Managed care systems and operations

Nursing Tasks, Methods, And Expectations

State of the Industry

The Art and Science of Nursing

Relative Pay Scales

Male Nursing Roles

Sex Stereotypes

The Influence of the Nationalized Healthcare Debate

Proposed Methods toward Recruiting Nurses

Joint Corporate Campaigns

Steps to Recruiting Men

Wages issues

Recent employment trends in the nursing field have demonstrated a disconcerting drop in the number of employed and employable nurses. In what has been traditionally a female dominated filed, the exit rate of both men and women, as well as the approaching retirement of a majority of existing nurses, threaten the long-term care quality of hospital and other in-patient care facilities.

This paper examines some of the factors behind the current nursing shortage, and offers suggestions as to how to reverse the trends which, if left unchecked, threaten our nation's health care delivery system.

Introduction

Since the days of Florence Nightingale, patients in hospitals around the world depend on the care of nurses. These trained professionals assist doctors and specialists in virtually every area of medicine. In addition the 'extra set of hands' needed for many medical procedures, nurses provide a special type of one-on-one contact that is outside of the scope of a doctors daily responsibilities. The special, intimate contact offered by nurses has built significant value in the field of nursing. This hands on; personal touch is a needed component to the overall health and well being of in-patient care.

In most modern medicinal institutions, as well as practical training programs, nurses are taught to provide skillful services, as well as compassion and caring. Patients and doctors alike realize the value of the services nurses provide. After Florence Nightingale revolutionized the profession in the 1850's, deaths in hospitals dropped dramatically, from 420 per 1000 to 22 per 1000 (Kurzen, 1997). Since that time, hospitals and rehabilitation centers have depended on the skilled nurses in addition to the doctoral staff. Soon thereafter, practical nursing programs developed in the late 1800's were designed to increase the opportunities for women (Kurzen, 1997). These institutions soon became vital to the growth and effectiveness of hospitals and health facilities. The demand for nursing services grew so dramatically that national organizations flourished by providing supervision and planning for the growing profession. Within a relatively short period of time, nursing had evolved from a pink-collar employment to a female dominated, respected profession.

For many nurses, the daily chores and duties begin long before sunrise. After receiving briefs and updates on hospital conditions, nurses must check the charts of their patients (Wolkomir 1998). Patient charts include crucial information about the administration of medications and special notes from physicians. Any mistakes in the administration of medicine can be fatal, so it is the responsibility of nurses to give precise dosages (Wolkomir 1998). After completing orders from doctors, nurses perform more ordinary tasks. Many patients are unable to complete simple acts of daily hygiene, so nurses are responsible for these care giving tasks as well. A nurse featured in the article "The Quality of Mercy" said that she did not "mind her work- despite the high tech gear and the life-and-death responsibility- requires services as humble as Jesus' washing of his disciples' feet" (Wolkomir, 1998).

Patient care studies detail treatment and therapies provided by nurses for treatment of various illnesses (Livesay, 1998). In addition, care studies outline problems and expected outcomes or goals due to a particular treatment. Nursing is a highly skilled profession with huge amounts of responsibility. Nurses perform these numerous duties daily for not one, but a large population of needy patients.

Statement of the Problem

At a time in which medical care costs are accelerating along with the demand for additional care, the number of applicants for career nursing positions is in a steady decline. For over 6 years, numerous studies have identified this trend which will leave the nursing profession over 100,000 nurses short by the year 2020. Like a monster thunderstorm which created by the combination of many weather factors and front, many factors are combining to create this impending 'storm' for our health care delivery system.

The problem is not limited to the United States. During the recent SARS outbreak in Toronto, the shortage of nurses in our northern neighbor exacerbated the crisis. (Silas, 2003) When hospital beds fill, and the conditions are life threatening, if the hospital, or in the current climate, the entire North American continent, cannot meet the demand with trained professionals, the results can affect the entire population. The shortage of nurses during this particular crisis meant they were overworked and exhausted at a time when they needed all of their powers of observation. Though it's not known exactly how they contracted the disease, but two Toronto-area nurses did lose their lives in the fight against SARS. Had adequate nursing staff been less in number, or the SARS outbreak proven more difficult to halt, the potential for a cataclysmic epidemic loomed over the entire city. (Silas, 2003)

Nursing Tasks, Methods, and Expectations

The field of nursing is not only concerned for the physical care of sick and injured patients. The field of nursing also seeks to address the emotional wellness of their patients also. "Nurses practice medicine as an art, marshaling compassion and skill in equal measure" (Wolkomir 41). Because of Florence Nightingale's efforts in the 1800's nursing has formed itself into a profession which seeks to address the emotional and psychodynamic well being of the patient as well as the physical health. While dealing with an oncology patient, Vanessa Livesay stated "comfort is the most important gift [my patient] can be given. Support must be offered, whether accepted or not. If the spirit is in distress, there is usually little comfort for the body" (Livesay, Care Study).

