1. No category

At the Intersection of Health, Health Care and Policy
Cite this article as:
Debbie Ward and Bobbie Berkowitz
Arching The Flood: How To Bridge The Gap Between Nursing Schools And
Hospitals
Health Affairs, 21, no.5 (2002):42-52
doi: 10.1377/hlthaff.21.5.42
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Arching The Flood: How To
Bridge The Gap Between
Nursing Schools And Hospitals
Nurses’ ability to think critically, to supervise, and to make
autonomous decisions goes largely unexercised.
by Debbie Ward and Bobbie Berkowitz
PROLOGUE: Cyclical labor shortages in the nursing profession have traditionally
been addressed by wage increases and augmented federal subsidies for training
and education. The current hospital nursing shortage, however, does not seem to
be amenable to off-the-shelf remedies. A recent survey of acute care hospitals in
the state of Washington, for example, found that higher pay was not as helpful to
recruitment and retention efforts as were improved working conditions, increased teamwork, and lower patient-staff ratios.
The use of educational subsidies has also become more problematic. Shifting
patterns of nursing education are one complicating factor, as three-year, hospitalbased diploma programs have given way to two-year associate degree
credentialing and more recently to increased demand for bachelor’s level and advanced practice nurses. Meanwhile, evidence piles up that quality and patient
safety suffer when hospitals are understaffed.
The following discussion by two leading nursing educators places challenges in
the workplace and the field of education in a common context. Debbie Ward and
Bobbie Berkowitz argue that the diversity of the nursing profession ought to be regarded as a strength rather than a source of factionalism; that the many capabilities of the profession can be used as assets in workplace redesign; and that educational institutions have a critical role to play in effecting these transformations.
“Partnerships between schools and hospitals should map new career paths and
not re-erect mere hierarchical ladders that apply only to the current workplace,”
they write.
Ward is an associate professor at the University of Washington School of
Nursing and a trustee of the consumer-elected board of Group Health Cooperative. She holds a doctorate in health policy from Boston University. Berkowitz is
professor and chair of the University of Washington Department of Psychosocial
and Community Health and director of the Robert Wood Johnson Foundation’s
Turning Point program. Her doctorate in nursing science is from Case Western
Reserve University.
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ABSTRACT: A gap persists between what nurses can do and what they are employed to do,
between the education nurses obtain and the work design of hospitals. Despite agonizing
over standardization, current nursing education reflects the pluralistic nursing workforce,
and nurses hold accountability for it. But nurses have not been proportionately or effectively involved in restructuring the hospital workplace. The result is that nurses are both
overworked and underused. Fortunately, this gap may be bridged with a number of shortand long-term policy solutions.
J
o h n g r e y d i d n ’ t l i k e t h e i d e a of going into the hospital, but now that
his grandson James was a hospital nurse, he felt a little better about it. James
told him that a lot has changed in hospitals. “Some of the things you hated
most last time you were there will no longer bug you,” he assured his grandfather.
“For one thing, you won’t have to wait around wondering when the doctor will
come in to tell you what’s up. Your chart will be on a computer by your bedside,
and the nurse will review it with you. Hospital nurses have more responsibilities
than they used to. When I go to patient rounds every week, our team reviews the
population of patients we’ve seen over the past three months. Your hospital stay
will be part of the ranking our team will get about the care we provide.” James recalled that when he interviewed for his job, the recruitment manager had said,
“There is no such thing as ‘just a staff nurse.’ The staff nurses at this hospital manage patient care, and that includes planning care, case coordination, staffing, team
practice, discharge planning, and evaluating patient outcomes.”
Many of today’s nurses are prepared to provide this kind of care. But unfortunately, this scenario is fiction. A nurse’s ability to think critically, to supervise, and
to make autonomous decisions as a full partner in the provision of hospital care
goes largely unexercised. The result, especially among the latest generations of
women, whose employment horizons continue to broaden, has been an exodus
from nursing and a critical nursing shortage.
What can be done to take better advantage of nurses’ hard-won skills? We propose that although some important solutions can come from developments in
nurses’ education, it is first and foremost a matter of improving nurses’ work environments. Hospitals that fully use nurses will not only justly reward them for
their capacities but will also reward themselves with greater loyalty and continuity, enrich the care delivery system with dynamic innovation, and provide patients
with superior care.
