Evolution of the staff nurse role in hospitals, March 5, 1990

Moderator: University of Iowa, History of Medicine Society. March 5, 1990. This evening's speaker is Myrtle K. Aydelotte, PhD. Professor and Dean Emeritus of the College of Nursing at the University of Iowa. Dr. Aydelotte's talk this evening is entitled, "The Evolution of the Staff Nurse Role in Hospitals." Myrtle Aydelotte: I appreciate that, I have been around a long time as they say in the trade at the university. I do want to make one slight announcement, and that is that I myself have never been a staff nurse. So I really don't know how to explain my interest in staff nursing, except that I do appreciate and recognize and know what they are, but I have no personal experience. I had my experience in staff nursing as a student, because we were involved in the student labor period at the time when I was at the University of Minnesota, although that was one of the very major leading schools when I attended it. A review of the evolution of the staff nurse role in hospitals provides us with a picture of the growth of an occupation as it moves toward professionalization. We are a semi-profession, we are still not yet accorded a full professional status. A review also gives us an intimate look at the work of women, and the change in that work over a period of time. For these two reasons, social historians are increasingly interested in nursing as a subject for research. There's much more interest recently. It also gives authors study of the experience women undergo in a working in a culture which has traditionally been dominated by men. It's a man dominated culture. Unfortunately, practicing nurses, those who are providing bed-side care, have not recorded their experiences to a large extent, although some sources give us information about the occupants of the role, mainly through questionnaires and interviews. We've had lots of studies. I think nursing has probably been the most studied occupation in the history of the world. But most of the nursing literature reflects the perceptions of what I call the nursing elite, that is nursing educators and those in leadership positions in clinical practice. Now in my presentation tonight, I want to demonstrate the changes in the staff nurse role over the last century, which is a long span of time. In order to accomplish that, I'm going to first give a very brief, quick overview of nursing education by which staff nurses have been prepared, and then I'm going to define what I mean by the word staff nurse, because I found out my own husband doesn't know what the word staff nurse means. You can see that we haven't talked about some of these things. Then by using data, selected to represent time intervals and obtain from various sources, including some from the University of Iowa library special collection, which Earl Rogers helped me run around and root into, I'm going to describe how that role has been evolved. Now a staff nurse is a position designation. It's a practice position designation for graduates of all preparatory programs in nursing, and that position encompasses levels or steps attained by increasing proficiency in the provision of nursing care. For example, a staff nurse may be designated as staff nurse one, two, or three, which I think is kind of stupid, or may be placed in a salary designation of several steps. The salary step designation of the University of Iowa hospitals and clinic proposes nine steps for the staff nurse position. The nurse will enter at the beginning step and then over by segments of time and meeting certain kinds of merit increases can move up nine steps. The staff nurse position is also one I call time-bound, in that the individual has an assignment of specific hours of work, 7 to 3, 3 to 11, 11, to 7, or that may be ten hours a day, it may be 12 hours a day, there are great variations. So it is time-bound. The person works a certain period of time, and is place-bound, in that the person has a fixed nursing unit assignment. They're assigned quote, C32, C33, or the clinic. In other words, they are not mobile. It reminds me of a home in which the women stay in the house and the men go out. The family as a model has been used in some of the literature. At the university hospital as I said, the nurse may, has a choice of the times of which she may be employed during a day. The term role reflects a complex behavior that is expected of one who occupies a given position or a given office, is a certain kind of expectation of behavior. Tonight I'm going to discuss the staff nurse role as the employee, and the behavior that has been expected of her or that she's performed in relation to patients, peers, institutions, and physicians. So with that background, let me discuss a little bit about the development of nursing education. One of the earliest attempts to improve nursing care patients was made in the New York Hospital in 1789, when a series of lectures were given to attendants caring for the sick, 1789. I didn't go out of the United States, I stayed here. Then almost 70 years later, in 1857, New York Infirmary offered a four month course in nursing, and it was