All Nurses Are Not Equal

My best friend Reid made an interesting point the other day. “I have,” she said, “an alphabet soup of certifications. I have ACLS. I have BCLS. I have TNCC. I have ENPC. I have pieces of paper that tell me I can run traumas and defibrillate people. I have critical care courses up the wazoo. Some of these things I paid for on my own, because I wanted to improve my practice and give better patient care. So,” she concluded,”why the hell am I being paid the same as the med-surg nurse upstairs who has none of these?”

Good question. In Ontario, at least, the nurses union — ONA — has decreed that all nurses are equally qualified to work in every setting, and are interchangeable in terms of duty and practice. It’s a very pretty idea, but theoretically and practically speaking, it’s rubbish. Floating a med-surg nurse to the ED is a College of Nurses complaint waiting to happen. It’s dangerous for both patients and for nurses. Even ICU nurses have trouble coping in the ED setting (but for some reason, in my experience, the reverse isn’t as nearly as true.) The difference, I would argue, is not in the provision of basic nursing care or even the intent to provide good patient care but in skill sets, critical thinking and training. Emergency nursing, like any other high-acuity nursing speciality, requires considerable initial and ongoing education, but also, it’s important to remember, has a much higher standard of practice and responsibilities.

Further the lack of any differential in pay according to training/certifications acts as a disincentive for nurses to continue their ongoing education. For example, the fee for the Trauma Nursing Core Course (TNCC) is sometimes, but not always, paid for by hospitals, but in any case, there is no real recognition of nurses completing the certification. So apart from professional pride, why do it? Appeals to professionalism are a bit naïve and idealistic, and only go so far. If you can encourage any nurse to upgrade their skills and education by offering pay differentials, I would be for it. Better educated nurses with better skills and better critical thinking skills means better patient care, better outcomes and ultimately, higher nursing morale. The myth that all nurses are created — and remain — equal has to go.


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  1. #1 by Lynda M O on Monday 31 October 2011 - 1422

    Nurses who put in the time and energy to continuously educate themselves should be paid better and most likely have a lot better job satisfaction too.

  2. #2 by The Nerdy Nurse on Monday 31 October 2011 - 2238

    These certifications are a higher level of nursing education and nurses should be compensated accordingly.

    This seems to be one of those reasons why Unions are not always a good idea.

    I agree with your friend. Her certifications and “hi stress” work area mean she is more “valuable” as a nurse. She should be compensated accordingly.

    Working in med-surg (as I did for many years) is not nearly as stressful as working in ER/ICU, in my humble opinion.

    The union needs to take a closer look at this.

  3. #3 by LC on Tuesday 01 November 2011 - 1347

    Agreed. As a general rule in the workplace more responsibility equals more pay and more education required for a job equals more pay. Working in emerg I need all these additional credentials and am required to have the knowledge/skill/judgment to do many things that ward nurses do not know how to do, aren’t allowed to do or choose not to do. Why am I being paid the same amount?

    I don’t think our union will ever take this issue on. It’s too ingrained in our profession’s culture that we are all equal (across North America anyway). Trying to place a value/wage level on each different area of nursing would be like political suicide for union staff.

  4. #4 by Maha on Tuesday 01 November 2011 - 2327

    I absolutely agree. I’m thinking of writing the Emergency nursing certiication exam next year. I’m lucky that my manager will reimburse me if I pass but I will see absolutely no difference in my pay because of these extra letters after my name. I’m doing this for purely personal reasons but if I were in a slightly different social situation, I don’t know if I could plunk down the $500 out of pocket. Unions may feel that this issue is political suicide, but it’s a slap in the face when I invest so much time and energy into my professional development only to be paid the same wage as someone who refuses to flush a catheter because ‘we don’t do that’. Nursing has got to be the only profession that doesn’t monetarily reward it’s members with extra education and I honestly believe that’s a huge reason why we’re not respected as much as we should be.

  5. #5 by AnonymousRN on Friday 04 November 2011 - 2356

    Interesting the comments above seem to only be from ER nurses. If you took a survey of all nurses throughout the hospital, I think that many would think that they deserve to be compensated. Psyc for the crazy factor, ER for the chaos that the world throws at them, med-surg for the high patient load and acuity that gets higher every day, L&D for the joy of life and the drama that comes with it, waiting placement for the nursing home aspect…. I could go on and on.
    If our pay was determined by how “stressful” our positions are, then I would have gotten paid more when working on my old medical floor than I do in my current ICU position.
    It is interesting to me how we share a common job title as “Nurse” or “RN” but we always seem to need to make our jobs more important and better than the job that our co-workers do.
    Encourage continuing education, absolutely. There is always more that can be learned in whatever area you work in.
    But encouraging the “my job is more important than your job” attitude…. in my opinion…. that can go.

    • #6 by LC on Saturday 12 November 2011 - 1706

      I agree our wage shouldn’t be determined by how stressful our position is – but I think it should be determined by how much responsibility we have. When you work in an ER you are expected to possess additional knowledge and skills above a ward nurse, whether it is performing and interpreting ECGs, getting IVs, drawing blood, managing a patient on a ventilator et cetera. At triage you have to assess patients and make decisions about how soon they will receive care, decisions that come with a much higher level of risk then most decisions made by a ward nurse – decisions that you can only make with confidence after having years of experience caring for patients across the spectrum of acuity. Isn’t this something you should be compensated for?