The Hospital Experience
Although nursing is a wonderfully rich and diverse discipline that provides opportunities to work in a broad range of settings, the majority of novice nurses
choose the hospital as their first work experience.1 Possibly this is because the image of nursing is still so commonly associated with acute care that many novice
nurses equate nursing with caring for individuals at the bedside rather than caring
for entire communities in public health nursing. Whatever the reason, 60 percent
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of today’s nurses are employed in hospitals.2
Novice hospital nurses find themselves in the antipodes of the world they imagined as students. Bret Simmons and Debra Nelson call nurses the most stressed of
all health professionals, as a result of the physical, psychological, and social factors
of their work.3 At a recent conference sponsored by the Washington State
TriCouncil for Nursing, nursing leaders cited the factors that contribute to a
shrinking workforce: low status, high physical and emotional demands, lack of
continuing education and promotional opportunities, increased patient acuity, increased demands for technical knowledge, lack of professional autonomy, salary,
inflexible scheduling, mandatory overtime, shift work, staffing ratios, lack of leadership, and lack of mentoring.4
To understand these issues more fully, the Center for Health Workforce Studies
at the University of Washington sampled eighty-three acute care hospitals in
Washington State.5 The findings indicated that although hospitals are attempting
to address some of these issues, most of the incentives actually being offered were
considered ineffective. For example, although 17 percent of the hospitals offered
higher salaries, none of the respondents felt that this was effective for either recruitment or retention. Instead, the hospitals felt that promoting teamwork and a
positive working environment, low patient-nurse ratios, and residency-training
programs would be more effective.
It seems that at a time when the nursing shortage is approaching crisis proportions, hospitals have been unable to address the critical issue of nurse satisfaction:
work design. Although the nursing shortage has been exceedingly well documented, there has been little willingness to examine and rectify the conditions
that have created a gulf between education and practice.6
The Context For Nursing
The current state of the nursing occupation reflects powerful and synergistic
forces that affect family and work life, politics, education, economics, and our
unique nonsystem of health care. It would be challenging enough to examine these
forces individually and in concert, but their complexity is compounded by attitudes about the place of women in the family and the workplace and the intimate
toil of tending the naked bodies of strangers. Nursing is packed with metaphor:
mothering, class boundaries, equality, sacrifice, intimacy, and sex.7
When average citizens report that “I saw the nurse” or “I talked to the nurse,”
they could mean any of a vast array of workers. They may mean the boss’s daughter
or girl Friday—one of the uncounted unofficial caregivers who check in on patients or even (illegally) administer medications in board-and-care homes. They
may mean someone in one of the 1.4 million licensed or unlicensed nurse aide positions in hospitals, extended care facilities, and private homes.8 Or they may be referring to one of the 329,000 medical assistants who work in physicians’ offices
and hospitals.9 They may have in mind someone in one of the 700,000 licensed
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practical nurse (or licensed vocational nurse, as they are called in Texas and California) positions in nursing homes, physicians’ offices, and clinics.10
Some restrict the title of “nurse” to one of the 2.6 million registered nurses
(RNs) who have graduated from an approved nursing program and passed a national licensing examination to obtain a state-issued nursing license.11 Others may
refer to one of the 196,279 advanced practice nurses: nurse practitioners, clinical
nurse specialists, midwives, or nurse anesthetists, whose education is usually at
the graduate level but may range from extensive in-service or clinical experience,
or both, to master’s and doctoral degrees as well as postdoctoral work.12
n Workhorses. Our concern in this paper is with the gamut of nurses who work
in hospitals. Even before the era of the matron—that redoubtable and disciplinarian
invention of the great pioneering nineteenth-century English nurse and social reformer Florence Nightingale—hospital nurses have been workhorses. In the early
1900s they moved wholesale from private duty to hospital nursing, but they did not
collectively or authoritatively assume management of their own work environments. The American Nurses Association proved to be relatively powerless against
the American Hospital Association to improve labor standards for nurses.13 Lacking
the power to manage the hospital environment, nursing was unable to help design
and implement systems from the ground up that could make the hospital the highquality, patient-focused setting it should be.