free. Free, it didn't cost anything. The first class of trained nurses in the United States was graduated from the New England Hospital for Women and Children in 1872, and one year later, in 1873, three training schools based on the English model set up by Florence Nightingale were established at Bellevue, New Haven, which is now Yale New Haven, and Massachusetts General. So really the first trained ... the earliest ones on which we have been modeled, came in in 1873. Now here at the University of Iowa, we had an interesting beginning, which I did not find reflected in our catalog, although it was there in 1949, but I went back to the catalogs of the university to find out. The homeopathic medical department about which Professor Stowe [inaudible 00:07:44] spoke on February 15th of this year established a two year course in nursing in 1893. The nurses were paid, these young women were paid at the rate of a dollar and 50 cents per week, with board, room, and laundry. The quote, and I'm quoting, instruction is most thorough and practical. A certificate signed by the president of the university and the hospital board being given at the close of the second year. Unquote. In 1895, this program changed to a one year course, and the students were called pupil nurses. The two year course became the professional program. The admission requirements state that a nurse must be 20 to 35 years of age and have a common education. A year later, the provision of board, room, and laundry continued, and the stipend was increased to $8 a month for personal expenses. Now there was a fee of $5 for the first year, which was totally theoretical. I wonder what they did. The second year consisted of practical work and one lecture per week, and in the third year, the students continued their practical work, and were assigned topics for essays, at least maybe they could write. Now the first reference to the establishment of the second program, we had two programs here for a while, under the medical department, appeared in the 1896-1897 catalog of the university. The program was two years in length, but changed the next year to three years. You see these are going parallel. The 1897 to 1898 catalog stated that the program was open to women, men weren't mentioned, of course, and the admissions would take place when vacancies occurred, which to me was puzzling. When would a vacancy occur? I suppose it's when they left or something. The studies consisted of lectures, practical work, and a complete course in invalid cookery. Two years later, the description of this program of studies included 64 lectures given by physicians on 17 subjects, such as the medical specialties, plus ethics, observation, hygiene, and disinfection. The superintendent of the hospital who was a nurse gave lectures on hospital administration, ward management, and massage. I had a course of 32 hour course in massage when I was a student. I could do it. In 1917, the applicant to the nursing program conducted by the medical department was required to be between 20 and 32 years of age, able to meet all educational requirements established by the state board of registration of nurses, and they established a three month probationary period. The hospital's dependence upon student nurse labor is reflected in this statement, and I'm quoting. The practical work of the hospital may at any time necessitate variations in the arrangements of these courses and special lectures of interest to nurses maybe added if deemed advisable. So you see the practice was just all changed. The University of Iowa catalog of 1918-1919 makes no reference to the program of nursing chaired by the homeo medical department. So one can just assume that it was discontinued along with the demise of that department. This catalog, the 1918-1919, carries the first reference to the program containing liberal arts and professional nursing. The diploma program was just three years in length, was continued. The University of Minnesota program in which I enrolled was established also in 1919. The developments of nursing at the University of Iowa parallel the nation. The growth of nursing schools was rapid once the value of nurse student labor became apparent. I am going to turn on a slide now. Baccalaureate education grew rapidly in the 1950s and associate degree programs within community colleges were introduced in 1952. Oh, this is number one. I want to go back, I'll go back. Yeah, this is one. 1950, during the 1950s, we introduced the baccalaureate education, which you see the very rapid number until about the 1930s, and this is an important date, and so I broke one of my stages in that. There was an oversupply of nurses during the, in the late '20s and '30s, and especially at the time of the depression, because of the large number of students being produced, being enrolled and graduates produced. Baccalaureate education here at the university as I said was introduced in the '50s and had its major growth. Here at the University of Iowa, the school of nursing, which was a department within the hospital, became a college in 1949, and the integrated four year baccalaureate program which we now have became