Nurses Seek to Upgrade Their Profession in a Changing Medical World : Image Problem Contributes to Lower Status

Times Staff Writer

The choice was not an unusual one in some working-class families 20 years ago.

According to the values of her parents, Barbara Limandri could become a nun, a nurse or a schoolteacher. A stint at Catholic school convinced her that she was not nun material, Limandri said. And she did not wish to spend her days herding toddlers.

So Limandri became a nurse.

A scholar who researches women in crisis and a member of a radical feminist nurses' organization, Limandri, now 36, is a contradiction of her family's notion of what a nurse should be. But since she grew up in the nurse-nun-teacher days, it's sometimes hard for her to reconcile her activism and her career choice.

A Feminist Nurse?

"I'm a nurse, for crying out loud," Limandri said during a recent interview at UC San Francisco where she's a doctoral student in nursing. "How can I be a nurse and be a feminist at the same time? How can I be a nurse and attend a Take Back the Night march (an annual rally protesting violence against women)?"

Limandri's quandary--how does my traditional occupation jibe with my image of myself as an aware, involved individual?--is a dilemma familiar to nurses everywhere in the '80s:

--A rural nurse practitioner working in Northern California remembered that she once advised a childhood friend that "only dumb people" become nurses.

--A psychiatric nurse practicing in San Francisco said she had read about Cherry Ames (the nurse-heroine of a series of popular children's books in the '50s) when she was growing up. "I decided this Cherry Ames character was too sweet for words, and I was not going to be this person."

----Patricia Underwood, president of the California Nurses Assn., said that based on the stereotype that nurses are either chaste angels of mercy, or sex objects: "It looks like we're in a subservient practice that no mother would want her child to go into if she's at all a humanist.

"Image is our major problem and has been as long as I've been in nursing--25 years," added Underwood, a clinical professor at UC San Francisco's School of Nursing. "The way that patients, physicians and legislators see us produces great problems. And a whole lot of that has to do with the fact that we're a women's profession." (Although the number of men in nursing is increasing slowly, 97% of all nurses are women.)

More and more nurses are obtaining master's and doctoral degrees; and some are entering specialities in much the same way doctors have done for years. But it's not the growing complexity of the job that most often comes to mind when people think of nurses--it is their ability to provide solace, classically thought of as a woman's duty.

Just as emotional leanings are sometimes used to cast doubt on the competence of women in politics and other fields, nurses have found their capacity for caring used against them. The implication, Underwood said, is that a nurse cannot be compassionate and technically competent at the same time.

The devaluation of nurses' work has been graphically reflected in the budget structure of hospitals. While patients normally receive an itemized bill for every cotton ball and syringe used during a hospital stay, nursing care still usually falls under the category "room rent," according to Underwood.

Studies currently in progress at several universities will attempt to determine--in monetary terms--just what a nurse's attention is worth. Once these guidelines for "costing-out" nursing service are established, Underwood said, health care providers will be able to gauge exactly how much a nurse contributes to a patient's recovery.

'Full-Fledged Partners'

American Nurses Assn. President Eunice Cole and other nursing leaders hope such studies will help to speed nurses' battle to become what Cole called "full-fledged partners in the health care delivery system."

Because of a shift in medical economics, measures such as costing-out nursing care have attained greater importance. Prospective pricing, a new federal payment plan for Medicare patients, went into effect in 1983 and is expected to be fully in swing by 1987. The system is intended to control costs by putting a ceiling on the amount Medicare will pay for specific conditions. Hospitals that provide service for less than the specified amount will be able to pocket the difference.

With the race on to cut expenses and shorten patient stay, nurses suddenly find themselves in a position of influence.

Increase Efficiency

It has traditionally been the responsibility of nurses--not doctors--to know what a unit of blood or an IV needle costs, Underwood explained. They are the ones who can increase efficiency by, for example, stocking individual instruments rather than full sets of prepackaged tools for suture removal, as pointed out in an article on prospective pricing in the journal of the California Nurses Assn. As reported in the same article, a New Jersey nurses' group showed that when nurses are thorough in their charting habits, physicians tend to rely on those observations and order fewer tests, again bringing down costs.