As a result, nurses are instructed and trained to "discuss various modes of therapy encountered by patients" (Guidelines for Rehabilitative Nursing 3). Nurses are trained to look beyond the medical science, and seek to combine efforts which calm and comfort the patient in order to facilitate healing. Because of this dimension, nurses cannot be classified as "doctor's helpers," or glorified gophers who know alittle bit about medicine, but not enough to be a doctor. The desires if the nursing profession are different than the physician in that they seek to comfort and nurture the patient toward current health so that their bodies are more able to process whatever long-term healing is needed.. Nurses in modern hospitals also work to promote a team unit between the doctors, staff, patient and patients family as the group strive together to overcome the patient's illness. "The patient and family as the core of this team will require the assistance of physicians, nurses, and other professionals. Therefore it is the nurse's responsibility to identify measures to facilitate cooperation between the nursing staff and the rehabilitation team" (Guidelines for Rehabilitative Nursing)

Nurses are further instructed to be perceptive of the feeling of patients. "Guidelines for Rehabilitative Nursing" states that the nurse will be able to "observe relationships/interactions among patient, family and staff members and discuss the effect of these relationships on the patient's rehabilitation" ("Guidelines for Rehabilitative Nursing" 3). Toward this end, nurses are also trained extensively in communication with patients. Often it is what the patient doesn't know how to say, or want the patient is unsure of how to communicate that can be the key to their treatment. Nurses are instructed to use broad opening statements and acknowledge a patient's thoughts, often through silence and not verbal sympathy. No other person in the hospital carries the holistic view of healing other than the nurse. Without their talented and professional care, the health care delivery system, including the quality of care and the quality of life for the patient suffers.

Literature Review

The declining roles for those applying for nursing degrees have been of growing concern for the past half decade. The nursing population has also been slowly aging without new nurses coming into the profession equal to the rate of those who are retiring, and making career changes. As a result, the nursing industry faces significant challenges in the near future. Unlike finding additional workers for entry level jobs to address seasonal business fluxuations, or hiring new workers for a factory which opens a new facility, producing talented and qualified nurses is a 2-4-year process. The science of nursing must be taught. The art of empathic care must also be present in the new nurses if they are to make a valuable contribution to their field. Other factors are adding to the impending nursing shortage crisis. The average age of the nursing population is over 40, and the median retirement age is 50. Nurses over the age of 50 find that they loose the ability to provide care for patients that often involves moving and lifting them. A third factor influencing the nature of the shortage is that the aging baby boomer population is likely to require extended health care. As this largest segment of our population ages, the chance is great for additional long-term to be required for an increasing number of citizens. Together, this combination of factors is leading toward a health care crisis which is much larger than the question of whether or not the government finances prescription drug coverage.

The State of the Industry

As inferred above, many factors are contributing to the nursing shortage crisis. This section will discuss the major contributory influences.

1. Poor Working conditions

Dissatisfaction with pay and increasingly stressful work conditions, aggravated by a shortage of nurses at hospitals across the country, is spurring job actions in the health care field. Many nurses are choosing to leave the profession, and seek better conditions, or higher pay scales. Because of what the University of Wisconsin (UW) Hospital calls "staffing shortages," the hospital frequently calls for nurses to volunteer to work overtime. Unfortunately, the shortage has created the situation requiring mandatory overtime form much of the staff. If a nurse works one shift and no one has volunteered to take that position for the next shift, the UW staff aspects the nurse to stay on the job. Otherwise, the nurse could be viewed as abandoning the patients. While this possibility is present in most care facilities, UW Hospital has far more mandatory overtime shifts per nurse than other hospitals in the area, and the trend is rising. In 2000 another Wisconsin hospital, Meriter hospital had 400 mandatory overtime shifts spread among its 700 nurses, which is just over 1/2 shift for each nurse. In 2001, UW Hospital had 2,600 mandatory overtime shifts for 1,100 nurses, which is close to 2 1/2 shifts for every nurse. (Conroy, 2001)

As a result, the thorny subject of diverting of patients from the hospital to other care facilities came at a time when the UW were engaged in a bitter contract negotiation with the nurses union. The union claimed mismanagement was causing a nursing shortage and undermining patient care. The UW hospital said it was trying to address a shortage being felt by hospitals nationwide. But the bottom line of the situation was that "Patients were at risk every day because of this situation," said Bonnie Strauss, chief negotiator for District 1199 of the Service Employees International Union, which represents 1,100 employees, mostly nurses, at University Hospital. "They have beds. They don't have the staff."

2. Declining Nurse Population

Hospital nursing staff are trained to watch over the overall well being of their patients. A setting in which the care of the patient is being compromised, regardless of the reason, is an employment environment which creates additional stress and conflict for the nurses. The result is that the hospital can't keep nurses when the poor work conditions, including mandatory overtime, double shifting and short staffing are a regular part of the work-scape. Andrew Campbell, a veteran nurse in the pediatric intensive care unit, said: "The conditions just continue to get worse." (Mosiman, 2001)

The first report to spot the negative trend predicted in 1997 that Canada would be short at least 69,000 nurses by 2011. Subsequent studies have made corroborating projections. A report released recently by the Canadian Institute for Health Information (CIHI) reveals that there are now 70 per cent more nurses aged 50 and over, than aged 35 and under. The average age of Canadian nurses is 44.2 years. Nurses tend to leave the profession as they reach their mid-50s, when their bodies can no longer handle the physical demands of the job, such as lifting patients. A study reported in the New England Journal of Medicine last year found that "low nurse staffing" increased the rate of "life-threatening infections, shock and bleeding." (Silas, 2003)

According to Business Wire magazine, by 2011, the number of new nurses entering the profession is projected to exactly equal those retiring. In 2000, only 32% of nurses were less than 40-years old and 26% less than 30-years old. A significant increase in nursing supply is necessary to recover past losses.' (Business wire, 2003)

The chart below represents data collected from a 2001 survey of 1092 hospitals nation wide.

