WICHITA, Kan. -- When Susan Kruger asks new nursing students at Wichita State University what they think nurses do, they usually say: "We do what the doctor says."
That makes the head of the nursing department wince.
But when those same students graduate a few years later, they use such terms as "leadership," "patient advocacy" and "team management" when describing nurses' roles. And that makes Ms. Kruger smile.
The change in nursing students' perceptions reflects the quiet revolution that is transforming the profession. What once was a non-technical field emphasizing good bedside manners is now a multifaceted profession emphasizing a broad range of management skills.
Instead of just carrying out doctors' orders, nurses increasingly provide primary care, serving as the main link between medical care technology and patients.
"I'm not saying the nurses should be running everything, but the nurse is there 24 hours, seven days a week," says Donna Swindle, vice president for patient care at St. Joseph Medical Center. "They're in touch with the family's needs, the patient's needs and the doctor's needs. They have to be independent thinkers."
Employers and nursing organizations, as a result, are pushing students to set their sights on a bachelor's degree or a master's degree, not just an associate degree.
"In years past, doctors wouldn't let nurses take a temperature or a blood pressure," she says. "Now they [doctors] don't have the time, and the nurses have the technical expertise to do a lot more. The doctor provides the guidelines for care, but the nurse carries it out and is responsible for the day-to-day stuff."
That move toward greater responsibility is one of the most important recent developments in nursing.
Another is the increase in the number of students of nursing.
After a decade in which there was a much-publicized shortage of nurses and an uncertainty about the role of nursing in health care, the field is emerging in the 1990s with renewed career appeal and sense of mission -- and enrollments at nursing schools are booming.
"Nurses, and the idea of nursing, has grown, and we now have a better idea of what we can do," says Debra Logan, a graduate of
the WSU program. "It's a much broader image."
In the early 1980s, the field was fairly stable. Wages were not particularly good and chances for advancement were limited, but nursing was seen as a fairly reliable source of income in troubled economic times, says Joan Felts, head of nursing at Kansas Newman College in Wichita. Hospital occupancy rates were on the upswing, and jobs always seemed to be available.
By the mid-1980s, however, hospital occupancy rates began dropping, nursing schools had trouble attracting new recruits and a shortage set in. Educators, administrators and nurses disagree over the causes of the problems, but three factors seem to emerge:
* In 1984, Medicare set limits on how much it would reimburse hospitals for most medical procedures. The limits became a guide for other insurers, who were trying to standardize health care and prevent some hospitals from keeping patients under extended care in order to milk more insurance money.
As a result, patients were discharged faster, hospital occupancy rates dropped, fewer nurses were needed and administrators trimmed their budgets, either by cutting or leaving open some nursing slots.
"The following year, in 1985, our enrollment just went zip," says WSU's Ms. Kruger. "The word was out that there were no jobs."
* People with jobs had little incentive to keep them. Pay was average at best and did not rise much no matter how many years of experience a person accumulated, says Gloria Kilian, nursing dean at St. Mary of the Plains College in Wichita.
The field had always lured women who used nursing as a supplemental income for their families; even today, more than 95 percent of American nurses are women. But in the mid-'80s, a lot of those women stayed at home or cut back to part-time work, experts in the field say.
* Following the inroads made by the generation before them, young women in the 1980s were lured by the glamour and potential of jobs in other sectors that had long been male strongholds. To many, nursing seemed like a job that played to some stereotypes that women were trying to shake.
"The impression was that nurses worked sun-up to sundown for no money, and all they did was follow doctor's orders," says Arneatha Martin, director of education and research at St. Joseph Medical Center.
Adds Ms. Kilian: "Our image was bad, and it didn't help that all anyone saw in the media was negative things, like high health-care costs and so forth."
By the late 1980s, nursing schools were having trouble filling their classrooms. And hospitals and clinics, which had recovered from the initial shock of the Medicare limits, were opening their doors again to new nurses but not finding many people lined up to come in.
Since then, the situation has begun to turn around.