SIGRID ERIKSSON, a nurse for 20 years, had the healthiest of reactions when she glanced down to check her notebook. "Nine probable hires," she said happily. "That's really pretty good. If we get only two hires, we've covered expenses."
That was odd talk for a nurse, except that Eriksson's elation came not as she worked in a hospital but as she was winding up her three days at a recent employment convention in a Washington hotel. She was one of two nurse recruiters at the booth (rented for $340) of National Medical Enterprises, a Los Angeles firm that owns and manages some 40 hospitals in six states.
More than 60 other nurse recruiters had come to this job fair, all representing either hospitals or health care companies that are alarmed about -- and agressively taking action against -- the chronic and often acute shortage of nurses.
The competition to find nurses is so intense that Nursing Job Fair, a Boston company, had scheduled employment conventions in seven major cities in the first four months of 1980. Each was booked to capacity by recruiters hard on the hunt for nurses.
Or at least nurses who want to work as nurses. Of the country's 1.4 million nurses, according to the American Nursing Association, some 420,000 are inactive. A survey commissioned by HEW projected that in 1982 a need will exist for between 1.2 and 1.6 million working nurses.
Geographically, some areas are more critical than others. Illinois has 106 hospitals that have 1,800 openings for nurses. The National League for Nursing reports that Arizona cannot fill 21 percent of its budgeted nursing slots. In western Tennessee, it is 32 percent, in Texas 14 percent and California 17 percent.
But behind the blacks and whites of the numbers game lie a number of grays that defy easy analysis but which suggest that the profession is currently bedeviled both by the demands of its own members from within and economic and social pressures from without. Some believe that nursing needs only an aspirin; others call for major surgery.
As members of a humanistic profession, nurses work within a natural tension; they are called on as a group to uphold altruistic values while individually each nurse is subjected to authoritarian and economic structures that can have little concern, much less reward, for intangibles like kindness and caring.
Nursing isn't a job; it's a vocation. It is 98 percent female but it is accountable to professionals -- doctors and hospital administrators -- who are mostly male. Worksite pressures can force the nurse who began as an idealist to burn out and become a mere functionary, ever cautious lest she turn up as the object of incident reports or patient gripes.
These philosophical probings are far from the concerns of the nurse recruiters. Rounding up the workers is their mandate.
Imagination helps. A hospital in De Moines, having trouble getting nurses top work the 11 p.m.-7 a.m. shift, offered the use of a new car as part of the deal for a one-year contract to work nights.
In a Long Beach, Calif., hospital the problem is not the night shift blues but the daytime gripes: St. Mary's Medical Center has installed what it calls "the job line" by which nurses can phone in their complaints anonymously.
In a Minneapolis hospital, a bounty of $500 is paid any employe who brings in a registered nurse for full-time employment. Other hospitals around the country pay $1,000.
In Palm Springs, Calif., the Desert Hospital has 300 nurses on its current staff. But with a planned expansion from 225 beds to 361 beds, about 30 more nurses are needed. "In order to insure the health and happiness of its nurses," the hospital said in the current issue of Nursing Job News, "an Employe Assistance Program has been created." It "provides counseling services for staff members who may be experiencing personal problems, such as financial difficulties, marital discord, alcoholism or substance abuse."
Even with new cars, job lines and perks, one fact remains: Nursing is hard work, often wearying and usually poorly paid. The average national salary for full-time working nurses is $6.78 an hour, which in many areas is about the same wages as supermarket checkout clerks. Women dockworkers, unloading crates of bananas on the New York waterfront, earn $10.40 an hour.
Although only some 15 percent of America's nurses are unionsized, RN magazines reported lat month that "full-time" general duty nurses who are covered by AFL-CIO, Teamsters, state and federal employes union or other nonprofessional association contracts earn, on average, nearly 20 percent more than the mean for all full-time general duty nurses." Nurses working in private, fro-profit hospitals receive salaries 2 percent below the mean.
A generation ago, nurses were thinking less about their low pay. The career alternatives were few. "For many young women," says Charlene Dean of the nurse recruitment office at John Hopkins Hospital in Baltimore, "it was pretty much a choice of one of the big three: nurse, teacher or secretary. But now it's changed. Just look at affirmative action. Women can get preferential treatment for mid-management positions in any number of industries that were once closed to them. And they start off with better salaries than a lot of nurses are making after 10 years in the hospital."
At the same time that nurses are making only the faintest progress financially -- while toiling next to physicians whose average income is $65,000 -- it appears also that they are working harder. Constance Holleran, a nurse and a lobbyist for the American Nursing Association, believes that "the demand on nurses has increased because of the changing nature of health care. People are in and out of the hospital so much faster today that the patients, while in the hospital, require more intensive nursing care. In the past, where one nurse might have had eight to 10 patients, she now has two or three -- but who are very sick. Thus, throughout the hospital, you have the same number of patients but they are sicker. And the nurse must work harder.
As members of one of the traditional "women's professions," nurses are finding that suddenly both the definition and image of their work is changing.
The turf problem is the most obvious. The nurse of 1980 has moved into diagnostic, treatment and prescribing territories that were far off limits to the nurse of only 1960. She has also left behind, or is proudly walking around, much of the menial.
Susan Sparks Le Duc, in an aptly titled article, "We've Been Put Down Long Enough!" in a recent issue of RN magazine, described an incident in a pediatric unit: "A doctor walked rapidly up to the nurses' station and proclaimed that a boy on the unit 'needed a nurse.' The nurse dropped what she was doing and went to the youngster, only to discover that what he needed was a diaper changed."
