For now over 75 years, The Baylor Line has been publishing vivid storytelling from across the Baylor Family. I don’t think our archives full of deep, inspirational features should live solely on shelves, so we are bringing them back to life in BL Classics. This May 1990 Classic piece profiles Dr. Phyllis Spear Karns, dean of Baylor’s School of Nursing, as she tackles a national nursing shortage, evolving healthcare demands, and a rapidly diversifying student body. From launching one of the first patient care management master’s programs to navigating rising enrollment and shifting demographics, Karns and associate dean Mary Nowotny reveal how Baylor prepared nurses for the complexities of 1990s healthcare. \
On the first day of each new semester at the Baylor University School of Nursing, Dr. Phyllis Spear Karns looks incoming students in the eye and reminds them that they are entering a profession—not just training for a job in a hospital. She tries to impress on them the level of accountability and responsibility that will be expected of them from day one. She emphasizes that the career they have chosen will be challenging and complex—yet full of rewards.
Karns, who received a bachelor of science in nursing degree from Baylor in 1960 and now serves as dean of the nursing school, also readily admits to these rookies that the program—and the profession—is more difficult today than when she attended school.
“I’m fond of saying to students that when I graduated thirty years ago, I went through the equivalent of five academic years of education and only had to learn half as much,” she jokes. “I also tell them the situation will only get worse for them—they will continue to be confronted by more technology, more complexity, more medical advances.
“If they haven’t walked out by the end of my speech, I know they’ll make it through the next two years,” she says with a laugh.
Although Karns may tease students about the challenges they will face, she and the school’s twenty faculty members take seriously the challenge they face in preparing students for the demands of today’s nursing profession.
In two short years, they must teach students to be compassionate and computer-literate, to somehow balance the traditions of Florence Nightingale with the demands of an increasingly complicated health-care delivery system. Students must learn to deal with age-old processes like childbirth as well as leading-edge procedures like organ transplants, to stand on the school’s Christian foundation while making the transition to the twenty-first century.
“We can’t teach students everything they need to know about nursing,” admits Dr. Mary Nowotny, associate dean of nursing. “But what we can and do teach them is critical thinking—the ability to make decisions on their feet.”
Managing patient care
Although critical thinking is not listed in the course catalog, it may very well be one of the most important parts of the nursing school’s curriculum today—for undergraduates and for candidates in a graduate program Baylor will introduce this fall.
To keep Baylor’s curriculum current and meaningful, the nursing faculty continually evaluates the school’s courses against industry trends. A case in point is the growing publicity in recent years about case management programs. Within the last ten years, the government, as well as private insurers, has challenged hospitals and physicians to lower the costs of delivering health care. At the same time, consumers are pushing for higher quality care. Caught between these seemingly contradictory demands are institutions and individual health-care practitioners, all searching for ways to operate more efficiently.
“One answer to this problem,” Nowotny says, “is for hospital or clinic personnel to monitor each patient’s care more closely—to view each case as an ongoing relationship rather than as a series of unrelated office visits or hospital stays.” The concept is called case, or patient, care management.
Although the term may be logical, health care professionals, to fill this emerging management trend, many nurses may currently possess the required skills and capabilities. Aware of the need for more extensive training programs, Baylor began several years ago to study ways to prepare practitioners for this new age of nursing.
The result is a new master’s program combining courses in traditional nursing theory, research, and ethics with business courses in budgeting and accounting and a detailed study of health-care policy and reimbursement.
According to Karns, a graduate of the program would be prepared to address the quality of patient care as well as cost containment.
“A common application of patient care management,” she says, “will probably be in an on-going care area, say in a breast cancer clinic. In such a setting, a nurse could coordinate the entire span of a patient’s care from initial diagnosis through testing, surgery, chemotherapy, and rehabilitation, ensuring that the day-to-day progression of testing and procedures is set up according to schedule.” The nurse would also manage the resources to pay for that care.
In the hospital environment, patient managers would coordinate care with primary nurses, physicians, social workers, home health-care providers, and families to develop, deliver, and evaluate patient care.
“The result of this new focus is more control for providers, lower costs for insurers and employers, and more consistent care for patients,” Karns says.
The concept of patient care manager is still so new that Baylor is one of the first nursing schools to offer such a study program at any level.
“This role is being developed by the seat of the pants in institutions today,” she says. “But once it catches on, it will spread like wildfire.”
