The nursing situation in North Carolina, as in the rest of the nation, can be described quite simply: There is an acute shortage of nurses, and this shortage is increasing. Two measures sufficiently demonstrate the shortage. One is the ratio of nurses to the population. In 1962, North Carolina had only 2.37 active nurses per 1,000 population as compared to a national average of 2.97. This national average was heavily influenced by the deficit states; some of the better-supplied states had much higher ratios. A more direct and compelling measurement of the professional nursing situation in North Carolina is found in a survey conducted in 1962 by the Duke Endowment, which revealed a total of 2,106 unfilled full-time positions.1 Approximately one out of every five professional nursing positions in the State was unfilled. From figures obtained in a census of all general hospitals in North Carolina in 1963 by the Employment Security Commission of the State, it was found that only 35 percent of such care was being rendered by professional nurses.2 The Surgeon General's Consultant Group found a need for at least 4.0 active nurses per 1,000 population in 1970, but believed that a ratio of only 3.17 will be reached by that time.3 For North Carolina to reach the anticipated national ratio of 3.17 for 1970, as inadequate as that ratio will be, would require a total of 15,850 nurses in active practice at that time. This is approximately 44 percent more than the total of 11,045 registered nurses (full-time and part-time) who were in active practice in the State in 1962.
The nursing situation would have been quantitatively much worse in 1962 except for several major factors that cannot be expected to continue to influence the situation. One of these was the extraordinary number of nurses who returned to active status during the 1950s. The deteriorating situation has been greatly obscured by another major development. This is the dramatic increase in the number of licensed practical nurses since World War II. This group has developed almost entirely in the last two decades, and in 1962 totaled nationally 225,000. The number of licensed practical nurses in North Carolina has shown similar dramatic increase. In 1963 the number licensed was 5,724 as compared to 2,205 in 1951. This rapidly emerging group was able to fill partially the void of the professional nurse during recent years. A number of the functions previously performed by the professional nurse were passed to the practical nurse. This relief of the professional nurse shortage has been exploited fully, however, and the shortage it was obscuring will be increasingly brought to the surface. The relief was largely fictional. Actually the number of both professional and practical nurses combined falls far short of the accepted ratios of these groups to the total of personnel rendering direct nursing care to the patient. Practical nurses will serve to improve considerably the quality of care by assuming those functions appropriate to their training and competence which are now being performed by aides and orderlies, or are not being performed at all. They cannot, however, make up for the shortage of professional nurses.
The task of the professional nurse is growing more, rather than less, complex. The functions requiring less training than that possessed by the professional nurse have already been assigned lesser trained personnel. A further dilution of the quantity of service performed by the professional nurse will result in a hazardous diminution of the quality of service. The continuing advances in medical science are greatly increasing the difficulty and complexity of nursing care, and responsibilities requiring the level of skill of the professional nurse are increasing rather than decreasing. In fact, the professional nurse of the future must have a better scientific preparation and educational background if she is to be able to cope adequately with the tasks being pressed upon her.
The current educational background requirement of nurses represents a serious problem in a number of states. Certain nursing positions require at least a baccalaureate degree, others are best filled with nurses having such a degree. Faculty positions in schools of nursing and positions in public health nursing specify a minimum of a baccalaureate degree. Nursing administrative positions in hospitals and other agencies call for individuals with a better general education than that of a strictly professional nursing education.
North Carolina suffers an acute shortage of nurses holding a baccalureate degree, and this shortage in turn will have an increasing effect on any effort to increase the quantity or quality of nursing graduates. Of the 11,045 active nurses registered in the State in 1962 only 881, or 8 percent, held a baccalaureate degree or higher. Nationally the percentage was 10 percent. The Surgeon General's Consultant Group on Nursing recommended that the percentage be approximately 18 percent.4
The low ratio of nurses with a baccalaureate degree in North Carolina is reflected in the situation in the several types of positions requiring such a degree. Of the 454 faculty members in all schools of nursing in 1963, only 223, or 49 percent, had a baccalaureate degree or higher. Of these 223, only 90 were employed in the baccalaureate degree nursing schools, and, if the faculties of these baccalaureate degree programs are removed from the total, then only about 1 of every 3 faculty members of the nonbaccalaureate programs had as much as a baccalaureate degree. In a period when a minimum of a baccalaureate degree is considered essential for teachers in secondary schools, it would seem equally desirable that the majority of teachers in schools of nursing possess no less than such an education.