Adapted from First Consulting Group. "The health-care workforce shortage and its implications for America's hospitals

The nationwide shortage at hospitals is occurring despite a 39% increase in the number of registered nurses nationwide in the last five years, to 2.74 million. More of these nurses - about two out of five - are choosing not to work in hospitals or nursing homes. They opt for easier, better-paying jobs at health maintenance organizations or pharmaceutical companies. The Department of Health and Human Services (DHHS) predicts a shortage of 400,000 nurses by 2020. (Agovino, 2001)

Other agencies which have been watching this trend foresees no relief to the nursing shortage given increasing demand, an aging workforce, and inadequate supply, according to a report released today by Fitch Ratings. The current and projected personnel shortages, especially among registered nurses (RNs), present one of the greatest operating challenges for health care providers nationwide. 'Any improvement in other areas from operational efficiencies or favorable rate increases from managed care payers will be offset by labor cost inflation. Therefore improvement in the credit quality of many hospitals and long-term care providers would be prolonged. Imbalanced supply and demand, which is expected to worsen as retiring nurses outstrip replacements, should create financial strain for many providers in an industry that is gearing up to meet the aging population's anticipated demand for more services,' said Chad Farrington, director Fitch Ratings. (Business Wire, 2003)

The Art and Science of Nursing

The goal of nursing is to "...assist persons to achieve their optimum level of health in situations of normal health, illness, injury, or in the process of dying" (Canadian Nurses Association, 1998). This goal is achieved in the nursing profession through the two related segments of health care which draw from different skill categories. The science of nursing concerns itself with the application of medical care, while the art of nursing focuses empathetically on the emotional and holistic needs of the patients. Nursing as a science involves the technological and research aspect of patient care. The art of nursing is a more holistic view and takes into account all the patients mental, emotional, physical and spiritual needs.

The science of nursing includes mastery of the knowledge base required to function as a nurse, and the accurate application of that knowledge and knowledge is fundamental in the growth of any discipline, especially one which offers care for a complicated creature as the human being. According to Talbot, (as cited in Potter, Perry, 1997) knowledge is information, and discovery is the creative process of obtaining new knowledge. Research is used to scientifically prove theories as well as to discredit others. Personal experience may bring research and increase the body of knowledge. Since nurses have started to do research, they have begun to build their own body of knowledge, instead of borrowing that knowledge from others (Leddy, 1998).

The growing body of knowledge corporately contained within the maturing nurse population is a valuable asset. This knowledge has been built by experience and in recent years by nurses who have undertaken personal research. Managing this body of knowledge, which has been created post-graduation, is an important and valuable asset to the entire field on nursing. This knowledge should be passed along to up coming nursing staff before the current nurses retire. In an environment which is understaffed, the flexibility needed to pass this knowledge along to the new staff could be forever lost.

Research and experience in the nursing field has allowed positive evolution within the profession. According to Meleis (1997), nurses use knowledge of human responses to health and illness in the healing process. Meleis (1997) states that the nurses uses this knowledge by promoting health, by helping to care for the patient, by helping the patient learn to care for themselves, and by helping empower the client, teaching them to use available resources. Philips (2000) discusses Rogers' idea that "nursing science is the prerequisite to the process of nursing" (Philips, 2000).

On the other side of the coin, the art of nursing is also important in every way to the success of the nursing profession, and the success of the individual pursuing a nursing career. Physical health and holistic health are very closely related, and both constructs consider what is best for all aspects of the patients' well being. According to Potter and Perry (1997) holistic health is becoming so popular because of the belief that comfort affects personal physical and mental functionality. Holistic health concerns are considered to be an important part in an individual's wellness. Holistic health looks at all aspects of a person's wellness, and the nurse is responsible to assess the need of the individual and to make sure that all these needs are met.

In terms of the art of nursing, "Caring (for the patient) is a mutual exchange in which both parties relate on the level of their shared humanness." (Montgomery, 1993) While the patient is looking to the nurse for caring reassurance as (s)he receives medical treatment, the nurse is also assessing the patients emotional well-being, and in tern giving out of his or her emotional resources to help the patient. This caring process, as Montgomery has described it, is essential for all individuals in feeling loved. A person who feels loved, and has someone to share that love with them is going to heal quicker than a person whom is left to themselves and forced to take on the entire situation with no additional help. It is for this reason that caring requires three things, compassion, competence, and commitment.

According to Roach (1998), compassion is the ability of the nurse to listen and feel what the patient is saying without using judgment. Compassion is a way for the nurse to become closer with the patient without invading the patients' privacy by placing himself or herself in the other person's shoes, if you will, and comprehending the situation thorough the patient's eyes. Compassion is important in caring because people are able to recognize this quality, and usually respond to the gentleness.

