Changing how the world thinks about nursing

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Q: Should we refer to every non-physician caregiver as a "nurse," no matter what type or level of training that person has?

A: No, just as we would not refer to every non-nurse caregiver as a "physician." Nurses are life-saving, autonomous professionals with advanced health training and unique legal and ethical responsibilities. Referring to non-nurses as nurses is not just confusing and unfair. It can be dangerous. In particular, by helping to blur the distinctions between nurses and less highly trained assistive personnel, the practice adds to the devaluation of nursing that has been a critical factor in the denursification of clinical settings and the life-threatening nursing crisis. The Center urges everyone to do her part, in a sensitive way, to increase awareness of who is and is not a nurse.

The Center has noted that a wide range of persons--and even many physicians--commonly refer to anyone they come across in a health care setting who is not a physician as a "nurse." Such supposed "nurses" may include hospital technicians, medical assistants, nurses' aides, clerks, and even in-home day care providers (sometimes called "baby nurses") who may have no more than a few days of CPR training. This broad practice would in many cases seem to reflect a vague belief that anyone the speaker regards as a non-physician assistant (especially if female) must be a nurse. In a 2005 episode of the popular "Dr. Phil" television show--an episode in which Dr. Phil was actually trying to make amends for a damaging remark he had made about nursing--the host repeatedly referred to a nurse's aide as a "nurse." We doubt that Dr. Phil would have referred to someone who used his several weeks of training to assist a physician as a "physician." In other cases, the supposed "nurse" has significant training--but not in nursing. The practice of calling a wide range of personnel "nurse" persists even though nursing is a distinct, autonomous profession with its own legal and ethical responsibilities, and even though legislation in some jurisdictions makes "nurse" a restricted title, in order to protect the public from the dangers of unlicensed practitioners (see New York and other US states).

However, if patients, health workers and members of the public rely on non-nurses for nursing care, disaster can ensue. Minimally trained, unlicensed care givers are not qualified to do what real nurses do, such as save lives in emergency situations, monitor and manage very sick patients, provide skilled psychosocial care, and educate patients about serious chronic conditions. Even referring to social workers, respiratory therapists and others with advanced training as "nurses" harms nursing because it decreases understanding of what nursing really is, and may contribute to the public's vague sense that "nurses" handle all tasks that seem peripheral to the important work of physicians. This runs counter to the reality that nurses are key members of a diverse team of health professionals who do not revolve around physicians, but around the patient. Of course, such misimpressions also damage the other advanced professions, which deserve full credit for their own expertise.  
When a patient asks an apparent "nurse" with only a few weeks training to address or explain his condition, and the "nurse" has no clue, the patient may conclude that nurses have no clue.

Why does this happen? The reasons may relate to nursing's historically undervalued and underempowered status. In general, the term "nurse" has very broad application, and it is often used to describe unskilled care or tending, e.g., "his wife nursed him back to health," "the baby nursed herself to sleep," or "he sat there nursing his beer." This signals a linguistic environment in which "nursing" requires no general health care expertise (though successful breastfeeding does require skill which is largely overlooked). Moreover, those with little real understanding of the nursing profession, including much of the public, the media, and too many physicians, may not distinguish between nurses and others whom they see as assistive personnel because they may genuinely feel there is no significant difference. If you regard nurses as marginally skilled handmaidens, it's hard to see why you should not refer to anyone who is near the bedside and isn't wearing a white coat as a "nurse." It's really just another way of saying "nice helper," right? And of course, many still assume that any female at the bedside must be a nurse, as female physicians can attest. Moreover, today a wide variety of caregivers may wear similar scrubs, and this may have the unintended effect of blurring the lines between nurses and others at the bedside.

At the same time, there are certain groups whose immediate interests may not seem to lie in clearly defining who nurses are. A minimally trained caregiver may not feel a strong urge to correct someone who refers to her as a nurse. Some "baby nurses" appear to actively encourage the confusion. Hospitals and other facilities may likewise have no strong incentive to clear up the confusion, especially in the managed care era in which many have replaced skilled nurses with minimally trained caregivers in order to cut costs. Indeed, some facilities have reportedly impeded nurses' efforts to identify themselves as RNs to patients. One potentially effective way to weaken a group is to dilute its identity. When a patient asks an apparent "nurse" with only a few weeks training to address or explain his condition, and the "nurse" has no clue, the patient may conclude that nurses have no clue.

Sadly, some nurses themselves may contribute to this unfortunate trend to the extent they fail to clearly identify themselves, either through their attire or their words. We have noticed that even some of the most highly trained and experienced nurses fail to explain that they are nurses. For example, they may simply say that they are caring for a particular patient, or say, "Hello, I'm Bill." Potential reasons for this may include that nurses have long been socialized to minimize their role in care, to be "unsung heroes" with busy hands and closed mouths, as part of what Suzanne Gordon has termed "the virtue script." Keeping your head down can also be an attractive option when there is trouble. Identifying yourself means taking risks that some would rather avoid, however self-defeating that may be in the long term. Some nurses may fear exposing themselves to scrutiny and potential liability.

What can be done? We urge everyone to do what he can, in a polite and sensitive way, to make clear who is and is not a nurse. We suggest that nurses make clear, either through their attire (e.g., a prominent "RN" patch) or their words, that they are nurses. We urge physicians and other health workers to learn the basic differences between nurses and non-nurses, and if they are not sure whether someone is a registered nurse, to simply ask. We also urge practitioners in outpatient settings to avoid giving patients the impression that personnel are nurses if they are not nurses. We hope non-nurse health workers who are mistaken for nurses will make clear that they are not nurses. Non-nurse health care workers deserve credit for their own qualifications, but not for nurses' qualifications. We hope that hospitals and other facilities will not only allow nurses to identify themselves as nurses to patients and colleagues, but that such facilities will take an active role in helping the nurses do so. A stronger nursing profession will benefit such institutions in the long run, even though nurses may cost more in the short term than those without their training and skill. We urge legislators in jurisdictions in which "nurse" is not yet a protected title to consider making it one. We also believe the media has a special responsibility to learn and make clear who is a nurse and what tasks nurses perform. And we hope that patients and other members of the public will try to learn more about what nurses do, and the important features that distinguish them from other health care workers.

Also see and add to our discussion on "Do nurses need a new name?"

last updated: October 26, 2005

 

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