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Challenges for nursing in the 21st century.

WITHIN THE PAST DECADE, the nursing shortage has presented many faces: fewer persons are interested in nursing; few students are enrolled in schools of nursing (Green [1987] described this as "trouble in the pipeline"); and fewer nurses are employed by hospitals. Another component of the shortage is that nurses, especially hospital nurses, express dissatisfaction with their practices (Aiken et al., 2001).

This lack of satisfaction has several causes but similar outcomes: decreased retention, especially among specialty practice nurses; frequent turnover; early retirement; or departure from nursing. In some hospitals, a significant component of the specialty nurse workforce is outsourced. Active international recruiting has increased the number of foreign-born nurses in the workforce. Nurses over 50 years of age have been lured back to work or encouraged to increase their participation in the workforce. Hospitals employ more travel nurses, agency nurses, foreign-born nurses, and older married nurses (Buerhaus, Staiger, & Auerbach, 2003). The changing composition of the nursing workforce and the dissatisfaction of practicing nurses contribute to the complexity of the nursing shortage.

Looking at the nurse workforce, you might wonder why the profession is challenged by a shortage. There are approximately 2.8 million registered nurses in the United States; and 80% practice nursing. Ninety-five percent of these nurses are female; 12% come from minority backgrounds; 59% work in hospitals; 32.3% have baccalaureate degrees, 7.3% have master's degrees, and 0.6% hold doctorates. Most nurses have associate degrees (40%) and the majority of new graduates come from associate degree programs (55.4%). The average age of the RN was estimated to be 45.2 years in the year 2000 (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2001). Teachers with master's-level preparation have a mean age of 48.8, while doctorally prepared teachers have a mean age of 53.3 (American Association of Colleges of Nursing [AACN], 2003; Spratley et al., 2001).

Negative Nursing Affectivity

It is easy in times of challenge and rapid change to present nursing as a troubled and embattled profession (Steinbrook, 2002). Expressions of negative points of view about nursing practice and the profession of nursing, itself, gained public notice as many groups tried to convince the Congress of the United States to re-authorize and adequately finance the Nursing Education bill (Donley et al., 2002). The outcome, the Nurse Reinvestment Act of 2002 (PL 107-205), embodies many new modalities to support the practice of nursing, the continuing professional development of practicing nurses, and the education of students and new faculty. However, the studies, testimony, and white papers, developed at the beginning of this century to advance the passage of the Nurse Reinvestment bill, presented a sad history and uncertain trajectory of American nursing. Unless this literature is balanced by other studies and writings, a particular social event, the creation of a "worst case" lobbying strategy designed to attract attention and funds in an environment of scarce resources, will cast a long shadow on how nursing is perceived in the United States and around the world.

Affectivity reflects a predisposition to perceive and experience events in a negative or positive way (McCrae & Costa, 1991). For many years, American nursing has suffered from negative affectivity, manifested by the ability to look at the profession of nursing and its workplaces, especially acute care hospitals, in terms of deficits. Nurses are very

good at identifying and discussing problems in nursing. Opinions of what is wrong with the nursing profession, for example the nursing shortage, which have always found easy expression during "coffee breaks," now appear in the literature. This worldview presents nursing as a glass that is always half empty.

Crafting a Generational Perspective

The contemporary shortage of nurses is usually discussed in relation to the large population cohort, the Baby Boomer generation. This generation encompasses the largest number of American nurses and the largest American workforce. It has influenced all sectors of education and the economy, possibly because Boomers believed that they could quickly achieve higher standards of living than their parents had enjoyed. It is the generation most affected by feminism, suburban living, the birth control pill, television, and the two-income family. In the United States, generations X and Y, who followed the Baby Boomers, do not share their parents' or grandparents' work ethic or sense of loyalty to employers (Tulgan, 2000).

Generations X and Y came of age when American women had many occupational, professional, and personal choices. In the United States, bright young women, interested in science, are advised to study medicine, pharmacy, biomedical engineering, or health law. Ideological changes within and between generations are also evident in other cultures. For example, Koreans, the 386ers, who do not remember the Korean War, have different ideas and values than Koreans born before that conflict (Fairclough, 2004). Labels like X, Y, and the 386ers are superficial ways to describe differences among the generations. However, understanding the qualitative as well as quantitative differences between generations is vital in shaping nursing's workforce policy and attracting new members into the field.