The second quality required to demonstrate caring as a nurse is competence. According to Roach (1998) competence is the ability to show the patient that the nurse understands the skills involved his or her profession. This skill is important because it is very difficult for a patient to open up to a nurse in which they do not have confidence. A patient will have a hard time connecting with a nurse who is incapable of simple tasks such as changing dressings or giving a bed bath. Simple communication can make a world of difference to the patient, and in order to foster the communication, the nurse must demonstrate that he or she has mastered the details of the profession.

For a strong relationship to develop between the nurse and the patient, commitment is the third essential 'C'. Commitment is the junction point between "one's desires and one's obligations...'(Roach, 1998). Commitment is important in the relationship because without it, the patient will feel uncared for, and will thus have a hard time relating to the nurse. Things as simple as a back rub before a patient goes to bed can show the nurses commitment towards the patient's overall well being, and help develop the relationship from both sides.

These three 'C's are essential skills for successfully performing the duties in the nursing profession. The environment which is currently evolving is defined by lack of adequate staffing, lower than expected pay scales, difficult work shifts. The ongoing presence of elements make it more difficult to practice the art of nursing with the skill and finesse required to excel in the field. The science of nursing goes on, as these functions are performed with little emotional involvement. But the art of nursing, connection with the patient in order to fully facilitate his or her healing cannot be done in an environment which demands so much, and gives back so little.

Relative Pay Scales

Throughout history, there have been minor recurring shortages in nursing, mainly caused by the underpayment of nurses. Unfortunately, because the pay scales have been controlled by large organizations, the shortage in supply and increased demand has not translated into rising pay scales. Hospitals attempts to be cost efficient caused pressure on nursing wages to remain low, and the lower pay scales have in turn caused people to not give nursing a second thought as a career.

A nurse's salary varies dramatically across the different types of nursing jobs today. An experienced nurse will average $25,000 per year where as the professional nurse will average more than $31,000 per year. In the 1990's, a nurse started at $27,000 per year, experience nurses at $33,000 per year, head nurse around $47,000 to $53,000 per year. In 1994, a nurse anesthetist was the highest paid nurse receiving between $44,800 to $68,200 per year. The more experienced the nurse, the higher the income a nurse will receive. Careers in nursing are expected to grow throughout year 2005 which could lead to greater diversity in the pay scales for nurses. This growth will be driven by technological advances in patient care, which will likely require greater levels of training prior to accepting the position. This in turn could lead to demands for higher wage and benefit packages.

In the '80s, nurses' salaries improved significantly. Data shows that from about 1983 through 1992, RNs had one of the fastest growing incomes of all professions in the country. They were running 4 to 6% increases above inflation during that period." According to the U.S. Department of Labor, the middle 50% of registered nurses earned between $37,870 and $54,000 in 2000. And the potential for much fatter paychecks exists. Advanced practice nurses, such as nurse anesthetists, can make more than $100,000 a year. "The money is much better now" Lutheran General's Nilsson said. (Rackl, 2002)

Male Nursing Roles

Historically nursing has been considered a single-sex occupation, identified as a role that is inherently natural to the female gender. Thus, it has become identified as a profession deeply embedded in the gender-based power relations of society. Nursing is an occupation established by women; it supports the stereotypical "feminine" image with traits of nurturing, caring, and gentleness in contrast to stereotypical masculine characteristics of strength, aggression, and dominance. For this reason, occupations requiring these qualities have been considered exclusively suited to women, and labeled "women's work."

Due to these cultural barriers, men were not accepted readily in nursing schools for many years (MacPhail, 1996). Interestingly, in 1888, Darius Odgen Mills established the first male nursing school in America (Halloran & Welton, 1994), based at Bellevue Hospital in New York City. This school of nursing provided education and training for nurses to care for psychiatric patients. However, men's contribution to nursing has been mostly forgotten. This non-recognition has likewise perpetuated the feminine image of nursing in society and the perception of the male nurse as an anomaly.

Nursing as we know it today came to be regarded as a woman's profession through the efforts initiated and developed by Florence Nightingale during the 19th century. She saw nursing as suitable for women because it was an extension of their domestic role. It was assumed that it was natural for women to become nurses because of their innate care giving and healing traits; nursing was not a place for men. At that time, more and more women entered the profession of nursing. Nightingale's image of the nurse as subordinate, nurturing, domestic, humble, and self-sacrificing, as well as not too educated, became prevalent in society. Thus the ostracization of men in nursing was established.

Today, Only 5.4% of the country's 2.7 million nurses are male. At several suburban hospitals, the rate is half of the national figure. One look inside the classroom dashes any hope of imminent change. Men make up only 9.4% of students pursuing baccalaureate degrees in nursing. (Rackl, 2002) And a recent nationwide survey found that a mere 1 in 10 men would consider a nursing career. This is no laughing matter to healthcare experts who are struggling to stave off the massive nursing shortage headed our way. "The American Hospital Association says that hospitals have a shortage of 126,000 nurses and in 20 years that stands to triple," said Johnson & Johnson spokesman John McKeegan. "If you eliminate men from your recruitment group, how are you going to solve that problem? You're eliminating half the population." (Rackl, 2002)

The practical side of the equation is the for those men who do function in the role of nurses, like their female counterparts, male RNs work in practically all facets of the nursing profession, including managed care, ambulatory care, home care, public health care and nursing care. The majority of male nurses can be found hard at work in the emergency rooms, operating rooms, intensive care units, maternity wards and general care areas of major metropolitan hospitals.