A similar reflection of the shortage of nurses with the necessary academic qualifications is found when the situation in local public health agencies is studied. For nursing positions in these agencies a baccalaureate degree is specified by all standardizing bodies, including the U.S. Public Health Service, which provides a substantial part of the financing for local health units. In North Carolina, of 606 nursing positions in those units only 97 persons, or 16 percent, possessed a baccalaureate degree or better in 1964. 5
Further evidence of the shortage of nurses with baccalaureate degrees is seen in the previously referred to study made by the Duke Endowment. This study revealed a total of 754 vacant positions in categories in which a baccalaureate degree is usually considered essential. The total does not, of course, include or reveal the number of such positions filled by individuals with lesser academic qualifications.
Recommendations of the Survey
The recommendations that resulted from the 1964 "Survey of Nursing Education in North Carolina" were that ( 1 ) a new pattern of organization and of financing nursing education be developed; (2) nursing education be recognized as a proper and vital function of institutions of higher education; (3) responsibility for basic and graduate nursing education be recognized as an obligation of the tax-supported institutions of higher learning; (4) every avenue and factor affecting the recruitment of qualified students into nursing be exploited; (5) an action program be initiated to bring all diploma and collegiate schools of nursing up to minimum national approval standards; (6) provision be made for systematic planning for nursing education on a state- wide basis; and (7) the State's Nurse Practice Act be revised to permit greater flexibility on the part of institutions of higher education in developing the most appropriate pattern of nursing education for the future. The first four of these recommendations, with supporting rationale, are presented in detail below.
1. It is imperative that positive action be taken immediately to develop a new pattern of organization and of financing education for registered nurses. This recommendation represents a recognition of the increasing inability of hospital diploma schools of nursing to produce a sufficient number of graduates to maintain an adequate supply of registered nurses. It does not advocate or imply the disappearance of the hospital diploma schools. These schools have carried the full load until recent years and have produced 92 percent of the registered nurses now residing in North Carolina. Some of these hospital schools remain very strong, and some of them doubtless will remain so for many years to come. The record is quite clear, however, that they have been falling behind in their efforts to provide an adequate supply of registered nurses for North Carolina and in the relative number of graduates they are producing. The total number of graduates of diploma schools decreased in the five-year period from 1959 through 1963 from 603 to 556. The significance of this decrease is better seen when expressed in terms of graduates to population. The ratio was 134 graduates per million population in 1959, and 118 per million in 1963. This means that in 1963 the hospital schools were producing relatively 12 percent fewer graduates than they were in 1959.
The output of graduates from the hospital schools can be expected to decrease both relatively and absolutely, rather than increase. If the hospital schools continued their present output, and the predicted population total of 5 million is reached in 1970, the annual ratio of graduates to population will have decreased to 93 per million of population. It is unlikely that the present number of hospital school graduates will be maintained. The trend is for hospital schools to close rather than open. The Report of the North Carolina Committee to Study Nursing and Nursing Education showed 43 schools as being in operation in 1949.7 As of 1964 eighteen of the hospital schools had closed and no new ones had opened.
The reasons hospital schools are closing are basic and will have increasing impact year by year. Rapidly rising hospital costs with the consequent necessity for hospitals to economize is a major reason. This reason will become accentuated as hospital costs continue to increase at a rate of 5 to 7 percent per year over the foreseeable future. A second reason is the increasing cost of nursing education and the inability of hospitals to meet these educational costs from patient revenues. These costs too can be expected to continue to rise at a rapid rate. As faculty and other salaries are increased and as the costs of teaching materials and equipment rise, there is no way for costs of education per student to go but upward so long as there is no increase in the number of students taught per teacher. The necessity for the hospital schools to upgrade the quality of their programs will also have a substantial upward influence on costs. More and better faculty means higher unit costs per student. The same is true of library, laboratory, and classroom supplies and equipment that must be significantly improved if any of the hospital schools not approved by the National League for Nursing is to attain approval by the NLN.
The temptation to close its school of nursing is a very strong one for a hospital. It does not need a school in order to operate a high level program oí patient care. To operate a nonapproved school is a stigma and reflects on the excellence of its other programs. The nursing school also represents a financial burden that is not being borne equally by all hospitals and thus adversely reflects on the operating costs of hospitals that conduct nursing schools.