State legislatures cannot protect nurses against being treated as cleanup crews by doctors, but medical practice laws have been changed in nearly 40 states in the past 10 years in ways that give expanded medical authority and responsibility to nurses.
What the legislatures don't give, many nurses are ready to take for themselves. Nurses of 20 or 30 years' experience tell of the days when they were seen as a whitened angels fluttering at the feet of doctors playing God. If the deity entered the room, a nurse would instinctively rise and offer her chair. Today nurses not only stay put but they might be sitting there thinking about the best approach to take when they next witness a doctor giving incorrect or unethical medical treatment.
Occasionally, a nurse comes along who can take no more of the structure but who still loves her vocation, and refuses to leave it. Since 1971, Lucille Kinlein has seen 1,700 patients in her Hyattsville, Md., office. She practices nursing, not medicine. "Organized nursing and most nurses," she argues, "have chosen to remain under the mantle of medicine, with three results: One, achievement of professional status in the field is impossible. Two, the professionally oriented nurse cannot find fulfillment. Three, the public is deprived of a much needed and different kind of care."
In "Nurse," a best-seller about a big-city general hospital, Peggy Anderson summarizes what is happening: "Many nurses want to bring their own intelligence to the job and are becoming aggressive about doing so. A lot of our time is still spent carrying out orders written by doctors. But more and more often nurses are questioning is considered good nursing judgement. So is making suggestions to doctors about things that might help patients. So is refusing to carry out an order you disagree with, so long as you do it according to established procedures. I think a nurse must make decisions that affect what she's doing. If she's a robot, she's nothing."
Superficially, this thinking appears to be the early restiveness that will soon erupt into a rebellion against the doctors. In reality, it is an overdue move toward professional independence that separates medical diagnosis and care from nursing diagnosis and care, the two intended to create harmony, not opposition.
This isn't mere theory. It is working in routine ways. A Washington-area physician, who has a high-volume office practice and employs eight full-time nurses, says that "90 percent of what I know and what I can do my nurses know and can do also. I have trained them in patient education, which is the key to sound medical practice. Even if I spend only five minutes with a patient in my office, my nurse can spend up to an hour afterwards. I make it a practice that no patient leaves my office without a chance to know as much about their disease as they desire. If they are still unhappy, I schedule them to come back early in the morning when I will give them all the time they want. The nurse that runs my office knows more about the mechanics of the specialty than most of the physicians in practice. Remember, she works with these problems every day and is experienced in both the side effects and benefits of the medications used."
However much this doctor's enlightenment creates an independent professional function for nurses, the handmaiden image still persists throughout all of medicine. A survey by RN magazine noted that "three out of four doctors regard nurses as their assisants -- and nothing more." The editors concluded that for nuses who care about "professional indentity, this has got to be a fairly depressing statistic."
Another downer in the survey is that "more than 78 percent of the MDs believe nurses already have enough say in patient care, and close to another 10 percent feel they have too much authority already."
One of the most dramatic moves for independence is in the growth of supplemental personnel services. These are independent firms that allow nurses to choose if, when and where they work. The hospitals pay the firms and the latter pay the nurses.
Hospital administrators grumble about the supplementals, as do others in organizational settings. "These days," said one director of nursing at a local hospital, "everyone wants to work days, Monday through Friday. I have no shortage of nurses for those shifts. I run low in filling up nights, weekends and holidays."
Shift rotations may be health hazards in themselves. A 30-month study sponsored by the National Institute for Occupational Safety and Health found that rotation "imposes excessive physical and psychological costs on shift workers."
In Washington, lobbying groups like the American Nursing Association have their own struggles. In late 1978, President Carter pocket-vetoed the Nurse Training Act, a decision that meant a severe cutback in grants, loans and training aid programs. The administration argued that two decades' worth of federal aid had already gone to nursing schools and that the problem now was less in the shortage of nurses than in their retention.
Henry A. Foley, head of the Health Resources Administration, says there is no evidence that "we are suffering from a lack of production [of nurses]. We are just not holding them in the hospital setting once they are produced." Three prblems still remain, Foley argues: low wages, inadequate training and sagging morale.
Budget fights are popular in Washington because an illusion of simplicity is created. Regarding nurses, both sides are right. Sen. Richard Schweiker (R-Pa.) had the facts with him when he told Foley during recent hearings that nurses laugh at the administration's health policy in nursing. "There isn't a hospital I go to that doesn't laugh at it and wonder what's wrong." And Foley is on firm ground when he says that "There's no evidence that if we keep producing nurses in the old way that they will stay in the profession. We have to be concerned about sitting down with nurses and hospitals and figuring out -- together -- ways to provide incentives for nurses to stay in the workforce."
The traditional out for this impasse is a summon a commission for "a study." That's what Congress did, with the interim findings due next fall. Or winter. Or spring.
Until a coming together of all interests occurs, nursing is likely to be trammeled by one "no" after another: no to legislation for training funds, no to wage increases that might keep nurses from leaving to become real estate brokers, no to younger nurses asking for professional independence, no to union organizing, no to the movement that wants to shed the image of nurses as women would couldn't make it through college.
Into this vacuum of negativism, a few yesses are needed. Despite their care industry, nurses are probably the least difficult group to deal with. Large numbers of them are idealists.
Without some immediate and strong attention from outside the profession -- from physicans, administrators, politicians and bureaucrats -- nurses are likely to be forced more and more to treat their ailing craft rather than the ailing patient.