A historical perspective on the nursing shortage, EA West, WP Griffith, R Iphofen

Tags: nursing shortage, nursing practice, health care, profession, work environment, Florence Nightingale, New York, job satisfaction, Cooter & Pickstone, Canadian Journal of Nursing Leadership, Australian Nursing Journal, nurse education, National League of Nursing, nursing education, American Journal of Nursing, Journal of Advanced Nursing, professionalism, institution, American Association of Historical Nursing, University of Wales, Bangor, United Kingdom, Historical Perspective, image distortion, Western medicine, patient care, Journal of Holistic Nursing, comparative analysis, Nelson, R., satisfaction, Griffith Ron Iphofen, Health care delivery systems, Harvard Business School Press, Edith A. West, Nursing Shortage Recruitment, Indiana University of Pennsylvania, medical specialization, skilled profession, Senior Lecturer, School of History & Welsh History, Hong Kong Nursing Journal, professional education, student nurse, Institute for Women's Policy Report, Reno, student nurses, retention issues, health care professionals, care provision, nursing education and practice, recruitment literature, health care system, American nurses, American Association of Occupational Health Nursing, occupational health nurses, Rehabilitation Nursing, British Journal of Nursing, Journal of Health Economics, Contemporary Pediatrics, business values, Oxford University Press, 14_4.htm New Hampshire Nurses' Association
Content: Edith A. West W.P. Griffith Ron Iphofen A historical perspective on the Nursing Shortage
Recruitment and retention problems, public image distortion, and negative work environment have been the major contributors to nursing's continual "shortages" throughout the years (Armstrong, 2002; Vonfrolio, 2006). It is not possible to isolate a single causative factor because of the problem's complexity. The literature also contains no simple description of the status of the nursing shortage. However, health care leaders agree that the current shortage has a negative impact on the nursing practice environment, nurse retention, and the profession's ability to recruit nurses; the problem is global in scope and heading for crisis if not abated (American Association of Historical Nursing [AAHN], 2001; CNN, 2001; National League of Nursing [NLN], 2002; Peterson, Edith A. West, MSN, APRN, BC, is Assistant Professor of Nursing, Indiana University of Pennsylvania, Indiana, PA. W.P. Griffith, BA, PhD, is Senior Lecturer, School of History & Welsh History, University of Wales, Bangor, United Kingdom. Ron Iphofen, PhD, MSc, D Hyp, Cert tHE, BA, BPhil, is Medical Sociologist and Director of Postgraduate Studies, School of Healthcare Sciences, University of Wales, Bangor, United Kingdom.
2001). Most experts also agree that for sustained change and assurance of an adequate supply of nurses, solutions must be developed in areas of education, health care delivery systems, policy, regulation, and image (Nevidjon & Erickson, 2001). The Usual Suspects: External Barriers to Change Since the dawn of "the golden age" of Western medicine in the 1800s, the demand for nursing services has become part of a wider demand for medical care (Cooter & Pickstone, 2003; Leathhard, 2000). The evolution of medical specialization brought in its wake a host of ancillary skill practitioners, such as therapists, pharmacists, and X-ray and lab technicians. Nursing, which was never really highly prized because of its history as a "female" vocation from the start, came to be viewed as just another ancillary skill (Davies, 1980; Lancaster, 1999). When a medical model was introduced in nursing education at the turn of the 20th century, the trajectory of nursing changed from that of a "vocation" essentially providing comfort to dying, hopeless cases, to one of a trained, highly skilled profession (AbelSmith, 1960; Lancaster, 1999). The application of science to medicine (and nursing), coupled with immense technical advances in the treatment of sickness over the
years, have made an increasing demand on the intellectual and technical skills of nurses. As medical mastery of techniques in the cure and treatment of disease progressed, and an array of specialty areas arose, a great deal of what was once considered exclusively medical practice became a routine part of nursing practice. For instance, skills such as intravenous therapy, blood transfusions, nasogastric intubations, medication administration, and multiple sterile procedures once were performed exclusively by physicians. The increase in clinical responsibility has led nurses to give most custodial patient care, once considered the center of nursing practice by Florence Nightingale, to unlicensed nursing assistants and domestic and housekeeping staff (Applebee, 2006; Wilson, 2006). Health care delivery systems also evolved to keep pace with advances in medical Science and Technology by shifting focus from community (public health) roots to a more institutionalized model for the provision of care (Connolly, 1998). This shift was driven by the mostly male medical community whose phenomenal achievements in the war against disease, made possible in large part by major discoveries in the biological and physical sciences, gained them powerful political allies and unprecedent-
