Nursing since 1945
War and postwar shortages moved
Nursing toward a greater division of labor and specialization. Formal programs were developed for the so-called auxiliary nurses who assisted registered nurses (RNs) on the wards, and they were licensed as practical nurses (LPNs), working under the supervision of RNs. As
hospitals and medical care grew more specialized, services like intensive care, cardiac care, burn units, and dialysis spawned new nursing specialties. Nursing leaders, long committed to college
education for nurses, intensified the campaign to raise
standards and to remove nursing education from the control of the hospitals. The Brown report, a 1948 assessment of the present and future of nursing, recommended college degrees as the minimum credential for professional nurses. The proposed standards caused bitter conflict in nursing ranks, and at first college education made slow inroads.
From the late 1930s to the late 1970s nurses faced a curious dilemma. Hospital expansion supported a continuing demand for nurses, and the field gained some authority from the prestige of medicine and from a shortage of nurses. Yet nurses continued to suffer the disadvantages of female workers in a sex-segregated workforce. Their incomes lagged dramatically behind those of men with equivalent education, and nurses also earned less than women in comparable "female" jobs such as social work or teaching. On the job many hospital-based nurses felt the tension of increased responsibilities, without commensurate authority over working conditions or decisions about patient care.
In the late 1930s unionization began to gain some support from nurses critical of an overly passive and cautious ANA. In response in 1946 the ANA set national standards for minimum salaries and working conditions and helped local associations to use those standards in negotiations with hospitals. Unionization gained momentum in the 1960s and 1970s. The ANA changed its no-strike policy in 1968, and in 1974 the Taft-Hartley Act's prohibition of collective bargaining in voluntary hospitals was revoked.
Nurses have also responded to the frustrations of hospital work with revised and expanded forms of nursing
practice. The theory and practice of primary care has emphasized the need for continuity, and one
nurse may now coordinate all the aspects of care for an individual patient, reducing the fragmentation of institutional care. Nurses have also tried to establish career ladders that affirm the value of bedside nursing: the nurse-clinician can advance in salary and authority without leaving her patients for supervisory positions, the traditional route upward in nursing. Nurse-practitioners and nurse-midwives have tried to carve out independent domains, challenging medical practice laws and reimbursement patterns that constrain autonomous nursing practice.
Into the 1990s, nurses have struggled to define their places in a health-care system characterized by escalating costs, disproportionate investment in critical care, and political impasse over the federal government's role as provider of comprehensive health care. In some cases cost-containment efforts by the federal government and insurance providers resulted in layoffs and work speedups for
Hospital nurses. As patients were discharged "quicker and sicker," nurses faced new challenges in community agencies called to assist patients convalescing at home. Cost pressures have also created potential opportunities for nurse specialists to assume some of the work of assessment and management formerly reserved for physicians. This practice has gained a wider acceptance with the increased influence of managed care health plans that lower costs by emphasizing health maintenance and controlling access to expensive specialists.
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