Code of Professional Conduct
A nurse cradling a child who is receiving treatment for asthma. A nurse holding the hand of a frail diabetic patient and encouraging him during the discharge process. A nurse’s empathetic expression for a frightened teenager facing emergency surgery.
Are these the images we leave with our patients? Do they reflect how we see ourselves? Is our image obvious only in what we do, or is it also about what we say, how we say it, and what we wear? Consider these questions:
• How has our image changed over the years?
• Who is defining the image of the nurse?
• What can each nurse do to affect our image?
• How do we confront and address the negative images of nursing?
Our changing image
Over time, nurses have had many images, ranging from the angel of mercy to the sexual stereotype sometimes portrayed in works of fiction. Florence Nightingale depicted the nurse as inferior to the physician. As a child, I read every book in the popular Cherry Ames series and dreamed that every day I worked as a nurse would be a Cherry Ames day. This series ran from 1943 to 1968 and, interestingly, is now back in print. Other representations and misrepresentations that have shaped our image include Hot Lips Houlihan in the television series MASH and some less-than-inspiring nurses in soap operas. In 2001, the Center for Nursing Advocacy was founded to address the nursing shortage. After deciding to focus on improving the portrayal of nurses in the media, the Center began a series of annual Golden Lamp awards for the best and worst depictions of nurses. The Center has developed letter-writing campaigns to target producers of shows that don’t show nursing in a positive light, such as ER and House. In December 2006, after 5 months of effort, the Center persuaded Coors brewery to stop using “naughty nurse” imagery in its ads.
Most honest and ethical
For many years, a Gallup poll has identified the most honest and ethical professions in America. And for 8 years in a row, nursing has been in the top 10. For the last 5 years, nurses have been number one (see Most honest professions). But is this ranking really relevant to the concern we have about our image? What really matters to patients and their caregivers? What do we care about and look for in our colleagues? How much impact do these perceptions have on our image? (See Nursing’s image: What do nurses think matters most?)
Dressing with Snoopy and Sponge Bob
As the image of nursing evolved with time and changes in healthcare delivery, our appearance changed, too. The catalogue scrub companies who bombard nurses with their mailings have played an important role in this appearance change. Today, many nurses think nothing of wearing clothing adorned with cartoon characters. What other professions that serve the public have cartoon characters on their uniforms? Police officers, pre-hospital staff, judges, firefighters, and others would not be seen with Snoopy, Sponge Bob, or animal characters covering their uniforms. Why does nursing represent itself in this way? We let people outside of our profession influence how we present ourselves to the public. Sandy Dumont, an image consultant, makes this comment about the way we dress, “You’re the only thing between the patient and death, and you’re covered in cartoons. No wonder you have no authority.” Many organizations have started to address this issue by changing the dress codes for nurses. These changes also make it easier for the patient to identify who is a nurse.
The face of nursing
The face of nursing—that is, the overwhelmingly female face—also affects our image. Although the number of men in nursing is growing, we need more campaigns and targeted recruitments to draw men into the profession. The old Cherry Ames image keeps the profession primarily female. As more men enter the profession, they will become role models and mentors for others. And other men will look at nursing as they do other career options, such as being a police officer or firefighter. Our patients may be in the best position to answer the question, Who is the nurse? A nurse diagnosed with cancer found herself on the other side of health care. Here’s what she had to say, “I must say the majority of the time I knew who the nurses were…by the way they carried themselves and their professionalism.”
Redefining our image
Professor L.D. Andrews of Rogers State University says that to create a new image for nursing, nurses must:
• value nursing and project that image daily
• take themselves seriously and dress the part
• recognize the value of what they do
• believe in themselves and their colleagues.
Our image is evolving as nurses fill seats in the House of Representatives and news stations use us as resources for their stories on healthcare issues. These opportunities allow us to represent the reality of nursing and to show how the profession contributes to health care.
