It is becoming more of a mystery to me why people are choosing nursing as a career. I am seeing more people assigned to neonates that have little knowledge in how to care for this ill population, or worse, any lack of interest in improving their skills or knowledge base to do so. "Bodies in boxes" is a term I have heard to describe this specific type of nurse-management knows exactly who they are, but there must be a name to place beside a patient's name on the assignment sheet. Professional nurses also learn very quickly who they are from interactions during report at shift change or by picking up the pieces once they have assumed care responsibilities from them. Outrage over the lack of care may wane over time as nothing is done to remove the unprofessional nurse from the situation. Thus, I am left with the question, why are unprofessionals in a profession, especially in a profession that is devoted to the care and well-being of a segment of some of the most vulnerable patients, sick neonates, and their families?

During a brainstorming conversation, a colleague thought a presentation on vulvodynia may be of significant interest. Vulvodynia? Never heard it!! Being a curious scientist and professional nurse, I immediately sought out a source to find out what this is. Vulvodynia, a diagnosis of exclusion, refers to a disorder of pain, burning, and discomfort in the vulva. OK, now I can understand what my colleagues are discussing. I can speak authoritatively and with assurance. It was not difficult to find the answer, and it took very little time. What holds back the unprofessional nurse from doing the same?

A 28-week neonate, day of life 22, is npo, receiving antibiotics and moderate support from a mechanical ventilator. When asked why the neonate is npo, the unprofessional nurse had no answer. Basically, her shift report consisted of relaying what the routine was for the day: vital signs every 4 hours, blood gas at 1600, and rates for the intravenous fluids. In no way does this information convey a plan of care or priorities specific to the patient's needs. From the medical record, the professional nurse found that the neonate had been tolerating feeds until 6 days ago when the abdomen became distended and symptoms of respiratory distress increased. A septic workup was done and the neonate was placed on a "Nec watch." Currently, all symptoms suspicious for necrotizing enterocolitis have dissipated, and the neonate is on day 6 of 7 for antibiotic treatment. Now the professional nurse is well equipped to develop a plan of care to effectively care for the patient.

I get even more incensed when I see a junior nurse with some baseline knowledge "precepting" the novice nurse. The junior nurse has 14 months of experience and, in my estimation, places her or him in the novice category. From my experience it takes at least 2 years for the majority of nurses to move from being functional nurses to those who have developed critical thinking skills enough to begin to anticipate what signs/symptoms to expect from an ill neonate. Why then, is the novice nurse teaching the novice nurse. More importantly, what is the novice nurse teaching the novice nurse? I heard 2 preceptors fighting the other day over their patient assignments. The argument was resolved by the charge nurse who assigned the preceptor with the less experienced novice nurse to care for the sicker patient, as the new nurse was new and needed the experience. The baby required a seasoned nurse to skillfully develop a plan of care and ensure that the medical plan was implemented properly. What the patient actually received was 2 novice nurses who were in reality only capable of carrying out orders. A professional nurse would not be assigning 2 junior nurses to care for such an unstable patient, just as a professional educator would not have nurses who still required precepting themselves be preceptors. From a deposition in a medical malpractice case, I read a nurse's testimony that she had no understanding of what peak inspiratory pressure was and that it was not important because she had nothing to do with the ventilator. She firmly stated that the ventilator was the responsibility of the respiratory therapist; she merely worked around the tube!!

I wonder what families would say if they were cognizant of the way the nurses are often trained "on the job" today. The majority of institutions that I have consulted with have educators who have recently been appointed to the position because they were nurses who were interested in the position. Few have actual educator skills or knowledge. Designing an orientation program that discusses persistent pulmonary hypertension and extracorporeal membrane oxygenation in the first week and thermoregulation at week 10 with clinical experience in the middle is a perfect example of why many neonatal nurses today have such a limited knowledge base. And, if this is all that is expected, then I suppose I should have no expectation that the bedside nurse is actually thinking about the patient's condition with a solid understanding of the physiology and pathophysiology. The educator often does not last very long in the position because physicians, administrators, and risk management are unhappy with what is produced. Rather than hiring a clinical nurse specialist, who has advanced knowledge along with the clinical skills to mentor both preceptors and novice nurses, another educator with similar skills as the previous one is hired.

The watered-down education and clinical skills then become perpetuated until abhorrent practice is accepted as the norm. Anyone who expects more is labeled as difficult and demanding. And, I am finding, these professional nurses are becoming silent, because they are tired of fighting against the majority. While they are quietly working as a solid part of the multidisciplinary team, they are also contributing to the downward spiral of knowledge and skills. So, I would like all professional nurses to find one novice nurse they can mentor, incite, and excite about learning more. Reclaiming an unprofessional nurse from the dark side would really be something. And, I do not really care what the professional nurse teaches. I really would like the novice to have a solid understanding of the patient and be able to concisely convey priorities and treatment plans in a shift report. But you choose. Pick one thing that you are best at. Or, pick a number of things that you have a lot of interest in. Professional nurses know that the greatest majority of unprofessionals do not belong to their professional organizations nor do they read clinical/research articles. Discuss patient management, ethical concerns, public policy, emerging technology, anything. Get their interest in the profession back. That would be such an energy boost to patients and nursing. I still care, and I have not given up yet, but I am really tired of seeing "bodies in boxes."

M. Terese Verklan, PhD, CCNS, RNC

Associate Professor and Neonatal, Clinical Nurse Specialist, School of Nursing, University of Texas, Health Science Center at Houston