a reality in 1950, and the diploma program was discontinued in 1952. I lived through that period, and there's some interesting materials about it. When I came here as a dean in 1949, after being interviewed by every head of the department in the College of Medicine, and that's no lie, I was, the faculty consisted of three full-time members. When I left in 1957, the deanship in 1957, there were 40 faculty members full-time, and the faculty of course is much larger today. Now the evolution of the staff nurse role in hospitals is closely related to the development of nursing education, and the numbers of graduates produced. The oversupply of nurses in the first part of this century and the periodic shortages of nurses have helped to carve out the role of the staff nurse. Currently, we have a large number of schools. This totals up to over 1400 if you were to total it, and they are all contributing the approximate number of practicing nurses today is 1.8 million, 68% of which work in hospitals. You'll notice that these are all programs leading to the entry to practice. We have two doctoral programs, one at Rice University, one at Case Western Reserve, another one is going to open at University of Colorado. We have seven master's level entry practice, and the others are baccalaureate, associate degrees, and diplomas. We could have the lights now. Oh no, just leave it on for one more minute, I'm sorry. Now for my review of the literature and documents, I've constructed five stages in the evolution of the staff nurse role. From 1857 to 1930, I am calling it demonstration of value, and I'm talking about the demonstration of value of nursing. 1930 to 1939, a short period I'm calling accommodation and indoctrination. That's when nurses moved in, the staff nurse position moved into hospitals. 1940 to 1960, resistance and rationalization, a very turbulent period in terms of hospital nursing. 1961 to 1980 was a great impact of specialization, and nursing became highly specialized, and 1981 to the present, I'm calling differentiation and assertion, and there's some interesting things happening. So now we can have the lights. Thanks. During 1873 and 1900, nurses proved their usefulness in the care of patients, and hospitals and physicians moved into the control of nursing by establishing schools of nursing, and these became a source of labor to the hospital and to the physicians. Many of the hospitals at that time were small private hospitals operated by physicians. You know, this is before the [inaudible 00:16:56] report. Now unfortunately, schools of nursing had no independent financial backing or endowments. They were to be the Nightingale system had them independent of hospitals and physicians, but because of financing, the schools were not operable. At the beginning, the apprentice system of nurse training became very well established. It was a form of apprentice training. There were very few graduate nurses employed in hospitals, and nurses engaged in private duty. Now I'd like to call your attention to the word duty. Nurses never moved into private practice. It was a duty to care for people. That was the concept. There's been some interesting writing on that, and I think it's interesting that there were general duty nursing consisted, persisted for a long time in terms that one was obliged to care. The family, as I said, became the institutional model for the hospital in the early years, although there's no one family model that was universal, as I would say. One early speaker stated, quote, nursing is woman's work, peculiarly and particularly. No man can compete with her. Doesn't this sound noble? It is her field and by nature, she is eminently fitted for it. The young woman best adapted for nursing required good health, common sense, and a glad spirit. She was admonished to rise above the menial task and say, quote, blessed be drudgery. This appeared in the literature. A Miss Janie from Cedar Rapids, Iowa, in 1912, described the night service in the hospital. The night nurses' duties, and this could be a graduate nurse, usually a a first year after graduation, included early morning toilet, serving breakfast, seeing the ward was left in perfect order, most of the care having to patients being done by special duty nurses, because patients all had their own nurses. Overseeing the pupil nurses, and making up dressings and supplies. The day staff nurse came on duty at 7 in the morning, and directed the junior nurses, the pupils, attended to the most seriously ill, inventoried the medicines and supplies, carried out medications and treatments, assisted with serving meals, observed patients, and followed medical orders. This is in the description. Prior to 1930, there was little distinction between the work performed by students and the graduate nurse. Very little distinction. They were doing the same work. The 1928 study conducted under the auspices of the Committee on the Grading of Nursing Schools indicated that one-fourth of the 954 schools, and the schools were the source of all the labor. There were 954 schools, one-fourth had three graduate nurses or less. All the rest taken care of by students. I