n Nursing education. Nurses have never lacked for innovative ideas. But too often their energies have been confined to the academy. Some 24 percent of practicing
RNs in the United States today are graduates of diploma nursing schools.14 Heirs of
the Nightingale model of in-hospital training, diploma schools were usually affiliated with hospitals and espoused a model of training that relied heavily on the use of
students as workers. When one of the authors was living in upstate Connecticut in
1974 and decided to become a nurse, her choice was between two extremes: the Diploma Nursing School at Vassar Brothers’ Hospital in Poughkeepsie, New York, or
the newly reinvented program for nonnurse college graduates at Yale University in
New Haven, Connecticut. These extremes represent one of the tensions in nursing—between the apprentice and university models of education.15
Florence Nightingale was truly the intellectual founder of modern nursing, and
the contradictions in her own character continue to be reflected in the preparation of today’s nurses. Although her own intellectual aspirations were vast and unquenchable, the apprenticeship model of nursing training she espoused was rote
and limited. It took several succeeding generations after Nightingale before nursing leaders began to give voice to their own intellectual and career aspirations by
forging another path in nursing education. The women who founded nursing
schools in American universities were, in Virginia Woolf’s phrase, the “daughters
of educated men.”16 Perhaps inevitably, they set criteria for improving the lot of
white, unmarried, nonimmigrant nurses that closely reflected their own class.
They were not the politically scrappy daughters of working-class immigrants who
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shaped the American labor movement; nor were they the visionaries who established the first educational venues for black nurses.17 Rather than honing a model
of grassroots advancement through guilds or unions or other forces on the occupational side, white, upper-class nursing leaders chose to wedge open the doors of
universities to aspiring nurses. By advancing nursing education and developing a
nursing elite, they hoped to make manifest the intellectual and organizational
educability of women and bring them into parity with the male occupations—
medicine and law—after which they modeled themselves.18
Nurses, however, do not take the path through the narrow graduate funnel
modeled by medical and legal education. Today’s nurses are primarily educated in
two- or four-year programs, having earned an associate degree (40 percent of today’s RNs) or a bachelor’s degree (29 percent).19 Some influential constituencies,
including the Department of Veterans Affairs (VA), are demanding more bachelor’s degree nurses. The VA is proposing to spend $50 million to move its nursing
staff toward the educational minimum of the bachelor’s degree.20 A California
nursing leadership organization is proposing that by 2010 this degree be required
for licensure.21 In a reversal of the trend for 1980–1995, the last four years of the
1990s saw a greater increase in nurses’ seeking baccalaureate degrees (17 percent
increase) than associate degrees (13 percent increase).22
Most aspiring nurses, however, still do not choose or cannot afford a university
education. After the decline of the diploma school, a majority of today’s prospective nurses turned to community colleges to suit their needs, thereby choosing a
middle path between the apprenticeship and university models. A two-year associate degree in nursing (ADN) graduate recently wrote that the community college approach was the only reasonable one for him. As a young father, he needed to
work and could do so as a licensed practical nurse (LPN) while completing the
qualifications for RN licensure.23 He argued that associate degree education is also
often the most appropriate route for older students and students of color.
One result of the tensions over education has been Balkanization: sharp separation by education level. Repeated attempts have been made to standardize education for nursing practice; there has been less movement toward raising one big
tent under which all nurses, regardless of education, might gather.
Short of radically reducing the educational boundaries, there is still plenty for
nursing educators to do. Students of color should be vigorously recruited to all
levels of schooling. Men must be welcomed to nursing school. The most innovative
and flexible pedagogy must be fostered. But most critically, the bridge between
the academy and the health care establishment must be broadened.
n Staffing. In 2001 the American Nurses Association conducted a survey of RNs
asking them to describe their work environments. Of those responding to the survey, 75 percent said that the quality of nursing care at their hospitals had declined
over the previous two years.24 Although the evidence is still being gathered on the
extent to which RN staffing contributes to quality, nurses feel overwhelmingly that
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something is wrong with quality in the workplace. Some states are beginning to respond to their concerns. California, for one, recently mandated nurse-patient ratios.
Although such mandates may make a difference in the satisfaction that nurses
experience, will it improve the quality of care? The evidence suggests that it will.
