I stop you on the street and ask you to describe a "nurse:' Let's see: Your great-great aunt, who was a pioneer nurse on horseback, was the sole source of medical care for a large part of Nebraska. What a magnificent woman! Oh, but then you remember the school nurse who did nothing but apply bandaids, or call your mother when you were sick. What a bimbo she was! Soap operas are full of nurses who flirt with doctors and don't seem to fit either of these images. Clearly, nurses seem an undefined group.

What does it mean to be a nurse and how does one become a nurse in the U.S.? When I decided to go to nursing school I was considered an oddity by many, a disappointment by some, and a young woman with a career future by a very few. Basically it was a choice which I do not regret, but one which I have often felt the need to justify. The high powered academic community in which I grew up could not comprehend my decision. Perhaps those people knew too few pioneer nurses. Certainly in that community the concept of active service was considered secondary to intellectual pursuits. But the opportunity for active service was one of the most powerful, positive forces which led me into nursing and which I share with many of my colleagues. I wanted to spend my eight or ten working hours playing an active role in the lives of other human beings. I made my career decision in the 1960s during a time of social upheaval, doubt and cynicism among college students in general and women in particular. However, I knew that I wanted a job with a purpose. What leads my colleagues into nursing?

How many times are we asked as we progress through school, "What do you want to be when you grow up?" The answer will change many times before reality and maturity make the decision final, but for a fair number of American girls the answer sometime during their development is, "I want to be a nurse." Certainly until recently very few boys gave that answer. What does it mean to be a nurse, and what has happened to the nursing profession to lift the sexual restrictions and alter the goals and aspirations of the young people choosing this profession?

The nursing profession has gone through a maturation process during the past twenty years. It has spent a good deal of time and energy seeking to define its identity and trying to professionalize its image. The exceptional nurses over the years have tried to give their work shape and form, something which could hold its own in the health world. However, for reasons that I will go on to elaborate, external as well as internal pressures have kept it from being as successful as many of us had hoped that it would be. Nursing has suffered, and continues to suffer, from less standardization in educational requirements or in training process, and less uniformity in job definition than many other professions.

What do young people have in mind when they choose careers in nursing? Probaby most are about as unrealistic as their friends who hope to become plumbers, doctors, teachers or restaurant owners. Some see glamour in working with doctors in life and death situations. Many are glad to know that a job is most likely available at any time and in any place. But I venture to say that underlying these reasons is the desire to have a job in which they can help in some concrete way. To be able to make a difference in other people's lives. Corny but true.

I will restrict my discussion to the R.N., (registered nurse). Even the name is confusing, for "nurse" often refers to almost anyone in a white uniform in this country.

Today in the the U.S. most R.N.s receive basic nursing training in three ways: 1) in a three year hospital-based certificate course; 2) in a two or three year junior or technical college based diploma course; 3) in a four or five year university based program resulting in a B.S.N. (Bachelor of Science in Nursing). There is little uniformity in nursing curriculums. Nurses take courses in anatomy and physiology, microbiology and psychology. The B.S.N. students receive training in public health, while the other students do not. The certificate and diploma graduates receive a great deal more "hands on nursing" training and experience than do the B.S.N. graduates, while leadership, independent decision making and management skills are stressed in the university based programs. And yet upon graduation and after successfully passing the licensing exam, all of these students have become nurses. Even the licensing exam provides the profession little standardization, for each state establishes its own passing grade, and then reciprocity depends upon the score which was accomplished.

Professional socialization into nursing is also in a state of flux. Reality shock is certainly not unique to nursing graduates; all neophyte professionals feel the gap between themselves and the experienced worker. Learning to "think and act" like a professional of any kind is a gradual process that begins in school in the form of formal indoctrination and is completed during one's adaptation to the work force. For nurses, I am arguing, this process is made more difficult by the lack of confidence of the indoctrinators and the multitude of conflicting expectations of the work place. Perhaps I first really felt like a nurse when it was I who was being asked the questions, rather than asking them. You can not imagine how sobering it is to have a patient depend upon your skills and judgment with almost divine-like expectations. New doctors also experience this, but they are programmed to expect it. New nurses are revered more by some of their patients than we are ever prepared for. When a patient treats you as if you are an authority, you suddenly find yourself thinking all the trials of nursing school were worth it. You are really a nurse and it is fun. But new nurses are all too familiar with the negative feedback they also receive. Nothing seems to be done in quite the same way as it was in nursing school.

When I was in nursing school from 1974-76 we were told that soon a "nurse" would be required to have a B.S.N., and that all other nurses, namely the L.PN.s (licensed practical nurses), and non-university graduates would be given another title. In other words, the students who had been encouraged to be independent thinkers, to be decision makers and problem solvers in their own right would be called nurses, while those who received more technical training would be called something else. Nursing as well as the working world would be able to recognize and reward a professional man or woman who was expected to have a fundamental grasp on a body of material and be able to apply it to a wide range of situations. Needless to say the nursing schools and nurses who were not university trained were not pleased with the prospect of a demotion. The proposal was seen as elitist by some and genuinely unnecessary by others. The nursing profession's own lack of cohesion and standardization is the major "internal pressure" preventing a clearer definition of nursing.

Job definitions are shaped by society as well as by the professional organization. What does society expect from nurses? One of the most important external pressures upon the nursing profession has been the medical community. Despite a valiant effort to the contrary, nursing has been and continues to be defined by the needs of doctors. Nursing's attempt to become an independent, self-reliant profession has been only partially successful. Both medicine and nursing will have to adapt to the rapidly changing health arena, but nursing continues to react to these changes, rather than to be a step ahead of them. Until the flux in the American health field settles down it will be very difficult for nurses to find their place. Particularly the B.S.N. graduates will continue to graduate from nursing school with a set of skills and aspirations which will conflict with those of their actual work place. Until nursing schools and the work force better define the job that they expect of nurses, and reward them accordingly, there will be a high rate of attrition among nurses. If bedside nursing is what we should aspire t0. then compensate the hard working hospital nurses with humane hours and decent pay. If becoming nurse practitioners or midwives or nurse anesthetists is what society needs, then encourage new training, new job definitions and new titles. But whatever the health care system demands in this country, the nurse needs to know when he or she enters nursing school what is going to be expected of him and her. This will not eliminate the "reality shock" of suddenly finding oneself expected to function as a nurse after graduation, but it will clarify the role that will be expected of the new nursing graduate. Clearer job definitions will also give the health care industry the opportunity to use these skills more wisely. This country needs to reward those with a mission for service or it will suffer in the future.