should say, pupils. One-half had six graduates or less. One-half of 954, and three-fourths had 12 or less. Three-fourths of the schools. Three-fourths, that's over 600 schools. Only 11 schools had more than 90 graduate nurses. You can see that there were very few. The typical hospital was paying graduates $96 per month, and general duty was one of the most unpopular branches of the nursing profession. Nurses were having a 12 hour day, though in California, the eight hour day was introduced in 1915. The superintendents of nursing preferred students to graduate nurses, and as early as 1926, there was an attempt to introduce reviewal procedures, development of standards, and there was a great concern about attitudes. This stage of the evolution of the staff nurse is characterized by the elite, by the elite, some of the superintendents attempting to describe and emphasize the role of the staff nurse. But in spite of their efforts, although the value of nursing service was recognized, many superintendents preferred to maintain student labor and little prestige was given to the role of the staff nurse. The dependents of hospitals upon student labor increased as the number of hospitals increased, and as a result, when the depression occurred in the United States, thousands of nurses were unemployed, and that led to the next stage. There were thousands unemployed. They were on WPA, they were [inaudible 00:22:24] projects, it was just a very severe thing. So that leads to the next called stage which I called accommodation and indoctrination. The decade of the 1930s opened with an uneven distribution of nurses. Nurses were eager for private duty in hospitals but not in homes. Private duty. The patients couldn't pay for it, so they didn't have it. There were thousands unemployed, but the great majority unwilling to take positions in hospitals. One of the proposals was the reduction of supply, which is ironical, when I hear what's going on today, and the large schools were responsible for the oversupply. Two years prior to 1930, Anna Wolfe, who was a superintendent of nurses at the university clinics, University of Chicago, addressed the question upon general duty, could be made more attractive to graduate nurses. She stated, the nature of the work must maintain their interest. The hours of work must be reasonable, allowing time for recreation and rest. Compensation must be fair and adequate, for the qualifications of the incumbent. The individual must feel that there is dependence upon her service, and she's growing intellectually in it, and is becoming a better prepared woman for whatever else she may choose to do. Well most of them married, if they could, and left. The 1930s and 1940s saw the creation of a graduate nurse labor force tied to hospitals. In 1930, 70 to 75% of all registered nurses were private duty nurses. Three-quarters of the workforce. By 1946, 16 years later, only one-sixth to one-fourth were still employed, self-employed. They'd all moved into the labor force of the hospital. There are some very interesting reports on this period of the movement. Now the period, this period with the movement into the hospital is characterized by the development of personnel policies for nurses, programs for indoctrination, division of labor in nursing, and great unrest. In 1932, the American Nurse Association urged by letter, urged hospitals to reduce the number of students and to employ general duty nurses. Positions for graduate nurses were advertised for $15 per week. At the end of the decade, nurses were earning less than female faculty workers. Hospitals continued in spite of a large number of graduates, to prefer undergraduates to graduates, since it was less expensive. It was less expensive to provide nursing care and nursing education, than to provide nursing care alone. Robert Neff, whom some of you may recall, who was then the superintendent of the University of Iowa Hospital, he came in 1928, and was the president of the American Hospital Association, calculated in a study done here that to educate a student in nursing costs $650 a year. That was board and room, you see. The rate of replacement of that student by a graduate would be $85 a month, plus $41.70 maintenance, or $1520.40 per year. So it was cheaper to have students. He urged that nursing education should be regarded as a public responsibility, and the society should pay for the cost of nursing education, which is an interesting factor that I learned about Mr. Neff. I didn't know he said that, but he said it in two publications, and so that is what he said. The transition of nurses from private duty to general duty took over a period of the next 15 years, and the change undercut autonomy and control of nursing practice. In 1934, the Committee on the Grading of Nursing School published its report. Susan, I'm gonna have another slide, please. Provides a picture of the work performed by the staff nurses in hospitals. I'm sorry, I don't think you could read this too well, but out of this total, if you were to read all of these, out of these, the total range, over half of all the activities are what we would call of the curative