Patricia Prescott found that RN staffing levels were linked to patients’ morbidity
and mortality, lengths-of-stay, and costs.25 One of the attributes that apparently
contribute to these findings is the greater status, autonomy, and control achieved
by RNs when they are in greater proportion to other staff. These attributes may
contribute to better-quality nursing care and therefore better patient outcomes.26
Joyce Verran completed a comprehensive review of staffing related to the quality of hospital care and organizational variables for the Institute of Medicine’s
(IOM’s) study on staffing adequacy.27 She found that the proportion of RNs has a
positive influence on severity-adjusted Medicare mortality rates, as does a professional practice environment. A professional practice environment was characterized by unit-level self-management, participant decision making, use of primary
nursing, peer review, and salaried status for RN staff.
The link between staffing and patient outcomes has been underscored by work
on “outcomes potentially sensitive to nursing” (OPSNs).28 In three samples of hospitals, including a national sample of Medicare patients in 3,357 hospitals, a group
of patient outcomes has been identified—from skin pressure ulcers to cardiac arrest to postsurgical infection—and analyzed against staffing levels. A relationship
between selected patient outcomes and nurse staffing in acute care is being established, and models for OPSNs in medical patients such as urinary tract infections,
pneumonia, and shock demonstrated a reduction in event rates associated with
higher RN staffing.
Have these findings had an influence on staffing in hospitals? The picture is
confused. Current staffing is a complicated mix of multiple levels of nursing personnel and other clinical staff. Although nursing personnel ranging from RNs and
LPNs to nurse aides decreased by 7.3 percent nationally over a twelve-year period,
the proportion of RNs grew. At the same time, other personnel who provided care
in hospitals declined, leaving the RN in a stressful situation, given the increase in
patient acuity.29
n Magnet hospitals. Magnet hospitals provide a bright spot in this picture: a
compelling model that embraces the concepts of nursing status, autonomy, and control. The Magnet Nursing Services Recognition Program for Excellence in Nursing
Services developed the program based on a 1983 study by the American Academy of
Nursing, which found that facilities that attracted and retained nurses despite a
nursing shortage had certain measurable characteristics, each of which was predicated on recognition of nurses’ contribution to patient care and the environment of
the facility.30 They were (1) effective and supportive leadership, (2) nursing staff involvement in hospital decision making, (3) commitment to professional clinical
nurse qualities, (4) participatory management, (5) autonomy and accountability,
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and (6) a supportive environment.31 Comparing nurse job satisfaction in magnet and
nonmagnet hospitals, Valda Upenieks found that nurses employed in magnet hospitals had a greater level of job satisfaction and demonstrated a greater level of
empowerment.32
Bridges To Build
Are today’s nurses educated to fill the roles we envision? The answer is a qualified “yes.” Does the standard hospital workplace offer these roles? The answer is
“no.” Much of today’s nursing education strives to prepare students for critical
thinking, for autonomous decision making, for supervisory skills—the skills
James’s recruiter described in the opening of our paper. But today’s hospital workplace does not put them to use.
What will constitute improvement in the nursing workforce? It is challenged,
like all other sectors, by today’s health care environment: a raging flood of public
dissatisfaction and apprehension, of inequitable access, and of highly variable
quality in care and service. Not just more nurses, but major changes in work design are called for, and the creation of multiple connections among workplaces,
educational institutions, and the health care policy–shaping apparatus.
n Workplace redesign. The American Academy of Nursing has begun to sponsor a study commission to take a fresh look at workplace design.33 The American Association of Health Plans and the American Hospital Association would be appropriate partners in this work, or a government-sponsored body such as has been
proposed in some of the pending federal legislation addressing the nursing shortage.
A multidisciplinary commission must be able to question all assumptions about the
design of health care institutions and develop more innovative and inclusive structures than we have today.