According to Margretta Styles, dean of the School of Nursing at UC San Francisco, recent studies show that nurses are able to speed recovery and reduce complications after surgery by giving patients a detailed rundown of the sights, smells, sounds and sensations they will experience during a procedure.

And it is the nurse, because he or she has hourly contact with a patient, who is often the first one aware that a patient is ready to go home. Under prospective pricing constraints, doctors may be more likely to heed the nurses' recommendation for discharge, thus saving hours or days of unnecessary hospitalization.

Nurses also are the ones who teach self-care techniques that can help people avoid hospitalization altogether.

Underwood said she once knew a patient who kept returning to the hospital simply because he could not get his medication routine right. Every time he scrambled the prescriptions, his condition flared.

"That man had been put on 21 different medications by different doctors who hadn't consulted with each other. He was spending his whole day taking pills. He needed a nurse," Underwood said. "That's what nurses do, they help patients figure out how they're going to get through the day from morning to night. They help you adjust your medical regimen to your life."

Focus on Patients

While doctors treat the illness itself, nurses focus on patients' response to the disease and the treatment--that's Underwood's definition of the profession.

"Nurses have always wanted to know, what does the illness mean to the patient and his family?" Styles added.

As nurses begin to use their skills to save hospitals money, Underwood said they will start to be more fairly represented on governing boards. Nurses have tended not to have equal say in the tripartite structure--administration, medicine and nursing--that rules most hospitals.

"It used to be a broad back and a warm hand were all you needed in nursing," Underwood said. Now that a nurse is as likely to be named vice president of the hospital as she is head nurse, she needs to understand hospital management. Underwood said that's one reason more nurses are pursuing advanced degrees.

The publicized nursing shortage of the early '80s ended abruptly two years ago as nurses around the country began to be laid off in response to factors that included the introduction of prospective pricing.

The National Assn. of Nurse Recruiters reported last summer that the demand for nurses is beginning to perk up again. But without the lure of instant jobs, enrollment in nursing schools remains depressed. Many of those who do choose the field are enrolling in master's and doctoral programs. "As medical knowledge has expanded, two years is no longer enough to train someone who's going to stand between you and death," Underwood said.

Trend in Schooling

In the early '60s there were only a handful of advanced degree programs for nurses in the country; most nurses were prepared in two-year programs. Now the trend is toward a minimum four years of schooling; and as of 1983, there were 155 nursing master's programs nationally, with a projected demand for 267,000 master's prepared nurses by 1990 (a National Institutes of Health figure).

Of the 29 institutions offering baccalaureate degrees in nursing in Los Angeles County, Cal State Long Beach, Cal State L.A. and UCLA also award master's degrees in nursing. The UCLA School of Nursing plans to implement a doctoral program within two years, but for now, UC San Francisco is the only institution in the state preparing nurses at a doctoral level.

Often rated the No. 1 school in the country for nursing education, UCSF is the training ground of many of nursing's leaders worldwide. As Dean Styles said, "This is where the river starts."

With advanced education comes specialization. There are now more categories of nurses than the nurses themselves can keep up with. One of the largest subgroups is the clinical nurse specialist classification, for which nurses receive several years of training similar to what a physician undergoes in establishing a medical specialty.

At UCLA Medical Center, there are at least 18 different clinical nurse specialties, according to Director of Nursing Margaret Neill. She said patients at UCLA sometimes mistakenly refer to the nurse specialists as "doctor," assuming that anyone commanding so much technical knowledge must be an MD. "But they (the nurses) correct that impression very quickly, because they are proud of being nurses," Neill said.

Now that the doctoral programs have graduated a substantial force of nurse-scholars, Underwood hopes eventually to see the establishment of a National Institute of Nursing, on a par with the National Institute of Medicine, so that nursing may be studied as a science independent of medicine. (A Senate bill that would have cleared the way for such an institute was vetoed by President Reagan last October.)