type. You see number B, carrying on curative nursing procedures, 94. If you look at the bottom, you'll see that there was little attention given to teaching or counseling of the patients or the establishment of a psychological atmosphere. There were no activities on cooperating with the family, hospital personnel, health, social agencies. There were non-educational activities which I'll speak to. There were no teaching majors, and these were from actual observations of what nurses were doing in hospitals. The non-educational ... we can turn on the lights again. The non-educational activities dealt primarily with housekeeping, errands, and include quote, cutting paper for day and night reports, unquote. Doc and Stewart report that by 1939 by degree, many of these duties were now turned over to other workers, and were being eliminated. But the tendency toward routinizing and standardizing nursing work in this period continued to the use of time and motion studies, and I remember doing time and motion studies when I was a student in 1939. The application of scientific management further reduced the individuals' control of how the work would be performed. The literature in this period includes articles on how to build a good staff, in other words how they make them behave. The characteristics of a nurse able to adjust to situations and a lot on the staff development. A study of some of the factors influencing the service of 500 graduate nurses in 75 hospitals reported that 70% of the nurses were between the ages of 20 and 29 years of age. The salaries ranged from $25 with full maintenance to $92 with full maintenance. There's a wide range of salaries. Nurses were working 48 hours a week, and the assignments were heavy. One staff nurse sums up this as follows: when a hospital employs general duty nurses, the field isn't as large as it first seems. The nurse who is helpful to the student, liked by her patients and fellow workers, and well thought of by her supervisor, quote, is the one who's interested in her work. But it gives you a picture of what kind of conformity was expected of that nurse. Well in 1940, not all was happy at the University of Iowa hospitals and clinics. There was a considerable dissatisfaction among the nurses. This was in 1940. In a letter to the president, Dean McCuhan, then dean of the medical school, refers to the shortage of nurses in hospitals throughout the country, and reveals that in 1938, a small group of nurses were attempting to organize through CIO, which is a labor union. The nurses were being paid $75 a month, with board, room, and laundry, whereas other hospitals were paying $50. We were paying more, we were ahead of things. Dean McCuhan also referred to the nurses' complaint about unsatisfactory restrooms. Now I trust that that was resolved. You know, but they were unhappy about the restrooms. Which tells you again, something about how they were being cared for. An item of interest occurred on March 7th in 1940, in that Mr. Neff received authorization to employ graduate nurses who were wives of persons employed at the university. I brought that out because if we did not employ wives now, I don't think the hospital could be staffed in part. But it was in 1940 when that first act- they discovered accidentally that she was employed, and was already married, and so Mr. Cobb, who was then the business manager, indicated that it would be all right for her to be employed, and that set the practice. 1940 to 1960 was a period that I call resistance and rationalization. The continuation of the application of scientific management, and you have to remember that this is a period when scientific management was applied to everything, and it was the application of scientific management, and the conditions of work that led to further resistance on the part of nurses. Nursing leaders who had chosen to control the expansion of nursing schools and oversupply of nurses by the employment of nurses in hospitals continued to meet great resistance from their own ranks. Great resistance. In 1946, pushed by rebellious nurses and the leadership of the California Nurse Association, the American Nurses Association established the economic security program, which endorsed the role of state nurses association as collective bargaining agents. I attended that convention when it was held, it was in New Jersey. Nurses began to organize in 1960. The division of labor, which had been introduced in the second stage further differentiated the role of the general duty nurse who became a coordinator of care, because she was coordinating the care provided by aides, orderlies, practical nurses. Then the associate degree nurse came in in 1950. During World War II, nurses were urged to serve the war effort by working in hospitals, but many chose to work in industry, instead, because the salaries and wages were much higher. Feelings and emotions ran very high, and we were almost put under some kind of subscription, but that never materialized. But in 1947, of registered nurses, about one-third were working as staff nurses in hospitals. Today there's about 67% working as staff nurses. Two-fifths of the time, and