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ed public recognition and support (Cooter & Pickstone, 2003; Leathhard, 2000). Medicine rapidly became the professional discipline and gatekeeper to the burgeoning diagnostic and treatment resources now being housed in institutional settings, and physician education began to include areas of specialization as well. With the aid of substantial investments by governments and philanthropists, medical institutions for education, research, and specialized patient care began to expand. This financial backing, coupled with overwhelming success in the treatment and cure of disease, brought physicians public recognition, confidence, authority, and a very powerful political lobby (Cooter & Pickstone, 2003). Nursing, on the other hand, was handicapped by the fact that virtually all its practitioners were female at a time when this precluded any serious aspirations toward empowerment by either the existing political establishment or the general public. At the end of the 19th century, Florence Nightingale's strategy of nurse education meant staffing hospitals with a strictly disciplined labor force of probationers who practiced under the watchful eye of physicians; this model was based on hospitals' existing institutional framework. Nightingale's effort to make the profession "respectable" was tied to the prevailing Victorian idea of womanhood, with nursing subordinate to medicine (Leathard, 2000). This inherently created a system that was too strict to yield enough nurses to meet the demand, even at a time when women were not given a choice of vocation outside of teaching or nursing. The system of nurse education conceived in this fashion made political and economic sense for its time (Davies, 1980; Leathard, 2000). The model existed until the start of the 20th century, when the battle for control of nurse education, better standards, and recognition began. With it came a debate concerning the cyclic staff shortages that perpetually plagued institutional
settings as their number increased due to urbanization, industrialization, and immigration (Connolly, 1998). Hospital nurse training schools opened because of a need for staff, but often the advertised nursing education did not exist. It was an exploitative system whereby a cheap labor force of female nurses worked 12-hour days, 6 days a week, 50 weeks per year in a strict, paternalistic, demanding environment, without any contractual agreement to the hospital or the school at the completion of the training (Baly, 1995; Connolly, 1998; Davies, 1980). The prevailing ideology was that nursing was an occupation that required a specific temperament or nature best suited to a woman and required no skill or intellect. It was perpetuated by the few women within the profession in a position of authority who became the profession's gatekeepers (Williams, 2000). AUTHOR: Williams not listed in reference list. Historically, hospital administrators chose the women for these positions with input from the staff physicians. Hospitals and physicians in particular have always had a keen interest in how nurses practice and have introduced other related state statutes and provisions to prohibit medical diagnosis and treatment, including prescribing and dispensing medications [AU: Please cite a source.]. This has hindered nurses' efforts to be recognized for reimbursement for services and to implement the full scope of nursing practice (Cooter & Pickstone, 2003; Leathard, 2000). Historically, nursing education and practice environments were defined, structured, reformed, and restructured in large part by non-nurses. Nurse leaders, made vulnerable by ambivalence to class and craft (or vocation) versus profession issues, remained unable to make a clear, concise, collective impact at the bargaining table (Deloughery 1998; Olsen, 1991). Public recognition of nursing's contributions to patient care was obscured in part by the prevailing medical model. It was also
affected by the move from community (public health), where nurses functioned much more independently, to the institution, where medicine dominated all aspects of care provision. The primary problem surrounding recruitment and retention issues in nursing education and practice was a continual lack of consistent adequate financial support aimed at not just recruiting but also retaining nurses in practice (Gabe, Kelleher, & Williams, 1994). Also, nurses lacked the public recognition afforded to other professions, owing as much in part to their own modest, unassuming behaviors, and an inherent predisposition to view their work as collaboration with other health care professionals rather than solely attributed to them. Nursing also has had to justify its value to society, in large part due to the "Angel of Mercy" image that was perpetuated during wartime both inside and outside the discipline in efforts to recruit nurses during another shortage (Norman, 2000; Wick, 1987). Few have attempted to deal with such issues of nursing work as a narrow pay range, little extra pay for working undesirable shifts, disincentives for full-time work (particularly for married women with children), and pay unrelated to educational expertise (Institute for Women's Policy Report, 2006). Real sustained positive change would certainly need to include licensing nurses with one entry level to practice according to their education; allowing them to practice autonomously as equal contributing members of any health care team alongside other health care practitioners in accordance with their professional competencies and education; and paying them accordingly (Reno, 2002). The Not-So-Usual Suspects: Internal Barriers to Change The literature is filled with research on the most recent nursing shortage, job satisfaction, nursing's image, and virtually all external elements that impact the discipline (Forsyth & McKenzie, 2006; Ku, 2005; Nethenson, Schafer, &