Unlike women in the field, male nursing professionals must find ways to deal with female patients who are uncomfortable with their care, women colleagues who feel threatened by their presence, and the public, which tends to assume that all male nurses are homosexuals. The stereotyping of females into the nursing roles is not limited to those who hire nurses. Female patients are often uncomfortable with the idea of male nurses administering their care, such as pelvic exams and mammograms.

Many women have difficulty communicating with male nurses, and feel more comfortable discussing private issues with someone of the same gender. Aside from sexual stereotyping, male nurses say they must also learn to deal with female patients who are uncomfortable having a man as a nurse, especially during intimate, female exams. Some women prefer females being in the room with the doctor during the pelvic exam," says 49-year-old Lawrence Jaquess, an emergency room staff nurse at St. Louis Regional Medical Center who routinely assists physicians with this procedure. The 16-year RN veteran says he has learned to respect patients, rights and not to take their preferences personally. (Townsel, 1996)

For those men who have made the transition into the female dominated world of nursing, they are often able to build compassionate tendencies because of their own experiences. One of the male nurses surveyed described how the military prepared him for leadership in a mostly male environment, but it did little, he says, to prepare him for his new role as a male nurse on a mostly female career path once he left the service. "Being a male nurse allowed me to see what its like for women to work in a man's world - it turns the tables on you," he says. He recalled one time when he and a female doctor entered a patient's room at the same time. "The patient looked at me and said, 'Doctor, so what's going on?" he recalled. "The doctor and I looked at each other, and I explained to the patient, 'No, I'm the nurse. She's the doctor." (Townsel, 1996)

Ray Anthony Hughie, a junior public health nurse with the New York City Department of Health's maternity services and family planning bureau, understands this dilemma well. The 37-year-old RN makes weekly home visits to high-risk mothers, teaching them the fundamentals of child care. He offers tips on the correct way to hold an infant, how to take a baby's temperature and breast-feed. Usually, parent and child are comforted by Hughie's affable nature. But depending on the subject matter, the 10-year-nursing veteran says, interaction between him and patients can get strained. "It depends on the culture of the person," Hughie explains. "I treat a large community in which women don't speak about things like breast-feeding with men. But once I make my presence and objectives Clear, the barriers come down and [the mothers] become more receptive." (Townsel, 1996)

The stories of men who have successfully crossed the gender barriers to create a successful nursing career are few and far between. Recent graduates of the nation's nursing schools are leaving the profession more quickly than their predecessors, with male nurses bolting at almost twice the rate of their female counterparts. About 7.5% of new male nurses left the profession within four years of graduating from nursing school, compared to 4.1% of new female nurses, according to the study by a University of Pennsylvania researcher. It was reported in the journal Health Affairs. "In general, nurses are looked down upon, especially by physicians," said Jerome Koss, a nurse since 1978 and an administrator for Fox Chase Cancer Center in Philadelphia. "It's changing but it's still an issue, and I think men are much less tolerant than women of that kind of treatment." The research, which looked at data in a national survey of registered nurses conducted by the U.S. Department of Health and Human Services in 1992, 1996 and 2000, is the latest to highlight the nationwide nursing shortage. (Loviglio, 2002)

If it were possible to put aside social attitudes toward man and women and their roles in the work place, we could see that general differences in attitudes, temperaments and approaches to care do exist between men and women. The differences to not make one gender more qualified for the task than the other. The differences do not create insurmountable obstacles to recruiting men for a female dominated field. But by understand the differences between the sexes nursing recruiters could more successfully bridge the gap between perceived qualifications and the actual needs of the nursing fields. In England, the Government requested that the National Health Services (NHS) look at the results of the largest ever survey of NHS nurses, carried out in 1994. The study was undertaken to determine some of the differences between men and women who are in nursing careers. The report found that:

Men were significantly more likely than women to be found in the higher nursing grades. Among registered nurses, there were twice as many men as women in the senior grades.

Female registered nurses had better post-basic nursing qualifications than equivalent males.

Male nurses were more likely than females to expect to move to a better job in the near future.

Women were more likely than men to work in specialist areas which had limited chances for promotion, such as community nursing. Men were more likely to work in mental illness and disability.

Female nurses were considerably more likely to have taken a career break.

Forty-five per cent of female nurses worked part-time, compared with five per cent of men.

The authors of the report suggested nurse employment policies should be reviewed to take account of the experiential differences between men and women nurses. The study also identified paths that could be pursued to build off the natural strengths of the different genders in the nursing fields. (Birmingham Post, 1998)

Unfortunately, when the nurse is a man, societal images of the caregiver role are not associated with the gender. For example, Williams (1995) conducted in-depth interviews with 32 men employed in nursing. One nurse reported that a teacher at a day-care center told his daughter that her father could not be a nurse, and insisted that he must be a doctor. Allen (1996) defined gender as perspective social constructions created in systems of injustice. He suggested that descriptions of gender "depend upon an array of theoretical assumptions and not upon some guarantee of correspondence to a 'real' world independent of our conversations about it." Thus, nursing has been socially constructed as an occupation requiring gender traits that are associated with "feminine," regardless of the sex of its individual members (Chinn, 1999).