I'm going to have another table, another table. Two-fifths of the time of general staff nurses was spent on duties that presumably could be delegated to less trained personnel. This is a report of activities of staff nurses in hospitals. No, no, I didn't do it. There, there it is. This listing indicates that division of work was taking place. The staff nurse was supervising and teaching non-professional workers such as aides and orderlies as well as practical nurses, which you can see that there was administration was 17%, which had not been noticed before, the direct patient care, equipment and supplies 4%, errands, care of the environment, teaching was still persisting. But there's a change that occurred here. We're just gonna leave it [inaudible 00:35:09], I'm coming to another one. The combination of conditions of work and economic rewards contributed to a serious drop of enrollments in schools or nursing. Half of the institutional nurses included in a 1947 study conducted by the Bureau of Labor Statistics worked a 48-hour week, slightly over half that number were exercising the option of living out, they're beginning to live out, and although a fair proportion was receiving medical and retirement plans, insecurity was a problem. They could be laid off without any notice. There were no contracts. A great deal of insecurity. In 1958, ten years later, then a year later than this, but ten year later than this other one, the ... let me go back to this. This was the 1947 survey, which you can't see very well. I'm going up to the one. This study was done in 1957 of the ANA undertook a large study of nurses, and the result of the total studies indicating this, one sociologist indicated that nurses were having five major functions in the '50s. The technical functions of nursing procedures carrying out nursing care, and administrator ordering supplies and keeping records, and organizer who maintains the systems of controls, communication, and supervision of non-professionals, and the teacher and trainer. Two other researchers who were doing the study of nursing at Charity Hospital in New Orleans stated that most of the functions were routinized and followed the order of an assembly line. That was the way the work was being organized and perceived. We can have the lights again and not ... Thus the role of the staff nurse in the 1950s was described as possessing an ambiguous status. The prestige was not great. The relationships with physicians were strained, and nurses were isolated in a rigid social system in which the relationships were impersonal. The work was under constant scrutiny, and the nurse was the object of a large number of demands. In 1954, 35% of the general duty nurses in a Kansas City survey of 2400 were making less than 3,000 a year, and only 8% were making over 4,000 a year in 1954. Then we moved into the next stage, which I call specialization. The next stage of the development of the staff nurse role was greatly influenced by the diffusion of technology into hospitals, which resulted in the development of intensive care nursing units. The first type of intensive care to develop was the post-operative recovery room, and that was present in nearly all medium and large size hospitals by the early 1960s. I can remember when it was established over here. By 1974, nearly all hospitals of 200 beds or more had ICU, intensive care units. 84% of all voluntary hospitals with 300 beds or more reported coronary care units. I was one of a group of research nurses accompanied by other researchers, physicians, and hospital administrators, who made visits to some of the coronary care units in the 1965, around 1965. The development of other types of specialized nursing units was rapid, and the crucial element of the functioning of the unit was nurses prepared to observe and to take care of those patients. Now the introduction of intensive care, and I recall this vividly, was best illustrated by the title one article appearing in the American Journal of Nursing in 1969. This was about four years after I'd made that visit out to Pennsylvania. Quote, intensive care nursing, specialization, junior doctoring, or just nursing. There's a great deal of skepticism among the nursing community as to whether or not this is really nursing or was it just junior doctoring. But in spite of the questioning about expansion and acceptance of the technology, nursing specialization quickly took hold, and a report made to the surgeon general in 1963 called Toward Quality Nursing gave impetus to the movement. Specialization in nursing advanced at this very rapid rate, and prior to 1968, aside from divisions of practice in the American Nurse Association, which were very traditional, medical, surgical, pediatrics, obstetrics and so forth, there were only two other specialty organizations. The Association of Operating Room Nurses and the American College of Midwives. By 1973, the number of specialty organizations was so great that a federation was created to facilitate action and coordinate the action of all of them. In 1988, there were 22 specialty nursing organizations representing nurses practicing specialties in hospitals, excluding those in other settings. 