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Anderson, 2007; Raymond, 2004; Salvage, 2006; Sengin, 2001; Spiers, 2006). What is curiously lacking is any internal analysis of the problems surrounding these issues. History presents observational data that can document relationships or discover an association between two or more variables. These observations can reveal emerging trends and illustrate responses which might be applicable today in some form. Consistently stressful work environments with little monetary or prestige incentives for nurses have been a mainstay in nursing history. The following excerpts are documented responses from nursing students in training at the time of a previous nursing shortage, which occurred 59 years ago. As part of a survey designed to determine why student nurses left training in the midst of a nursing shortage in the 1940s, the following comments were made (Cohen, 1948): · Priority given to tidying of lock- ers and straightening of beds before the care of the patients. · The unfair working of routine by retention of nurses on duty after time for relief, without compensation. · Nurses have frequently to miss a meal because they are delayed by a lengthy dressing or post operation treatment. If the nurse is 10 minutes late for the meal, she is severely reprimanded without the cause of lateness having been ascertained: the reason for lateness may not be volunteered. Should the patient be neglected in such cases? · The first few months of training are to most girls a nightmare. She becomes seriously afraid of being reprimanded and humiliated in the presence of the patients for several of the minor offences due to lack of experience and knowledge. · I was placed on night duty and was on duty for 21 consecutive nights without a break. When I complained, I was told I was bring disloyal to the nursing profession. My case was not the only instance of nurses working 21 nights without a
break. · Unjustified reproach when nurses report sick. · The constant harsh and unfair treatment meted out... · The rudeness...to young nurses starting their training. The first thing which greeted me...was, "What will they employ next? They seem to send me anything." · The long working hours and short leisure periods, and interference with those leisure periods...when off duty. · The present iron-rod discipline which seems to be thought necessary should be replaced by understanding and leadership. · Bewildered by the thousand and one duties, many futile, finding no sympathy in those above...and not given credit for a grain of intelligence. Any attempt to justify oneself was insubordination. A report which included these remarks was published by DR. Cohen [AU: Who was Dr. Cohen and what were the circumstances of his report?] in 1948 to address a nursing shortage and recommended, amongst other things, the "humanizing" of hospital discipline for nurses. These remarks underscore the uncaring atmosphere that existed within an institutional culture that purportedly provided care. Students described the work environment as unfair, unduly harsh with long hours and little leisure time, unnecessarily strict with patient-focused care deferred in preference routines and record keeping. Cohen also suggested that any reform implied criticism of the senior nursing staff or required a curtailment of their power over the student nurse would likely meet resistance. He added that the institution itself also had a policy or established interest to defend, only those who could view the situation dispassionately, even when their own interests seemed affected, were likely to welcome change. Cohen (1948) also suggested a "scientific approach" to hours of work, conditions, energy or output required of the nurses and of nurse to patient ratio, and rightly compared this new health care
system to an "industry." He also suggested a discipline for students and nurses befitting a professional life, salaries based on consideration of "productivity," and working arrangements which would not be subordinate to the existing routine of medical ward visits that constituted one of the chief obstacles to introducing a workable 3-shift work day for nurses. This assessment by Dr. Cohen subscribes to the prevailing 20th century business model still in use to deliver health care (Arndt & Bigelow, 2006). It accepts a reward system for employees based on organizational performance which links skills-based pay to performance and increased productivity (Frederick, 1995). Many of these calls for reform, particularly those appropriate length of PROFESSIONAL EDUCATION, public acknowledgment and recognition, adequate working conditions with appropriate nurse-to-patient ratios and salary, were made over half a century ago in both America and Great Britain, yet are still being called for today (New Hampshire Nurses' Association,2004; Palmer, 2003; Trinkoff, 2006; Vonfrolio, 2006. Reform continues to be needed even after a great deal of study of these issues, suggesting that a purely "scientific" approach to these issues is not sufficient to address the "humanity" in the equation necessary and make the sustainable positive changes to the work culture that would keep nurses in practice. Nursing shortages have created many "fast track" nursing programs designed to shorten training for students, along with more funding sources to entice students to enter the field (Reno, 2002). This new strategy to address nursing's shortage issues is not really new. In the 1940s, the Cadet Corps was instituted to facilitate entry into the profession with accelerated training as demand exceeded supply of nurses during World War II (1941-1945). Yet, following the war, another shortage occurred (Reno, 2002). These efforts, along with legislation designed to help nursing
