Looking toward the future for nursing practice

By Leslie Neal-Boylan | 01/01/2015
 
This chapter from The Nurse’s Reality Shift: Using History to Transform the Future focuses on changes in health care over the years and the future of nursing practice. While discussing topics such as bullying, burnout, and relationships with physicians, author Leslie Neal-Boylan challenges nurses to use lessons from the past to lead nursing and other health care professions to a new future of practice.
 


Bea, the special duty nurse, couldn’t be there today. “Could you sit with Mr. Farber for an hour?” the doctor had asked me. He told me to call him if need be, and he’d come and pronounce the patient dead.
 
Book cover of Nurse's Reality ShiftI scrambled around for a uniform, finding a crumpled dress in my “winter drawer.” It smelled of cedar and cigarettes from my husband’s sweaters. It was a bit old fashioned, but Mr. Farber certainly wouldn’t care. My organdy cap needed no inspection, however. A cherished possession earned after all of the vicissitudes of nurse’s training, it was not yet an anachronism. It was a cap of linen with a black ribbon on the edge. The cap, which I had perched tentatively on my head, was emblematic of my status as a registered nurse.
 
This was 1958, and nursing was almost entirely a profession of women. I wanted to go sit with Mr. Farber and ease his dying moments. My neighbors would watch the children until my husband got home, and he would give them dinner. “Must she nurse everyone in Brooklyn and run every time someone calls?” I could just hear my husband saying this when he arrived home to find me gone. But he was proud, too. I was the neighbor with the magical qualities. I could “make it better,” just as my mother had done many years before.
 
A cab took me to the large teaching hospital nearby—the place where I had played in the emergency room as a toddler while waiting for my mother to finish work as the charge nurse. I would roll myself in bandages and sniff the disinfectant and elixirs in heavy little glass bottles. I would grind the glass stoppers as I removed them, enjoying the crunching sound while hoping they wouldn’t break, and use the stoppers to place scent behind my ears, the way our upstairs tenant did when putting on her makeup. At dusk, my mother and I would walk home along the streetcar tracks. I would smell quite awful but feel very happy.
 
When I arrived at the hospital, I met Mr. Farber’s wife outside his private room. She extended her hand and a $50 bill to me, but I told her I wouldn’t accept it. We entered the room together. Mr. Farber was nearly invisible behind the heavy cellophane oxygen tent that was draped at his sides and tucked into the bedding. A lime green oxygen tank stood beside the bed. I scanned the room for a “no smoking” sign and felt reassured that it was posted beside the bed.
 
I introduced myself to the patient and reminded him that we had met once before at his cousin’s wedding. He didn’t respond, but I sensed that he understood. Before I had a chance to assess Mr. Farber further, his wife asked me to step into the hall to meet their best friends. I was annoyed by the distraction and had already placed the stethoscope to my ears, but removed it and followed her out of the room. Seated on the steps of an old metal staircase the staff seldom used were a man and a woman of indeterminate age. I hardly noticed the woman because the man was in tears. “Nurse,” he said, “please don’t let Joe die on me. We’ve been together since Anzio.”
 
I sent the three to have coffee in the hospital cafeteria and went to the nurse’s station to confer with the nurse on duty:“Blood pressure and pulse have been very erratic,” she said as we walked down the corridor. “He had a massive heart attack. Just stay with him, it won’t be long now.” Back in his room, I opened the zipper of the oxygen tent and I placed the blood pressure cuff on Mr. Farber’s—Joe’s—arm. His blood pressure was OK—not great, but within normal limits. So too were his pulse and respirations. I repeated this every 15 minutes and then every half hour since there was no change. His wife brought coffee and a sandwich for me and lightly waved to Joe before going home with her friends to rest.
 
The doctor called me at the nurse’s station at about 10 p.m. “Is it over yet? I really need to call it a day,” he said wearily. “No, it’s not over,” I said. “He’s improving! His vital signs are stable. This man is not going to die today—not for quite a while, I think. I am going to give the charge nurse report and go home.”
 
Bea called me three days later to thank me for covering for her. “Joe wants to know where his angel is. He says you certainly looked like an angel with a cap through that tent. He’s out of bed and in the chair today without oxygen.” Later that day, she called again to tell me that Joe’s good friend and Army buddy had dropped dead on the way to the hospital to visit him. I was horrified. The stress his friend had been going through had gone completely unnoticed by all of us.
 