Cyr (1992) surveyed 25 male nurses to investigate the perceptions of being a male nurse. The most prevalent negative factor identified was sex stereotyping resulting from the general perception that nursing is a female profession. According to Villeneuve (1994), language and images are dominant forces, which may have the effect of marginalizing any group. It could be argued that the label of nursing as women's work is a significant deterrent that inhibits recruitment of men into the profession and aids promotion of the sex imbalance in the nursing workforce. Because of their gender, male nurses have been prohibited from working in specific clinical areas, such as maternal/infant child care.

Williams (1992) claims that cultural barriers are more pronounced in the media's representation of men's occupations. She contends that women in traditionally male professions have achieved acceptance on popular television programs. Today; women are portrayed as doctors, lawyers, and architects, but where are the male nurses, teachers, and secretaries? These beliefs are reinforced by language used in nursing. Women in nursing are simply nurses, not "female nurses"; however, men in nursing are frequently identified as "male nurses." Egeland and Brown (1988) maintain that the use of the qualifier "male" when referring to male nurses implies that they are different and not in keeping with the norm in society. These images, perceptions, and language influence societal views of the nurse. This, too, leads to the marginalization of men nurses and fortification of negative stereotypes.

Villeneuve (1994) stated that the work belongs to neither sex. By excluding males, such messages constitute a critical barrier to men considering nursing as a career. This is demonstrated in the example of a 1997 photo feature called "Nurses at the Bedside" in the American Journal of Nursing. Of the 15 pictures of the nurse caring and working with clients, none shows a man. Likewise, Schaffner's review of 1997 nursing journals, inclusive of all articles, advertising, and author photos, reveals that.06% included a man.

Sex Stereotypes

Another commonly held stereotype concerning men who choose nursing as a career is that they are effeminate or gay (Williams, 1995). According to Williams, it is assumed by society that in order to be a nurse, female attributes such as a capacity to serve, empathize, and nurture are required. Hence, men who nurse must be "feminine" and are regarded as gay. Although there are a number of gay men in the profession, this stereotype forms a major obstacle to many heterosexual men who might otherwise consider pursuing a career in nursing.

Williams (1992) also suggests that the stigma associated with homosexuality leads some men to enhance or magnify their "masculine" qualities. Using focus groups, Kelly, Shoemaker, and Steele (1996) investigated the experience of being a male student nurse. All participants reported that nursing is viewed as a women's profession, and several stated a fear of being perceived as unmanly by their peers or by clients. These beliefs fostered among the men a view that the profession is a threat to their masculinity. Subsequently, these men felt a need to show their wedding ring or to mention their wife and children in order to acknowledge their heterosexuality. Consequently, as a result of these attitudes and perceptions, one can understand why nursing remains an occupation low on career choice for males.

The Immanent Threat of Universal Health Care

Although not typically included in discussions of the nursing shortage, evaluating factors for the declining roles in nursing applicants is not complete without considering the simultaneous increase in a political push toward nationalizing the health care delivery system. This topic is currently a hotbed of disagreement as different political wills jockey for position. But since the subject of universal healthcare became the rally point for big government ideologues during the Clinton administration, the immanency of possible radical changes to the country's health care system must be weighed as a factor which is influencing men and women to stay away from an industry which could be "taken over" by a Washington-based bureaucracy.

The subject has been alternately pushed onto the media front pages and then allowed to suffer from lack of adequate medical attention required to keep it alive. While the idea resounds in the desires of the American public, the reality of how to fund such an expansion of government entitlement programs remains elusive. The idea of universal coverage sounds great to the country's two largest two sectors of growing population which will be the chief beneficiaries. The aging baby boomer generation is approaching retirement and beyond, and a universal healthcare system will cater to their rising health care costs. This generation is one of the largest in the country, and offering them the opportunity to "opt out" of paying for coming health care expenses is a significant personal benefit. The other sector of the U.S. population which is growing at a rapid rate is the poor, including underemployed, and legal and illegal immigrants. Although this group pays little in taxes and contributes little to the overall real economic progress of the country, politicians continue to cater to class envy by declaring that the 'rich' have health care coverage, why shouldn't those at the lower end of the economic scales have the same benefits.

Many of these cost drivers have been a focal point of the health care debate for years. According to the Mercer/Foster Higgins 2002 national survey of employer-sponsored health plans, the average cost of healthcare benefits for active employees increased 7.3% in 1999, 8.1% in 2000 and 11.2% in 2001. In 2002, costs were expected to rise an additional 12.7% or more (Becker, 2002). Adding these costs as a new mandatory expense to the American business community without redesigning the health care delivery and funding system would be a lethal blow to many small businesses.