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when in crisis, have been a double-edged sword in regard to the recruitment and retention of nurses. The cycle has been that they are successful in bringing students in quickly with monetary incentives when there is a staffing crisis. However, economic solutions alone do not impact effectively for cultural change in the existing health care system and thus do little to keep nurses from leaving the profession (Reno, 2002). Economist Anthony Heyes recently argued that lower wages "attract better `vocationally called' nurses," with the inference that lower-paid nurses make better nurses (Heyes, 2005, p. 561-569 [AU: What exact page was the quote found on? Please pick one page only.]). He identified nurses as being in a" vocation-based sector" [AU: page number?] along with teachers. He argued that increasing wages "might attract the `wrong sort' of people into the profession and highlights an (in)efficiency wage mechanism." [AU: page number?] Nelson and Folbre (2006) indicated an alternate belief that wage incentives in the Unites States are one factor contributing to the nursing shortage and that wages actually retain "good" nurses. They discussed the impact of pay on employee morale and retention and emphasized that a calling to nursing does not necessarily guarantee skill. It can be argued that some individuals could well be attracted into nursing based solely on the objective rewards and either leave when the workload begins to take its toll and the pay no longer compensates for this or approach the job as less of a service and more of a business venture. It also may be that nurses who consider the profession a service vocation but find the existing system does not attach any value to this ideology are equally apt to leave the profession or find a way to live with the inherent job dissatisfaction. In both cases, the nurse is adversely affected and the decision to stay or go negatively affects patient care and the profession. The truth is, neither of these
viewpoints alone is correct or realistic. People enter professions to which they believe they are suited physically, mentally, emotionally, and spiritually. They also expect to be adequately compensated within the work environment. This has created a paradoxical approach to what is fundamentally a very complex problem. It has also forced nurses to take sides regarding whether good nursing care is the result of superior clinical and technical knowledge alone or having a calling to the profession when both are not only essential for good nursing care, but are also necessary to draw and keep "good" nurses in practice. Manifestation of the existing ambivalence within the profession has been most noticeable in the recent surge in literature aimed at debunking the supposed Nightingalism, which purportedly exists, and is thwarting professional advancement (Buchanan, 1999). Some have even suggested that due to the crisis in nursing, it is time to "retire Nightingale as a symbol" (Nelson, 2003, p. 48). One historical analysis seeking to determine the power utilized by Nightingale concluded that though she did demonstrate the leadership required to achieve major reforms, she was "not able to empower other nurses and this continues to have a lasting impact on nursing's development" (Selanders, 1998, p. 141). The counter argument is that a woman who was nursing's first theorist, researcher, statistician, administrator, educator, visionary, public image, and patient care reformer has decidedly empowered and inspired others (Easson-Bruno, 2003). The idea that this crisis is escalating exponentially in relation to both the dominant culture and technological advances is just beginning to enter the collective psyche of the general population. Light, Hopson, Hopson, and Hagen (2006) recently noted that most people are aware of the national shortage of nurses. They then proposed that "talented and skilled workers are entering and leaving the health-care profes-
sions in a revolving-door-fashion," crediting stress as a symptom and citing the cause as "problems from every facet of society falling on health care workers" (p. B11). The authors then focused on a new phenomenon of workplace violence (verbal and in some cases physical), which is a direct result of the increased pressure placed on health care workers who choose to remain in the industry. This situation creates a cyclical crisis (as a recent study completed by the Federation of Nurses and health professionals [AU: Please cite a source for this.] aptly illustrates). Nurses leave the profession, thereby generating an environment that is even more difficult for the nurses remaining. As many as 50% of currently employed RNs have considered leaving client care within the past 2 years. Another study completed by the American Nurses Association found as many as 54% of nurses would not recommend nursing as a profession (Palmer, 2003). Their reasons included inadequate staffing, heavy workloads, and increased use of mandatory overtime. Breaking the Negative Cycle by Bridging the Great Internal Divide While nurses must continue to advocate for change in the external barriers, they also need to address the internal barriers. A first step would be to develop strategies to bridge the gap that exists between nursing practice and education. Time has proven that though pay incentives and benefit packages will certainly draw nurses into the profession, they will do little to keep them if the work environment can be described as, "harsh, humiliating and futile" (Cohen, 1948, p. 72). Job dissatisfaction continues to be a key international contributor to the crisis of recruiting and retaining nurses. In Germany and Hong Kong, nurses also cited organizational climate as a key cause for their dissatisfaction (Demerouti, Bakker, Nachreiner, & Schaufeli, 2000; Siu, 2002). Dissatisfaction occurred not with salary issues,