Second Revolution

Higher education is the second revolution in nursing, along with changing economics, that Styles hopes will put the Cherry Ames stereotype to rest forever.

"There are some physicians who don't want to see this happen, and who make public statements that nurses are overeducated," she said. "But most physicians are increasingly aware (that with the changes in medicine) our futures are tied together."

The other great hope for nurses in beating a centuries-old image problem is the women's movement. Underwood is a supporter and former member of the group Cassandra, a name taken from the title of an essay by Florence Nightingale (described by a Cassandra member as "a flaming feminist nurse") on men's and women's roles in health care.

Although she is traditional enough to disapprove of the jargon the group uses to conduct their meetings (they refer to local chapters as "Webs"; the members as "Websters"), Underwood said, "I'm very fond of what Cassandra does. They will never represent the mainstream of nursing (which, she said, is slow-to-change), but I think that they're important because they prick our consciences. Because they represent extreme feminism, they ask the rest of us to at least represent middle-of-the-road feminism."

Questions of Concern

Cassandra was formed as a splinter group at a 1982 convention of the American Nurses Assn. Members--who include nurse educators, nurse scholars and "front-line" nurses--share a concern about certain questions:

--Why do nurses consistently earn so much less than doctors? In the South, nurses make as little as $14,000 a year; in Los Angeles, an average RN salary is $26,198. Yet the average national income for an MD is $100,000, and some specialists make more than $2.5 million. (Figures are from the California Nurses Assn.)

--Why are patients routinely referred to as "he" and nurses as "she" in nursing texts and college courses? Why are doctors often addressed by title, and nurses only by their first names?

--Why do physicians record their observations in the "progress notes" section in the front of a patient's chart, while nurses' comments are relegated to the back page, a sort of addendum?

--Why do men who graduate from nursing school often gain easy admittance to administrative positions, while women who graduate with equivalent grades are often doomed to a frustrating creep up the ladder? (Some men in nursing say that's not so. See adjoining story on male nurse Mike Meyer.)

--Why do nurses bear much of the responsibility for a patient's health, and have none of the authority to make medical decisions?

Spokesperson Barbara Limandri said Cassandra members (numbering about 300 nationally) decided, "If the ANA doesn't want to look at these as issues of sexism, then we need another organization that will.

'Stick Our Necks Out'

"ANA is concerned about the issues women believe in, but we in Cassandra want more for nurses, and we're willing to stick our necks out for it," she added.

For all the work being done within the profession to forge a bolder identity for nurses, some of the causes' greatest supporters may turn out to be patients.

Sarah O'Connell, a 47-year-old stage and film actress who lives in Los Angeles, had only been in the hospital twice before in her life, both times to give birth, when she was diagnosed with a tumor of the colon last April. Since that time, O'Connell has been in and out of the hospital for surgery and chemotherapy. She has gotten to know nursing intimately.

"I've had 22 IVs in 30 days," said O'Connell, speaking from her bed at the Hospital of the Good Samaritan. She wore freshly applied peach nail polish on her hand where an IV needle was taped. "I know now which nurses are good and which aren't, and when Pauline (Schenk, her chemotherapy nurse) walked in, I knew I could trust her.

"I was warned by my internist that a lot of these doctors (cancer specialists) will look at me as a ruptured colon and not a person. That's OK. As long as I know that some nurse is looking out for all of me."

More Respect for Nurses

Author Lewis Thomas is another patient who left the hospital with an elevated respect for nurses.

"My discovery . . . is that the institution is held together, glued together, enabled to function as an organism, by the nurses and by nobody else," Thomas wrote in his book "The Youngest Science: Notes of a Medicine-Watcher" (Viking).

"Knowing what I know, I am all for the nurses. If they are to continue their professional feud with the doctors, if they want their professional status enhanced and their pay increased, if they infuriate the doctors by their claims to be equal professionals, if they ask for the moon, I am on their side."

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