On Duty: Power, Politics, and the History of Nursing in New Jersey

6. Autonomy: Into the Twenty-First Century

172 C h a p t e r 6 ˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚˚ Autonomy Into the Twenty-First Century On May 31, 1989, a subcommittee of the House of Representatives’ Committee on the Judiciary heard testimony on the Immigration Nursing Relief Act of 1989. Faced with a nursing shortage, legislators wanted to “stop the hemorrhaging” by providing permanent resident status of foreign-born registered nurses and by implementing measures to “make the profession more appealing and accessible to U.S. labor.”1 Darlene Cox Cheaney, nursing administrator at University Hospital in Newark , urged the bill’s passage, claiming the loss of sixty-eight foreign nurses would close eleven critical care and sixty medical-surgical beds. Constance Patten, vice president for nursing of Raritan Bay Medical Center in Perth Amboy, noted that foreign nurses were “vital to the maintenance” of health care since continuing changes in delivery would “only reinforce this demand [for nurses].”2 The Nursing Relief Act, cosponsored by thirty-one legislators, nine from New Jersey, became law on December 18, 1989. Since it “placed increased responsibility on institutions to solve nursing shortage problems before relying on immigration,” both the New Jersey State Nurses’ Association and the American Nurses Association (ANA) had supported it, the ANA urging hospitals to employ nurses above prevailing wage rates in areas that were most affected.3 In a retrospective analysis of U.S. recruitment of foreign nurses during the period 1965–2002, Barbara Brush and her colleagues speculated that such recruitment would “continue to operate unless efforts are made to improve nurses’ work environment, job satisfaction, and retention.”4 While nurse executives needed immediate relief from the nurse shortage, nurse leaders, distant from the daily fray, wanted a tool to hold hospital executives accountable for the enhanced recruitment and retention efforts of U.S. nurses. The tensions driving these two cohorts—nurse executives threatened with bed closures and nurse leaders focusing on broad policies—emanated from Autonomy: Into the Twenty-First Century 173 different sources of urgency. For nurse executives, bed closures, emergency room diversions, and patient issues demanded immediate solutions. For nurse leaders, professional autonomy and self-regulation were paramount. Once the Nursing Relief Act passed, thus keeping beds open, demands for the enhanced status of hospital-employed registered nurses had a legitimate platform from which to be launched. The Nursing Relief Act illustrates the complex interplay between short- and long-term goals as well as the dichotomization of service and policy in President Ronald Reagan’s era—an era emphasizing less government control in an increasingly competitive capitalist culture. As health was corporatized in the 1980s, hospital nursing services were bundled under “room and board” charges. Nurse leaders, battling for professional validation, sought direct reimbursement from payers for services rendered. Nursing’s embrace of capitalism, however, came at a time when citizens had reached a “negative consensus on the American healthcare system.”5 Health care had become too costly and uncontrolled. Educational Complexities Promising to decrease government spending, Reagan targeted reductions in health personnel training and nursing education, hoping to pare down to the bare bones the Nurse Training Act.6 The Nurse Training Act Amendments of 1979 included a mandate to study the need for continued federal support for Figure 6.1. Darlene L. Cox, chief nurse and administrator of patient care services at the University of Medicine and Dentistry of New Jersey—University Hospital, Newark, from 1986 to 1994 (Courtesy of Ms. Darlene L. Cox) 174 On Duty nursing education. The Institute of Medicine (IOM) was directed to answer three questions: Was federal support needed for nursing education? Why do nurses not practice in medically underserved areas, and how could they be encouraged to do so? Why do nurses leave nursing and how could they be encouraged to remain in (or to reenter) the field? A corollary question was also asked: How can practice settings be more conducive to the retention of nurses?7 Within two years, the IOM gave Reagan the validation needed to reduce nursing support. “No specific federal funding is needed to increase the overall supply of registered nurses,” the IOM concluded, “because estimates indicate that the aggregate supply and demand for generalist nurses will be in reasonable balance during this decade [1980–1990].”8 The IOM advocated expansion of graduate education, creation of incentive programs to attract and retain indigenous urban residents into nursing, incorporation of geriatrics in nursing education programs, continued financial support for nurse practitioners...