Because the Boomer generation was a unique demographic and social phenomenon, the American economy cannot replace Baby Boomers in the workplace. Yet no other profession has struggled, as heroically as nursing, to do so. The demographically driven prediction, that fewer nurses will be in the workforce of the future, has caused American nurses to blame themselves, their public image, their employers, and the practice of nursing itself. If nurses accepted that significant demographic shifts contribute to the shortage, they would appraise the shortage differently and seize realistic opportunities to create a better future for nursing. Demographic analyses also suggest that the nursing shortage will not be quickly or easily resolved.

Some occupational groups have recognized that fewer people have come forward to join their ranks. Others know that fewer of their type will be needed in the future. Nurses have not seen the future in this way. It is said in Washington, DC, that the nursing response to a shortage or to any bad news in health care is always the same: Get more nurses. It is difficult, perhaps impossible, to increase the number of people who enter nursing when the population is smaller, and young people, especially the young women of generations X and Y, have so many attractive career choices.

In the mid-'90s, the Pew Commission convened a panel to study the future of the health professions. Many nurses laughed, when the Pew Commission (1995) said in their report that there were too many nurses, most of whom were undereducated. In fact, the Pew Commission recommended that nursing should "Reduce the size and number of nursing education programs (1,470 in 1990) by 10%-20%. These closings should come in associate and diploma degree programs. These closings should pay attention to the reality that many areas have a shortage of educational programs and many more have a surplus" (Pew Health Professions Commission, 1995, p. vi). If the Pew Commission's report had been copied and circulated to members of 107th Congress as they debated the nursing shortage, the outcome of their deliberations may have been different. Yet if you read the report of the Pew Commission, now 10 years old, with a different pair of lenses, you read a prophetic message. It seems that the message of the demographers and the seers on the Pew Commission is simple; work on enhancing the quality rather than the quantity of nursing programs, and do not worry so much about increasing the numbers and expanding traditional modes of education. Make nursing education accessible and affordable. Consider the multiple points of entry into nursing and strengthen career ladders, looking beyond the RN to BSN programs. Develop new models of integration between education and practice, especially practice in integrated systems of care. Educate more nurses for advanced practice.

In the scenario developed by the Pew Commission, the question is changed. It is no longer, can nursing find more people to enroll in programs of nursing? The question becomes, can nursing create and develop an educated nurse workforce within real time, say by 2020? If nurses continue to frame the nursing shortage in terms of the past, they will miss the opportunity to participate in a meaningful way in health care delivery in the information age.

Changing Delivery Systems

It is incumbent on nurse leaders to orient nursing education to emerging health delivery systems. In the United States, acute care hospitals have influenced the content of nursing education. Many of nursing's heuristic methods, especially its models of clinical education, assumed that acute care hospitals would always be at the center. Managed care has placed hospitals on a continuum of care rather than at its hub. Home care, ambulatory care, and day surgery are the new models of care delivery. As people receive most of their care in their communities, families and friends are thrust into caregiver roles and health promotion and management of illness become more complex. Healthy People 2010, a result of a 10-year study, emphasizes that illness is more than a confluence of biophysical phenomena (U.S. Department of Health and Human Services, 2000). The determinants of illness are psychological, social, and environmental as well as biophysical. Health status is also affected by policies and programs, especially those that affect insurance coverage, a program that is not available to 45 million Americans, about 15.6% of the population (U.S. Census, 2003). Contemporary nurses must see health assessment and risk analysis in its broadest context and empower people to take responsibility for their health and health status.

In information societies, nurses must also bring and claim expertise in some area of practice. Can the nursing community act on an idea, certainly not new in the United States (in fact it goes back to 1965), that the baccalaureate degree is the minimum credential for the practice of professional nursing (AACN, 2000; Donley & Flaherty, 2002)? Is nursing willing to endorse the clinical nurse leader and experiment with generalist preparation at the master's level (AACN, 2004a)? Care delivery in the future will require nurses to be educated as knowledge workers: clinicians, clinical specialists, teachers, clinical nurse leaders, clinical information specialists, clinical nurse leaders, researchers, care coordinators, case managers, managers of complex systems of care, and primary and acute care practitioners.

