Restructuring hospital nursing: reversing the trend toward a professional work force

Registered nurses are currently threatened by a new managerial strategy to restructure work on hospital wards through the implementation of "Continuous Quality Improvement" and the "downsizing" of the professional work force. The strategy reintroduces nonprofessional and unlicensed nursing personnel in a manner that may displace large numbers of registered nurses (RNs) and affect patient care adversely. Ironically, not only is this change being implemented principally to reduce hospital costs rather than to improve quality, it reverses the cost-containment strategy implemented in the 1980s when hospitals displaced nonprofessional nursing workers and moved toward a professional work force. In this article, the author reviews the prior shift from "team nursing" with a stratified work force that included licensed practical nurses and nurses' aides to "primary nursing" and the trend toward all-RN staffing, and explains how this trend contributed to the present effort to reverse the process. The author then discusses current work redesign methods that have been adapted from traditional industrial applications to destroy work jurisdictions and further rationalize hospital production through the downsizing of the professional work force and the creation of cross-trained workers in a new team-based management approach. The article concludes by discussing nursing's response to corporate-imposed work restructuring and the significance of these changes.