Nursing Then and Now
What's changed since your pinning ceremony?
For over 30 years, Trudy Reyes, RN, has worked in intensive care at White Memorial Medical Center in Los Angeles. Early in her career, she remembers using a foot pump and administering a syringe she had to cool by hand in ice water in order to get a wedge pressure. Everything is different now: Cardiac output measurements are obtained automatically by computer.
“We had different kind of machines then,” says Reyes, describing the antiquated earlier methods. “We did a lot of manual things, manual calculations. Now, calculations are provided for you.”
These kinds of technological advancements have been seen across all healthcare specialties, not just in critical care. Daisy Aguilar, RN, an NICU charge nurse at White Memorial, has been most impressed with the improvements in the technology in her field over the course of her career. There are now advanced isolettes that keep the baby warm, are easy to open to access the baby and can effectively manage the baby’s temperature. “Critical babies who used to be 1:1 [nurse-patient ratio] are now 1:2 because of the monitoring that we can do automatically,” she says.
Reyes and Aguilar, both 56, both started working at White Memorial in 1981. Back then, there were even different nursing recruitment strategies. “There was a shortage of nurses,” Aguilar recalls. “White Memorial offered free board and lodging. It was a great opportunity.” (She is referring to the dormitory building on the hospital campus, which was offered to attract single nurses to work at the hospital.)
“Technology is so different from the time that I started,” Aguilar says, explaining that the hospital transitioned to electronic charting a few days before she spoke with us. “Now, everything is easy and we can spend more time on patient care.” Reyes, on the other hand, points out that nurses may now have less time to talk to patients because the documentation that must be completed on the computer is more thorough.
“New technology saves us time, but also adds more work and tasks,” Reyes explains. “So much time is spent on charting. Before computers, it used to be a simple narration. Now, you have to go system by system and put in details on each and every system. It takes time away from the patient.”
Deborah Suda, RN, BSN, MSN, is the perinatal unit director at the Ronald Reagan UCLA Medical Center, where she has worked since graduating from UCLA School of Nursing in 1978. She also describes computerized charting as one of the biggest changes she has seen. “It changed how staff nurses do their practice,” she says. “The computer is not always in the patient’s room. Even if it is, there is data entry. It takes time away from the patient.”
Although completing documentation on the computer takes time, some activities are much faster with the electronic records. Before computerized charting, “If we wanted a patient record, we had to request it or look it up,” Suda says. “Everything took a lot longer. Now, because of faster communication, the pace of work dramatically increases.”
Sicker Patients, Shorter Stays
Reyes recalls that earlier in her career, patients were frequently 1:1 (nurse-patient ratio). Now, they come in more critically ill. “Patients are much sicker and have multi-system failures,” she explains. Before, “if they had a drip, they were one on one. Now, they might have five different drips plus a ventilator.”
Marie Hodgkins, RN, MBA, patient care director at Loma Linda University Heart and Surgical Hospital, has over 30 years of experience at her facility. She graduated from Loma Linda University School of Nursing in 1973. For Hodgkins, 61, the most dramatic differences between her early career and today are the changes in overall patient acuity and how short patients’ inpatient stays have become. For example, early in her career, a cardiac bypass would often entail 10 days of hospitalization, but the procedure now averages just three days. “It puts more responsibility on the family,” Hodgkins says. “There are surgical drains and dressing changes.”
The shorter hospital stays are in part a result of the Balanced Budget Act of 1997, which changed how healthcare was paid by Medicare. Instead of paying on a fee-for-service basis, Medicare now made prospective payments, predetermined amounts based on the illness or condition, which encouraged providers to cut costs by limiting in-patient stays. There have also been changes in technology, with notable improvements in diagnostic tools, monitoring and documentation. “There is more consistency between caregivers,” Hodgkins says. “The change has been dramatic. It has facilitated managing patients.”
Thanks to television and the Internet, patients are now well-equipped with data — reliable or not — and perceptions. “People are more knowledgeable,” says Reyes. “They can research their own diseases.”
Suda notes how much more informed labor and delivery patients are today compared to the beginning of her career. “Patients are much more sophisticated, savvy, and come in very prepared with birth plans,” she says. “They know what they want and what outcomes to expect.” Nurses have to adjust their approach to teaching and patient care accordingly.
Thrown in the Deep End
What about new grads? The consensus is that they have it harder now, but are better trained and have more learning opportunities.