Beyond the politicians jockeying for position in the hearts of American citizens, another reason for the push for Universal healthcare is the pragmatic belief that in the long run it will reduce healthcare costs in general. If preventative care is available to everyone from birth, the result will be less-costly healthcare needs in people's later years. Early preventative measures also lessen the magnitude of epidemics; when more people are immunized and have access to treatment, disease cannot spread so easily. (University Wire, 2001)

Former U.S. Surgeon General C. Everett Koop recently stated: "I think I am right when I write that all Americans have the right to healthcare," Koop said. "If we agree that there is a right to healthcare, then we are also agreeing that someone must provide these rights," he said, noting that the right to healthcare is different than some other constitutional rights because it incurs a monetary cost on society. (Anand, 2000) Last year, in a survey of medical- school faculty and administrators published in the New England Journal of Medicine, 57% said they favored a single-payer universal healthcare system over either fee-for-service or managed care. Indeed, more and more doctors are now willing to work in coalitions where they learn from and fight for the needs of those whom they have traditionally considered inferiors or adversaries. (Gordon, 2000)

As a result, when President Clinton ascended the podium, and declared that universal healthcare is a right which Americans shared, no one questioned where the money would come from to fund such a huge expansion of the federal bureaucracy. The core question to answer, however, is not whether healthcare coverage is a right. The costs of health care are skyrocketing, and the needs of the population are unquestionably increasing. The question is: What is the most effective means of bringing down costs while at the same time expanding coverage without damaging the quality of services delivered?

Due to the heavy push in the political arena, medical organizations and states are appearing to climb onboard the idea. This may not be due to their belief that universal healthcare is a good idea for the country. Rather these organizations do not want to be mowed down by the sweeping changes that are becoming increasingly inevitable. But before the U.S. pursues this path much further, it would be wise to evaluate the health care systems of other countries which have an existing socialized, universal coverage system. Canada, for example, has had a universal healthcare system since 1947. Every Canadian citizen has access to basic health coverage as a 'right' of their citizenship. Many U.S. citizens who live near the U.S. - Canadian Border often will cross the border to fill medical prescriptions. In these instances, the prescription is less expensive because the Canadian government subsidizes the medical system. In other words, the absolute cost of the medicine is not lower, but the consumer cost is less because of government involvement.

While most Canadians are satisfied with their current system, economic pressure is building for reform. As a result, three of Canada's provincial leaders are signaling a move toward privatization which could significantly alter the Canadian healthcare landscape. "Our healthcare system is on life support and it is fading fast," said British Columbia premier Gordon Campbell recently. (Brown, 2002)

The premiers of Alberta, Ontario, and British Columbia say ballooning costs and long delays for some procedures can only be solved by private initiatives. Up to 40% of their individual provinces budgets goes toward healthcare.

The system survives, and thrives, because qualified and talented doctors apply their skills, in public or private practice. The doctor's reward for the risk they take, and the effort they put into their career is the profit they receive from their services, and the pride they can earn by providing the best service possible. Without a profitable enterprise, the entire system suffers, both in the quality of service are can provide, and the quality of talent it can attract to provide those services.

The trend of medical care to suffer when the federal bureaucracy becomes involves can be seen in the Canadian and other socialized systems. People in need of difficult or intensive medical care do not travel to Canada, Britain, or France. They come to America. Heart surgery patients come to America from across the globe because our health care system has been able to balance the needs of the individual with the needs and desires of health care workers to earn a profitable living in the field of their choice. If a government takes away, or sets fixed fees for services in the medical field, (or any field) the result is a decline in service quality and an increase in costs. To make a cross - industry comparison, if a business has a package that absolutely, positively has to be there over night, do they call the United States Postal Service, or Fed Ex? Regardless of rights, costs, or obstacles, the private system outperforms the government system on The influence of this unsettled debate cannot be ignored as the nation struggles with a shortage in nursing applicants. In what ways would the nurses' jobs be redefined if the U.S. government was determining what and how they would issue payments for services? In what ways would the nurses ability to provide quality, compassionate care to patients be diminished if the government was determining how long a patient could stay, and what it was willing to pay for. In the UW hospital, nurses are rightfully complaining about the condition of the hospital sue to lack of nursing care. The overloaded conditions created by lack of nurses is making it impossible for them to complete their tasks. The country can only imaging if a nationwide healthcare delivery system was administered with the care and compassion of the IRS, and with the attention to detail of the USPS.

While these are only vague images of possible scenarios at this time, students who are considering the nursing profession can only wonder if the worst case scenario comes to pass, will they be caught in the crossfire between their own desire to provide the best care possible, the patients needs, and a government bureaucracy. This scenario cannot be attractive to a college student considering a career for the rest of their life. Given the option of choosing a career with this impending forced reorganization, and a career path with a projected stable future, it is not surprising that more students are choosing for the stability and control over their future.

The nursing profession has been slow to mobilize its efforts to change it's public image. This crisis has been building like a distant thundercloud on the plains moving toward a Midwest community. But now that the dark clouds are on the horizon, and the small of rain is in the air, the nursing community is mobilizing to do more than find umbrellas. They need more committed people to make up the current shortfall, and to eliminate the coming shortages which will occur as the aging nursing professionals retire. At a recent national nursing policy meeting, the closing session of the conference was entitled "Attitude is everything!" (Taylor, 2003) According to Nursing Management writer Nichole Taylor, this session got the audience members on their feet and encouraged everyone's participation in recruiting and promoting the nursing profession. Other speakers, such as facilitator Louis Benson, PhD, President, The Benson Group, Delray Beach, Fla., advised attendees to view staff issues in a new light. "Think opportunity, not problem," he said. "Nursing leaders demonstrate that attitude is everything," said Benson. "Recruitment and retention of staff is more than technique, it requires enthusiasm about nursing and caring for others. Attendees echoed the sentiment that nurses want to work where they can make a positive difference and their contributions are appreciated. They proved that nurses impact people's lives in a positive way-not just patients, but recruits or fellow staff members, too." (Taylor, 2003)