These developments show promise, but our professional image needs more, and we need it now. Each nurse needs to explore how his or her actions or inactions affect our image. Nursing faculty need to work with the student nurse organizations to help promote the image of nursing. Nursing leaders need to recognize the daily impact they have on the perceptions of staff nurses, patients, and caregivers. And staff nurses must appreciate the importance of how they are perceived by patients and caregivers.
We also need to recognize the effect of our behavior outside of the workplace. For some nurses, nursing is just a job, and it shows in what they say and how they act at work and away from work. I have heard nurses emphatically state that they do not want their children to go into nursing and have to work in an environment where they are not respected, are underpaid, and have to deal with people who have unrealistic expectations. Obviously, these nurses are not helping to improve our image. When an old friend asks about your work, don’t roll your eyes or shrug your shoulders. Try responding by putting your shoulders back, looking the person right in the eye, and saying, “I am a registered nurse now, and I work at the hospital.” Encourage your child who is interested in nursing. Inspire a child to consider the privilege of being with people when they are at both their worst and best. Such everyday actions will improve the image of nursing.
What we must do
Part of changing our image is growing as a profession, and such growth requires a nurturing process. Our nurse leaders need to guide this process by doing the following:
• Cultivating a professional image by the way they represent the profession
• Defining unacceptable workplace behaviors and holding the staff accountable
• Teaching nurses the benefits of scripting such as, “My name is Shelley, and I am your registered nurse today.”
• Defining the appearance of the nursing staff in written guidelines and following through with consequences for those who don’t comply
• Involving the staff in developing the list of unacceptable behaviors and the specifics of a new dress code
• Posting, circulating, and advertising nursing’s accomplishments
• Using the local community newspapers for ongoing announcements
• Having staff contribute to the community by writing health-related articles in the newspaper
• Speaking to civic and community groups about what nursing is and does
• Listening to patients’ and caregivers’ perceptions of nursing
• Surveying staff, patients, and caregivers about these perceptions
• Teaching and mentoring staff on how to validate all they do with appropriate documentation and active committee involvement
• Teaching communication skills, so staff nurses feel empowered to respond to negative colleagues in a manner that confronts and stops behaviors that affect our image
The time for us to redefine our image is now. By working together, we can help ourselves and the public see the nursing profession clearly.
In the next in our series of blogs on the image of nursing, Sandy and Harry Summers explain the steps that everyone can take to change the image of nursing for the better.
In recent months, we have outlined the major stereotypes that plague the nursing image and undermine nurses’ claims to adequate respect and resources. Poor public understanding of the profession underlies many of the more immediate causes of the global nursing shortage.
Nurses themselves must play the leading role in improving their image, as we will discuss in detail in our final piece, to be published soon. Nurses must believe in themselves and project that belief to others. Nurses should persuade the media to provide a more accurate picture of the profession, and they should try to create new media themselves.
But first, we will explore what everyone - not just nurses - can do to help. Many segments of society can influence both media portrayals of nursing and people’s understanding of nursing generally. We can all listen to nurses and watch what actually happens when we interact with the healthcare system. What are the real nurses doing? Does the media we see reflect that?
Everyone should reconsider her assumptions when it comes to nursing. Do we credit physicians for things nurses really do? If a nurse does something impressive, do we say, “You could be a doctor!” - suggesting that being a nurse is inferior?
We can also consider whether our choice of language reflects the real nursing role, because language has a profound effect on how we think and act. For example, using the word “nursing” to mean breastfeeding subtly suggests that nursing is something we can do without health education, and that only women can be nurses. Likewise, might terms like “matron” and “ward sister” reinforce unhelpful gender stereotypes about nurses? And nurses don’t take “orders” from physicians. If nurses disagree with a physician’s prescription or care plan, they are ethically obligated to work for a better one - which is not something a person who just “takes orders” generally does.
Some parts of society have special influence. The news media can learn from nurses about what nurses really do. And reporters should consult nurses about all healthcare stories, not just nursing stories - though even many nursing stories include no nurse input, as we have seen. Nurses make great expert sources because they are trained to convey their knowledge to lay people.