Several factors have influenced the changes that have occurred in nursing practice since 2000. These factors include advances in technology, changes in reimbursement and funding practices, new legislation, and an increased variety of educational programs offered. There is more emphasis on the quality and continuity of care and on providing care by the appropriate staff in the appropriate setting (Indiana State Nurses Association, 2014).
 
The Affordable Care Act (ACA) is intended to emphasize disease prevention and increased use of primary care and community health services. Nurses, long accustomed to educating patients, must now understand the financial implications of various healthcare services and help their patients make informed decisions. Nurses are also used to working in teams and may be more likely to lead teams of other professionals to help prevent hospital admissions and readmissions. Technology, including electronic medical records, telehealth, and tools used to explore the impact of genetics and genomics on diagnosis and treatment, has required the nurse to become more familiar with informatics. Changes in funding and reimbursement require more accountability from inpatient facilities and their staff, including nurses.
 
Many of the issues raised by survey respondents and in today’s literature echo those from bygone days of nursing. Relationships with physicians in the practice setting, particularly for new nurses, remain a problem, as does bullying and burnout. Nurses report elitism and disunity in the profession, unacceptable working conditions, burdensome workloads, inadequate pay, a confused public image of nurses, and the use and misuse of ancillary staff.
 
Care-delivery models are changing, and nursing is being redefined. The nursing shortage continues, and more nurses are needed to move into community settings to practice. Nurses may be choosing high technology interventions over the basics of nursing care. There are not enough jobs for new RNs, and standardized residencies and orientations are necessary to ease the transition into practice. Communication, collaboration, and professionalism are suffering. Disaster preparedness, while a significant part of nursing in the form of preparation for war and the aftermath of war, has taken on new meanings since 9/11.
 
Relationships with physicians
While physicians may acknowledge that there is a shortage of their kind practicing in primary care, and although many (privately) acknowledge the quality of care provided by APRNs, they remain publicly skeptical of the ability of nurse practitioners to fill their shoes. The American Medical Association has been vocal in warning the public about the differences between NPs and physicians, and has made a point of highlighting the variations in educational preparation. While they may say we should all work together in teams, they espouse that the physician should lead the team (Iglehart, 2013).
 
Clearly, physicians as a group (with some exceptions) still see themselves as superior to nurses. This may never change. However, individuals and pockets of physicians do express respect for what nurses and are willing to work together and with other professionals. It is important as we move into the future and the changing healthcare landscape that physicians not only give lip service to interprofessional team work, but internalize it. Perhaps they should look at how poorly their efforts at superiority have worked in the past and embrace what everyone else has been doing with the common goal of high-quality care delivery.
 
Bullying and incivility
Nurses continue to encounter incivility, most often in the form of verbal abuse, in the work setting. There is a correlation between this abuse and patient safety (Budin, Brewer, Chao, & Kovner, 2013). A survey of 1,407 early-career RNs found that almost half of these nurses had experienced verbal abuse, mostly in the form of being ignored or spoken to condescendingly. These nurses were most often Caucasian, married, generally healthy, and not currently enrolled in school. Most were native English speakers and worked in a hospital doing 12- hour shift work. The researchers recommend “evidence-based strategies that address the problems inherent with verbal abuse from nurse colleagues” (Budin et al., 2013, p. 314) and suggest structured training in communication, conflict resolution, and assertiveness (Budin et al., 2013).
 
I think that although new nurses are most often the target (Budin et al., 2013) of verbal abuse, they may also display behaviors that encourage frustration on the part of their more experienced colleagues. This is not to in any way suggest that they or anyone else deserves to be mistreated; however, given the attitudes that nursing faculty often encounter from students, it is not a stretch to assume that these attitudes are carried over into the work setting after graduation.
 
Students can be abusive and demanding of faculty. They may come to class unprepared, miss class, or miss clinical days, but still expect good grades. Students often have their parents call and bully faculty and administrators. Students who are not respectful and are demanding and intransigent while in school are not likely to be humble when beginning their first job. Experienced nurses may be on the defensive when encountering new graduates based on past behavior, or they may be reactive when a new graduate adopts an attitude of entitlement when they know essentially nothing about actual nursing. Of course, there are people who are simply mean and may resent the intrusion of new graduates.
 