Some moderation of the effect of the closing of hospital schools can be expected by an increase in size of the classes in the nursing schools of some of the larger hospitals as their number of beds increases. It is unlikely, however, that this factor will significantly offset the trend of fewer hospital schools and fewer graduates.
2. The education of registered nurses should be recognized as a proper and vital function of the institutions of higher learning, both public and private, and these institutions should commit themselves as fully to the needs of nursing education as to other educational programs for which they have accepted responsibility. Nursing education is the only recognized professional discipline in this country taught outside institutions of higher learning. This is because it originated as a vocation in the early days of hospital development, when hospital care was largely a matter of custodial care. Like medicine at the time, nursing had little science, and the learning was largely a matter of on-the-job training. Unlike medicine, as the medical sciences advanced, the function of nursing education was not transferred to educational institutions. One reason for this was the work return the hospital obtained from the student nurse. The rise in costs of board, room, and other perquisites provided the student nurse, and the increasing number of class hours necessary to cover the rapidly developing body of knowledge required in modern nursing practice, eliminated the "net profit" in conducting a hospital nursing school at least two decades ago. A number of studies have been made on this matter in various sections of the United States in recent years. All are in general agreement with the findings of a study done by the Duke Endowment for the year 1963. This study, covering seventeen North Carolina hospital schools of nursing, showed an annual average net loss to the hospital per student nurse of $1,499. This figure represents the outlay per student after credit for the patient-care work done by the student at the rate which would have been paid a graduate nurse if those services had been performed by a graduate nurse. 8
One can argue with strong justification against the equity of passing on to the hospitalized sick the social responsibility of financing the education of the professional nurse. She is employed in many capacities outside the hospital and is employed in much greater numbers in hospitals without schools than in the hospitals with schools. The present system of financing nursing education represents an undue burden on patients in hospitals that have schools of nursing.
More important than the financial inequity surrounding the hospital school of nursing is the growing inability of the hospital school to attract students. This was not a problem until recent years because of the dearth of other career opportunities for women and the lack of financial resources for obtaining an education at an institution of higher learning. The hospital nursing school represented one of the few ways available to most female high school graduates to work their way through schooling for a professional career. The great change in the average income of families, the wide availability of scholarships and loan funds for higher education, and the acceptance of women into most professions have drastically changed the situation that led many girls to enter the hospital schools of nursing. There is ample evidence that nursing is an appealing profession, but the same evidence shows that student nurses increasingly want the content and the status offered by an education in a recognized institution of higher education. Both nationally and in North Carolina the nursing schools in educational institutions experience no difficulty in recruiting whereas the majority of hospital schools are not able to fill their classes. The Duke Endowment Survey in 1962 found 534 vacancies existing that year in hospital schools.9 An informal inquiry to the schools of nursing in educational institutions in North Carolina made in 1964 in connection with this study revealed that these schools had a surplus of applicants.
The establishment of schools of nursing in educational institutions would provide a means of utilizing the clinical resources in small hospitals which are otherwise unavailable. Although a small hospital by itself cannot provide sufficient clinical experience for a minimum-sized nursing school, it can provide excellent experience for a number of the students in an optimum-sized nursing school conducted by an educational institution. A properly located institution of higher learning can effectively pool the clinical resources of a number of small hospitals in the area. This fact will become especially important as community colleges develop throughout the State. These colleges will be spread across the State, and some will be located in areas where hospitals are not of sufficient size to have a school of nursing.
The establishment of schools of nursing in selected community colleges would offer several decided advantages. It would give them an attractive and important program to offer their communities. It would reduce considerably the cost of a nursing education since the nursing student would be commuting and thus avoiding the board, room, and other expenses incident to living away from home. It would attract to nursing local students who otherwise would have no opportunity for a nursing education. This would represent a contribution to the hospitals of the area; statistics indicate that nurses tend to locate in their home towns.