Creators of entertainment media should include characters to reflect the nurses who actually play central roles in the compelling healthcare that such media often shows physicians providing. Television shows like Nurse Jackie are a great start. But it would take decades of popular programming to counteract the image of nurses as peripheral subordinates (“Yes, doctor! Right away, doctor!”) that shows like House and Grey’s Anatomy have spread around the world.
Advertisers should consider the effects of nursing stereotypes and try to find alternative ways to sell their products. For example, in advertising products like alcohol, naughty nurse imagery is not technically required. Some companies, from Heineken to Cadbury-Schweppes, have been flexible in reconsidering specific ad campaigns.
Healthcare providers and executives should ensure that their public speech reflects understanding of nursing. Hospital managers might promote nursing as they do medicine, and publicise their efforts to strengthen the profession. And insurers and drug companies can advertise without wrongly suggesting that healthcare revolves solely around “doctors”, particularly given the growing role of advanced practice nurses.
Consider Médecins Sans Frontières (Doctors Without Borders). More nurses than physicians work for this international aid group, and nurses have played leadership roles in the group. Yet its name sends the public the message that the physicians provide most or all of its healthcare. We have urged MSF to consider a more inclusive name, such as Soins Sans Frontières (Healthcare Without Borders).
Government leaders and other policy makers should publicise their efforts to invest in nurses’ practice, education, research, and residencies, and place qualified nurses in visible positions of authority. Earlier this month, Nursing Times started a petition to ensure that at least one nurse sits on the board of each of the consortia that shape decision-making about the NHS. Such commendable inclusion is too rare. In 2007, Google created a Health Advisory Council with 25 members, and though many were physicians, not a single member appeared to be a nurse.
Foundations should undertake projects to build public appreciation for nursing. We have urged funders to consider an International Museum of Modern Nursing - an exciting, interactive science museum that would show visitors cutting-edge nursing practice and research. And in a 2006 opinion piece in the Baltimore Sun, Sandy and nursing scholar Kristine Gebbie proposed the creation of a Nobel Prize in Nursing to recognise nurses whose work has changed the world.
Nurses’ healthcare colleagues can also play a key role. Physicians should learn what nurses really do - for instance, that nurses do more than provide basic custodial care. In some innovative programs, medical students shadow nurses to learn what they do, or medical and nursing students take some classes together. And physicians should work to stop the crediting of physicians for nurses’ work, which happens everywhere from the hospital bedside to popular television shows.
Other health workers should ensure that they are not mistaken for nurses, which undermines the public’s sense of who nurses are. We admire the recent decision of Wales to adopt national nursing uniforms to help people identify nurses with different specialties and levels of authority.
What would the future look like if the public truly valued nursing? Understanding that nurses save lives can itself save lives - by providing the resources nurses need. Adequate resources for clinical settings are only the beginning. Through their holistic, preventative focus, nurses can intervene before conditions become severe, so patients don’t end up dead or in expensive hospitals. Teams of community health nurses and advanced practice nurses can prevent or manage much of the illness the world now suffers. Malaria might kill fewer children, obesity-related problems like heart disease could be greatly reduced, and many critically ill infants might be home with their families.
It can happen - if everyone makes an effort to understand what nursing really is.
At some stage or another most of us have relied on the contribution of a registered nurse to provide the support and knowledge we need to help get our health back on track. The nursing profession constitutes the largest segment of the healthcare system today and very few professions offer the chance to create as much an impact as nursing. In spite of this, the United States is on the verge of a critical nursing shortage. Nurse to patient ratios are being compromised, patient care is in jeopardy and the overall quality of care our nurses can provide is retreating. While shortages can often be overcome in hospitals with an immediate need, there is a steady decline in the availability of nurses as they digress into different occupations or don’t even consider nursing as a viable career option. It is important that steps be taken in the immediate future to address the underlying causes of the worsening nurse shortage and help promote nursing as a rewarding career choice.