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but in relation to feelings of being overloaded or due to factors that interfered with job and patient care, such as a lack of resources or a lack of a feeling of "achievement, recognition, and respect" (Demerouti et al., 2000, p. 454). Salary, hours of work, and tangible benefits have been considered important issues historically for nurses, but they have never been the sole indicators of satisfaction. In fact, they are often deemed secondary to issues of professional autonomy, good working relationships, and nurse-patient interactions [AU: Please cite a source.]. This reality is illustrated best when the order of importance within the work culture is reversed. In the United Kingdom, for example, where good relations existed between physicians and nurses and a team approach to care was valued within the institutional culture, nurses were most dissatisfied with their salaries (Grant, Nolan, Maguire, & Melhuish, 1994). Though the organizational climate was found to contribute to an increase in absenteeism in Hong Kong, nursing is a valued career with high pay and job security, nurses would not even consider leaving the profession (Siu, 2002). It could be argued that the focus on external motivators such as salary and other more tangible benefits to the exclusion of other, less tangible benefits has harmed the profession by causing some nurses to leave and those who remain to do so with feelings of disillusionment, dissatisfaction, frustration, and entrapment. The by-product of this crisis cycle was identified in nurses' work environments as "moral inhabitability" (Peter, MacFarlane, & O'Brien-Pallas, 2004, p. 359) in a recent Canadian study. This study focused on the difficult work environments of nurses and concluded that these environments had significant ethical implications for nurses. Chief among them were feelings of oppression, powerlessness, exploitation, marginalization, and interpersonal hostility for nurses. Work environments were perceived as dominated by medical
or business values and nursing perspectives were marginalized. The study concluded that the work environment was "morally uninhabitable" (p. 359) for nurses. Yet, even in these conditions nurses had still managed to find meaningful ways to resist this culture and positively influence the moral environment. Perhaps what is most telling about this particular study is the patronizing, vitriolic commentary it generated from a male medical assistant who saw the issues it raised as merely something "endemic to modern organizational life" (Paley, 2004, p. 364). He argued that nursing's account of "familiar, everyday experiences as evidence for an erosion of something specific to nursing" in the study as not being "authoritative" as it was based on "self-report and the nurses' self-justifying of (these) accounts" (p. 364). He reinforced the marginalization complaint raised by the nursing authors and also correctly interpreted the "moral inhabitability" being generated in the workplace "endemic to modern organizational life." The reality is that most people who choose to enter nursing believe that the heart and soul incentives are inherent to the profession and often do not look for them in recruitment literature (Williamson, 1990). Instead, they tend to look for the best tangible benefits being offered by employers and see them as another advantage to those inherent in a job where one is caring for people. However, when they find that these inherent humanitarian benefits not only do not exist but are not as highly valued as other skills inherent in nursing practice, they become disillusioned because incentives such as salary, paid sick leave, and vacation time do not adequately compensate for this lack (Peter et al., 2004). Conclusion History illustrates the struggle of early nursing professionals with problems similar to those of today. It also reveals methods, not wholly unlike those currently
used, which yielded similar results. History discourages by its habit of repetition, and discloses the human race's tenacity for outmoded ideas and methods. It also encourages, by bringing to light progress made, and the role earnestness and persistence played in its advance (Goodnow, 1921). Nursing's history provides contemporary nurses with the same intellectual and political tools that their predecessors applied to shape nursing values and beliefs to the social context of their times. It is a valid testimony meant to incite, instruct, and inspire today's nurses as they progress through new problems created by a rapidly changing health care system (AAHN, 2001). Nursing's advancement continues to be hampered by the schisms that persist within its own discipline. A dichotomy exists even today regarding what value (if any) should be placed on the concepts of compassion and care when intellect and technological skill mastery may be more highly esteemed by society. The debate also continues between rank-and-file nurses and nursing leaders surrounding issues of professionalism