Foreign physicians as one answer to the U.S. nursing shortage: from-"giving orders" to "receiving orders?"
February 17, 2004 -- Today NPR's Morning Edition included a report by Alan Tomlinson about Florida International University's new program to train foreign physicians to become registered nurses, which the piece presented as a potential way to address the current nursing shortage. The story does at least suggest that foreign physicians require significant training in order to practice nursing in the U.S., though it is not clear if listeners will realize that would also be the case with U.S.-trained physicians. And the story largely fails to convey that nursing is an autonomous profession with its own scope of practice, and listeners may be left with the impression that nursing is mostly about "taking orders" from physicians and coordinating tests for them.
The story explains the dilemma of foreign physicians who come to the United States but are unable to practice medicine here because of daunting examinations that must be taken in English. Most of the piece is about the new nursing program for such students at Miami's Florida International University, an accelerated 18-month program sponsored by Hospital Corporation of America that attracted more than 600 applicants for its first class of 40.
The story focuses on one Haitian student who is completing the program. This student, who was granted political asylum after fleeing Haiti, seems happy to be starting work as a nurse. But the story also highlights the difficulty this "once proud" physician has had in adjusting to nursing, running an audio quote of him noting that before he had been "always giving orders, now you are receiving orders." The story notes that another part of the adjustment is that the physician students are used to prescribing treatment but not "following through with patient care." In an audio clip, the program's nursing director says that early in their clinical training, students could rattle off the results of diagnostic procedures, but did "not necessarily know if the patient had already been downstairs for a chest X-ray or had had the cat scan or if the lab technician came in to draw the blood," because that had not been part of their prior practice as physicians. The story notes that 32 of the 40 original students "made the transition" and completed the program.
The net result of all this is mixed at best for nursing. Listeners will get some sense that nursing requires significant training independent of medicine, though we fear many may assume that relates more to the fact that these students were not trained in U.S. medical schools and/or are not native English speakers. The story does stress how many applicants there were for the few open program places. But the piece also suggests that the physician-to-nurse transition is a demotion, since the Haitian physician was "once proud"--pride and nursing must be mutually exclusive--and since physicians "give orders" and nurses "receive orders." Unfortunately, the examples chosen by the nursing director may reinforce this impression, since they all relate to nurses following up on tests, as if that was the main nursing responsibility. Even the way the student attrition is presented suggests that it may have had more to do with the physicians swallowing their pride than actually having trouble with the requirements of the program.
In fact, nurses do carry out physician care plans and tests if appropriate, but that is not the main work of nursing. Nurses independently assess patient conditions and needs and initiate care based on those assessments. Nurses do countless things every day that are critical to their patients' survival and well-being without any physician involvement, and indeed, there are large portions of nursing practice that physicians would not be qualified to assess, much less perform. No one who heard this piece--which is in large part about the differences between nursing and medicine--would get any of that.
One subtext of stories like this is that it's easier to become a registered nurse than it is to become a physician in the United States. Certainly, fewer years of formal education are required to obtain a nursing license, and competition for admissions to many nursing programs may be less intense. Obviously, given the current shortage, competition for employment may also be less intense. But we would note that nursing school is far more challenging than is commonly realized, and that it is not easier to become a highly skilled nurse than a highly skilled physician. We would also stress that simply having aptitude or experience in medicine is not an indicator that one will succeed in nursing. Though the two professions are both key parts of the health care team, and there is obviously a substantive overlap, they differ in their basic orientations toward care, their training, their knowledge bases, and their required skill sets. Nursing is not a subset of medicine, but an independent profession that is just as critical to patient outcomes.