Rethinking our Sacred Cows in Nursing

By Rose O. Sherman, EdD, RN, FAAN

I was reminded this week of how difficult it can be to challenge our “sacred cows” in nursing.  These are ideas or practice that we have held or done for so long that they often go unquestioned.  We have seen with evidence-based practice that we have challenged some of our clinical sacred cows such as instilling normal saline into endotracheal tubes before suctioning.  But sacred cows go beyond our clinical practice and often extend to our thinking about our own professional careers.  A good example is where we think our new graduates should begin their nursing practice.  A new graduate called me this week because she is having difficulty finding that first job.  When I asked her about her job search, not surprisingly it had been limited to acute care hospitals.  I asked her why and she told me that she had been told throughout her nursing program that every new graduate should have at least two years in an acute care environment prior to looking for employment in another setting.  In talking with colleagues, this advice is commonly given to our students.  But given our current healthcare environment, is this advice still practical or even possible for some graduates?

What is Different Today

Historically, more than 80% of the new graduate workforce have begun their practice in acute care settings.  There are very practical reasons why this advice has been given in the past.  Because of their size, hospitals and larger health systems have historically done much better on boarding of new staff than smaller settings and also have been willing to hire new graduates.  More than 60% of the nursing workforce worked in hospital settings and these were the sites of many career advancement opportunities.  Hospitals also tend to be higher paying settings.  Our health systems have been notoriously hospital-centric so not having hospital experience as a professional made you an outlier.

Today with health reform. the landscape is rapidly changing.  The most recent data we have nationally from 2013 indicates that 57% of nurses work in hospitals – a 5% decline from 2008.  The most rapidly growing employment opportunities today are in long-term care, home health, hospice and other community-based settings.  In some regions, new graduates are experiencing considerable difficulty finding employment in hospitals whose censuses may be declining and financial picture is uncertain.  When I read discussion boards that include comments from new graduates, many seem stunned and angry that the shortages being discussed don’t seem apparent in the employment marketplace.  Our profession has done a good job of conveying the remarkable opportunities that exist with a nursing career but failed to convey the message that these opportunities may not be in hospital settings and may not have a three 12 hour tour schedule a week.

What Can be Learned in Other Settings

In looking at some of the skills and competencies needed in the changing healthcare environment, a key question to ask is whether these can be developed in other settings.  I believe the answer to be yes and perhaps with effective onboarding – maybe even better than in acute care settings which tend to be well resourced and demand less in some ways in critical problem solving.  With changes in health reform, two key competencies will be managing patients across the continuum of care and population management.  With 10,000 Baby Boomers turning 65 each day, skills are managing a geriatric population are extremely important.  Where better to learn that than in a long-term care setting.  Home health environments provide enormously valuable skills in really understanding the challenges of managing care across the continuum.  Advanced care planning is a key concern today yet working in a hospice setting provides valuable insight into how challenging this can be.  These are the kind of discussions that we need to have with our new graduates.  Nursing is a professional career and not a “job”.  Professionals should always consider the competencies and skills that can be learned in any setting and how this could fit into their career planning.  Steve jobs offered some excellent insight into this with his 2005 commencement to the graduates of Stanford University when he reflected on his own career.   He observed ” you can’t connect the dots looking forward; you can only connect them looking backwards.  So you have to trust that the dots will somehow connect in your future.  You have to trust in something – your gut, destiny, life, karma, whatever.  This approach has never let me down, and has made all the difference in my life.”