TODAY'S NURSE, NO LONGER A HANDMAIDEN

Dawn Dresel, R.N. at Saint Francis Medical Center, checked patient's charts for lab results, records and medications.

There was a time when a nurse's duties were pretty straightforward: You did whatever the doctor said and whatever it took to make the patient more comfortable.

Times have changed. Nurses today are making more critical decisions, including initial assessments of patients who need acute care, and doing more management tasks.

Nurses are more autonomous now, said Karen Hendrickson, assistant administrator at Southeast Missouri.

In addition to working at the bedside with the patient, she said, nurses are involved with research and case management, making sure the patient moves smoothly through the health care delivery process.

The nurse no longer serves as "a handmaiden" to physicians, Hendrickson said.

"We've evolved from that to being a profession that is independently licensed from the physician," she said.

But, she added, teamwork between physicians and nurses is still essential to good health care.

And nurses, like physicians, have become more specialized. Advanced practice nursing -- nurse practitioners, nurse midwives, clinical nurse specialists and certified registered nurse anesthetists -- is the career fast-track for nurses now.

Maggie Schuch, R.N., manages the cardiothoracic intensive care unit at Southeast Missouri Hospital.

"I remember when I first got out of nursing school, the head nurse at one place where I worked used to get coffee for the doctors," she said. "That doesn't happen anymore."

Schuch works at the bedside with the patient and doing typical management stuff -- paperwork, scheduling, etc. She is also the clinical expert in the unit.

"I think I get a unique point of view regarding the nursing staff, what their competencies are, what their capabilities are, what the issues are, that I wouldn't have if I merely sat in the office," Schuch said.

Schuch, who has 15 years' experience as a nurse, is one of a growing number of nurses seeking advanced degrees. She is working on her master's degree in nursing.

"Nurses are seeking advanced degrees more than they ever have before," she said.

Before 1980, Schuch said, most nurses received their degrees from hospital-based programs.

"It was a lot of hands-on work, but not a lot of book work," she said.

Now nurses have to keep up with changes in technology and changes wrought by managed care, Schuch said.

Hendrickson cited reports from the National League for Nursing that the nurse-practitioner certification is the most sought-after designation by nurses and employers.

Nurse-practitioners work under the guidance of a cooperating physician, but are able to diagnose, treat patients and prescribe medication on their own.

Managed care is the impetus, Hendrickson said. Nurse practitioners "are more cost-effective," particularly for primary care, so insurance companies and health care providers prefer to use them as health care resources.

Nurse practitioners also improve health care access in medically underserved areas where patients may not be able to get into see a physician.

Hendrickson, a nurse herself, also has a doctorate in education.

Caring for the patient is still at the core of nursing.

"The only reason patients come to the hospital is for nursing care," Schuch said. "Otherwise they could be outpatient."

Nurses have taken on the role of patient advocate in recent years, she said, "trying to safeguard quality outcomes. There have been so many concerns with health care corporations and big insurance companies trying to meet the bottom line that we've had no choice but to safeguard patient rights."

The push to cut health care costs means hospital patients are sicker now than in years past, which means they require more intensive care, said Jeannie Fadler, vice president of patient care at St. Francis Medical Center, who has 25 years' experience in nursing.

"The patients that we had in ICU 25 years ago are today in the home being cared for either by a home health nurse or a by a family member," Fadler said.

Because patients are sicker, nurses' diagnostic and assessment skills have to be sharper, she said.

Tonya Buttry, chairperson of Southeast Missouri Hospital's College of Nursing, said nursing education has changed tremendously in the last several years, reflecting changes in health care.

"The curriculum in the core areas -- what causes an infection -- has remained the same. What has changed is who we're caring for. We're trying to teach our students more about how to care for people in the community as opposed to in a hospital," Buttry said.

When Buttry went to nursing school, most of her courses and practicums were based on care in the hospital setting.

But people are spending less and less time in the hospital, and more in nursing homes, rehabilitative centers or at home. That means nurses have to learn new ways to care for patients.

"We're trying to get our folks into clinical settings in the community," Buttry said. That means going into nursing homes, home health agencies, doctors' office and schools.

"Many of our graduates are going on to work in those settings, as opposed to hospitals," she said.