      You mentioned it’s not good to encourage a ‘my job is more important that your job’ attitude. I don’t think it is fair to accuse those of us in critical care areas of having such an attitude based on the comments we’ve made here. I don’t think my job is more important than a ward nurse, nor do I think I’m more important than one, I’m just pointing out the extra education and responsibility required for me to do my job.

      To be clear, I’m not trying to bash ward nursing. RNs across the hospital have very important roles and I don’t think med-surg nurses have it easy. Like you said it can be one of the most stressful areas to work. But stress because of workload is different from stress due to responsibility. If a patient decompensates on a floor then most hospitals have a program where the nurse can call a critical care response/outreach team to help. In the ER we can’t use that team – I have to know what to do/be the response team myself – a responsibility I gladly take on but one I feel I should be recognized for in my salary.

      • #7 by Anonymous on Tuesday 27 December 2011 - 1330

        Don’t you think that a workload, an assignment carries responsibility? Ward nurses are NOT playing tiddly winks.

        Don’t you think that a ward nurse has to know what to do in a great many circumstances? Including knowing when to call in the reinforcements.

        In the ER, you have everything at your fingertips to handle serious emergencies, including resp and cardiac resuscitation materials, meds, apparatus, etc. And unless you are in a very isolated location, you have other staff to come help you PDQ – like Anesthesia, surgeons or internists, resp therapists, other nurses.
        The med-surg nurse has to run the length of a football field or more to get equipment, has to wait for others to come help, has to initiate CPR and do it alone until help arrives, has to start IV’s, apply pressure to bleeding, and then be written up for not responding to someone’s call light for a soda pop for the visitors. As usual, here are nurses bashing each other.

  6. #8 by Anonymous on Tuesday 08 November 2011 - 0934

    I absolutely agree with anonymous!

    I am an ICU nurse with 23 years of experience. I recently started in my local PACU- what a shock compared to a downtown teaching hospital. I did however learn that we all have something to learn from each other! It is our collective wealth of knowledge that adds to our quality of care. We all have strengths, we all have weaknesses and we all think our job is the “most stressful”.
    It is simply a matter of choice.
    Nursing is a wonderful profession, and it very difficult to define in terms of knowledge boundaries.

    Let’s grow up and lose the “my job is more important that yours” attitude. Let us all respect our colleagues in the way in which we want to be respected.

  7. #9 by Andrea on Thursday 12 January 2012 - 1748

    I know this is an old post but…
    1. I agree that we shouldn’t perpetuate the “my job is more important than yours” attitude. I work on a surgical floor and it is absolutely crazy sometimes(I’ve also worked ER). I have a friend that has gone on from our floor to work ICU, and after a year she says that she couldn’t imagine having to take care of 4 patients again. They’re different, and we choose them because it’s where we want to be.
    2. On the other hand, further education SHOULD be rewarded. ACLS, TNCC, and the like are crucial courses for critical care areas; however, they take a weekend to complete. I’m in favor of further compensation for CNA Certification. In Alberta RN’s recieve another 50 cents/hour for this certification.

    I think a lot of our training on med surg floors is more informal, wound vac applications aren’t really a necessary skill in the ER, but on the floors they are quite routine and require a certain knowledge base and skill set. Just an example :)

    Besides, if everyone that worked ER, ICU, etc. was better compensated than those on the med/surg floors, what would happen to our med/surg staff??

  8. #10 by Joan Price on Friday 02 November 2012 - 1426

    I don’t know if I agree that CEUs for nurses should equal more compensation. A friend of mine is an LSW. She is required to attend them just to keep her license. She is never compensated extra. Additionally, she has picked up certifications for things (i.e. sexual trauma crisis intervention certification), and she was never compensated extra in any position for having that certification. I think that people should be compensated more if that training is relevant to the position you’re applying to when it isn’t typically relevant to the field. For instance, if my friend decided to be a sexual trauma therapist, then I’d think she should get paid more if she is working in a position that deals mostly or solely with that population; however, if she decides to just work on a general psychiatric unit, then her certification may help her, but it isn’t necessary for her to complete her job, so extra compensation shouldn’t be given. I will say that both professions are grossly under-paid in general, and I wish both fields could give more to their dedicated employees.

  9. #11 by Me nurse on Monday 24 April 2017 - 1052

    I do believe a MS nurse does no have the skill set to work in the ED or ICU. However to say that an ICU nurse can not work in the ED, that’s rubbish. In the ICU there is no cold, fever,flu,back pain,stitches etc . The ICU everyone is critical and could crash at any moment. The nurse in the ICU must be prepared for that. I think the ED nurse is much sloppier than the ICU nurse and has trouble adjusting..where a single the icu nurse in the ED doesn’t.

  10. #12 by altenpflege kleidung on Thursday 20 December 2018 - 0331

    Gut geschrieben. Echt toll. Danke.

  1. I will not be a nurse. « Digital Ballpen

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