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Physicians can ease nursing shortage.

The nursing shortage continues to plague American hospitals and health care services, and no reliable solution appears on the horizon. The 5.8 percent increase in nursing school enrollments in 1989, the first increse in five years, will have a relatively small impact on the supply of nurses needed to meet the demands for nursing services this decade. Already, the critical shortage of nurses has resulted in a decline in the quantity and quality of health care to the public. Hospitals coast-to-coast are closing, limiting admissions, closing emergency departments, delaying scheduled surgeries, holding patients in the recovery room because of a lack of nurses in intensive care unites, and so on. Overworked nurses are "burning out" under the stress, compounding the problem.

The solution to the nursing shortage is clear. In the short run, the current supply or nurses must be used more efficiently and effectively without compromise to quality or cost. In the long run, recruitment efforts must be successful increasing the number of people who choose nursing as a career. The first solution has been addressed intensively and consistently in recent years by management journals nationwide. The second solution has been a priority for schools or nursing for decades. Responsive strategies, however, have been reruns of old steps without major innovation. The decline in people entering nursing has been painfully evident. A recruitment stragetegy that has not been explored to its fullest is the role of physicians in influencing career choices in nursing as supported by history, culture, and experience.

Physician Influence on Career

Choice in Nursing

The factors that influence a person to choose nursing as a career are multifold. Nevertheless, the public image of nursing has been noted as highly influential in this choice. The stereotypical public perception of nurses is that they serve as handmaidens to physicians in a work-intensive profession oflow esteem. This perception is also held by a substantial number of nurses. They believe the past paternalism and parochialism of medicine has conferred the feeling of powerlessness throughout the profession. Staien et al. point out that nurses see themselves as fighting for freedom and that the medical profession has been one of their main sources of oppression. [1] The Association of Academic Health Center describes the traditional hierarchical doctor-nurse relationship as exerting stifling, anti-intelectual effect on nurses that results in dissatisfaction with professional roles. The negative interprofessional relations contribute substantially to the nursing shortage. [2]

In a recent issue of the Chicago Tribune, [3] a nurse was quoted as saying "...nurses need more respect from the medical staff, should be allowed to do more professional nursing, and should have a say on how health care is delivered. Right now, nurses are at the bottom of the totem pole." This kind of publicity reinforces the public's low opinion of nursing.

Stein refers to the physician-nurse relationship as the "doctor-nurse" game. [4] Although this game was more popular in the past, it has left its mark on the public and on nurses. Briefly, the point of the game is that open disagreement between the players has to be avoided. Nurses convey their recommendations to doctors without appearing to make them. The physicians requesting recommendations do so without appearing to ask for them. According to the game, if the doctor interprets the subtle messages as challenges to his/her authority, the relationship breaks down, with the nurse losing the game.

Stein et al. also point out that it is not unusual for those in power to be oblivious to the fact that those under them may feel oppressed. [1] These doctors are comfortable with the hierarchical relationship. They see the nurse's role as primarily one of carrying out doctors' orders, and they are frustrated by nurses who want an equal relationship. In short, they want the status quo to continue because "it works."

The most recent example of negative publicity about the nursing profession by doctors was the AMA's proposal to develop "registered care technologists" (RCTs) to "replace the missing nurses" by the bedside. This movement reinforced the notion that physicians wanted to control patient care at the exclusion of nurses. Moreover, it was interpreted as devaluation of nursing, because it conveyed the message that nurses could be easily replaced by another health care worker with less training. Rather than working with nursing on a plan to bring more support services to the nursing staff and more people into nursing education, medicine was competing with nursing and, at the same time, abandoning it. Even though the AMA dropped its proposal in the face of intense opposition, this event contributed to the general public apathy about nursing as a career.

It comes as no surprise, then, that nowadays women would rather be doctors than nurses. In 1986, for the first time in history, woemn who intended to become doctors outnumbered women who intended to become nurses. [5] Because nursing is 97 percent women, the changing career aspirations of college women, encouraged and supported by society, have a critical impact on the supply of potential nurses. This negativism has infected the nursing profession as well. In a pool of 8,023 nurses, 60 percent have not encouraged other people to enter nursing, while 38 percent have. [6] Mothers who are nurses have directed their daughters away from the profession because it is so "demanding and thankless."

Thus, the nursing profession has an image problem. Public understanding needs to change. One way to catalyze such change is through a model of nursing practice that conveys authority, accountability, trust, and success. One that is encouraged and supported by physicians. One that is publicly understood and valued.

The Rush Model

Rush-Presbyterian-St. Luke's Medical Center is the largest academic medical center in the Midwest. This corporation encompasses hospitals, managed care programs, a university, a hotel, and other ventures and has as its major mission the delivery of a full range of high-quality health care services. The nursing service, comprising approximately 1,300 nurses, is responsible for staffing more than 900 beds, 24 operating rooms, ambulatory health service departments, and Rush Home Health Nursing Service.