versus unionism; the truth is that unions and professional associations respond to market changes in much the same way (Davies, 1980; Olsen, 1991). The question of where nurses should be educated and for how long has never been adequately answered as a result of this dichotomy. Nurses also have been identified as an oppressed group because of their lack of power and control in the workplace, specifically within health care institutions (Cleland, 1971; Davies & Beach, 2000; Rafferty, Robinson, & Elkan, 1997). In most cases, liberation from oppression cannot come from the leadership of the group or even from the dominant group. Rather, empowerment is said to come from unveiling the cycle of oppression and the myth developed in the system (Freire, 1971). It could be argued that nursing did not view itself nor did the general public view it as oppressed until its practice was
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forced into the system of institutionalized care. The question nursing needs to ask itself is, "Has institutional identity in both education and practice environments impeded the ability to impact more successfully for sustained, positive change within these environments?" (Olins, 1989, p. 14). If this is indeed the case, the tragedy has become that the defense mechanism being used to protect this identity, which has been to look outside of our own discipline for its causes, has led to further crisis with tragic effects on the discipline of nursing, nurses, patients, and the health care delivery environment (Pauchant, 1992). The crisis-prone individual manages in the belief that a crisis can be handled by increasing power or technology, denying the possibility of a crisis, or involving fate as an excuse to do nothing about it. Leaders may feel trapped by the same structural and bureaucratic rigidity as their employees or students within their organizations and end up merely trying to survive within them as well (Pauchant, 1992). The continual recruitment, retention, work environment, and image concerns that nursing faces are not caused solely by those barriers which exist external to the discipline, such as a lack of political power, funding, or the institutionalization of health care. They also are being created by the inability to deal with barriers within the discipline. Nursing shortages are created by both forces and cannot be stopped by merely viewing them as endemic to modern organizational life. They will not be halted solely through gaining political savvy or socio-economic clout, or by embracing science and technology over humanitarian aims either. In order for sustained positive change to occur in nursing practice environments, nurses must be willing to unveil those barriers within the discipline itself that deal with the very basic questions of identity and practice as professionals. When these questions are settled, we will then be in a position to draw the "right"
sort of people into the profession. It is these people who will then be able to create a "morally habitable" work environment for themselves as well as their patients that will keep them in practice and project an accurate image of the discipline that is a reflection of both the art and science that is nursing. References Abel-Smith, B. (1960). A history of the nurs- ing profession. London: Heinemann. American Association of Historical Nursing (AAHN). (2001). About AAHN. Retrieved January 18, 2007, from https:// secure.aahn.org/index.html Applebee, G. (2006). A brief history of medical professionalism and why professionalism matters. Contemporary Pediatrics, 23(10), 53-58. Armstrong, F. (2002). Time to change the image of nursing. Australian Nursing Journal, 10(5), 20-22. Arndt, M., & Bigelow, B. (2006). Toward the creation of an institutional logic for the management of hospitals: Efficiency in the early 1900s. Medical Care Research and Review, 63(3), 369-394. Baly, M.E. (1995). Nursing and social change (3rd ed.), London: Routledge. Berney, B., Needleman, J., & Kovner, C. (2005). Factors influencing the use of RN overtime in hospitals, 1995-2000. Journal of Nursing Scholarship, 37(2), 165-172. Buchanan, T. (1999). Nightingalism: Hunting nursing history. Collegian, 6(2), 28-33. Cleland, V. (1971). Sex discrimination: Nursing's most pervasive problem. American Journal of Nursing, 7, 542547. CNN. (2001, April 19). New survey says nursing shortage will get worse. Retrieved January 18, 2007, from http://archives.cnn.com/2001/HEALTH/ 04/19/nursing.shortage/index.html Cohen, J. (1948). Minority report: Working party on the recruitment and training of nurses. His Majesty's Stationery Office, London: Royal College of London Metropolitan Library Archives. Connolly, C.A. (1998). Hampton, Nutting, and rival gospels at the John Hopkins Hospital and Training School for Nurses 1889-1906. Image: Journal of Nursing Scholarship, 30(1), 23-29. Cooter, R., & Pickstone, J. (2003). Comparison to medicine in the twentieth century. London: Overseas Publishers Association, N.V. Davies, C. (1980). Rewriting nursing history. London: Croom Helm. Davies, C., & Beach, A. (2000). Interpreting professional self-regulation. London: Routledge. Deloughery, G. (1998). Issues and trends in nursing (3rd ed.), St. Louis, MO: Mosby. Demerouti, E., Bakker, A., Nachreiner, F., & Schaufeli, W. (2000). A model of burnout and life satisfaction amongst nurses. Journal of Advanced Nursing, 32(2), 454-464. Easson-Bruno, S. (2003). Don't blame
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EA West, WP Griffith, R Iphofen

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