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The tapestry of care
The tapestry of care Author: Suzanne
Gordon, BA, Arlington, Massachusetts
For t h r e e years, j o u r n a l i s t S u z a n n e Gordon o b s e r v e d three n u r s e s - - N a n c y Rumplik, a n u r s e in the H e m a t o l o g y / O n c o l o g y O u t p a t i e n t Clinic; J e a n n i e Chaisson, a m e d i c a l clinical n u r s e specialist on a general m e d i c a l unit, a n d Ellen Kitchen, a geriatric n u r s e practitioner m h o m e c a r e - - a t a B o s t o n teachi n g hospital. Using their e x p e r i e n c e s with patients, nurses, p h y s i c i a n s , and other colleagues as a p r i s m to look at n u r s i n g practice, history, n u r s e - p h y s i c i a n relationships, a n d nursing's future, Gordon h a s written Life Support: T h r e e N u r s e s on t h e Frontlines. This b o o k is an a t t e m p t to s h o w the A m e r i c a n p u b l i c the i m p o r t a n c e o f n u r s i n g practice. In today's health care climate, w h e r e c o s t c u t t i n g is directly targeting caregiving, it a r g u e s that n u r s e s are a p r e c i o u s r e s o u r c e w e m u s t p r e s e r v e a n d defend. This e x c e r p t is from Life Support.* A
p o s t e r d e c o r a t e s t h e wall of m y study. P a i n t e d in t o n e s of sepia, f a d e d teal, rust, a n d pewter, it shows a medieval woman, worried and attentive, h o l d i n g on h e r lap a pale, g l a s s y - e y e d child. A t her s i d e sits an e a r t h e n w a r e p i t c h e r which, w e a s s u m e , h o l d s a m e d i c i n a l potion. T h e p a i n t i n g , d a t e d 1660, is from a D u t c h m a s t e r G a b r i e l M e t s u (cc 1660) a n d is entitled, "The Sick Child." U n d e r n e a t h , is t h e title of t h e e x h i b i t i o n a n d b o o k t h a t it i n t r o d u c e d , Nursing: The Oldest Art. It m a y b e t h e oldest, b u t in t h e c o n t e m p o r a r y world, it is also one of t h e m o s t invisible. O n e of t h e m o s t invisible arts, s c i e n c e s , a n d c e r t a i n l y one of t h e m o s t invisible p a r t s of our h e a l t h c a r e s y s t e m . W h e n w e h e a r t h e w o r d s hospital, m e d i c i n e , a n d health care, i m a g e s of t e c h n o I o g y a n d - s c i e n t i f i c i n v e n t i o n often s p r i n g to mind. Mecharf~babventilatots, d i a l y s i s m a c h i n e s , i n t r a v e n o u s pumps;"Jbiomedical r e s e a r c h , surgery, m e d i c a t i o n . T h e s e , m a n y believe, are t h e life s u p p o r t s in our h e a l t h care syst e m . It is this s c i e n c e a n d t e c h n o l o g y t h a t k e e p s p e o ple alive, t h a t h e l p s t h e m c u r e a n d heal. In fact, t h e r e are other equally i m p o r t a n t life s u p *From Life S u p p o r t : T h r e e N u r s e s on t h e F r o n t l i n e s by Suzanne Gordon, w i t h an introduction by Claire M. Fagin, RN, PhD, FAAN, ©1997. Reprinted by permission of Little, Brown & Company. Available at your local bookstore, or to order a copy call 1-800-236-READ.