With respect to hospital operations, medicine, nursing, and administration manage via a matrix model. As shown in the organizational model above, the Vice President and Dean for Medical Affairs, the Vice-President and Dean for Nursing Affairs, and the Vice-President for Administrative Affairs share accountability for operations, planning, and decision-making across their respective areas of responsibility. There is no status difference among vice presidents, which means power, authority, and accountability are equalized. Urification of practice and education are also present in this model. This means that medical, nursing, and administrative professionals from the President throughout the organization wear two "hats" or have two sets of interdependent responsibilities--one for health care delivery and the other for education. It should be remembered, however, that a matrix model can work in a hospital without the academic mission, a structure that will be the focus of this discussion.

The matrix reflects the patient care team--the doctor, the nurse, and the administrator from the top down to the unit level. As shown in the model, vertical and horizontal communication is facilitated and expected. Upward communication meshing with horizontal communication is necessary for successful matrixing.

In matrix management, decision-making is pushed down to the lowest possible level, and the teams (doctor, nurse, administrator) meet, plan, and approve strategy together. This means managers must be flexible in regard to their area of control and must be willing to work with one another to achieve corporate goals. Overlap of responsibility exists, which makes it possible for individuals to be involved in many areas by virtue of indirect authority or interest.

The concept of matrix organization is facilitated further by geographic proximity. At Rush, the matrix managers at each level have offices in close association. This ensures formal and informal discussion and reinforces sharing of ideas. In short, the day-to-day responsibilities of the hospital are delegated to a multidisciplinary team of professionals who share input and critical thinking, which leads to better decisions and facilities communication. This model has worked effectively at Rush since 1972, when it was conceived and implemented by a physician executive.

The matrix model is an exemplary example of respect and empowerment for nursing. In addition to equal management status for nursing at Rush, medicine and nursing share a similar model of self-governance. Hospitals are familiar with the medical staff organization, which is one form or another is active in hospitals nationwide. The Rush Professional Nursing Staff Organization (PNS) is the counterpart to the medical staff. PNS shares the same organizational model as its counterpart and is held accountable for standards of practice, nursing care evaluation, documentation, infectious disease and sepsis control, and professional growth. As nursing reports at the medical staff meetings, so also does medicine report at the meetings of the nursing staff. Rush nurses view self-governance as a means of harnessing professional pride, self-image, and clinical visibility. The rights, responsibilities, and obligations of this structure enable nurses to serve patients through standards emanating from a unified effort. In this way, nurses at Rush feel empowered and recognize their importance and value to the corporation. They expect to generate ideas for creative change and to contribute to strategies generated by their team counterparts. In this climate of equality, respect, and trust, nurses feel high self-esteem. This positive feeling is reflected in the corporate employee opinion survey, where nurses report high job satisfaction.


How, then, can physicians contribute to solving the nursing shortage? It is important to note here that respectful and intellectual communication between doctors and nurses uses the skills of the latter and augments job satisfaction and the ability to contribute to patient care. In fact, the outcomes of patients in intensive care units have been positively associated with the level and quality of doctor/nurse communication. [7]

It appears that two major steps could contribute to a positive image of nursing. First, physicians should "go public" in their marketing of nursing. Essential are media appearances, writings, speeches, and informal conversation that praise the nursing profession as an elegant and desirable career. It is also important to communicate the importance of the nurse as a competent partner in the care of patients and the satisfaction and reassurance the doctor gains from this relationship. Because physicians at this point still are primarily men, they should appeal to men seeking new careers. They could help eliminate the myth that nursing is only for women, Indeed, it is a profession that demands compassionate and bright people who earn high salaries and a prominent place in decision making in health care. This kind of positive marketing needs to be in place for an extended period and on a consistent basis. The second recommendation is to put the proof of these positive beliefs into practice. One way is to emulate the matrix model of management at Rush.

If the suggestions offered here were to be supported and activated by physicians nationwide, it is hard to believe that the image of nursing and, therefore, the shortage of nurses would not take a turn for the better.


[1] Stein, L., and others. "The Doctor-Nurse Game Revisited." New England Journal of Medicine 322(8):546-9, Feb. 22, 1990.

[2] Association of Academic Health Centers. The Supply and Education of Nurses, Policy Paper 1. Washington, D.C.: Association of Academic Health Centers, 1989?

[3] Kleiman, C. "Labor Betting Nurses Ready to Organize." Chicago Tribune, Section 3, pp. 1,5, March 22, 1990.

[4] Stein, L. "The Doctor-Nurse Game." Archives of General Psychiatry 16:699-703, June 1967.

[5] Green, K. "Who Wants to Be a Nurze?" American Demographics 10(1):46-8, Jan., 1988.

[6] "Nursing Shortage Poll Report." Nursing '88 18(2)::33-41, Feb., 1988.

[7] Knaus, W., and others. "An Outcome from Intensive Care in Major Medical Centers." Annals of Internal Medicine 104(3):410-8, March 1986.

Leo M. Henikoff, MD, FACPE, is President and CEO and Kathleen G. Andreoli, DSN, is Vice President for Nursing Affairs and John L. and Helen Kellogg Dean of the College of Nursing, Rush-Presbyterian-St. Luke's Medical Center and Rush University, Chicago, Ill.
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Author:Andreoli, Kathleen G.
Publication:Physician Executive
Date:Sep 1, 1991
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