”I feel sorry for the young nurses,” Reyes says. “They have to swim fast in order to not be taken by the current. There are so many tasks on each patient. The computer shows you your tasks: turning every two hours, suctioning, Accu-Chek every two hours.”
Decades ago, nurses received only a month of training. Today, Reyes and Aguilar say White Memorial provides four to five months of training, including individual training with a preceptor. Aguilar is very glad that her daughter, a new RN graduate, had an opportunity to complete this specialized orientation. “It is the best opportunity a new grad can have,” Aguilar says. “The knowledge and training is more intense.”
Suda says she had no formal training in labor and delivery when she started over 30 years ago. “Residents and fellow nurses taught me,” she says. “Now, we have measurable competencies. Expectations are enormous and much more transparent. That’s a lot of pressure, I think.”
In addition to having quality learning opportunities on the job, new grads also are more educated from nursing school. According to the 2008 National Sample Survey of Registered Nurses conducted by the Health Resources and Services Administration (HRSA), the percent of nurses who earn a bachelor’s degree as part of their initial nursing education has nearly doubled from 1980 to 2008. The percentage of nurses who earn an associate degree has more than doubled within the same period.
“It is a wonderful change,” says Beverly Malone, Ph.D., RN, FAAN, chief executive officer of the National League for Nursing. “Higher degrees have become more of the norm.” Malone attributes this shift to the greater availability and accessibility of education. “Truly, nursing in my day was about how much you could remember — how much you could fit into your head,” Malone said. “Now, it is about problem-solving and access to information.”
Today, there is also a much more diverse nursing workforce. According to the HRSA, both the number of men in nursing and the number of RNs from minority backgrounds has quadrupled from 1980 to 2008.
A New Look
Nurses today are well-educated, more diverse, technologically savvy, tapped into information, clinically challenged and efficient — and may be dressed in colorful pant scrubs.
The nurses interviewed do not report much change in uniform since they started at their facilities, but Hodgkins did have to wear all white early in her career and Reyes recalls wearing a white nursing cap in one of her first nursing jobs at a small facility in Michigan. “We had to iron and starch our own caps so they would stand up like a bedpan,” Reyes says. “You could tell you were a nurse by your uniform.”
“Nursing is more refined and identifiable and that’s really exciting,” Malone says. “There are brilliant leaders saying things we do we don’t need to do anymore. Nursing is much more evidenced-based.” Over the last three decades, technology has advanced, regulations have changed and culture has evolved, but the nursing profession is still at its core a profession about helping people to wellness and caring for others. That will never change.
What do you remember?
I remember that we had no cell phones or pagers. If the office needed to reach us, they called around to all the homes we were scheduled to visit and hoped that the patient or family member would remember to give us the message. If we ourselves had an emergency, we had to find a pay phone. I once went into a bar to use the phone to call the office.
— Elizabeth Hanink, RN, public health nurse and Working Nurse staff writer
The procedure that comes immediately to mind when I think back to the olden days in CSU [cardiac surgery unit] in 1970 was titrating Isuprel. All of the cardiac surgery patients were on IV Isuprel after surgery. The Isuprel was titrated one to two drops per minutes. There were no smart pumps in those days. We titrated the Isuprel with the second hands on our watches, a rather time-consuming and inaccurate method.
The other not-so-innocuous procedure was taking CVPs with a patient on Nipride. We did not have a second line for the Nipride or transducers for the CVP. Every time we took a CVP using a manometer, the patient got a bolus of Nipride, dropping the blood pressure. Luckily for us, human beings are very resilient.
— Mary Anne Hattemer, RN, manager, Doheny OR, DICU, St. Vincent, Los Angeles
We used to guard the left atrial pressure (LAP) line with our lives to make sure no one injected air into the balloon. It had to be taped and secured and visually inspected during bedside report. Many years later, we have the Swan-Ganz catheter. Cardiac output was done using the Fick method: The RN had to mathematically convert every reading from the monitor.
We had a carpenter ruler to measure CVP. The patient bed was brought to the flat position, then we used the ruler to level the manometer. We instructed the patient to inhale and exhale, and took the CVP reading during the exhalation phase.
— Jo Aguilar, RN director, med-surg, St. Vincent, Los Angeles
I remember having to count IV drips against a second-hand watch to ensure "accurate" infusion rates. Now we use smart pumps to deliver accurate IV infusions. I remember nurses having to get medications, including narcotics and opiates, from larger bottle of pills and pouring our own medications. Now, we have unit doses and Pyxis medication dispensing systems.
— Roseanne Maehara, RN director telemetry, St. Vincent, Los Angeles
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