Suzanne Gordon is a journalist and author of Lifo Support: Three Nurses on the Front Lines. J Emerg Nuts 199'7;23:148-52. 18/9/79837
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p o r t s in our h e a l t h c a r e s y s t e m . T h e s e a r e t h e 2.2 million n u r s e s in A m e r i c a w h o m a k e u p t h e l a r g e s t prof e s s i o n in h e a l t h care, t h e l a r g e s t f e m a l e p r o f e s s i o n in A m e r i c a , a n d t h e s e c o n d - l a r g e s t profession. T h e s e w o m e n - - a n d m e n - - w e a v e a t a p e s t r y of care, k n o w l e d g e , r e l a t i o n s h i p , a n d t r u s t t h a t is c r i t i c a l to p a t i e n t s ' survival. This b o o k is t h e story of t h r e e of t h o s e n u r s e s p r a c t i c i n g on t h e frontlines of n u r s i n g , of t e c h n o l o g y , a n d of t h e m a n y c h a n g e s in our h e a l t h c a r e s y s t e m . N a n c y Rumplik, J e a n n i e C h a i s s o n , a n d Ellen K i t c h e n have, b e t w e e n t h e m , m o r e t h a n five d e c a d e s of e x p e I i e n c e c a r i n g for t h e sick. T h e y w o r k in a n a c u t e c a r e h o s p i t a l - - o n e of H a r v a r d M e d i c a l S c h o o l ' s t e a c h i n g hospitals. T h e Beth Israel is n o t only k n o w n for t h e q u a l i t y of its p a t i e n t care, it is also w o r l d - r e n o w n e d for t h e quality of its n u r s i n g staff a n d its i n s t i t u t i o n a l c o m m i t m e n t to n u r s i n g . I n s i d e Beth Israel, N a n c y Rumplik, J e a n n i e C h a i s s o n , a n d Ellen K i t c h e n are also r e c o g n i z e d for t h e i r e x p e r t i s e . N a n c y R u m p l i k is a n o u t p a t i e n t n u r s e w h o w o r k s in a n a m b u l a t o r y c a n c e r clinic; J e a n n i e C h a i s s o n is a m e d i c a l clinical n u r s e s p e c i a l i s t on a g e n e r a l m e d i c a l floor; a n d Ellen K i t c h e n is a n u r s e p r a c t i t i o n e r w h o delivers h o m e c a r e services. Their w o r k t h u s s p a n s t h e s p e c t r u m of w h a t n u r s e s do on i n p a t i e n t h o s p i t a l w a r d s , o u t p a t i e n t s e r v i c e s , a n d in t h e h o m e a n d community. A s y o u w a t c h t h e s e n u r s e s wor k w i t h p a t i e n t s , it m i g h t b e e a s y to c o n c l u d e t h a t t h e k n o w l e d g e , skill, a n d e m p a t h y t h e y d i s p l a y are extraordinary. In fact, t h e r e are h u n d r e d s of t h o u s a n d s of e x p e r t n u r s e s like t h e m w o r k i n g in hospitals, n u r s i n g h o m e s , r e h a b i l i t a t i o n facilities, p s y c h i a t r i c i n s t i t u t i o n s a n d m e n t a l h e a l t h clinics, rural a n d u r b a n h e a l t h clinics, p u b l i c health, h o m e care, a n d h o s p i c e c a r e all a c r o s s t h e nation. W i t h o u t their c a r e of t h e body, p a t i e n t s w o u l d n o t r e c o v e r a n d heal. W i t h o u t their c a r e of t i l e soul, p a t i e n t s w o u l d b e u n a b l e to w i t h s t a n d t h e a r d u o u s h i g h - t e c h t r e a t m e n t s on w h i c h our m o d e r n m e d i c a l s y s t e m d e p e n d . W i t h o u t their a c c e p t a n c e of d e a t h , our d e a t h - d e n y i n g m e d i c a l s y s t e m w o u l d e x a c t e v e n m o r e suffering from p a t i e n t s a n d their families. A l t h o u g h n u r s e s are s o m e of t h e m o s t c o s t - e f f e c tive professionals, t h e for-profit, m a r k e t - d r i v e n h e a l t h c a r e t h a t is s w e e p i n g this n a t i o n - - a n d m a n y othe r s - i s t h r e a t e n i n g t h i s v a l u a b l e r e s o u r c e . To g a i n an a d v a n t a g e in t h e c o m p e t i t i v e n e w h e a l t h c a r e m a r k e t p l a c e , h o s p i t a l s all over t h e c o u n t r y a r e t r y i n g to
Gordon/JOURNAL OF EMERGENCY NURSING