We should nurture our new nurses and adopt the attitude of esprit de corps from days of old in nursing. However, new graduates must do their part and come to school and work prepared, without the expectation that others will solve their problems for them. This, again, is where critical thinking plays a significant role in nursing practice. If a student is accustomed to having every need met, then where is the incentive to learn how to solve one’s own problems?
 
Workload and burnout
Several nurse respondents mentioned self-care and the need for work-life balance. Nurses both in academe and in practice report little time or energy for life outside of work. I have written about “nurse heroics” (Neal-Boylan, 2012) in the context of nurses with disabilities. We are ingrained with the obligation to be available and ready to fulfill every patient need during every waking moment. Nurses rarely take their breaks or mealtimes in part because they feel obligated to be present, but also because they are wary of how other nurses will view them if they leave. While “presence” is an integral part of nursing care, we need to trust our colleagues to cover for us so we can restore ourselves. Nurses with disabilities have conveyed that if they take a sick day or take a break to rest, even though they are entitled to these opportunities, they are considered shirkers. Florence Nightingale (1860) encouraged nurses to take time to rejuvenate, writing that one could not care for others well if she did not care for herself.
 
Susan Trossman (2014, p. 1) says that because nurses and females are nurturers, we give until our own well-being suffers. It is important that we review our schedules, learn to say no, set limits, and turn off communication technology when we are not working. Time-outs, breaks, vacations, and exercise are other strategies suggested by nurses in Trossman’s article.
 
I hear a lot about how hard nurse educators work. I know this from personal experience. But I also know that professionals in other disciplines work just as hard. Nurse academics are expected to teach a full load, participate on committees, keep current clinically, and maintain a program of scholarship. If one wants to also have a life outside of work, this becomes a tremendous challenge. I think the profession should help nurse academics and clinical nurses learn more about time management. It’s not something we teach sufficiently in schools of nursing. We may suggest that students learn how to balance work and life activities, but we are generally not doing enough to teach them techniques for doing this. If they have to care for several patients at once while in school, they may, of necessity, have to learn to balance priorities. But, we have to improve on this ourselves before we can be of much help to students.
 
I think it is wonderful that many in the profession are calling more attention to the need for self-care. However, hard work and sacrifice are as old as nursing itself. My grandmother worked 12-hour shifts, 5 or 6 days per week in the 1920s and 1930s. She and her colleagues picketed for 8-hour days. We like to think that we work harder than ever today or have more demands on our time. But in fact, the nurses of yesteryear did not have the time-saving technology that we have now. My grandmother had to sterilize the glass syringe and needle she carried with her between patients. She and my mother, who was also a nurse, had to prepare meals for patients as part of patient care. There are many things earlier generations of nurses had to do that we no longer need to do. To be sure, some new tasks have supplanted those responsibilities, but careful analysis reveals that earlier generations managed to do more with less. We like to see ourselves as martyrs to some extent (myself included). I don’t think our emphasis on long hours and self-sacrifice can even begin to lessen until we have enough nurses to care for our patients safely and we give permission to one another to care for ourselves.
 
Pay and poor working conditions
In general, nurse respondents reported difficult working conditions. This problem seems to be pervasive across settings. Many also said that nurses are paid poorly or unfairly and that there should be a differential between the associate degree-prepared nurse and the baccalaureate-prepared nurse. There were many comments about unionization and how this should be eliminated because it does not serve the nurse well.
 
Nurses continue to be responsible for several complicated patient cases, particularly in inpatient settings. This jeopardizes safety and makes the nurse liable even though the expectations are unreasonable. The issue of too many patients to one nurse has long been a problem in nursing, going back to having student nurses run the hospital during the night shift. However, if there is a nursing shortage and/or if organizations are unwilling or unable to pay for RNs, then the nurse is put in charge of more patients than anyone can reasonably manage. We must continue to rail against this practice, but not settle for an increase in the use of ancillary staff to relieve our workloads.
 