Within the past 30 years, nurse researchers and scholars have learned more about the phenomena of nursing. The discipline of nursing is more coherent and more scientific because of their work. Nurses in practice and faculties in schools of nursing can base some patient care and curricula development on evidence, clinical indicators, consensus, and best practices. As nurses move beyond anecdotes, case studies, rituals, protocols, and opinions, practice is evidence based and outcome

oriented. However, the knowledge explosion has encouraged nurse faculty and staff development educators to add more content, create more requirements and assignments, usually in multiple forms, talk faster, show more Power Points, and increase pressure on themselves, their students, and colleagues. Academic nursing has created curricula that cannot take much more adjustment. Faculty and students cannot address everything about nursing, regardless of the length of the programs. The state of knowledge makes this impossible. However, faculty can create curricula to help students enhance their cognitive skills, methods of reflection, critical thinking, problem solving, analysis, synthesis, and ability to evaluate structure, process, and outcomes. Students can learn to use extant information and mine new knowledge through research, scholarly inquiry, and the use of data banks, practice guidelines, and Internet resources. Faculty can help students publish and contribute to the growing body of nursing science. Most importantly, faculty can help students find meaning in nursing and in their practices.

Increasing Complexity

The changing patterns of health care delivery have increased complexity in all practice environments. Evidenced-based practice models have intensified rather than simplified nursing care delivery because they have been inserted into traditional practice patterns. Nursing lacks systems to plot its patterns of care delivery (Pyzdek, 2004). Consequently, except in limited circumstances, nurses are unable to predict what activities make a difference in the outcomes and satisfaction levels of their patients. The inability to identify and control the processes, protocols, patterns, rituals, and tasks related to safe, compassionate care delivery and better health outcomes does not assure professional practice.

The field of engineering uses a statistical technique, principle component analysis, to determine what is important to control in systems (Pyzdek, 2004). Recently several clinical indicators of patient well-being have been related to nursing intervention. If nurses are to work smarter in complex environments, where a shortage of nurses is a constant factor, work redesign schemes must include process control features. As teachers cannot teach all possible content in nursing, practicing nurses cannot add more methodologies, expectations, and tasks. Future-oriented practice puts aside biases about rituals, tasks, and the traditional subject matter of nursing. It lets go of patterns, even those painfully acquired through education and experience, and uses data and the wisdom gained from experience to assess health care, nursing care delivery, and nursing education from the 64th floor (Heifitz & Laurie, 1997). This orientation lets nurses see that they cannot replace the Baby Boomer nurses in the profession, or practice nursing as they did in the '80s and '90s. A view from the top helps educators accept that the curricula can not encompass the extant nursing knowledge. It shows practicing nurses the folly of building practice models solely on economic principles.

Complexity calls for new modes of thinking, what some authors call thinking "out of the box." Working "out of the box" is working with X, an unknown variable. It is working outside traditional boundaries, or coloring outside the lines (The University of Texas, 2004). Nurses approach ambiguity and complexity differently. Intrinsically, the practice of nursing lacks surety because the objects of nurses' work are human beings with energy, intelligence, and free will. Yet, some nurses think "in the box" because they have invested years in their discipline; they believe that the current flux in health care is a storm, not a sea change; they worry about licensing boards and accrediting agencies; and they want to offer their students and patients a recognized epistemology that has borne the test of time. Their specialties and their curricula are their road maps. Other nurses are ready to think "out of the box" because they no longer find meaning in the patterns that they see before them; they view the changes in nursing education and health care as a watershed from which there is no going back; and they are intrigued by the possible futures of nursing.

Views and Visions

People who bring about major change in complex systems view reality differently. They see how things can be. They may be charismatic or inspirational people. They may be loners. They are usually very bright and possess empathy and imagination. Some visionaries can take an idea from dream to reality and strategize about their worldviews. However, for many visionaries, the idea is more important than implementation strategies. Zaleznik (1992) thinks that visionaries and strategists--leaders and managers--differ in their conceptualization and respect for chaos and order, and in their sense of self. These qualities of visionary, strategic thinker, and culture builder rarely exist in one person. It is not surprising that people who write in the management literature say that the leaders of the future will be small groups.

Visionaries probably think differently because they use a variety of cognitive processes. Zohar (1997) lists three types of thinking: serial thinking, associative (parallel) thinking, and quantum thinking. Serial thinking produces lists, protocols, procedures, and flow charts. It is the stuff of computer programs, mathematics, staffing patterns, research protocols, and traditional curriculum plans. Associative or parallel thinking helps form connections between events and thoughts. Kerfoot (1998) says that associative thinking is rooted in emotional and physical experiences and is called thinking from the heart. Associative thinking guides pattern recognition and skill development. The third form of thinking, quantum thinking, arises from many areas of the brain and enables people to challenge assumptions and mental models. Quantum thinking is holistic and integrative (Kerfoot, 1998).