c u t their costs. O n e popular c o s t - c u t t i n g s t r a t e g y is l a y i n g off n u r s e s . T h r e e f o u r t h s of all A m e r i c a n h o s p i t a l s a r e e n g a g e d in or d e v e l o p i n g p l a n s for "restructuring" a n d m a n y are l a y i n g off m o r e t h a n 20% to 50% of t h e i r n u r s i n g staff. For t h e first t i m e in a d e c a d e , m a n y n u r s e s feel t h e i r p a t i e n t s are in danger. With g r e a t sadness and distress, they say that hospitals and i n s u r e r s will n o t allow t h e m to deliver t h e k i n d of q u a l i t y c a r e t h e y h a v e b e e n e d u c a t e d to g i v e p a t i e n t s a n d families. Yet this v e r y r e s t r u c t u r i n g a n d d o w n s i z i n g of h e a l t h care i n s t i t u t i o n s is t o u t e d as o n e of t h e w a y s to cure our s y s t e m ' s s e r i o u s defects. T h e latter a r e well known. T h e A m e r i c a n h e a l t h c a r e s y s t e m suffers from lack of a c c e s s , too m u c h f r a g m e n t e d , e x p e n s i v e h i g h - t e c h t r e a t m e n t , not e n o u g h a t t e n t i o n to h e a l t h m a i n t e n a n c e a n d d i s e a s e p r e v e n t i o n , a n d failure to a t t e n d to p a t i e n t s ' e m o t i o n a l a n d social n e e d s , as well a s their p a i n a n d suffering. R e d u c i n g t h e n u m b e r of e x p e r i e n c e d , e d u c a t e d n u r s e s hardly solves t h e s e p r o b l e m s . A l t h o u g h A m e r i c a n h o s p i t a l s a l r e a d y u s e 20% fewer n u r s e s t h a n a n u m b e r of other i n d u s t r i a l i z e d countries, h o s p i t a l a d m i n i s t r a t o r s a n d s o m e n u r s i n g e x e c u t i v e s n o w a r g u e t h a t u n i t s staffed w i t h e d u c a t ed, e x p e r i e n c e d n u r s e s are a luxury w e c a n no l o n g e r afford. Yet, in 1992, t h e a v e r a g e staff n u r s e e a r n e d a little less t h a n $33,000 a year, t h e a v e r a g e clinical n u r s e s p e c i a l i s t e a r n e d a b o u t $41,000 a year, a n d t h e a v e r a g e n u r s e p r a c t i t i o n e r e a r n e d slightly less t h a n $44,000 a year. (At a major t e a c h i n g h o s p i t a l like t h o s e in Boston, staff n u r s e s in a u n i o n - b a r g a i n i n g unit c a n e a r n u p to $67,000 w h i l e a clinical n u r s e s p e cialist or n u r s e p r a c t i t i o n e r c a n e a r n m o r e t h a n $80,000). N u r s e s ' salaries a n d b e n e f i t s c o m p r i s e only a b o u t 16% of h o s p i t a l ' s total costs. Compare this with the average income of physicians. A c c o r d i n g to Modern Healthcare's 1996 physician compensation report, average physicians compensation in internal m e d i c i n e is $135,755, in family practice $128,096, in anesthesiology $193,242, oncology $164,621, and in general surgery $199,342. Some s p e c i a l i s t p h y s i cians e a r n up to several million dollars a year. A s u r v e y c o n d u c t e d in 1995 b y Hospitals" & Health Networks, t h e m a g a z i n e of t h e A m e r i c a n Hospital Association, stated that the average base salary a n d total c a s h c o m p e n s a t i o n for h o s p i t a l CEOs w a s $188,600. In a large h o s p i t a l t h a t w e n t u p to $280,900. A n d in a for-profit c h a i n it's far higher. In 1995, at a g e 43, Richard Scott, CEO of C o l u m b i a / H C A H e a l t h c a r e C o r p o r a t i o n , r e c e i v e d a s a l a r y of $2,093,844. H e p e r s o n a l l y c o n t r o l s s h a r e s in C o l u m b i a / H C A w o r t h $359.5 million.
N u r s e s ' salaries s e e m particularly paltry w h e n c o m p a r e d w i t h s o m e of t h e m o s t e g r e g i o u s w a s t e in the system~he i n c o m e of t h e CEOs of for-profit HMOs. In 1994, t h e e x e c u t i v e c o m p e n s a t i o n p a c k a g e s of t h e CEOS of t h e s e v e n l a r g e s t for-profit H M O s a v e r a g e d $7.9 million. E v e n t h o s e in t h e not-for-profit s e c t o r of i n s u r a n c e e a r n s t a r t l i n g s u m s . In 1995, J o h n Burry Jr., c h a i r m a n a n d CEO of t h e nonprofit Ohio Blue C r o s s Blue Shield, w a s p a i d $1.6 million. A c c o r d i n g to a r e p o r t in Modern Healthcare, a prop o s e d m e r g e r w i t h t h e for-profit C o l u m b i a / H C A H e a l t h c a r e Corporation w o u l d h a v e p a i d h i m $3 million "for a d e c a d e - l o n g , n o - c o m p e t e c o n t r a c t . . , a n d u p to s e v e n million for t w o c o n s u l t i n g a g r e e m e n t s . "
R e d u c i n g t h e n u m b e r of experienced, educated n u r s e s hardly s o l v e s these problems.