Back to basics
Many nurses who responded to the survey described the loss of “back to basics” nursing care. They claimed that nurses do not provide basic care anymore, such as bathing, ambulation, IV care, etc. While none seem to regret the advances in technology that save lives and often enhance nurse efficiency, they worry that these basics of care are being passed on to ancillary staff. Nurses “who have been around” and were educated to provide the basics remember learning that “AM care” was an opportunity to talk to the patient and conduct a thorough assessment. As another example, emptying the urinary catheter was an opportunity to examine the color of the urine, its consistency, and odor, as well as the volume.
 
We have given many tasks to ancillary staff because of our time constraints and our need to focus on activities that require critical analysis. However, electronic health records often prevent us from looking at the patient while we take a history or actually examining the patient instead of relying on the previous nurse’s notes. I experienced this with my own father, who was discharged to a rehabilitation facility after a long hospitalization. When I went to see him for the first time, I helped him get out of bed to go to the dining room. He was sleepy in bed because he was given much more of a medication than he ever took at home. This resulted in the LPNs (who provided all of the care, along with nurse’s aides) to leave him in bed and delay his lunch and any opportunity to go to physical therapy or to ambulate.
 
When I got him up, I helped to dress him. Seating him on the edge of the bed, I noticed a huge hematoma all along one side of his back. The nurses denied that he had fallen. No one had looked at his back or at his chart, which clearly stated that he was taking a blood thinner. No one had alerted the physician or checked his blood levels. An RN would have understood the implications of the medications and their dosages on his level of awareness, would have looked at his skin and noted the hematoma, and would have connected it with his anticoagulant. This is not an isolated example, but exemplary of what happens in many settings in which non-RNs provide most of the “basic” care and RNs are too removed from the assessment of the patient.
 
Elitism
Interestingly, elitism seems to have been a problem in nursing since the profession’s early days. Nurses caring for patients considered nursing leaders to be too far removed from actual clinical practice to be able to understand their needs. This perception has continued, and is clearly alive and well today. Additionally, the perception of disunity has grown. Nurses feel that we are separated from one another with regard to educational background, professional organizations (which compete against each other for membership and resources), work setting, and job title.
 
Survey respondents asked that nursing faculty keep current clinically and that nursing administrators be willing and able to “get their hands dirty” in clinical settings. Many nurses feel that we dismiss bedside nursing as being performed by nurses who are either new to nursing and going through the rites of passage or who cannot, for whatever reason, go on to graduate school to move away from the bedside. How did we get to a point of conveying that the nurse at the bedside was somehow deficient or incapable of “professional” or leadership status? In public, we may laud their work and expertise, and find ourselves supremely grateful to them when they are caring for our own loved ones. But among ourselves, we whisper that nurses must go on for higher education.
 
Nurses who care for patients embody what nursing is in the public view. The public trusts nurses because of the “bedside” nurse who cares for their mother or child. We are fooling ourselves if we think the public trusts nurses above other professionals because they admire our educators or our researchers. The public sees nurses at the bedside and the immediate difference they make. They don’t see the impact of nurse educators or researchers except very indirectly.
 
Clearly, nurses who provide direct care full time feel that they are viewed as somehow inferior to nurses with graduate degrees or in leadership positions. If we want RNs to continue to provide care to patients, then we must show appreciation for the nurses who perform that care. Otherwise, we could have LPNs and nurse’s aides, as well as other health professionals, take over the care of our patients so all nurses can be administrators, professors, and researchers. I don’t think this is what we want, but we talk out of both sides of our mouths. Yes, nurses should have at least a baccalaureate degree, but must they get a graduate degree to work to the fullest extent of their ability? If we make a revamped and reconfigured DNP the practice doctorate as entry into practice and eliminate other entry-level degrees, the RN will be prepared to care for patients at the bedside and also have a working knowledge of all of the areas they will need to know to practice in the future.
 
We could fit into the DNP curriculum all the material a nurse needs to know to keep up with a changing healthcare system, including the basics such as pediatric and adult care (with added emphasis on community and mental-health nursing), but with the addition of genomics, informatics, infectious disease, economics, business, global health, quality improvement, and other topics. A practice doctorate for entry into the profession is not unreasonable, given that physical therapists now require a doctorate and occupational therapists have moved in that direction. No one could look down upon a nurse regardless of what he or she chooses to do because we would all have respect for each other’s foundational knowledge and skills. We could eliminate our preconceived ideas and prejudices about what each of us knows because the foundation would not only be the same, but be comprehensive and futuristic. We could eliminate public confusion about who is a nurse and what a nurse knows.
 