22. The number, the nature of the specialization is varied. Now specialization resulted in marked changes in the nurse's role. Introduced was assessment of patients' conditions, monitoring of risk conditions, application of high level or clinical judgment, and instructions to patients and families and evaluations of care. I do have another table to show you, and I'll get my act together so I'll put this on right. I don't know whether you can see that very well, but I think it's interesting to note that administering medications of course continue. These were activities reported by nurses providing direct patient care. These were nurses who were doing direct patient care. They were supporting, sustaining and supporting persons who are impaired or ill during their therapy, instructing patients and management, instructing and counseling the patient family, obtaining health histories which had not been done before, implementing therapies, and you'll notice that there's a number, one-third reported medical management of selected conditions, selecting plan of treatment as a result of interpretation of laboratory results, all of these were introduced as a result of the specialization. This change in the kind of practice nurses were doing changed relationships to physicians because physicians became dependent upon the nurses' skills and judgment. It also created conflicts. Changes were also apparent in the nurse hierarchy, since nurses no longer became interchangeable parts. I could have the lights again. Interchangeable parts and could be transferred easily from one type of nursing unit to another. It used to be that a nurse could be in a medical nursing unit, then she could be transferred to surgical nursing unit, and back and forth without any difficulty. That was eliminated. The relationship to the patient took a different form, since the acuity of the patient required very intense service and staffing configurations changed sharply. It became labor intensive. The technology instead of reducing the need for nurses created the need for more. The care of some patients required one full attention and there are situations now in which one patient requires the attention of two nurses, or a nurse and a half, if I can use that word. Now the care also demanded the nurses become prepared and especially either through independent study or training, and training programs provided by the institutions and nurses became credentialed. But in spite of all these changes in practice, or because of the end of it, the demand came, and then we began to experience another shortage and we're in another shortage at the present time. That moves us up to the next time. Changes in the practice of nursing in this decade in our present decade, can be inferred from a study of nursing practice of newly registered nurses made by Cain, Kingsbury, Colton, and Estes, that was made in 1986. It was made here at the ACE. This study was conducted to evaluate the validity of the current examination for a licensure, and I'm not going to go explain the methodology, but a questionnaire giving a list of 22 activities was used for the data collection, and then those were classified into 17 categories. The table I will show you represents the ranking of the waste assigned to the activity category, which indicates the frequency and the level of critical, the critical nature of the activity. So I'll turn this on. You can see, now these were nurses who had been working for only six months. Samplings were taken at six months, and then at another six months, and I did not include those of foreign nurses, because it was given to some foreign nurses. Which you can see that the two, if you looked at it ranking by weight, these new nurses, activities were primarily in terms of meeting physical needs that would be nutrition, feeding, the various physical needs of individuals, but the second one is monitoring clients at risk. These were patients who had very unstable conditions. They performed routine activities, and you would expect that of the new nurse, but planning and managing patient care, preparing nurses for procedures, then ensuring safety, and look, here comes then quality assurance and safety. We had never seen that before in any of the other statements. Assisting clients with self-care, and assisting clients with mobility needs. Now part of this may be the way the statement is formulated, but it also indicates that there are certain kinds of changes occurring in the practice as you look at it. Okay, that's I think turn that on again. Yeah, mm-hmm (affirmative). The prediction is that my prediction, I'll say, is that further differentiation of the nursing role will take place. The need for highly technically skilled nurses will continue, but I'm predicting that they will be accountable to their practice for their practice to a nurse with advanced preparation who will serve as the case manager for the group of patients, and the leader of the staff nurse group. Things are getting so complex that I think we're going to reorganize ourselves differently. Currently, demonstrations are underway testing this