According to a report conducted by the Health Resources and Services Administration, 30 states are currently suffering due to a lack of nurses being able to fill positions. Ninety percent of long term care facilities do not have sufficient staffing to provide even the most basic care and home health agencies are being forced to refuse new admissions. This outlook does not look promising for the state of healthcare in the United States. Currently there are 126,000 unfilled nursing positions across the country, a number that is expected to reach 1.1 million by 2012. More new nursing jobs are expected to be created for registered nurses than for any other occupation, so the time is right to help make a difference and pursue a rewarding career in nursing.
The nursing shortage is not a recent phenomenon, in fact it has been occurring since World War II. It is however, only in the last few years that the shortage has begun to have a significant impact to our healthcare systems. A steep population growth, a declining number of applicants to nursing schools, an aging workforce and a baby boom generation that will require concentrated healthcare services in the coming years are all contributing to this situation.
As new opportunities have opened up for young women and stresses have been added to the profession, many are opting to choose other careers besides nursing. Women and men are weighing their interests with a career choice that will bring them worthy compensation as well as enhancing their quality of life. Unfortunately, nursing is currently falling short on both of these. Women are now pursuing many competitive, attractive, and lucrative careers that were impossible to achieve thirty years ago. Women are entering law school, medical school, and the corporate world in droves. Research indicates that 35% fewer women would choose nursing as a career in the 1990s than they would have in the 1970s.
Declining Enrollment and Educators
New admissions into nursing schools have dropped dramatically and consistently for the past six years. Additionally, nursing colleges and universities denied 32,617 qualified applicants in 2005 due to the shortage of nursing educators. Faculty age continues to climb; higher compensation can be found elsewhere luring potential educators away from teaching. The Health Resources and Services Administration stated in a 2006 report that, "to meet the projected growth in demand for RN services, the United States must graduate 90 percent more nurses."
The lack of younger people entering nursing has raised the average age of nurses. In Maryland, the average practicing RN is 46 years old, nationally the average working RN is over 43 years old. About half of the RN workforce will reach retirement age in the next 15 years. On top of this, the average age of new RN graduates is 31. Nurses are entering the profession at an older age and offer fewer years of work.
America's demand for nursing care is expected to balloon over the next 20 years. The future demand for nurses is expected to increase dramatically when the baby boomers reach their 60s and beyond. The population aged 65 years and older will double from 2000 to 2030. Furthermore, the population aged 85 and older is the fastest growing age group in the U.S. The Bureau of Labor Statistics ranks the occupation of nursing as having the seventh highest projected job growth in the United States. The real issue is that during this time of increased demand for health care, the overall number of nurses per capita will begin to decline. By 2020 the number of nurses will fall nearly 20 percent below requirements.
For sustained change and assurance of evading the forthcoming shortage, solutions must be developed in several areas: education, health care systems, policy and regulations, and image. This shortage is not exclusively a nursing issue, but will require a collaborative effort among nursing leaders, practitioners, health care executives, government, and the media.
Creating Cultures of Retention
The American Nurses Association Magnet hospital program has had a proven success in raising the standards of nursing practice and improving patient outcomes. Currently there are 85 organizations that are designated Magnet hospitals. Magnet facilities are characterized by strong administrative support, adequate nurse staffing, strong communication, nurse autonomy, better control, and a vital focus on the patient and their family.
A growing body of research indicates that this program is making a positive difference for nurses, patients, and the hospitals as a whole. Research is proving that through this program, nurses are having increased satisfaction as well as increased perceptions of productivity and the quality of care given. Studies also indicate that these facilities have lower incidence of needle stick injuries, lower burn out rates, and double the retention of non-Magnet facilities. By adopting the characteristics of Magnet hospitals, facilities will be able to create a culture of retention that empowers and is respectful of nursing staff.
Strengthening the Infrastructure
In 2002 the Nursing Reinvestment Act was signed by President Bush to address the problem of our nation's nursing shortage. This initiative was intended to promote people to enter and remain in nursing careers, thus reducing the growing shortage. The law establishes scholarships, loan repayments, public service announcements, retention grants, career ladders, and grants for nursing faculty.