N u r s e s are clearly not t h e c o s t e s c a l a t o r s in t h e s y s t e m . Quite t h e contrary. Their c a r e s a v e s not only lives b u t money. Over t h e p a s t 20 years, this fact h a s b e e n confirmed in s t u d y after study. In major s t u d i e s c o n d u c t e d in 1976, 1986, 1989, 1994, a n d 1995, m e d i c a l a n d n u r s i n g r e s e a r c h e r s directly linked t h e n u m b e r a n d e d u c a t i o n a l qualifications of r e g i s t e r e d n u r s e s on h o s p i t a l u n i t s to lower m o r t a l i t y r a t e s a n d d e c r e a s e d l e n g t h s of h o s p i t a l stay. R e d u c i n g t h e n u m b e r of e x p e r t n u r s e s in t h e hospital, c o m m u n i t y , a n d h o m e h e e d l e s s l y e n d a n g e t s p a t i e n t s ' lives a n d w a s t e s s c a r c e r e s o u r c e s . N u r s e s h a v e also h e l p e d to i n c r e a s e a c c e s s to our h e a l t h care s y s t e m . M a n y p r o v i d e s e r v i c e s to s o m e of t h e 41 million A m e r i c a n s w h o h a v e no h e a l t h i n s u r a n c e or to A m e r i c a n s w h o live in a r e a s t h a t p h y s i c i a n s t e n d to avoid. It is Ellen K i t c h e n a n d her c o l l e a g u e s w h o g i v e h e a l t h c a r e to poor, m i n o r i t y w o m e n a n d their n e w b o r n s , w h o staff rural h e a l t h clinics in w h i c h few d o c t o r s c h o o s e to p r a c t i c e , or w h o go into t h e h o m e s of t h e elderly a n d h o m e b o u n d allowing t h e m to live on their o w n for as long as p o s sible. A g a i n , b y h e l p i n g elderly c i t i z e n s to live at h o m e , r a t h e r t h a n in a n u r s i n g home, this k i n d of c a r e s a v e s billions. C h o o s i n g to s a v e m o n e y b y r e d u c i n g n u r s i n g
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care a g g r a v a t e s t h e i m p e r s o n a l i t y a n d i n h u m a n i t y of a m e d i c a l s y s t e m t h a t t e n d s to t u r n h u m a n b e i n g s into their d i s e a s e s a n d t h e doctors who care for t h e m into s o p h i s t i c a t e d clinical m a c h i n e s . W h e n t h e y ' r e sick, p a t i e n t s do n o t only ask w h a t pills t h e y should take, or w h a t o p e r a t i o n s t h e y should have. T h e y are p r e o c c u p i e d w i t h q u e s t i o n s like, "Why m e ? Why now? How c a n I deal w i t h this? How c a n we, as a family, c o p e ? W h e r e is h o p e ? Is there m e a n i n g ? Is there God?" B e c a u s e of their history, a n d their daily work, n u r s e s live t h r o u g h this day-by-day, m i n u t e - b y m i n u t e attack o n the soul. T h e y k n o w that, for the patient, there is n o t only a sick or infirm body, b u t a life, a family, a c o m m u n i t y , a society t h a t has b e e n disrupted a n d t h a t n e e d s to heal.
Doctors o n E.R. are c o n s t a n t l y barking out the simplest commands--" get a blood pressure, a Chem-13 (blood chemistries), type a n d c r o s s a n d call t h e OR, or call r e s p i r a t o r y t h e r a p y " - to e x p e r i e n c e d ED n u r s e s . Although n u r s e s help u s live a n d die, i n the p u b lic depiction of health care, p a t i e n t s s e e m to e m e r g e from hospitals w i t h o u t ever h a v i n g b e n e f i t e d from their assistance. W h e t h e r p a t i e n t s are t r e a t e d in a n e m e r g e n c y d e p a r t m e n t i n a few short hours, or on a critical care u n i t for m o n t h s on end, w e s e e m c e r t a i n that p h y s i c i a n s are r e s p o n s i b l e for all t h e s u c c e s s e s - - o r f a i l u r e s - - i n our m e d i c a l system. In_fact, w e s e e m to believe t h a t t h e y are r e s p o n s i b l e h-et.o~ly for all of the c u r i n g b u t for m o s t of t h e caring. - ,;' Nurses, on t h e other h a n d , r e m a i n s h a d o w y figures m o v i n g m y s t e r i o u s l y in t h e b a c k g r o u n d . On television series, n u r s e s often a p p e a r as c o m i c figures. In TV s h o w s like t h e short-lived Nightingales, the sit-com Nurses, or t h e m e d i c a l d r a m a Chicago Hope, n u r s e s are far too b u s y p i n i n g after doctors or racing off to aerobics classes to actually care for patients. The n e w hit E.R. gives n u r s e s more promin e n c e t h a n m a n y other doctor shows. N o n e t h e l e s s , doctors on E.R. are c o n s t a n t l y b a r k i n g out the simplest c o m m a n d s - - " g e t a blood pressure, a Chem-13 (blood chemistries), t y p e a n d cross a n d call t h e OR, or call respiratory t h e r a p y " - - t o e x p e r i e n c e d ED nurses.