DeBono (1967) synthesizes these patterns of thinking in what he calls lateral thinking. Noting that most people are serial or vertical thinkers, he posits that the brain, a self-organizing system, processes information in asymmetric patterns using lateral as well as vertical processes (DeBono, 1967). He also observes that logical, vertical thought processes can take a person so far. If a person can then introduce mental stimuli or triggers, the mind suddenly leaps horizontally or laterally to a new vertical path. With a bit more logical thought, a solution materializes. DeBono (1997) calls this trigger a "PO" from the English word, suppose. PO introduces discontinuity into the thought process, and creates a sideways leap into an alternative logical thought pattern. PO takes the mind beyond a linear yes or no response and introduces suppose or maybe.

Putting Ideas into Practice

"Out of the box" thinking about the discipline of nursing requires a strategist as well as a visionary. It is interesting to explore the thought processes of the people who can put ideas into practice. SOFTBANK's CEO, Masayoshi Son, said, "that in high-tech ventures, there are no footprints left by anyone else. You have to think, and act as you think" (Webber, 1992, p. 93). Strategists make concepts work. They possess the ability to understand events without being influenced by them and are able to make decisions quickly without being deterred by perceived danger or opposition. A strategist does not need access to unlimited resources (Henderson, 1994). In fact, the literature is quick to acknowledge that requests for more money, people, and equipment may be the first indication that a person or unit is under-performing and not on the golden brick road of innovation.

The biographies of inventors and entrepreneurs reveal how they built fortunes and empires. Rarely did they start with them. Thayer (1999) makes a case for investing in the bricoleur, a person who accomplishes what needs to be done with the resources on hand. Creativity is not about money or equipment; it is about people with ideas, know how, and cultures that are open and supportive. Visions and strategies occur in time and place. The current management literature emphasizes the critical importance of environments that nurture creativity and make way for "out of the box" thinking. The Magnet hospital concept capitalizes on this construct by emphasizing the importance of the workplace culture in nurse satisfaction and safe patient care (Stolzenberger, 2003). Arguing that expectations influence behavior, Taylor (1990) says that organizations that want nontraditional ideas should find/hire creative people and provide environments that encourage, support, expect, and recognize innovation. Endorsing this theme, Business Week (2004) celebrated its 75th anniversary by dedicating several issues to innovators whose ideas and actions changed their fields of practice. Cultures, where different types of thinking are encouraged and shared, are also important because visionaries need external stimulation. Dialogue builds neural pathways and stimulates new mental associations. Great ideas need to be debated, tested, and built upon.

"Out of the box" thinking about nursing evolves from a vision of a new nursing and new educational and health care systems. It flows into an identification of the critical elements necessary to bring that vision into being. It is expressed within a culture that evokes and supports change. Getting beyond the box requires nurses to be visionary, strategic, and builders of culture (Conti, 1998). In nursing and health care, good ideas must become strategies. The visionary cannot be so isolated that she loses sight of the organization's mission, its stakeholders, or the needs of clients and co-workers (Kaplan & Norton, 1992). "Out of the box" thinking creates new ideas or processes to be disseminated within the curriculum and the field of practice. Commenting on the need to incorporate innovation, Argyris (1991) says that success in the contemporary marketplace depends upon learning new ways of thinking and acting.

Nursing Leadership Challenges

What particular challenges do professional nurses face when they think "outside the box?" How significant are barriers created by lack of vision and adherence to serial thinking, work overload, comfort with extant methods and protocols, and investment in norms, standards, and reward systems? How open is the world of nursing to new ideas; ideas that change how nurses view and respond to reality? How full is the glass? Argyris (1991) thinks smart people have trouble being creative because they are successful problem solvers. Fear of failure often stimulates defensive and accusatory behavior rather than innovation. Argyris (1991) suggests that helping knowledge workers get "out of the box" and risk failure is a particular challenge for leaders.

American nursing faces another challenge that transcends budgets, respect for tradition, or the collective ego of the profession. The boxes that make up nursing in the United States are interdependent. Statutes, codes, and standards regulate nursing education and practice. However, the transformation of nursing to meet the needs of diverse people and to deliver institutional and community-based care requires more than conversion of deans, administrators, clinical specialists, staff nurses, practitioners, faculty, students, and the keepers of the regulatory and accreditation shrines. Getting "out of the box" demands a professional commitment to think creatively about nursing practice and education. It requires the courage to try something new and the chutzpah to use different strategies to open up the profession and its practice. In line with that thinking, Burton challenged Wisconsin nurses to burn the boxes (Wisconsin Nursing, 2003).

