing personnel in this case, are asked to practice the various techniques learned in session six days per week as homework and are given audiotapes to facilitate this process.
Increased occupational stress, job dissatisfaction, and burnout are contributing factors to increased attrition rates within the nursing profession. Similarly, a recent study by the AACN (2001) found that nursing school enrollment declined for the sixth consecutive year. Similarly, a large majority of the nursing workforce will reach retirement age within the next decade. These trends have many in the healthcare industry questioning who will care for the sick and dying in the years to come. One of many ways to combat this problem is to adopt already known and working programs on retention and recruitment of nurses. For instance, hospitals can develop nurse residency programs, aimed to positively impact graduate nurses. The main objectives of such programs can be to create an environment in which senior nursing students can practice the skills obtained in school, experience the reality of the work place encountered by an RN completing a 12-hour shift and to prepare participants to successful employment at the facility upon their graduation.
From the critical viewpoint, the working environment of nurses could fall under the definition of “challenging but rewarding,” if like in other occupations with difficult working conditions employers kept wages high enough to prevent chronic shortages. In the United States, healthcare market, particularly in metropolitan areas, is presented by small number of large employers, which are often engaged in unofficial agreements to keep wages at stable level and not to attract working for other employers in the area. From this perspective, the problem of nursing compensation is only partially about volume, but primarily about policy and anticompetitive behavior of the employers in healthcare industry. The only feasible solution in this situation is filing of group suits regarding unfair and anticompetitive practices of employers. From the general perspective, reduction to the very minimum nurse-to-patient ratios nationwide would also be a viable measure to resolve the dilemma of inadequate compensation of nurses. Undoubtedly, there are challenges for the future. In short, “the nursing profession needs to begin to recognize new trends and patterns” (Lowenstein1), while also recognizing “it is crucial that nurses learn to generate new ideas for care, utilizing the new medical and communication technologies that are blossoming daily, but also keeping our high touch together with the high tech” (Lowenstein 1).
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