Academics and researchers could still obtain an EdD or PhD. Nurses interested in being clinical leaders would still have myriad options from which to choose, such as the clinical nurse leader or the advanced practice registered nurse.
 
As things are now, there are so many roles in nursing extant and yet to be created that if a nurse with a BSN does not want to get a graduate degree, why should we pressure him or her to do so? I have seen so many students who apply for nurse practitioner programs who have no inkling what an NP actually does. Students are often encouraged to bypass clinical practice and go straight into a graduate program or to apply for graduate school when they don’t know what they really want to do in nursing. But when we do this, we shoot ourselves in the foot. We develop nurses with graduate degrees when we might not have jobs for them, and we expose the profession to further loss of educated nurses who become frustrated doing jobs for which they have no passion. As in days of old, these disillusioned nurses are likely to denigrate the profession to their friends and discourage them from becoming nurses.
 
Disunity
Nursing organizations should unite. The ANA is clearly making an effort to do this, and has many affiliate organizations (ANA, 2014, p. 5). The ANA has also undergone restructuring in recognition of the fragmentation of nursing’s voice and the reduction in membership that has taken place over the years.
 
It is important that we make nursing organizations, journal subscriptions, and nursing conferences affordable and accessible for all nurses. Many are so cost prohibitive, only nurse academics, administrators, or researchers can afford to belong or attend. Consequently, important information is not conveyed to all nurses, and nursing leaders are not exposed to points of view from the nurses who actually care for patients.
 
I think the inability to attend conferences or afford organization memberships also accounts for the variations in the survey responses regarding what is happening in nursing. Clearly, nurses are not all getting the same messages about what is happening in the profession, so it is difficult to speak with one voice.
 
Public image
Although nursing is a profession highly trusted by the public, many nurse respondents remarked that our image badly needs restoration. As described in Chapter 7, “Looking Toward the Future for Nursing Education,” nurses decry the appearances of both nursing students (in clinical settings) and nurses. Visible tattoos, fake and long nails, excess makeup, body piercings, and long-hanging hair does not convey professionalism. I have noticed that nurses don’t always put their hair up when caring for patients. Not only is this unsanitary for the patient, it also exposes the nurse to bacteria. Some nurses recommend going back to a standardized uniform that would eliminate these unprofessional aspects and also make us more recognizable to the public.
 
Ancillary staff
The issue of if and how ancillary staff is utilized to assist nurses or augment care delivery has been discussed throughout this book, starting in Chapter 1, “Nurses Are Made Not Born: Educational Reform Frames the Profession (1900–1935).” The problem continues to exist. Throughout our history, nurses have frequently won battles against others who would replace us with unlicensed healthcare workers. However, over time, we have given away bit by bit aspects of care that were once the purview of RNs. We continue to have LPNs in many settings. If we were more united as a profession, we would be more empowered to fight encroachment on our turf.
 
This may seem contradictory to what I wrote earlier about being more interprofessional. However, preventing others from doing nursing work is not counter to being interprofessional. We cannot allow others to undervalue us and therefore pay others less to do what requires the expertise and skill of an RN. It is time we eliminated the LPN role. Offering programs aimed at helping LPNs return to school for RN education is one approach, but only if we don’t water down what they need to know in an attempt to make education more convenient or expeditious. The culture change between LPN and RN is key to making someone an RN. Simply giving them the classes and clinical hours they did not receive in the LPN program is not sufficient.
 
With the ongoing nursing shortage, the problem of nurses performing tasks they are not licensed to perform is also an issue (Lubbe & Roets, 2014). This problem may be more common outside of the United States, but its existence warrants our attention as we plan for the future.
 
In the future, nursing roles are likely to morph and change. Nurses must have the final say as to how this happens. We must unite our organizations and our efforts to present a strong voice, and recruit physicians and other healthcare professionals to support our efforts to maintain the core values and purposes of the profession.
 