concept. The move will transform the relationship between nurses and physicians and will establish new patterns of governance within the nursing hierarchy. We have a very hierarchical system. Departmental governance, that is what goes on within the department of nursing, and the participation of nurse representatives in institutional policy has become a major concern. Nurses having something to say about the institution since they are providing basic services. Now at the University of Iowa hospitals and clinics, these ideas were introduced in the early '70s, and the current expectations of the staff is that they will include clinical practice, education, quality assurance, accountability, and professional responsibility. I want to show you the growth of nurses in the department here over the years because the growth has really been phenomenal. I'll have another one. This is the growth. I do not have the number of patients or the beds along with it, but in the year 1912, there were ten nurses. There were ten nurses, and I made that because the only way [inaudible 00:49:14] tell is there were nine graduates of the class of 1911, and one of the class of 1910, that gave the University of Iowa as their address. So that's an inference. The next one, there were five plus relief nurses, and I don't know what relief nurses were. But currently, in 1989, there are 1,029 staff nurses at the University of Iowa hospitals. Staff nurses. It has been a steady decline. Look at 1944, when there were only 27. That was a time of the great resistance and rationalization. Then the number in 1949 went up to 175. That's the year I came. I don't know where they were. I couldn't, you know, really I was a dean and it seemed to me that students were doing all of the, were providing most of the care. But there has been a steady growth, and of course there has been a change in the number of beds and a large growth in clinics. But currently we have ten, 28 nurses according to the department. The beginning salaries for staff nurses, I thought you'd be interested, I took only the year 1940, I couldn't find the earlier information, I didn't go back into the university budgets. 1940 was $900 a year plus room, board, and laundry. Then if you had one meal only and you lived out, it was $1300. There's been a steady growth of that, and the current approximate average salary is now $25,600 per year for staff nurses. If you converted that to real dollars, it'd be less, but this is what they're paying, what they're receiving in their check in 1989, and of course it's higher. These were the beginning salaries, not the maximum salaries. Okay. Now changes in the role of the staff nurse relate to the nature of the functions and activities performed for patients and clients. There's been a reduction in the specific task. We've no longer is, it's no longer as task oriented as it has been. But the functions have become increasingly complex, demanding clinical judgment and have changed the relationship with physicians. The role of the staff nurse in relation to the institution continues to be that of an employee. But the perception has shifted from that of an industrial worker involved in piecemeal assembly line work to that accorded a rising professional. I'll use that word rising. Expert staff nurses in many institutions are now really treated as full professionals with considerable autonomy, and many are accorded colleagueship by physicians with whom they work. The tensions between physicians and nurses continue to exist, but it's less at the unit level, where patients are cared for. There's tensions, there's no question about it. Not all nurses are really not treated as full professionals. They do not have the autonomy and control of their work to the extent that professionals do. I've read one author who said we'll never be professionals. So that was a little shock. The tensions I would say between physicians and nurses resides primarily at the policy and the resource level. That's where the great tensions are in terms of who's gonna get the money, who's gonna get the gain, who's going to be recognized, and that type of thing. Nurses do continue to be seen as less powerful than physicians. There's no question. Nurses are seen as not having access to patients, except through physicians and that has been present and it is something that is, should I say, guarded very jealously by the physician. A recent study conducted by the Indiana Hospital Association and Sigma Theta Tau, of which I was a part, presented finding that nursing is seen by students in high schools and the public as requiring intelligence, knowledge, and a high level of technological skill. It was also seen as very hard work. Nursing was not described as an ideal career. We had a checking between ideal career and nursing. It was seen as offering too limited monetary rewards and prestige, and too demanding. It was seen as a career of very high social value. Apparently, individuals believe that caring for people as nurses do is commendable, but society places a low monetary value on it, and are unwilling to pay for it. It is also unwilling to encourage it as a career. Thank you.