May 26, 1982
Dear Russ:
If I were going to address a graduating class of nurses this year, I think I would address the problems of nurse retention common throughout the country and approach the delicate but never the less very important problem of authority.
When it comes to nurse retention I would talk about all of the fine traditions of nursing and the fact that expectation of nursing sometimes is different (does not necessarily fall short of). For example, in her mind's eye the nurse pictures a baby such as depicted on the Gerber baby food jars but in reality has to deal with a child being treated for Leukemia who has lost all its hair and has Economo's all over his body.  Traditional bedside nursing has given away to problems in intensive care and specialized nursing such as those who work on an I.V. team or carry out nutritional support etc.  I am sure you know these things better than I.
Second subject is a little more delicate in that if your experience is that of mine you have witnessed over the last decade an increasing effort on the part of nurses to educate themselves scientifically which I think makes for some job dissatisfaction if they are not able to utilize the scientific training that they have spent so much trouble accumulating.  This then leads to who should do what in the clinical setting.  The primary care nurse is an example of places where a nurse feels that having learned so much she is in a decisionmaking process but doesn't realize that without the depth of knowledge of the physician her decision about a patient may not only be at variance with the physician but also may be wrong.  I would then talk about the captain of the ship philosophy and that medicine is indeed delivery of care by a team and that the nurse has an extraordinarily important role in it but she cannot usurp the physician's position as captain of the ship.
Still on the other hand, there are now so many new opportunities for nurses such as physician's assistants etc. that there is no need to compete with the doctor for an authority role but rather to do the job that the nurse is prepared to do and to do it to the best of her ability.
If you get into that subject you might even want to use as an example an initiative that I am working on now and that is the training of elderly people to control incontinence through biofeedback methods. I am not foolish enough to think that physicians are going to take very readily to the training of elderly patients with incontinence but I think that nurses, are very well equipped to do this sort of thing and using the teaching nursing homes currently being sponsored as an experiment by the Robert Wood Johnson Foundation would make a marvelous vehicle to learn the techniques and pass them on to nurses who will have to deal with the problem of incontinence in elderly people.
If you want to go in this direction as an example, let me give you a few figures.  The cost of incontinence in nursing homes is now in excess of 8 billion dollars per year.  Techniques underway at the National Institute of Aging provide a 70% success rate in ambulatory patients between 65 and 90. Those who do not respond fail because of the lack of cognitive functions.
My initiative is to teach incontinence training in nursing homes immediately after admission and before such irrevocably things as bed sores develop. I do believe that nurses properly motivated, trained, and guided could carry out one of the most dignity restoring and cost effective nursing initiatives we have ever had.
I hope this is of some help to you. This week should see the final decision on the selling of my house here and if that goes through then I can proceed with the Cape Cod venture.  I look forward to seeing you, perhaps this summer.
Sincerely yours,
C. Everett Koop, M.D.
Surgeon General