Care delivery
Despite the ongoing controversies faced by NPs as we try to solidify the Consensus Model and erase supervisory and collaborative agreements, we have made great strides in expanding health care-delivery services through nurse-managed health clinics (Title III of the Public Health Service Act http://legcounsel.house.gov/Comps/PHSA_CMD.pdf). APRNs manage these clinics and work with other disciplines to deliver high-quality primary care (http://www.nncc.us/).
 
As the population ages, the demand for nursing-home care is increasing. Residents require more services due to age and frailty. Those who can go back to or remain in the community are being cared for using home-health or other community-living options (Castle, 2008; Zhang, Unruh, & Wan, 2013). A study by Zhang et al. (2013) concluded that current nurse staffing in nursing homes is insufficient to meet the needs of the increasing nursing-home resident population and that government support is needed to increase reimbursement to help reduce gaps and improve efficiency.
 
We need to staff nursing homes with more RNs and decrease our reliance on LPNs and nurse’s aides. Nursing homes are not warehouses for our aged and infirm. Residents should receive the best care possible. Nursing-home owners have long been unwilling to pay for RNs. This continues to sacrifice quality and safety. The majority of the public does not know how to differentiate quality long-term care. It is our job to educate them.
 
Rutherford (2012) discussed the longstanding tradition of billing nursing services in the hospital under “room and board.” She claims that we are too focused on whether the current system reflects the value of nursing, but not focused enough on identifying “nursing revenue as a value driver” (p. 196) and a way to “justify an investment in the profession” (p. 199). Rutherford’s comments reflect changes happening in healthcare. We must become more business and finance savvy so that we are not at the mercy of others who determine what our services are worth. We need more nurses in the boardrooms of both healthcare and non-healthcare organizations so we can influence healthcare delivery and policy that affects healthcare.
 
Insufficient jobs
Nurses who responded to the survey confirmed what new nurses have said about the difficulty finding jobs right out of nursing school (Neal-Boylan, 2013). For many years, new graduates had many offers. Today, however, it takes longer to get a job in an acute-care setting. Many hospitals want experienced nurses, partly because residencies and internships can be expensive. It is important to help new graduates understand that nursing experience in other settings is not only very valuable, but also “counts” as nursing. If we increase our emphasis on nursing in community settings while students are still in school, they will be better prepared for these jobs and have a greater appreciation for the services they can provide outside of the hospital.
 
Residencies and orientations, preceptors, and mentors
Nurse residencies and internships, as well as strong and knowledgeable preceptors and mentors, can significantly affect the transition of new RNs and APRNs into practice. In its 2010 report, the Institute of Medicine (IOM) supported the need for residencies for all new nurses. Schools of nursing appear to be working to develop partnerships with clinical agencies to implement these programs. However, they remain without standardization (Barnett, Minnick, & Norman, 2014) and probably will for some time.
 
Barnett et al. (2014) conducted a survey of hospitals, and 198 responded. According to their findings, the residency programs differed with regard to length, but most often began with less emphasis on direct care of patients, which increased during the residency.
New nurse graduates and their mentors should understand that the content and structure of all nursing residencies are not the same nor are all implemented with the same labor inputs… When making a decision about which, if any, NRP [nurse residency program] to select, the new nurse should consider the number of residents entering and completing the program, the ratio of mentors to residents, activities, project requirements, and opportunities for career planning. (Barnett et al. 2014, p. 182–183)
A solid and lengthy orientation or residency is especially important for new graduates so they can develop confidence in their new role and others can rely on their competence. These orientations and residencies should become more standardized by setting. In other words, acute care hospitals should settle on a standardized curriculum and length of orientation and train and incentivize their preceptors. Additional information specific to each organization must be included, but the basics needed to work in acute care should be reviewed. Nurses starting out in home care or public health should receive 9 months to a year of consistent precepting as well as orientation about the unique aspects of home health or public health nursing.
 
Experienced nurses who move into new jobs also need good orientations and precepting or mentoring for their own sake and that of their patients. Many nurses who are experienced RNs but who returned for graduate degrees reenter the workforce in entirely new roles. While they are not beginners, they certainly require a period of familiarization.
 
