Thorny problems face Texas nurses

How’s the climate for nursing in Texas? About as hot and sticky as the summers, some would say. For years, nurses have struggled to up- date their nursing practice act against strong political opposition. Recently, the nursing board has been sued over rules for advanced nursing practice. Seeking to bring health care to rural areas, nurse practitioners have been challenged on their authority to carry out stand- ing medication orders without a physician look- ing over their shoulder.

On top of it all, a number of hospitals have had serious nursing shortages. Beds are closed, and positions go unfilled. The 14% nursing vacancy rate was defined as critical by Department of Labor standards, and it was expected to increase to 31% by the end of 1980.

Hospitals run full-page ads and recruit around the country and even the world. Yet about 18,000 licensed registered nurses in the state are not working in the profession. Why not?

Researchers at the University of Texas School of Nursing decided to find the answer. They sponsored a comprehensive study of the shortage problem, surveying 10,000 nurses and all the schools of nursing, interviewing small groups of RNs, and brainstorming on ways to attract nurses back into the workforce and keep them there. Responses to the ques- tionnaire were received from 3,500 RNs. Mabel A Wandelt directed the project.

Essentially, they found that nurses leave nursing and stay away mainly because of working conditions. Quality of care, the profes- sional role of the nurse, and job conditions were the three major concerns.

“Being pulled to fill in on another unit, rota- tion, frequent changes of assignment to varied

shifts, the heavy work load, the need for over- time, the work ci? weekends and holidays are the job-related elements,” the research report said. Personal problems included child care, quality of patient care, other personnel nurses work with, orientation, inservice, paperwork, and recruitment.

On one specific problem-overtime-a nurse who was interviewed commented in part, “When a nurse is willing and loyal, they should not overdo requests to her. A nurse who is willing is asked to stay overtime and be pulled from other units to work holidays and weekends, to come in on a day off. There is no thanks for overtime, rather the nurse is fre- quently scolded for not being off on time.”

Lack of administrative support is a serious cause of dissatisfaction. The researchers indi- cated that qualifications of nursing directors may be part of the problem. In over 60% of Texas hospitals, the director has a diploma or associate degree-an education that usually does not provide instruction in management or personnel development.

Nursing education got part of the blame as well. “Nursing is perhaps the only profession where the educators do not trust the prac- titioners to provide teaching and guidance for students,” the report stated.

Quality assurance programs are a means of reforming conditions that may make hospitals unsatisfying places to work, the researchers recommended. They also suggested a statewide independent study to investigate why some hospitals have waiting lists of nurses and others have 25% vacancies. Com- paring such factors as their personnel policies, salaries, and management practices might help to pinpoint why nurses stay at some hos- pitals and leave others. They further advo-

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cated organizing and coordinating the informa- tion collected and planning for change through a statewide body, such as the Blue Ribbon Committee appointed to study nursing supply and requirements in Texas.

Meanwhile, some hospitals are trying new approaches. Baylor University Medical Center, Dallas, was having trouble with weekend staffing. So the hospital ran a full- page ad offering 36 hours of pay and benefits for two 12-hour weekend shifts worked on Saturday and Sunday. For two 12-hour weekend night shifts, nurses were offered 40 hours of pay and benefits. They had 125 applicants the next day.

“Hospitals are finally coming around and starting to face reality,” Dorothy Schloss, RN, of District 4, Texas Nurses Association said. “You will find one hospital with no vacancies, and others who are crying for help. There has to be a reason for that, and the Wandelt study found it was job satisfaction and a nursing administration you can work with.

Nurses who work independently in rural clinics are facing obstacles created by chal- lenges to their authority to work under standing orders. For the past two years, nurses have been working for legislation to override an at- torney general’s opinion against the common practice.

The issue arose with the passage of the Rural Health Clinics Services Act in 1978. Nurse practitioners and physician’s assistants were authorized to receive Medicare and Medicaid reimbursement for services ren- dered under indirect physician supervision. This new national legislation was intended to make health care services more available in outlying areas. The rural areas of southern Texas are among the poorest in the nation. Twenty-two counties have no physician.

Soon after the act was passed, State Sen Chet Brooks asked the attorney general whether professional nurses with advanced education could perform a variety of functions without having a physician physically present. Differentiating between nursing and medical functions, the attorney general replied that nurses could carry out nursing functions with- out direct supervision. On written protocols, he said nurses could carry out acts involving nurs- ing practice independently, but they required physician supervision and control for dele-

gated medical functions. The attorney general believed standing or

written orders for medic-’ion were not per- missable because the law permits nurses to administer medications but not to prescribe them. “We believe the statutory language im- plies that a physician is to decide that medica- tion is needed,” he stated. “We believe our courts would probably hold that the provision of medication pursuant to standing orders, without a physician’s prescription for the indi- vidual patient, would constitute the practice of medicine and not a nursing act.”

Since the ruling, legislation has been intro- duced to give RNs the explicit legal authority to function under protocols, but it has not passed. The Board of Medical Examine; 3 adopted rules and regulations about standing orders, but these raised more questions than they answered. Last July, Senator Brooks again wrote the attorney general with 17 specific questions about the medical board rules. As of mid-December, the attorney general had not replied, and the issue was left hanging. Unfor- tunately, the climate in the next session of the state legislature may not be hospitable to legis- lation that could correct the protocol problem. According to Dorothy Schloss, many friends of nursing lost in the election.

As if these problems weren’t enough, the Texas Board of Nurse Examiners has been sued over rules it issued for advanced nursing practice. (See AORN Journal, August 1980, 322.) Many states have legally provided for expanded nursing practice, such as nurse- midwifery. But the Texas Medical Association and Texas Hospital Association took excep- tion to the nursing board’s authority, and took them to court.

After the suit was filed, the attorney general wrote an o?inion saying he did not believe the hospital alId medical groups had reason to bring the action, since their practice would not be affected. As of mid-December, no further action had been taken.

Patricia Patterson Associate editor

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