The mandate for increased patient safety is a lever for structural change. The
Leapfrog Group provides one example. Founded by the Business Roundtable, this
coalition of some 100 public and private enterprises providing health benefits is
working with selected health care entities, focusing the employer-purchasers on
the necessity of having high-quality care, backed by a developing set of purchasing
principles.34 Multiple pressures are being brought to bear on the hospital enterprise, including experiments in mandated staffing ratios, the data from which
should prove illuminating.
n Educational pluralism. Educational pluralism is healthy and perhaps
uniquely vital to nursing. Rather than fighting over educational mandates, energy
should be directed toward refining the skills and competencies that nursing practice requires and designing the workplace so that it suits the skill set to the requirements of patient care. Nursing educators and hospital leaders have an important
bridge to build, which could transform hospital nursing from what is perceived as a
static occupation into a truly dynamic career that affords continuing opportunities
for growth and advancement. Partnerships between schools and hospitals should
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map new career paths and not re-erect mere hierarchical ladders that apply only to
the current workplace. Such partnerships should consider a nurse’s entire career,
which may begin with training as a nurse aide and travel a pathway to advanced education and expanded practice opportunities.35 This calls for cooperation among
schools at all levels and among nurse-employing institutions of all types, and close
consultation with nursing unions and professional associations. Such partnerships
have been proposed in federal legislation sponsored by Sen. John Kerry (D-MA) and
others (S. 1597). The American Association of Colleges of Nursing is the program office for a Robert Wood Johnson Foundation “Colleagues in Caring” project intended
to assist states and regions with nursing workforce development; hospital and educational institutions are reportedly working together on key goals, including educational mobility.36
n Enhancing diversity. To move beyond the exclusionary approaches that have
kept nursing from truly reflecting the ethnic and economic makeup of the country,
nursing schools must make an effort to recruit students by promoting scholarship
opportunities sponsored by potential employers and state and federal education
support for students at multiple points of entry, especially assistants, aides, and LPNs.
The image of nursing needs to be enhanced within the media. Johnson and
Johnson is the corporate sponsor of a national advisory board that will spearhead
a multiyear campaign to ease the nursing shortage. The Campaign for Nursing’s
Future began in February 2002 with a series of advertisements in prime-time television depicting a new image for nursing (see www.discovernursing.com).
Although some gains have been made in this area, the image of nursing will
truly be improved only once a full-scale effort is under way to gain meaningful diversity. One such effort must be directed specifically at increasing the percentage
of men in nursing, now at a woeful 5.4 percent.37 Making diversity a visible, core
value in nursing will begin to bring about an important change in its image.
n State coalitions. Although action at the national level is vital, states will need
to take sensible approaches to bring about changes at the local level. As an example,
the Washington State Hospital Association and the Association of Washington
Public Hospital Districts produced a report that called for specific policy steps to
help stem the tide of what they termed an “emerging public health crisis.”38 The report recommended that coalitions of health care stakeholders take a comprehensive
workforce development approach to framing and analyzing the solutions to the
nursing shortage.
n Regulatory streamlining. There are multiple barriers to maximization of
nursing skills, and they will appropriately be subject to the policy process. Hospitals, for example, will argue for regulatory relief, while their critics will urge increased oversight. One barrier particularly relevant to nursing career advancement
is individual state licensure. A healthy step toward lowering this barrier is the Nurse
Licensure compact. Coordinated by the National Council of State Boards of
Nursing, the compact seeks to make it possible for a nurse licensed in his or her state
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of residency to practice in other states.39
n Constituency building. Although nursing comprises a very large workforce, it
is not yet a constituency. It is still too fragmented in its organization and weak in its
advocacy to make substantive improvements to the workplace. The professional organization model—high fees and select population—does not draw on nursing’s
strength-in-numbers, diversity, and predominance in hospitals. A nursing organization similar to AARP could transform the nursing workforce’s liabilities into assets
and dull the boundaries between educational levels. AARP organizes around a simple demographic: age. It marshals an exceedingly large population and expresses a
vigorous influence, even though its constituency is not ideologically uniform. With
the development of an AARP-model nursing organization, an extremely broad range
of nurses, from home caregivers to licensed and registered practitioners, could gain a
proportionate share of policymakers’ attention.
n Bringing down the silos. In the long run, hospitals will evolve to become
markedly different organizations. The new hospital nursing jobs might include the
following: the information nurse who meets the patient who has just received a new
diagnosis, evaluates the patient’s learning style, and delivers an appropriate stream
of information and options; the consulting specialist nurse/physician blend who
would rarely be present at the bedside but would act as consultant, in close communication with the hospitalist; and the home and community nurses who receive
nurse-to-nurse referrals and carry out short-term discharge plans but, even more
importantly, implement long-term chronic illness care plans.