Communication and collaboration
Nurse respondents acknowledged that there is value in giving the direct-care nurse some time to perform administrative duties, and for administrators to perform some direct-care tasks. Both parties should understand what the other does and how they contribute to the organization. In addition, more opportunities for inter-professional teamwork should be provided in the clinical setting, such as interdisciplinary rounding and conferencing. Include representatives from all healthcare disciplines in discussions of ethical dilemmas and patient issues. A chance to observe someone from another discipline as that person goes about his or her work could help to inform the nurse of who best to utilize for the good of the patient, and can also increase appreciation for how that discipline contributes to the care of the patient.
 
In addition, observing a nurse from within the continuum of care but in a setting different from one’s own can help nurses plan care. I once taught a graduate class of all acute-care nurses. I exposed them to home healthcare experiences. They were shocked, despite years of experience in nursing, at how hard it actually is for patients to implement what we teach them in inpatient settings when they arrive home. They vowed to plan future care and discharges with the home setting in mind.
 
In addition, previous generations of nurses and other professionals can provide insight into how elders might perceive the care they receive. They have the perspective of both a healthcare professional and an older person with illness or disability. Taking advantage of their experiences can lend insight into how to provide better care.
 
Professionalism
Professionalism (or lack thereof) may mean different things to different people. However, it was a common topic among nurse respondents. Nurses lament the lack of a unified professional image and the public’s confusion over who the nurse is. But the concern goes beyond this to a lack of pride in appearance and comportment and a disregard for both common courtesies and professional etiquette.
 
Nurses often set a poor example by displaying the same poor health behaviors about which we chide our patients, such as smoking, drug and alcohol use, and obesity. We want the public to differentiate the RN from the LPN, nurse’s aide, or housekeeping staff. Therefore, we should set ourselves above others in our professional appearance, with all due respect to our coworkers. If we present a disorderly or unprofessional appearance, then it is a logical jump to think we may be disorganized and incapable.
 
Disaster preparedness
The first three chapters of this book discussed how the nursing profession struggled with ways to prepare nurses to care for soldiers and the public during wartime and in the aftermath of war. While this remains a topic today for nurses serving in military hospitals, units in settings of war, and nurses who care for veterans, there is less emphasis in the general nursing literature on how to prepare the profession to go to war. Since September 11, 2001, there has been increasing emphasis on disaster preparedness and managing bioterrorism events. Disasters are increasingly prevalent and stem from global unrest, climate change, population changes, and new infections (Baack & Alfred, 2013). The demand for nursing increases with these events (Baack & Alfred, 2013; Lavin, 2006).
Not only must nurses be prepared to respond to major disasters to meet the needs of those affected, but they must also possess the knowledge needed for management of patients with special needs, such as the elderly, children, persons with mobility impairments, and even persons with mental health issues. (Baack & Alfred, 2013, p. 282)
I think there was a lot of emphasis on disaster preparedness in the early years of the new millennium, but the emphasis has since waxed and waned depending on what is happening domestically and around the world. It is important that nurses receive consistent reminders about how to manage themselves and others in the event of a disaster. Also, shootings in schools and public places have increased. Nurses should have a large role in educating the public to protect their safety and in providing mental health care and general healthcare to victims and families.
 
Conclusion
Sweeping changes are occurring in healthcare, and the landscape promises to look very different for healthcare providers in every discipline. Nursing can lead the way and model for others what we have known how to do for a very long time. Nurses have long worked in teams and have coordinated care for patients. Physicians consider the advent of the patient-centered medical home, for example, to be a new concept, when it is really basically a restructuring of the case-management models with which nurses are very familiar. The idea of working in interprofessional teams is not new, but if nursing can eliminate incivility within its own ranks, we can model for others how intra and interprofessional teams can work collegially and effectively.
 
Cost cutting has always been an issue in healthcare, but we must become even more vigilant than in the past about giving away nursing duties to other, lower-paid disciplines or to non-RNs. We must restore our image as identifiable, professional, and trustworthy. To do so, we should be readily distinguishable from non RNs, unify, support one another, and maintain a high standard for ourselves and our colleagues.
 
