I've lived through every one of the last 50 years in nursing, and I can tell you for sure that things have really changed (mostly for the better) and a lot of things have remained the same (mostly for the worse)! Among the things that have changed: Over the last 50 years, nursing has fulfilled Florence Nightingale's vision for it. When criticized for insisting that her trained nurses should be paid (critics said care of the sick was a corporal work of mercy and, as such, shouldn't require pay), Nightingale reportedly said, “I would far rather open a career, highly paid, than start a religious order.”
Nursing has unionized, expanded education, specialized, and developed advanced roles. We've also proliferated the number of organizations representing various nurses from 5 to about 105 and considerably increased average RN salaries from about $5,200 annually 50 years ago when the median US household income was $7,200 to $71,730 a year when the median household income is $63,688. Advanced practice RNs (APRNs) make more, with an average income of $93,128.
Of course, responsibilities have also changed. We used to take care of patients by giving them backrubs and baths, along with administering medications, performing dressing changes, taking vital signs (sharing one sphygmomanometer and stethoscope), and making frequent linen changes (at least once a day). We carried an average patient load of 10 to 15 patients on the day shift (acuity ranged from off-the-charts to self-care), and there was rarely more than one RN on the night shift. Today, RNs may carry anywhere from three to six patients on the day shift, but all of them would've been on the ICU (if it had been invented yet) 50 years ago. Moreover, there's a lot of churn: 50 years ago, the average patient stay was about 9 or 10 days. Today, it's about 3 days. Patients now not only go home quicker and sicker, but they also go home before the anesthesia is off their breath!
This churn, along with higher acuity, shift changes, and significantly increased clinical responsibilities, has led to the greatest change of all: RNs are more likely to delegate and supervise care than to give it. The nurse-patient relationship has altered accordingly; we certainly don't give backrubs anymore. Nurses need technologic training to work with enhanced medications, computers, and other digital devices, and we understand patients' tests, ECGs, and prognoses—and this isn't advanced practice.
APRNs include NPs, clinical nurse specialists, nurse anesthetists, and nurse midwives. According to the American Nurses Association, APRNs “treat and diagnose illnesses, advise the public on health issues, manage chronic disease, and engage in continuous education to remain ahead of any technological, methodological, or other developments in the field. APRNs hold at least a master's degree, in addition to the initial nursing education and licensing required for all RNs.”
What about the nurse manager, then and now? On Nursing Management's 25th anniversary, I wrote in “25 Years: A Slightly Irreverent Retrospective,” “Do you remember the nursing supervisor of yore? Authority in gleaming white. ... Spotless white cap...snow white uniform, opaque white stockings, and sensible, spotless white shoes combined to overwhelming effect. Her gold nursing pin was placed neatly above [her] name tag... The tag read ‘Miss Smith, RN, Nursing Supervisor.’ To see her was to respect her.” Today, the average nurses' uniform is scrubs. The average manager may wear scrubs, but generally also wears a white coat with his or her name and the name of the hospital embroidered on it. The higher up the management ladder you go, the less likely it is that the nurse leader will wear either. Nurse leader salaries generally range from $89,000 to $198,000. And today's CNO is a lot different than yesteryear's director of nursing, an RN who exercised responsibility in a managerial capacity, with duties that included hiring, supervising, and reviewing nursing staff; maintaining high standards of care; overseeing department budgets; reporting to higher-level staff members; managing patients' data and medical records; interacting with physicians, patients, and family members; and other duties as necessary.
Today's CNO has all these duties and more—much more. The CNO works with other healthcare leaders to establish policies that benefit staff and improve clinical care. He or she will likely be involved in advising senior management on best nursing practices, creating retention programs, establishing compensation wages, managing nursing budgets, planning new patient services, conducting performance assessments, and representing clinicians at board meetings. CNOs often spearhead personnel management, which means implementing the recruitment, hiring, and retention processes. They manage staff members working in multiple nursing departments in their health system but still report to the facility's CEO. They may also be corporate CNOs whose primary role is to standardize, develop, and ensure the appropriate translation of evidence-based care into daily practice—not just for nursing, but all clinical care (except medicine) throughout the health system continuum.
All of this sounds most impressive, and indeed it is. But the most important thing was well-said by Nursing Management's founding Editor Dorothy Kelly, “Perhaps [the old director of nursing] operated in a simpler day. Perhaps what nursing accomplishes today must be the work of a committee... It probably doesn't matter how we do things, just so long as we keep our eye and our heart on the patients. They are the ones who need us.” With these few words, she defined nursing's “stability zone.” One that she—and we—must hold safe as the pace of change accelerates faster every year.