The emerging role of patient care manager is only one of many opportunities that are available to today’s nursing school graduates.
Industry-wide cost consciousness has had a dramatic impact on employment options. Home health care and visiting nurse programs have mushroomed due to the push for shorter hospital stays and a trend toward less expensive outpatient surgery. The growth of alternative health-care delivery systems, like health maintenance organizations, has also increased the demand for skilled practitioners.
In the business sector, nurses are helping set up preventive or “wellness” programs aimed at cost-avoidance. In addition, large corporations and insurance companies are hiring nurses to manage their health benefit plans and implement cost-containing measures like second surgical opinions and precertification of non-emergency procedures.
“Even today, when most people think ‘nursing,’ they automatically think ‘hospitals,’” Karns laughs. “One of the greatest challenges of our profession is to broaden that image and wake people up to the reality of the 1990s.”
The threat of shortages
While the open window of opportunity is appealing to upcoming graduates, it has also contributed to a well-chronicled crisis in nursing—the shortage of qualified practitioners.
The decline in nursing students began nationally as early as the late 1970s. Opportunities for women abounded in business, in law, and in higher levels of medicine—areas traditionally dominated by men and associated with higher pay and greater perceived status than traditional female roles like nursing and teaching. Drawn by the promise of these new opportunities, fewer women pursued careers in nursing. In addition, inadequate compensation and overly stressful working conditions led some established nurses to pursue other careers.
During the 1980s, demands for qualified nurses increased significantly. Within the hospital environment, the use of diagnosis related groups (DRGs) has been a contributing factor. The DRG classification system was developed initially to standardize Medicare payments for common procedures and control the length of hospital stays. Since its implementation, the acuity level in hospitals has risen—which means the patients on each unit require more and attention from caregivers, and hospitals may have to hire additional personnel to support these demands.
Hospitals have also been admitting more elderly patients, who generally have more medical complications and require more care than younger patients. Chronic illnesses like cancer and AIDs also strain overloaded nursing staffs.
Despite doomsayer predictions that the United States will be short 200,000-300,000 nurses in the next few years, Karns asserts that the common beliefs about the nursing shortage are misconceptions.
“The shortage was not caused by great numbers of professionals leaving their practice,” she insists. “It was more the result of people moving from one area to another and of a greater demand for nurses than ever before—both in traditional hospital roles and in new opportunities for community service.
“I grant there is a downturn in this profession, just as there is in law or in teaching,” she continues. “The stress level in highly specialized units like critical care units and emergency rooms does take its toll. But a lot of the nurses move to other less stressful areas in nursing rather than leave the profession altogether.”
Karns believes the nursing shortage—whether misconceived or merely over publicized—has definitely contributed to the recent resurgence in nursing school enrollment nationwide.
Building the program
Although Baylor’s enrollment did not follow national downturns immediately, the trends hit where it hurt in 1987. That year, fall enrollment dropped below 100. That’s also the year that Karns came back to campus.
“The greatest challenge facing the school at that point was to increase the enrollment,” Karns recalls.
With her associates, Karns spent the next several years in concentrated recruiting efforts. Representatives traveled to high-school career nights, and the school placed ads in teen magazines to encourage early interest in the nursing profession. In addition to counseling coeds on the Waco campus, advisors worked closely with area community college students considering a career in nursing.
The hard work has paid off, and enrollment for this fall will top 150.
What has caused the upward shift in student enrollment? Besides the fact that her staff went out and beat the bushes, Karns believes the publicity about the nursing shortage has lured applicants toward the promise of job security. In addition, the image of nursing as a profession is being enhanced—with both higher salaries and greater responsibility afforded practitioners.
“I also have a more philosophical approach to support the statistics,” Karns confides. “I believe a lot of women who chose other professions in the seventies and eighties discovered that a high salary and a long title didn’t necessarily give them the satisfaction they expected. That realization led to a swing in focus from ‘me first’ to ‘others first’ and has made helping people a popular goal again.”
Consequently, nursing schools nationwide are seeing increases in returning students and in enrollment overall. Baylor’s statistics seem to support the trends—including a change in student demographics.
The nursing school once pulled 75 percent of its students from the Waco campus. Today, however, only about half of the incoming students have ever attended classes on the main campus.