In short, we must get our act together if we are to move forward. We do not want to be left behind, competing with each other over issues that should have been resolved years ago. Let’s standardize orientations and residencies within similar healthcare organizations so we know that all new graduates get at least a minimum amount of instruction. Let’s train our mentors and preceptors. Let’s finally recognize that most patient care occurs in community settings and value what nurses do there. Let’s encourage new and experienced nurses to explore new settings for nursing practice. Let’s be sure not to lose the basics of patient care and comfort, even while we learn about and use cutting-edge technology.
 
Let’s allow ourselves and each other to rest and restore our energies, and not look askance at a nurse who takes her vacation time or takes his lunch break or stays home when she’s sick. Let’s do away with the elitism that separates us from each other, prevents us from accomplishing everything we should, and prevents us from being able to present a unified image to the public. Let’s make sure we are in the forefront of disaster and emergency preparedness by keeping abreast of what is happening in the world and of the potential for global issues to threaten healthcare in our nation and the safety of our patients. 
KEY POINTS ABOUT THE FUTURE OF NURSING PRACTICE 
  • Relationship with physicians
  • Bullying and incivility
  • Workload and burnout
  • Pay and poor working conditions
  • Back to basics
  • Elitism
  • Disunity
  • Public image
  • Ancillary staff
  • Care delivery
  • Insufficient jobs
  • Residencies, orientations, preceptors, and mentors
  • Communication and collaboration
  • Professionalism
  • Disaster preparation  
Neal-Boylan_Article_SFWLeslie J. Neal-Boylan, PhD, CRRN, APRN-BC, FNP, FAAN, is dean, University of Wisconsin Oshkosh College of Nursing. In addition to The Nurse’s Reality Shift, recently published by STTI, Neal-Boylan is the author of The Nurse’s Reality Gap, Nurses with Disabilities, and Clinical Case Studies for the Family Nurse Practitioner.
 
 
 
References
American Nurses Association. (2014, May/June). Association news update; Welcome new specialty affiliates. The American Nurse, 5.
 
Baack, S., & Alfred, D. (2013). Nurses’ preparedness and perceived competence in managing disasters. Journal of Nursing Scholarship, 45(3), 281–287.
 
Barnett, J. S., Minnick, A. F., & Norman, L. D. (2014). A description of U.S. postgraduation nurse residency programs. Nursing Outlook, 62(3), 174–184.
 
Budin, W. C., Brewer. C. S., Chao, Y. Y., & Kovner, C. (2013). Verbal abuse from nurse colleagues and work environment of early career registered nurses. Journal of Nursing Scholarship, 45(3), 308–316.
 
Castle, N. G. (2008). Special care units and their influence on nursing home occupancy characteristics. Health Care Management Review, 33(1), 79–91.
 
Iglehart, J. K. (2013). Expanding the role of advanced practice nurse practitioners: Risks and rewards. The New England Journal of Medicine, 368(20), 1,935–1,941.
 
Indiana State Nurses Association. (2014, February/March). Independent study: The evolving practice of nursing. ISNA Bulletin, 7–10.
 
Institute of Medicine. (2010). Future of Nursing: Leading change, advancing health. Retrieved from http://www.thefutureofnursing.org/IOM-Report
 
Lavin, R. P. (2006). HIPAA and disaster research: Preparing to conduct research. Disaster Management and Response, 4, 32–36.
 
Lubbe, J. C., & Roets, L. (2014). Nurses’ scope of practice and the implication for quality nursing care. Journal of Nursing Scholarship, 46(1), 58–64.
 
Neal-Boylan, L. (2012). Nurses with disabilities: Professional issues and retention. New York: Springer.
 
Neal-Boylan, L. (2013). The nurse’s reality gap: Overcoming barriers between academic achievement and clinical success. Indianapolis, IN: Sigma Theta Tau Publishing
.
Nightingale, F. (1860). Notes on nursing: What it is and is not. Retrieved from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html
   
Rutherford, M. M. (2012). Nursing is the room rate. Nursing Economics, 30(4), 193–206.
 
Trossman, S. (2014, Jan/Feb). Toward civility: ANA, nurses promote strategies to prevent disruptive behaviors. The American Nurse, 46(1), 6.
 
Zhang, N. J., Unruh, L., & Wan, T. T. H. (2013). Gaps in nurse staffing and nursing home resident needs. Nursing Economics, 31(6), 289–297.
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