Health Horizons : PSYCHOLOGY : Nursing Redefines Itself : Many nurses are leapfrogging over doctors and administrators into top executive jobs. But there are growing pains too.

Nurse practitioner Irene Stuart runs a clinic for the homeless out of a Skid Row rescue Mission in Los Angeles. Call her a heroine--a fighter in the struggle to deliver health care to the homeless. Or just call her by her title, director of clinical services. All those fit.

Just don’t compare her to a doctor.

“Nursing isn’t doctoring,” said Stuart, an ex-Navy nurse who runs the UCLA School of Nursing clinic at the Union Rescue Mission.

Nursing is redefining itself, and Stuart is contributing to the new definition.

So are nurses such as Georgina Garcia, whose specialty is high-tech coronary care; or San Francisco-based nurse practitioner Susan Shea, who specializes in the treatment of AIDS, or Mary Ann Barnes, a registered nurse who is the administrator of the Kaiser Foundation Hospital in Harbor City.

Along with running clinics on Skid Row and using innovative technology to keep patients alive far longer than would have been possible a few years ago, many nurses are returning to medical schools. They are seeking advanced degrees and positioning themselves for a role as primary care providers in the health care reforms being sought by the Clinton Administration.

Nurses, at least in California, still must work within guidelines set by doctors. But the medical world is beginning to accept the notion that advanced-practice nurses, with master’s degrees and special licenses in fields such as pediatrics, family medicine and obstetrics, can do as much as 80% of what a physician can do.

“They (advanced-practice nurses) have had more training than an intern right out of medical school,” said Dr. J. N. Sarian, a radiologist who puts in four hours a week at the rescue mission clinic run by Stuart.

These days, nurses are starting their own practices with minimal supervision from doctors and are able to furnish or dispense drugs to patients. In corporate medicine, many registered nurses are leapfrogging over doctors and administrators into top executive jobs. Nursing schools are at the bursting point, with room for only one of every three qualified applicants in top schools.

But with all the gains come growing pains.

Registered nurses are finding more and more health care providers standing between them and their patients. Cost-conscious insurance companies and health maintenance organizations are putting the squeeze on hospitals, and they in turn are putting the squeeze on nurses. RNs are being replaced by a variety of unlicensed hospital workers who have less training but also cost less.

With industry analysts agreeing that the nursing shortage of a few years ago is over, nurses have gone from being chased and courted with bonuses and write-your-own-ticket jobs to the possibility of being laid off.

Today, nurses will find jobs, but the jobs may be on a night shift, in a specialty that wasn’t their first choice or even outside an acute-care hospital, in a long-term care facility or an in-home treatment program.

Stress is also high. As a result of cost-cutting, patients these days are in hospitals for shorter periods, being treated for more acute illnesses. As a result, ward nurses are likely to be wearing track shoes and beepers, all the better to keep them running from one patient to another. The Service Employees International Union, which represents registered nurses and licensed practical nurses in the female-dominated profession, released a survey earlier this year showing that nurses suffer significantly higher rates of such stress-related diseases as colitis, ulcers and depression than do women generally.

Nurses also say they have a continuing struggle to gain respect.

They point to a budget proposal by UCLA Chancellor Charles E. Young to eliminate the university’s undergraduate nursing school, ranked 15th in a nation in a recent national survey. It has three qualified applicants for every slot that opens. Outraged nurses believe that they are still suffering from gender bias, since the faculty at the nursing school is 98% women, roughly the proportion of women to men in the nursing ranks.

“Even today, nursing is considered less academic than other fields. We question why nursing is viewed as less academic than engineering. . . . We think it is a gender thing,” said Kathleen Dracup, a professor at the nursing school.

Linda McDermott, a nurse practitioner and a faculty member of the USC School of Nursing, went through a similar fight three years ago when USC administrators tried to close the nursing school there.

“I don’t think it bodes well for anyone that two nursing programs have been threatened in the last three years. No one ever talks about closing medical schools, even though it is a fact that you can educate five nurse practitioners with advanced degrees for the cost of one doctor,” she said.

Still, although nurses are far from satisfied, they seem pleased that after years of playing what one said was an invisible role in the health care system, they are beginning to get their due.

AIDS nurse Shea, who works out of a clinic run by UC San Francisco, said: “When I went to cocktail parties eight years ago, people’s eyes would glaze over when I told them I was a nurse. Now when I tell them what I do, that’s all they want to talk about.”