Many statewide initiatives are underway to address this issue as well. In Pennsylvania, six new nursing education initiatives have been announced to address faculty shortage by encouraging current nurses to return to school, earn graduate degrees, and teach the next generation of nurses. Illinois is unveiling a plan to provide faculty scholarships and grants to nursing schools in order to expand student enrollment. California, whose nursing programs currently have wait lists over three years, is trying to expand nursing education through a $90 million initiative.
What the public generally thinks about nursing and how the media portrays nursing shapes the current image of the profession. The public has heard about the stress nurses are experiencing, the shortage of staff, and stories of nursing errors that have injured or killed patients. Needless to say, the images provided by stories such as these do not bolster the desire to enter the profession. Nursing appears as an unstable, unpredictable, and high-risk career option.
Two national media campaigns have been launched to refine the image of nursing. Nurses for a Healthier Tomorrow is a coalition of 44 health care organizations working together to raise interest in nursing careers among middle and high school students.
It has often been said that in order to ensure a continuous flow of nursing students, children must be reached at an earlier age. Educators say that students often have their minds made up by fifth grade of desirable and undesirable careers, thus an early positive image of nursing is imperative.
Another market that needs to be pursued is males. Currently, male nurses account for only 5.7% of all nurses. If men were to enter nursing at the same rate as women, shortages would not be a concern. In order to influence men to enter the nursing profession, society and the media must eliminate barriers and stigmas facing men who may choose this career.
Travel nursing has been around for quite some time now. The industry began as nurses wanted to ski the slopes in the winter and sun bathe on California beaches in the summer, while being able to make a living at the same time. As the nursing shortage is reaching all time highs, travel nurses are in higher demand than ever. For hospitals that have had difficulty recruiting and hiring permanent staff, travel nurses have filled a gap that allows the hospitals to continue to fill beds, and in some cases, keep them open. Industry Analysts are reporting that 15,000 to 20,000 traveling nurses are used each week in U.S. hospitals.
Travel nurses enjoy the opportunity to travel and earn higher salaries. Housing and traveling expenses, health benefits, and a retirement program are all part of a good compensation package. Agencies report that many of their nurses make about twice as much as they would if they were staff at the same facility. Salaries vary by experience, location, and specialty, but generally run $22 to $35 an hour, translating to a salary of $44,000 to $70,000 for a nurse working 40 hours per week 50 weeks a year. A travel nurse in California may exceed $100,000 a year with overtime, says CEO of Aya Healthcare, Alan Braynin. The largest benefit to being a travel nurse is that they can pick and choose where they want to work and when. Rules about mandatory overtime, weekends, and holidays do not apply.
Staffing companies say that California has the largest market for traveling nurses. Currently there are 14,000 open nursing jobs in the state. In many cases these positions must be filled and are done so with travelers. In fact, 6% to 15% of California nursing positions are being filled with travelers.
There are 1.8 million nurses working primarily in hospitals, this is where the shortage will be felt the most and is being anticipated with the greatest concern. However, all practice settings will ultimately be affected. Past economic solutions will not work this time around; this shortage is unparalleled. It is structural in nature and will require many short and long term strategies in order to avert the crisis. What is for certain is that if proactive steps are not taken it will run its course.
Factors that have undermined the desirability of nursing as a career must be eliminated, workplaces must be improved, and cultures must be developed to empower and value nurses. Nursing schools need resources, substandard care cannot be tolerated, and most importantly, hospitals must foster a culture of retention. The demographics of the nursing profession - aging nurses, aging faculty, and low enrollment, combined with the demographics of society - aging baby boomers, and requirements for a higher level of medical care, are on a devastating course; however, it is not too late.
Since Florence Nightingale professionalized nursing in the 19th century, we have had cyclical nursing shortages, especially during times of war. In the past, whenever the demand for nurses exceeded the supply, more nurses were recruited and trained, and the shortages were quickly repaired.
Today’s 21st century nursing shortage is different. It is more severe and much more difficult to fix than previous nursing shortages.