Nursing schools in selected community colleges would significantly aid in the recruitment of nursing students in several ways. They would provide an opportunity for older students to enter nursing. In states that have developed a large number of nursing schools based in local junior colleges there is a large reservoir of women who did not continue their education upon completion of high school but are attracted by the opportunity to enter a service profession like nursing. The average age of nursing students enrolled in the junior college nursing schools of the nation is above thirty years. For personal and social reasons these women will not leave their communities and enroll in hospital schools of nursing. One of the major personal reasons is that of marriage. Many of these students must secure their education within the context of their marriage. Also, marriage represents a difficult problem to the hospital school of nursing student. While most hospital schools will now accept the married student, the educational programs and social life of these schools are built around the single woman and the resident student
3. A primary responsibility for nursing education, both basic and graduate, should be recognized as an obligation of the tax-supported institutions of higher learning, and the appropriate state agencies should be charged with the obligation to promote, within their particular areas of responsibility, the necessary programs in nursing education to assure an adequate and balanced supply of nurses in the state. This recommendation is not aimed at decreasing the activities and efforts of voluntary institutions of higher learning and the hospitals in the field of nursing education. The voluntary institutions and hospitals should be encouraged to maximize their efforts in this field They have unique contributions to make to it. The recommendation is a recognition, however, of the vital role that nurses play in the health care of the population and of the necessity that an adequate supply of properly prepared nurses be assured The role of the professional nurse is too essential to the public good to be left to the chance nature of voluntary decisions. Just as with the other professions, the tax-supported institutions of higher learning should accept an obligation to fill the unmet needs in nursing education. Neither the local hospitals nor the voluntary institutions of higher learning can be expected to accept such a responsibility.
In North Carolina, as in all other states, proposals have been made from time to time for state subsidy of nursing education. Few states have developed plans under which local hospitals receive a subsidy, and such aid as has been provided is so small per student nurse as to have little influence on the net cost to the hospitals of conducting schools of nursing. Legal and ideological reasons make it unlikely that tax funds will be used to any significant extent for subsidizing nursing education in voluntary hospitals and colleges. The practical approach is to provide tax support through taxsupported institutions of higher learning. Further, the provision of opportunities for professional nursing education in tax-supported institutions of higher learning will mean equal opportunity for a nursing career to all qualified individuals in the state.
The factor of opportunity for a professional career in nursing is important in itself as a reason for the establishment of schools of nursing in taxsupported institutions of higher learning. The purpose of these institutions is not solely one of looking after the service needs oi the state. It is also one of providing career opportunities for the individuals of the state. Nursing education should have a high priority in this respect. There is a strong demand for nurses; the likelihood of the individual remaining in the state and thus providing a return on the state's investment in her education is very great. Further, the utility of the nursing education for those who become housewives is quite valuable.
For a state that has historically been an exporter of its educated younger persons because of lack of career opportunities, nursing education should offer a unique appeal to the tax-supported institutions of higher learning in North Carolina. No other type of program of higher education for women gives such long-term dividends as nursing education. Because of the higher degree of standardization of medical and hospital procedures, the need of hospitals for nurses around the clock for seven days a week, and the flexibility that obtains in hospital staffing patterns, it is possible for the nurse to accommodate her work to the demands of marriage, age, and other factors that would compel her to leave the work force in most any other vocation or profession. This is borne out in the 1963 statistics on North Carolina nurses. In that year 70 percent of all nurses actively employed as nurses in the state were married. An additional 6 percent were widowed and probably maintaining a household while practicing their profession. Over 70 percent of all active nurses were over age thirty and well past the age when most women withdraw from the work force. Over 20 percent were over age fifty.
4. Every avenue and factor affecting the recruitment of qualified students into nursing should be exploited. Formal programs of recruitment are only as effective as the career they are attempting to sell is competitive with alternative careers. The image of nursing as a career is the dominant factor that will determine the number and quality of students seeking admission to nursing education programs. This image will depend largely upon the quality of the education offered and the working conditions to be expected upon completion of the education.
The increased identification of nursing education with the institutions of higher learning will undoubtedly enhance the image of nursing as a profession. Higher education is the status symbol of our society, As pointed out elsewhere in this article, the schools of nursing located in educational institutions report no difficulty in recruiting students. But this situation will likely change as a greater number of opportunities for enrollment in nursing programs in educational institutions is provided. Unless something is done to enlarge the pool of applicants, expansion of opportunities will result only in intensified competition between schools for an insufficient number of students or in the compulsion to accept an increasing number of marginal students.
There are undoubtedly many complex and obscure social and cultural factors involved in the desire and opportunity of female high school graduates to enter nursing. Nursing offers many intangible rewards to the individual and has inherent in its practice most of the satisfactions commonly listed as being of significant importance to the individual. Except for the rare, highly altruistic person none of these satisfactions can effectively overcome faulty and unsatisfactory economic conditions of employment. The compensation and other working conditions of nurses, wherever practicing and at whatever level of practice, must be set at a level commensurate with the educational and work requirements. The provision of additional educational facilities for nurses will serve no purpose if the working conditions of alternative careers are so superior as to divert promising high school graduates away from a nursing education and to attract graduate nurses away from the practice of nursing. Hospitals, as the dominant employer of nurses, must carry the responsibility and exercise the leadership in developing levels of compensation that will attract a sufficient number of entrants into nursing each year. The ultimate answer to the problem of a sufficient supply of adequately prepared nurses will depend upon the realism with which hospitals face the question of compensation.