At the same time, the average student age has increased. “Whereas once all of our students were in their early twenties, the age range for graduating seniors this year is twenty-two to thirty-eight,” Karns says, adding that many of the older students are also married and have families to support while they attend.
Minority enrollment is on the rise as well. About 17 percent of the school’s students are non-Caucasian, and several of those list English as their second language.
Male enrollment has also increased. Once an exclusively female institution, the nursing school currently has twelve male students representing almost 10 percent of its total enrollment.
Today’s students, notes Karns, have backgrounds as varied as their signatures.
“Some have just completed associate degrees at area community colleges and enroll at Baylor to pursue a four-year degree,” she explains. “Others already have baccalaureate degrees—in psychology or sociology, for example—and have discovered the difficulty of pursuing their chosen career without advanced degrees. Still others are returning students—those who left school years ago to enter the workplace or raise children and now want to finish their education.”
“Although not everyone can be a nurse, I do believe that as a profession it has something to offer just about everyone.”
Anticipating the nineties
With the changing pace of the healthcare industry and the changing face of its student body, the nursing school faces a number of challenges in the 1990s.
Karns lists continued aggressive recruiting as one of her top priorities.
“At our current growth rate, I don’t know whether we will reach the point where we have to cap our enrollment or if we will look at expanding our physical facilities,” she says. “But I’d much rather face those problems than face those low enrollment figures again.”
A related challenge will be in the recruitment and retention of faculty. With the shortage of nurses in the field and with pay scales in service meeting or exceeding those in academia, it will be more difficult to lure qualified people away from practice into the classroom.
“On the undergraduate level,” Nowotny interjects, “we must continue to revise the curriculum to reflect the changing demographics of patients. For example, we must incorporate more geriatric content into the program to address the growth of the aging population.”
Karns also predicts the school will face challenges in learning to deal with a more heterogeneous group of students.
Nowotny agrees. “The diverse student body is a new issue for private institutions like Baylor,” she says. “Older students and ethnic minority students have needs that are very different from the generic student who once came to Baylor straight from high school.”
Nowotny adds that the nursing school is also struggling to educate students with lower-than-average math and writing skill levels. “When students have difficulty setting up mathematical proportions, they can’t accurately administer medication dosages. And when their oral and written communication skills are inadequate, they can’t write up their patient observations clearly.” She believes early assessment and remedial work could improve the situation greatly.
Changes in the health-care delivery system may also pose challenges for the school and its curriculum.
“It’s becoming more difficult to find basic experience areas for our student,” Nowotny says. “Most urban hospitals admit more patients with serious illnesses and fewer with common maladies.” The school is increasingly turning to community hospitals and wellness programs as a training ground.
Looking at the future of the nursing school, Karns also expresses concern about endowments.
“We have an excellent library and learning resource center,” Karns says with pride, “but it takes money to develop faculty, to keep on top of the newest issues in the profession, and to help students make the transition from the academic to the clinical environment. Consequently, we’re always looking for ways to increase our endowment.”
“It also takes money to supply students with scholarships,” Nowotny says. “With the older students, there is an even greater need for financial aid. They often have families to support, and they come to school at great sacrifice.”
Finally, Karns sees a challenge for the nursing school as part of the Baylor University educational system. “Because we’re in Dallas, many people forget that the nursing school is as much a part of the university as the Hankamer School of Business or the School of Music,” she says. “It’s imperative that we build on the strength of the Baylor name by distinguishing the nursing school in its own right, rather than riding on the university’s coattails.”
“As I think of President Reynolds’s goal for Baylor to be the foremost Christian university in the nation, I see a real challenge for the nursing school to contribute to that goal,” she reflects.
‘Only the first step’
So what does Karns say to students as they graduate?
“I’m afraid I probably repeat most of my opening day speech,” she laughs. “But I try to remind them that they are beginning a practice. While they can feel a sense of pride in what they’ve learned, they must understand that it is only the first step. They are embarking on a lifetime of learning.”
Becoming more serious, Karns adds, “Throughout their time here, we try to convey to students how important a Christian perspective is to the nursing profession. I have a deep belief that Christianity provides the best framework for nursing. Nursing is a holistic profession, dealing with the whole person. We teach students that they’re not just concerned with repairing a broken leg or curing a disease. They’re concerned with treating a patient’s ailment or condition as it affects him spiritually, mentally, emotionally, and socially. You just can’t minister to all of a patient’s needs without that Christian perspective.”