Powerful consumer demand, safety imperatives, and cost constraints could revitalize some long-held ideas. Stanley Lesse long ago called for integration of
health care education and establishment of the National Academies of Practice to
bring together all of the mainstream health care disciplines.40 This group may yet
bring new levels of teamwork to bear on the improvement of the public’s health.
Policy Implications
Is it possible to align a vision of the health care environment and the vision of
the capacity and expertise of nursing? Is there a bridge to build? There is mounting
evidence that such hospitals as those with magnet designation provide nurses
with the challenges and opportunities they desire. Environments such as these,
however, will not exist without major incentives for the hospitals themselves and
for the system that supports health care. Public policy aimed at improving nursing
practice and nursing education is paramount for broad-scale adoption of any systematic change. Enlightened partners in health care and public policy must be
willing to make the crises of the nursing shortage a priority and take the opportunity to avoid redoing business as usual. A variety of stakeholders must work together to take collective action to support and shape nursing.
Public policies that support nursing education and provide incentives for hospitals to support clinical training, scholarships, and diversity must be aggressively
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pursued. In addition, hospitals need to be encouraged to follow the lead of magnet
hospitals in providing environments that support nursing autonomy and shared
governance. Nursing leaders must recognize that their right to empower the nursing workforce will need to be wrested away from hierarchical structures predicated on the subordinate role of nursing.
Nurses are perhaps uniquely prepared to become a truly modern and progressive workforce as their job and educational silos are being replaced with complex
webs with multiple points of entry. Far from being part of the problem of American health care, a democratized and integrated nursing workforce will be a fundamental contributor to its solutions.
The authors gratefully acknowledge the colleagues, students, and mentors who have contributed to their
understanding of nursing work, but they hasten to add that the opinions expressed are their own. The paper
benefited from the comments of three anonymous reviewers, and the editing skill and organizational forces of
Andrew Ward.
NOTES
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S. Skillman et al., How Are Washington State Hospitals Affected by the Nursing Shortage? Results of a 2001 Survey (Seattle: Center for Health Workforce Studies, University of Washington, 2002).
B.L. Simmons and D.L. Nelson, “Eustress at Work: The Relationship between Hope and Health in Hospital Nurses,” Health Care Management Review 26, no. 4 (2001): 7–18.
Washington State TriCouncil for Nursing, “The Future Nursing Workforce in Washington: Charting the
Road to a Do-able Future, Invitational Conference Executive Summary” (Seattle: TriCouncil for Nursing,
2001).
Skillman et al., How Are Washington State Hospitals Affected by the Nursing Shortage?
G. Bednash, “The Decreasing Supply of Registered Nurses: Inevitable Future or Call to Action?” Journal of
the American Medical Association 283, no. 22 (2000): 2985–2987; P.I. Buerhaus, “Is Another RN Shortage
Looming?” Nursing Outlook 46, no. 3 (2000): 103–108; P.I. Buerhaus, “ Is Another Nursing Shortage on the
Way?” Nursing Management 30, no. 2 (1999): 54–55; P.I. Buerhaus and D. Staiger, “Future of the Nurse Labor
Market According to Health Executives in High Managed-Care Areas of the United States,” Image: Journal
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Aging Registered Nurse Workforce,” Journal of the American Medical Association 283, no. 22 (2000):
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C. Fagin and D. Diers, “Nursing as Metaphor,” New England Journal of Medicine 309, no. 2 (1983): 116–117.
Bureau of Labor Statistics, “Nursing, Psychiatric, and Home Health Aides,” in Occupational Outlook Handbook, 2002–3 ed., stats.bls.gov/oco/ocos165.htm (20 February 2002).
BLS, “Medical Assistants,” in Occupational Outlook Handbook, 2002–3 ed., stats.bls.gov/oco/ocos164.htm (20
February 2002).
BLS, “Licensed Practical and Licensed Vocational Nurses,” in Occupational Outlook Handbook, 2002–3 ed.,
stats.bls.gov/oco/ocos102.htm (20 February 2002).
Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, The Registered Nurse Population March 2000: Findings from the National Sample Survey of Registered Nurses (Rockville, Md.:
U.S. Department of Health and Human Services, 2002).
Ibid.
L. Friss, “Nursing Studies Laid End to End to Form a Circle,” Journal of Health Politics, Policy and Law 19, no. 3
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(1994): 597–632.
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September/October 2002
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