Rebellion Among the "Angels"

Nurses are no longer content to be the doctor's handmaiden

Once, they evoked images of quiet docility: woman in white, sister of mercy, ministering angel. Walking softly through hospital corridors, tending to the ill and infirm, nurses did every duty from cleaning bedpans to assisting in surgery. They performed wearying, thankless tasks with such uncomplaining efficiency that doctors and patients alike could consider them the physician's handmaidens.

Not any more. Today the angels are in rebellion. Better educated, stirred by the feminist movement and caught up in the medical advances of the past generation, most of the nation's 1 million registered nurses are no longer content to be self-effacing Florence Nightingales. They are demanding better pay (current average: $13,000 a year), a stronger voice in patient care and, above all, freedom from what they consider the dominating attitude of doctors. Says Connie Curran, associate dean of nursing at the University of San Francisco: "Nurses are refusing to do the cleaning up after physicians; they're refusing to play the old male-female game."

Signs of the rising new militancy are apparent in many places. In Los Angeles last month, 500 unionized nurses struck a Kaiser Permanente hospital in a contract squabble with the big health maintenance organization. In Denver, municipal nurses are now suing the city, charging sex discrimination in salary scales.* Nurses in Denver make less than, say, a trainee traffic-signal repairman. An even greater disparity exists with doctors, whose median income is now more than $65,000 a year.

Some nurses have found that one route to better pay, to say nothing of avoiding drastically shifting hours, is to work only on a temporary basis, hiring out to hospitals through agencies. In California alone, there are about 800 such agencies; their popularity has created serious shortages among regular hospital nursing staffs. Pay at Hollywood Presbyterian Hospital, for example, is $93 a day (after agency fees) for a temporary vs. $64 for a staff member.

But working conditions are not nurses' only concern. They want professional advancement. Nursing has long had such specialists as the nurse-midwife and the nurse-anesthetist who assisted at surgery. But since the 1970s, the trend toward specialization has accelerated. Many more nurses are devoting themselves exclusively to coronary care, renal dialysis, burns, neonatal care, cancer, psychiatry, pediatrics, respiratory disease and geriatrics. Called nurse practitioners, they number about 15,000. Some work closely with doctors in special units of hospitals or in offices. Others, particularly in rural areas, where physicians are scarce, practice virtually on their own: for example, Eleanora Fry of Horseshoe Bend, Idaho, who operates a clinic in a town of 500. Often they perform services once exclusively the preserve of physicians: physical checkups, reading X rays, ordering lab tests and prescribing medications for complaints, such as vaginitis and hypertension.

A small but influential group of nurses has moved in a different direction. Convinced that specialization, elaborate new machines and close collaboration with doctors reduce nurses to "medical technicians," they want to return to traditional services, such as counseling, educating and comforting. In their view, hospitals are too bureaucratic to allow true nursing. Says Nurse Annette Swackhamer of New York City: "Doctors have the misconception that nursing is physical care." In fact, she says, the frenetic hospital milieu does not let nurses listen to a patient much or involve the family.

These practitioners act as independent health-care consultants. Accepting "clients" who may be ill or just troubled, they play a role that sometimes seems to be a cross between Marcus Welby and Ann Landers. Insisting that "medicine is concerned with disease, nursing with health," they preach the gospel of preventive medicine--or "health promotion," as they call it. Says M. Lucille Kinlein, who runs a thriving practice in Hyattsville, Md.: "We give people an opportunity to think in a different concept, namely to think wellness."

In the past, most nurses got their training in hospital-based schools. After three years, they received diplomas and proudly wore caps emblematic of their schools. Today, as the profession attempts to upgrade itself, more and more nurses are in the classroom rather than the ward, pursuing either two-year associate degrees or four-year baccalaureate degrees at colleges and universities. Enrollment in such courses has jumped so sharply (from 67,000 to 194,000 in the past decade) that more than half of traditional training programs have shut down for lack of students and money. One likely casualty: the 106-year-old diploma-nursing program at Boston's Massachusetts General Hospital, one of the nation's oldest.

Last year a third of the graduating nurses received baccalaureate degrees. By 1985, the American Nurses' Association, the national professional organization of registered nurses, wants baccalaureate degrees to be a requirement for licensing of all "professional" nurses; those with diplomas or associate degrees would be designated "technical" nurses. But even the B.S.N. may eventually not be enough. The National League for Nursing, a coalition of nursing administrators, educators and other leaders, argues that a nurse practitioner should have a master's degree. Some nursing officials are urging nurses to get Ph.D.s if they want to move on to teaching, research or administrative positions.

According to doctors, baccalaureate programs are putting too much emphasis on sociological and psychological theories, neglecting pathophysiology (the study of disease processes) and failing to develop essential skills. The result: poor bedside nurses. In some schools, it is possible to earn a degree without ever being on night or solo duty, assisting at a delivery or performing such basic chores as catheterizations and suctioning lungs. Says Dr. Lester Candela, a surgeon in Great Neck, N.Y.: "When these women meet an emergency and are matched against more experienced hospital school students, they're often embarrassed and suffer by comparison." Diane McGivern, associate dean of the University of Pennsylvania School of Nursing, acknowledges these shortcomings in some new graduate nurses but defends the curriculum by explaining: "We teach them problemsolving abilities and the analytic approach to handle situations."

Many nurses from both hospital schools and degree programs echo the doctors' concern. Loretta Chiarelli, head nurse of the emergency ward at Manhattan's Bellevue Hospital Medical Center for twelve years, says that many young college graduates arrive ignorant of routine procedures. Says she: "These skills --let alone complex tasks--just are not easily mastered amid the tensions and emotions of a ward setting." Adds Rita Bellersen, a coronary-care nurse at Veterans Administration Medical Center in Seattle: "We're now telling patients how to rearrange their entire lives. But we're forgetting to change their beds and to bathe them."

Yet the toughest, perhaps most emotional issue confronting nurses is whether they should be directly supervised by physicians. Many doctors favor expanding nurses' responsibilities, letting them handle minor problems, if only to give physicians more time for more serious cases. Nurses often do this anyway, with doctors' encouragement. But the majority of physicians, including many of the new women M.D.s, still insist on complete control. As they like to say: "If nurses want to act as doctors, they should go to medical school."

Activist nurses contend that the real reason for this obstinance is that physicians want to hold on to their economic power. Many doctors admit that up to 80% of all office care given by pediatricians and family practitioners could be handled by competent nurses. Says Dr. Leon Oettinger Jr., a pediatrician in San Marino, Calif: "With its heavy reliance on physicians, the American medical system can be said to be using Cadillacs to do a tractor's job." That may not be the kindest analogy, but the Department of Health, Education and Welfare agrees with the basic analysis: it has endorsed wider use of nurse practitioners in medical care as one way of keeping costs down.

The objections of physicians do not center on money alone. As Dr. Arnold Relman, editor of the New England Journal of Medicine, explains: "The risk'of [using] nurse practitioners or any other kind of nonphysician is that they do not have a broad and deep enough training to be aware of what they don't know. Nurses and doctors ought to work together as a team, but I am concerned about the idea of a team without a team captain." For the patient, says Relman, the important issue is always "am I getting the best possible care?" It is also a question for those who will have to deliver that care. -

* Nursing is still a female profession. Some call it a female "ghetto." Men account for 2% of all nurses.

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