It has been said that an efficient and economic worker is one who works at top capacity most of the time. When a person is working at less than capacity he is likely to be ineffective, dissatisfied, and bored, and to leave the position in a short time. On the other hand a person who is expected to perform tasks for which he is not prepared will undoubtedly perform inadequately, make mistakes, be dissatisfied, and leave the position in a short time or perform so badly that he will be fired. In either situation the functions and tasks are inadequately performed, the services rendered inadequate, and the worker unhappy and inefficient. In addition it is costly to an organization, which must constantly hire and orient new employees as well as discharge unsatisfactory employees. It behooves any organization to employ its workers according to their preparation, if the services rendered by that organization are to be effectively and economically produced. The nursing services within the hospitals are no exception.
The day is long past when a single worker, whether professional, semiprofessional, or subprofessional, is sufficient to provide nursing care to the increasing number of patients seeking care within hospitals. Within the memory of many nurses, nursing care in hospitals was performed almost exclusively by nursing students with the employed registered nurses serving as head nurses, supervisors, or administrators. About twenty-five or thirty years ago nursing was carried on by a single homogeneous group of nurses called registered nurses. Since then the number of registered nurses employed by hospitals has multiplied six times whereas the number of other personnel in the nursing department has increased from none to over five-hundred thousand. These additional persons, regardless of preparation or position, have been clasified as nursing personnel rather than as persons employed by or in the nursing department. The designation "nursing personnel" implies that all do nursing and that all do nursing equally well. Another aspect of the problem of heterogeneous personnel within the nursing department lies in the tendency to look at the provision of nursing care only quantitatively and not qualitatively. This situation engenders reliance only on the number of persons employed and not on their ability to perform the functions required.
Levine states, "recent research has turned up some evidence that a numerical ratio, such as hours of care per patient, does not provide a satisfactory standard for a hospital to use as a guide for staffing and utilization." 1 The number of nurses employed cannot be used as a measure of the quality of care provided. In fact, it can be shown that in some situations the quality of care is considered good when the number of hours of nursing care per patient is relatively low. This can be interpreted as representing improved utilization of personnel. Levine also writes of data that support the fact that "meeting the needs for hospital nursing personnel cannot be governed by quantitive considerations alone" (italics in original) and that "the average number of hours of nursing care available per patient is at an all time high; yet many hospitals report inadequacies in patient care..."2 He concludes that increasing the number of hours of patient care available will not ensure an increase in the adequacy of patient care. If one accepts this analysis of the problems of adequate nursing care, one must accept the imperative of proper and more effective utilization of nursing personnel.
The first consideration in the effective use of nursing personnel is the recognition and acceptance of the need for differentiation of functions within the occupation of nursing. We must accept the belief that nursing functions "can be considered as being on a continuum and that these functions can be differentiated sufficiently to make possible programs for the preparation of individuals to perform these functions."3 It would be illogical to expect a single program as adequate for both technical and professional functions, or to believe that several types and lengths of programs prepare the same type of worker. The professional functions of nursing require preparation which, by virtue of its nature, can be secured only within the senior college or university. The technical functions of nursing can be prepared for within the community junior college; it is this program which has come to be known as the associate degree nursing program.
The associate degree nursing program prepares a specific type of worker, the technical worker in nursing, for the functions commonly associated with the registered nurse. These functions are:*
1. Assist in the planning of nursing care
a. Plan nursing activities for individual patients.
b. Assist patient to participate in his own care.
2. Give general nursing care
a. Give hygienic care
b. Make patient comfortable
c. Assist the patient in maintaining normal body functions
d. Observe and report signs and symptoms
e. Perform selected procedures associated with medical therapy, e.g., give medications
f. Perform selected procedures essential to diagnosis, e.g., collect specimens
3. Assist in evaluation of care given
It should be noted that the associate degree program emphasizes direct care to patients. It excludes, by intent, any preparation for managerial or administrative tasks. Thus the graduates of these programs are prepared to give direct patient care effectively, to be challenged by this kind of assignment, and to receive job satisfaction from so doing. And unless so employed, these graduates are likely to be less effective, less satisfied, and less productive. It is also unfair to judge them in the performance of functions for which their program did not prepare them.
What are the graduates doing and how well are they performing? We now have specific information about associate degree graduates. It is safe to say that no other group of graduate nurses has ever been subjected to such close scrutiny or studied as often as have these graduates. All studies indicate that the majority of these graduates are employed in general hospitals and that most of them are involved in giving direct patient care. In the initial evaluation, which was a part of the Cooperative Research Project in Junior and Community College Education for Nursing, it was found that more than 4 out of 5 of these nurses were performing as satisfactorily or more satisfactorily than graduates of other nursing programs. In a study of graduates of one program, it was found that they were performing satisfactorily as staff nurses in accordance with the objectives of the program. This study also showed that the graduates were "dissatisfied with those aspects of the employment situation in which they were required to perform administrative or managerial functions for which they had not received preparation.4
In a recent doctoral study Forest investigated the utilization of graduates of associate degree nursing programs in New York City. Her findings indicate that 80 percent of the graduates employed were in staff nurse positions and that these 90 percent spend more than half their time in the technical functions of nursing. The majority also performed other functions, including managerial, clerical, cleaning, and medical-technical, for which their programs did not prepare them. She recommends that continued efforts be made to employ these graduates for the functions their program prepared them to perform so that they may work at the top level of their ability.5
What, can be expected of the associate degree graduates? They can be expected to give direct patient care which is safe and effective. They can be expected to enjoy giving this care, for its importance has been consciously and deliberately built into the curriculum. They can be expected to want to continue to learn, to be inquisitive, to seek help when such is indicated. They can be expected to admit to but not be ashamed of limitations. (Limitations should not be interpreted as deficiencies, for no program can prepare one for everything.) They may be somewhat slower in their work at the beginning than the traditional diploma program graduate, but this difference lasts only a short time.
