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Q: Is the World Flat?

A: Our space shuttle's flights may often be in the news, but here on Earth, U.S. nurses are still fighting to overcome what amount to flat-earth and pre-Copernican attitudes.

Many people still believe that nurses are subordinate, scut work saints, rather than professionals with critical-thinking skills honed by years of college-level training. Likewise, most Americans remain convinced that health care revolves around the nation's 700,000 physicians.

This is not a matter of nurses feeling snubbed. The current nursing shortage is one of the nation's most urgent public health crises. The nursing workforce is aging and burning out. While vast sums are lavished on medical training, research and technology, nurses struggle with short staffing that recent research suggests has already killed thousands of patients since the current shortage began in 1998. The U.S. now has an estimated 126,000 nursing vacancies. That shortfall that could become catastrophic as the nation confronts an aging Baby Boom population and potential mass-casualty events.

Today, 2.3 million registered nurses play a central role in U.S. health care, saving lives and improving outcomes countless times every day. They assess patients' conditions and autonomously intervene, coordinate work by the health care team, use cutting-edge technology to protect patients, and teach patients to manage their conditions.

But 2.3 million is not enough now - and it certainly won't be enough in the future. By 2012, the nation will need to educate an estimated 1.1 million registered nurses to eliminate the shortage. Recent legislative measures, like the Nurse Reinvestment Act of 2002 and California's 1999 safe staffing law, offer some hope. But their effect has been limited. The federal law has yet to receive adequate funding, and in California the powerful hospital industry, aided by Governor Schwarzenegger, has continued its fierce resistance to full implementation of the staffing law. Meanwhile, a recent study in the policy journal Health Affairs found no real evidence that the national shortage is ending, despite modest recent increases in the number of nurses.

Now is the time to start changing attitudes about nursing. The public must learn what nurses really do. For health care resources for nurses to increase, what is "common knowledge" about nurses must increase.

The media plays a key role in forming and reinforcing popular attitudes. Research confirms that the long-running NBC television drama "ER" affects viewers' health care decisions and provides the most significant impression of nursing for youngsters.

What does the public learn about nursing in the media? Occasionally it gets an insightful look at what nurses really do, as in HBO's recent "Angels in America" and an excellent October 2004 article on nurse practitioners in The Wall Street Journal.

But more often, what the public sees in the media confirms prevailing "flat earth" attitudes. This demoralizes nurses and discourages potential new ones.

Take television, and specifically "ER." Although "ER" nurses are competent and caring, the show consistently falls prey to the myth of the peripheral, subordinate handmaiden. "ER" nurses report to physicians. In the real world, hospital nurses do not. The show's nurses also aspire to medical school, though real nurses who go to graduate school are at least 50 times more likely to do so in nursing – not in medicine -- as 200,000 advanced practice nurses can attest. The show's wildly unbalanced ratio of major characters, roughly nine physicians to one nurse, constantly leads to scenarios that show physicians providing all important care. "ER"'s physician characters perform exciting tasks, such as defibrillation, but in real life, nurses do this job. The show therefore gives physicians credit for the life-saving work of nurses.

Other entertainment programming is far worse. A late 2003 episode of NBC's "Scrubs" purported to teach a nurse character that nursing is all about doing whatever physicians tell you, despite real nurses' independent responsibilities to advocate for patients. The fall 2004 season featured the debut of three new physician-centered network dramas, including one -- Fox's "House" -- in which all six major characters are physicians. Nurses effectively do not exist on this show.

In general, television news shows and documentaries ignore nurses' contributions to health care, feeding viewers a diet of all-physicians-all-the-time. Even commercials tend to reinforce the old stereotypes: Physicians are smart and commanding; nurses are deferential helpers and/or sex objects. A recent Dodge Caravan ad featured an omniscient surgeon essentially directing an operating room nurse to buy the vehicle.

We must educate ourselves about what nurses do -- and "we" includes the elites who craft public policy and media content. They must help raise awareness of nursing. Nurses in particular must speak out about their work. The Baltimore-based Truth About Nursing is now pursuing a major campaign to persuade "ER" to portray nursing accurately.

Consider the danger of living in a flat nursing world. One day you, or a loved one, might fall off the edge.

Last updated March 28, 2005.


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