The policies and practices relative to nursing faculty members in both diploma and degree programs are important facets of the question of compensation. Qualified individuals cannot be expected to seek the necessary education for such nursing faculty positions unless they are treated in every respect as are other faculty members of equal education and rank. Education costs money, both in direct outgo and in lost income, and persons with an aptitude and an interest in teaching cannot be expected to make the necessary investment unless they see some chance of recovering on the investment of time and money. This fact is clearly demonstrated when one looks at the education attainment of faculty members teaching in the schools of nursing in North Carolina during 1962. Only 223, or about half of the total of 431, had a bachelor's degree or better. Less than 17 percent had a master's degree, and mere were only two individuals with doctorate degrees in the enure total.10
The recommendations of this survey are realistic and quite feasible. They call neither for any abrupt changes in the pattern of nursing education nor for any large-scale provision of funds. If implemented, they will in effect represent the establishment of a long-range pattern of nursing education, permitting an orderly adjustment to the forces affecting this education that are developing throughout the nation. The impact of these forces is already clearly visible and will soon become accelerated. The nation has been drifting into a nursing crisis since World War II. The recommendations are intended to help the here-and-now nursing problem and at the same time to provide a plan for the future.
Some critics will believe these recommendations are deficient in mat they do not give precise estimates as to the number of new nursing programs needed or the number of graduates needed and a time schedule for producing both. Other critics might also believe that estimates of the number of baccalaureate graduates and the number of associate degree graduates should h ave been made. Such precise measurements are not possible because of the number of variables involved. What may happen with the existing hospital schools of nursing and the size of their enrollment prevents any valid recommendations as to the number of programs and graduates required in educational institutions.
The same observation may also be made concerning the differentiation between baccalaureate degree graduates and associate degree graduates. The important factor here is mat every possible priority be given to the establishment of baccalaureate degree programs. The graduates from these programs can fill the requirement both for additional registered nurses and also for the special positions in nursing administration, nursing school faculties, and in public health nursing requiring a baccalaureate degree. They are also prepared to study for advanced degrees. The quality and quantity of nurses to be produced from the hospital schools and the associate degree programs will be determined by the quality and quantity of graduates from the baccalaureate degree programs. The oft-expressed opinion that nurses with a baccalaureate degree will not pursue nursing as a career is not borne out by the statistics. In 1962, the percentage of all registered nurses in North Carolina reported as active was 82. During the same year the percentage of all registered nurses with a baccalaureate degree reported as active was 80.
The essential problem in nursing education can be stated in terms of the economic, social, and professional forces that are causing the hospital schools to be progressively less able to meet the need for registered nurses. This means the pattern for nursing education must increasingly involve programs in the junior and senior colleges. There is no other source to which to turn. This also means that the primary responsibility for nursing education must be increasingly accepted by the tax-supported institutions of higher learning. They are the institutions that receive direct public support and are thus obligated to assure the educational functions necessary for the public good.
- 1. Hospital, Para-Medical, and Medical Personnel Survey in North Carolina, April I1 1962. Mimeographed.
- 2. Manpower and Training Needs for Medical and Health Service Occupations in North Carolina, Raleigh, Employment Security Commission of North Carolina, 1962. 63 pages.
- 3. Toward Quality in Nursing: Needs and Goals, (Public Health Service Publication No. 992.) Washington, Government Printing Office, 1963. 73 pages.
- 4. Ibid.
- 5. Data provided by the Local Health Division, North Carolina State Board of Health, Raleigh.
- 6. Op. cit.
- 7. Nursing and Nursing Education in North Carolina, sponsored by the North Carolina Medical Care Commission and the University of North Carolina, 1950.
- 8. Comparative Study on Cost of Nursing Education in Seventeen North Carolina Diploma Schools, October 1, 1962-September 30, 1963. (Mimeographed.)
- 9. Op. cit
- 10. Except as otherwise noted, North Carolina data presented in this article were provided through the good offices of the North Carolina Board of Nurse Registration and Nursing Education, Raleigh.