Estimations vary according to the type of analysis used, but nearly all experts agree that US healthcare will have a shortfall of somewhere around 1 million registered nurses by the year 2020. Today, there are over 120,000 unfilled openings for nurses in hospitals and other healthcare settings, despite the fact that as recently as the 1990’s we had a relative surplus of nurses.
There are several reasons for the suddenness and severity of the current nursing shortage:
Fewer people choosing nursing as a profession. Nursing has traditionally been one of the few female professions. Today, women have more and better professional opportunities and fewer are choosing nursing. There are more men in nursing than ever before, but it is difficult to attract men to the profession because of the relative pay scale deficit of a traditionally female profession.
Retirement of baby boomer nurses. At the same time that fewer nurses are entering the profession, many are leaving due to retirement. One source says that 55% of today’s nurses will retire by 2020, and there are not enough new nurses available to replace them.
Nurses leaving the profession. Nursing burnout is reaching epidemic proportions for the same reasons that it is difficult to attract new nurses to the profession. Nursing is exceedingly stressful, physically demanding and exhausting.
Shortage of nursing faculty. Until late in the 20th century, nurses were mostly taught by physicians and nurses with hospital diplomas or bachelor’s degrees. There were few graduate-level programs and virtually no doctoral programs in nursing and most nurses were trained in hospital-based programs. Today, there are very few hospital programs; most nurses are college educated. The minimum educational requirement for a nursing educator is a MSN (Master of Science in Nursing). MSN level nurses are also in demand as nursing leaders, clinical specialists and nurse practitioners—and those positions are much more lucrative than teaching is. Thus, there is a critical shortage of nursing educators, and that shortage is the greatest barrier to relieving the current nursing shortage. Nursing schools are only able to accept a fraction of their qualified applicants each year because of faculty shortages.
This nursing shortage is a global shortage. In the past, hospitals have been able to fill nursing vacancies by hiring “foreign nurses” who were educated in other countries. Today’s shortage is global; all developed and undeveloped countries are experiencing a shortage of nurses, so there is nowhere to import them from.
Increasing demand. At this same critical juncture when we have large numbers of nurses retiring and are unable to recruit and educate enough nurses to replace them, the baby boomer generation is aging and requiring more healthcare, putting additional strain on an already overburdened healthcare system.
Strategies to address the critical shortage of nurses must remedy at least some of the reasons for the shortage. Some factors cannot be addressed—the baby boomers will age, will require healthcare and will retire. We can, however, address other issues that contribute to the nursing shortage and it is essential that we do so, as quickly as possible.
Attracting new people to the profession. Although this has been the first and only strategy needed to correct past nursing shortages, it is not the first thing we need to do this time. We currently have more qualified applicants to nursing schools than we can educate. As we correct other problems, however, we will need to attract bright young people—and especially men—to the profession. Nursing must become as attractive a career option as other professions.
Recruiting inactive nurses. In a 2000 study, about 12% of the nation’s nurses were “inactive:” not employed as nurses and not looking for work in the field. Some are employed in other fields and some are taking a career break. Inactive nurses are a neglected reservoir of educated, experienced professionals.
Educating educators. The lack of nursing educators is a huge bottleneck in solving the nursing shortage. We must create incentives that will attract graduate-level nurses into education. That includes increasing educator salaries so that colleges can compete with other employers and subsidizing advanced education for nurses who commit to teaching for a period of time.
Improving nursing’s image. There are two national media campaigns that focus on attracting people to the nursing profession. Both are educating people about the nursing profession and eliminating inaccurate stereotypes about nurses. These are an excellent first step toward improving nursing’s image. We must also improve salaries and benefits and allow nurses more control over what they do.
The 21st century nursing shortage is, indeed, different from all previous nursing shortages. It is more severe and, unless we act quickly to correct it, it will cause a healthcare crisis of cataclysmic proportions. Hospitals and other healthcare organizations cannot continue to provide services without nurses. As the shortage worsens, more and more people will be denied access to healthcare simply because there will be no one to provide it.