In any listing of expectations it is important to indicate what the graduates should not be expected to be. They should not be expected to be head nurses, or charge nurses, for management skills have not been included in their programs. They should not be expected to be team leaders for they have not had training in leadership skills. That kind of skill is definitely within the prerogative of the professional practitioner. This is not to say that some individuals within this group do not possess leadership potential; it is to say that the program does not include preparation for this function.
The common and loosely used terms "team nursing" and "team leader" need comment here. These terms and the concepts which underlie them, as developed by Lambertsen, are precise and specific. They carry with them certain conditions and responsibilities and mean more than a number of differently prepared people stationed in the same unit within the hospital. If, indeed, the team were used, each individual member would have his specific task and there would be proper utilization of all kinds of personnel. The ease with which individuals slide in and out of responsibilities, tasks, and assignments precludes adequate team functioning. Gleazer has indicated that the combining of skills of various personnel in a working team relationship increases the usefulness and productivity of each individual in the team. 6 Thus, if the team is to function at all, there must be a clear differentiation of functions with appropriately prepared individuals to carry out the functions. It behooves nursing service administrators at all levels to ascertain their role in instituting and supporting the nursing team or to state frankly their inability or unwillingness to use this particular method of providing nursing care. Having the functional method of assignment cloaked with the term "team" is to denigrate the concept of team nursing.
What must be done to increase the effective utilization of the associate degree graduate (and the baccalaureate graduate)? First there needs to be recognition of the distinction among the kinds of personnel, and the careful identification of the functions or activities which can be carried on by each category. The "all purpose" nurse is a thing of the past, necessarily so in view of the rapid and revolutionary advances in science, medical practice, and technology. It is illogical to say that practical nurse programs, diploma programs, and associate degree and bacalaureate programs all lead to the same end in a nurse. The differences need to be maximized, not minimized. We can no longer testify to the increasing complexity of patient care with correspondingly greater emphasis on the science content of the curriculum while at the same time give all nursing care to the practical nurse or aide. One or the other attitude must be wrong, for they are at odds with each other.
The notion that all registered nurses are or should be head nurses can scarcely be supported. According to information contained in Facts About Nursing, there are three registered nurses employed in hospitals for every practical nurse employed. If this ratio is true, it is difficult to understand the need for all nursing care to be given by other than registered nurses and the assigning of all registered nurses as head nurses. 7 It should also be noted that of all registered nurses employed in hospitals, nearly one-third are in administrative and supervisory positions. 8 Second, there needs to be clearly defined job descriptions so that distinctions are obvious. Third, all new employers need orientation. The expectation that a new employee is immediately a productive worker is unrealistic. For the beginning practitioner even more orientation is necessary, for no educational program completely prepares a worker. Fourth, inservice education is not a luxury, it is a necessity. To keep the nursing staff abreast of new methodology, new knowledge, and new procedures is but one responsibility of nursing service administration. Ginsberg states in his study, Human Resources, that "workers must now be led, since they can no longer be forced."9 Continuing education is a way to provide the leadership necessary for worker development.
It is the function of nursing education to produce personnel who know good nursing and who are prepared to make changes in the nursing care of patients. Nursing service must be prepared to accept and use the several types of personnel in nursing according to their abilities and their differences, and to advance nursing by using each worker to the limit of his ability. Ginsberg gives this warning: "Improved utilization can never be secured by edict, therefore experimentation and adjustment. The key to success lies with management."10 The challenge of proper utilization of nursing personnel must be met if quality nursing care is to be provided.
- 1. Eugene Levine: "Some answers to the 'nurse shortage'," Nursing Outlook, 12:30, (March) 1964.
- 2. Ibid., p. 34.
- 3. Mildred Montag: Education of Nursing Technicians, New York, G. P. Putnam's Sons, 1951.
- 4. New York City, Queens College: "Employer Expectations vs Staff Nurse Performance," Final Report, Sections 1-4, New York, The College, 1962.
- 5. Betty Forest: The Utilizations of Associate Degree Nursing Graduates in General Hospitals, Doctor of Education Report, Teachers College Columbia University, New York, 1965. (Unpublished)
- 6. Edmund J. Gleaser, Jr.: "Facing Up to Basic Issues in the Junior College Field," address at Third Annual Work Conference of the Center for Community and Junior College Administrators, Teachers College, Columbia University, June 18, 1962, pp. 4 and 5. (Mimeographed)
- 7. American Nurses Association: Facts About Nursing, New York, The Association, 1965, pp. 22 and 179.
- 8. Ibid., p. 22.
- 9. Eli Ginsberg: Human Resources: The Wealth of A Nation, New York, Simon & Schuster, 1958, p. 109.
- 10. Ibid., p. 150.