Highlighting the work of the Oregon Center for Nursing, she argued that turbulent times and a nursing shortage require both a common vision and a strategic plan to guarantee a diverse, professional nurse workforce, sufficient in number and appropriately educated to provide evidenced-based care and contribute to positive health outcomes (Wisconsin Nursing, 2003). Recently the American Association of Colleges of Nursing endorsed a proposal to radically change graduate education and the quality of the workforce. They proposed that graduate education prepare clinical nurse leaders and nurses with practice doctorates (AACN, 2004b).

Dollars and Sense

Another challenge facing nursing and all health professionals is the changing health environment. Given the nursing shortage and the flux and uncertainty in health care, it is not surprising that there is a search for vision, transformational leadership, knowledge management, and "out of the box" thinking about the coordination and enhancement of new educational and delivery systems. One particular aspect of the challenge is the economic tenor of health care delivery and policy.

In the United States and other parts of the world, rising health care costs are an important concern. Usually the impact of health care costs on the economy is measured as a percentage of the gross domestic product (GDP). The United States spends more of its GDP, around 14%, on health than any other country in the world. To put this into context, the median spending level for the Organization for Economic Cooperation and Development was 8% (Anderson, Reinhardt, Hussey, & Petrosyan, 2003). However, this explanation for concern with rising health care costs, accurate though it may be, does not address the importance given to economic imperatives in contemporary American health care. In 2003, the United States spent $1.7 trillion for health care services (Centers for Medicare and Medicaid Services, 2004). The steady period, 1992-1998, when managed care contained hospital-spending growth by an average of 3.4%, was followed by increased spending in the hospital sector, a 9.5% rise in 2002, despite shortened stays and early discharge (Institute of Medicine, 2003). The recent rise in hospital costs is associated with salaries, benefits, and malpractice premiums (Levit et al., 2004).

Health care is undergoing a violent revolution that has disrupted traditional health care practices and undermined trust in the healing professions. Business values have replaced or crowded out health care norms and many professional values. In some U.S. boardrooms, making/saving money occupies more time on meeting agendas than discussions of quality of care. Nurses and other health providers have been witnesses to, and at times participants in, this economic transformation of health care. In the United States, business models provide the theoretical framework that shapes health care delivery. Profit, risk sharing, the satisfaction of shareholders, and the economic principles of supply and demand, economies of scale, and return on investment are the concepts that govern contemporary discussions of health care. Federal and state governments, the hospital industry and many physician groups have surrendered leadership in health care to Wall Street investors and managed care executives.

The transformation is also evident in the language of health care. Patients are now consumers, and occasionally customers, patient care is a product line, and most, if not all, hospital and medical decisions are driven by the payment guidelines of the various private and government insurance companies. The economic imperative is also evident in the practice patterns of doctors and nurse practitioners. Payment for the time that physicians and nurse practitioners spend with patients in ambulatory centers is regulated. Ordinarily, the visits last between 7 to 15 minutes. In acute care hospitals, nurses face long shifts, mandatory overtime, short staffing, and inadequate ratios of professional staff to patients. Patients and health care providers feel rushed in all settings. They miss the rapport that they once enjoyed with patients. Patients believe that their doctors and nurses are very busy and are not giving them the time and attention that they need.

Ironically, the diminishment of professional and human values in health care has not reduced health care costs. Market models have not improved access to care, addressed disparities in health status, or enhanced health care quality. Presenting health care as a business has not inspired nurses or physicians or attracted young people to either profession.

Restoration of a health care delivery system that is grounded in humanistic values and centered on patients' well-being is a contemporary challenge. Nurses can act together and collaborate with physicians to restore altruism to contemporary health care. Nurses and doctors can join together to reintroduce person-centered values and more humanistic systems to balance the emphasis on making money, restricting access to care, and reducing health care costs. The public needs to be informed so that they can join with their physicians and nurses and demand a more humane and compassionate health care system.

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SISTER ROSEMARY DONLEY, SC, PhD, RN, C-ANP, is an Ordinary Professor of Nursing and Director, Community/Public Nursing, The Catholic University of America, Washington, DC.
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Date:Nov 1, 2005
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