USC’s McDermott, a nurse for 15 years, is happy to see the boom. Since USC made the decision to keep its nursing school open, enrollment has tripled, despite the hefty $17,000 a year it costs to attend. (But salaries have boomed too: Beginning RNs earn $40,000 to $45,000 a year and experienced nurses earn in the $60,000 range. Nurses with advanced degrees can earn up to $100,000).

“Nursing is a hot profession again,” McDermott said. She attributed part of the enrollment growth to the relatively good pay and the tight job market in other fields. But she said much of it is due to the expanding role of nurses.

“Today we are able to do what we were trained for much more . . . than in the past. With nurse midwives, it’s possible for a pregnant woman to go through prenatal care, delivery and post-delivery care without a doctor ever being involved.”

For Shea, a typical day might mean visits from patients seeking simple dietary advice or a house visit to a terminally ill AIDS patient. Shea oversees AIDS patients’ care from the first visit to the time of death, often counseling them and their families.

At her Skid Row clinic, Stuart--with the help of one other nurse practitioner and a part-time assistant--operates what is called a “nurse practice.” That means that nearly all the diagnoses, treatments and other medical services, including the dispensing of drugs, are provided by Stuart and another nurse. They figure that they can handle 80% of the medical problems they encounter, including ear infections, blood poisoning, bronchitis, tuberculosis and respiratory problems. More serious medical problems are referred to physicians in local clinics or hospitals.

Though it sounds as if she is doing the work of a doctor, Stuart does not want the two professions blurred. “A physician is interested in disease and studies disease in depth. The nurse’s primary role (is) to be an advocate of the patient. So what we do is a lot of teaching,” she said.

Stuart operates out of what essentially is one large room on the second floor of the mission. There are two partitioned examining rooms, one of which doubles as an office for the other nurse practitioner who works with her, Aaron Strehlow. They have no X-ray machines or modern diagnostic equipment, and they dispense drugs in limited quantities out of what appears to be a converted closet.

“Our practice is very much predicated on the amount of money we have,” she said.

Even so, she and Strehlow see 35 to 40 patients a day; about 10,000 men and women a year.

At the opposite end of the spectrum is Georgina Garcia, a registered nurse at the Kaiser Foundation Hospital in Panorama City and administrator of the coronary care unit.

For years, it has been difficult to get a true measure of the problem in certain heart patients, because they are, in effect, in the protected environment of the hospital.

But now ultra-sensitive portable heart monitors have been developed that can be sent home with patients. So when symptoms develop, such as heart palpitations or lightheadedness, a pocket-size portable transmitter allows the patient to transmit the electronic signals over the phone line that can produce an electrocardiogram at the hospital.

Garcia is waiting at the other end of the phone line, where she gets an EKG readout. Depending on the readout, Garcia can give friendly reassurance that everything is OK or call the paramedics.

“Everyone benefits. The patient doesn’t have to sit in the hospital for days and days and days; it allows us to have more accurate diagnosis and treatment. The cost savings are obvious--what it costs to have a patient on a heart monitor in the hospital for two weeks versus what it costs us to provide a monitor and use it only when there are symptoms,” she said.

At the Kaiser hospital in Harbor City, a registered nurse, Mary Ann Barnes, is the administrator of the 251-bed hospital. A onetime intensive-care nurse who saw her share of night shifts, Barnes has moved steadily up the organizational chart at Kaiser. Although nurses represent a relatively small number of top hospital administrators, medical industry sources said they are being given top executive jobs more and more.

“Nurses in top administrative jobs were rare in the past, but I have seen a big evolution occurring in the last five years,” Barnes said. “Typically what you had seen as a top-out for nursing was the job of director of nursing in a hospital. That is really changing. There are several other RNs in our system with top administrative jobs.”

As for the future, nurses say they can be counted on to continue to push the limits of their practices, both in terms of expanding their role in patient care and defining such things as minimum staffing levels at hospitals.

One outgrowth of that is an increasing militancy in collective bargaining. Another is a stepped-up effort to play a more influential role in politics, an arena in which doctors and hospitals have been enormously influential.

San Francisco-based Shea, active in the 26,000-member California Nurses Assn., a lobbying and collective bargaining organization, said: “We have been an invisible force in the health care system. Nurses are realizing that in order for us to continue to expand the role we’ve had, we have to be much more politically involved.”