If any progress can be made toward successfully crossing the bridges between where nursing is as a career today, and where the industry would like to see itself in ten years, it will take the courage of the entire industry. The nursing profession as a unified whole must take steps to:

Change its image

Positively manage its working conditions

Adapt its recruitment methods,

Modernize its pay structure

Take steps toward influencing policy regarding a nationalized health care system

As stakeholders in the future of their profession, these five elements need to be included in the marketing, and policy changes sought by the nursing industry in order to recruit and keep an expanding workforce for the 21st century.

Proposed Methods for Increased Nurse Recruiting Efforts

The crisis is looming - an imminent, worldwide nursing shortage; a rapidly aging nursing workforce and faculty; an older and sicker population; and mounting evidence attributing adverse outcomes and patient deaths to overburdened staff. The response since the turn of the new millennium has been attracting more and more attention to he problem. Papers, presentations, and action plans from hundreds of nursing and healthcare organizations within the past year. In an article for Nursing Spectrum Magazine, and an online nursing resource center, Wendi Bonifaze interviewed health care professionals across the country for ideas which could be applied by nursing stakeholders at every level. The following ideas are just a few which were brought forward by those in the field.

We're missing the last big catalytic action... And we ignore the private sector at our peril." "This is a worldwide problem, and we need a presidential task force, Department of Health and Human Services (HHS), or Institute of Medicine (IOM) report to pull all the research and efforts together. Congress passed a weak bill with no money in it, and prospects are dismal. "Nursing leadership must look to the private sector instead of government. We must help industry and business see their personal health and economic success are at risk.

Collaborate anywhere, anytime you can." Share information whenever we see opportunities for collaboration and synergy, trying to prevent duplication and maximize resources."

Take credible scientific evidence to management and legislators to show the consequences of poor staffing." Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction," published in the October 23 Journal of the American Medical Association determined every additional patient in the average nurse's workload increased surgical patients' risk of death by 7% and the risk of hospital death increased by 31% for patients having common surgeries in hospitals staffed at eight patients per nurse, rather than four.

Aggressively recruiting nurses or students into a dysfunctional health/nursing system is neither cost-effective nor ethical." The real issue is governments are failing to develop essential human resources and countries are using international recruitment as a fast, cheap solution, draining poor countries of nurses. The primary role of government is ensuring sufficient human resources to meet taxpayers' needs.

You have to fix your house before you show it to the public to sell it." Leadership development, as well as open communication, at senior and front-line levels is one of the keys to developing and retaining nurses. The lack of leadership, and lack of opportunity to influence leadership is the main reason employees leave organizations

Let's all do a lot of things." Look at potential partners and develop many alternatives.

Explain to the world how important nurses are. And run for office so you can make the rules." You have to translate good will and trust into support for the profession. Public relations campaigns are expensive; but almost everyone knows a nurse, and nurses do wonderfully person to person. Ask for community support, for votes; ask your employer or alumni group to request funds and scholarships.

Strive for leadership positions at the bedside, in the boardrooms, and in Congress." Everybody's busy; but leadership is critical to change things, one at a time. It doesn't depend on your position, but on taking time and effort to convince others.

Training is not a cost. It's an investment that pays back very quickly." Someone else can always offer more money. The key driver of loyalty is training and development.

Offer opportunities for career transformation; and focus nurses on highest, best use." Technology is expensive; but it pays off in efficiency, productivity, and professional environments that younger generations expect.

The on-boarding process is not just the first days or weeks; it's months and years." Attrition is high in the first 90 days. We're developing an on-boarding process for the first 18 months.

We need to provide, support, and bolster nursing education and professionalism at all levels." Nationally, within six months of graduation, an estimated 30% of nurses leave nursing. They may lack reality-based education.

We need hospitals and nurses to adopt schools and students."

Hospital consortiums can provide facility space; faculty hours; joint appointments for faculty and medical centers; and contributions for nursing skill labs, computers, and tuition (Adapted from Bonifazi, 2002)

Corporate Joint Campaigns

Johnson & Johnson recently reported that after years of declining enrollment in nursing schools, their efforts in orchestrating a national coordinated campaign is slowly helping to turn the tide. Joining with Health and Human Services (HHS) Secretary Tommy Thompson and leaders of national nursing organizations to celebrate the first anniversary of The Campaign for Nursing's Future, James T. Lenehan, President and Vice Chairman of the Board, Johnson & Johnson, announced that because of the campaign and other recruitment efforts, baccalaureate nursing school enrollments increased by more than 8% between 2001 and 2002. Moreover, 84% of nursing schools are experiencing rising applications and enrollments based on new survey findings.

A year ago, the nursing profession was off the radar screen of many young adults and second-career seekers," said Mr. Lenehan. "Now I am pleased to note we are making progress in addressing one of the most serious problems affecting the health care sector." (PR Newswire, 2003)