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In reality, t h e s e n u r s e s w o u l d h a v e t h o u g h t of all this before t h e doctor. In a n e m e r g e n c y d e p a r t m e n t as b u s y a n d s o p h i s t i c a t e d as t h e one on E.R. (this is, after all, a level I t r a u m a center), t h e first c l i n i c i a n a p a t i e n t w o u l d see is a triage n u r s e w h o w o u l d a s s e s s a p a t i e n t a n d d i c t a t e w h a t he or s h e n e e d s , w h o will see h i m or her, a n d w h e n . E x p e r i e n c e d n u r s e s will, i n fact, direct less e x p e r i e n c e d residents, s u g g e s t i n g a m e d i c a t i o n , test, c o n s u l t a t i o n w i t h a specialist, or transfer to t h e o p e r a t i n g room. The great irony of E.R. is t h a t Carol Hathaway, t h e n u r s e in c h a r g e - - a n d t h u s one of the key figures in a n y real e m e r g e n c y r o o m - - i s generally r e l e g a t e d to comforting a child or following p h y s i c i a n direction rather t h a n h e l p i n g to direct t h e staff in s a v i n g lives. Not only do doctors d o m i n a t e television, t h e y are also t h e focus of m o s t hard n e w s health care coverage. Reporters rarely cover n u r s i n g i n n o v a t i o n s , u s e n u r s e s as sources, or report on n u r s i n g research. W h e n reporters a n d politicians c o n s u l t w i t h h e a l t h care experts a n d report on their r e c o m m e n d a t i o n s , or their r e s p o n s e s to reform proposals, t h e y i n v a r i a b l y i n t e r v i e w p h y s i c i a n s , r e p r e s e n t a t i v e s of p h y s i c i a n organizations, or health care policy specialists w h o t e n d to look at health care either t h r o u g h t h e p r i s m of m e d i c i n e or t h r o u g h e c o n o m i c s . T h u s a 1990 study, "Who C o u n t s in N e w s Coverage of Health Care?", of t h e h e a l t h care c o v e r a g e i n three A m e r i c a n n e w s p a pers of record--The N e w York Times, Los Angeles igmes, a n d The Washington Post--documented t h a t out of 908 q u o t e s t h a t a p p e a r e d in 3 m o n t h s ' w o r t h of health care stories, n u r s e s were q u o t e d exactly 10 times. C o n v e n t i o n a l w i s d o m has held t h a t w h e n m o r e w o m e n e n t e r e d the n a t i o n ' s n e w s r o o m s , t h e y w o u l d p a y greater a t t e n t i o n to t h e varied c o n t r i b u t i o n s of w o m e n in society. This h a s n ' t h e l p e d t h o s e w o m e n w h o are n u r s e s . Of the 119 articles w o m e n journalists clearly authored, there w a s a larger p e r c e n t a g e of female m a i n sources (23.53%) t h a n in t h o s e a u t h o r e d b y m e n (16.01%). F e m a l e journalists t e n d e d to q u o t e m o r e female p h y s i c i a n s , h o s p i t a l a d m i n i s t r a t o r s , o r g a n i z a t i o n a l s p o k e s p e r s o n s , politicians, a n d policy makers. But female reporters did n o t seek out n u r s e s for s o u r c e s of i n f o r m a t i o n or expertise a n y more freq u e n t l y t h a n their male counterparts. Today, t h e revolution in health care h a s b e c o m e b i g n e w s . Occasionally reporters t u r n their a t t e n t i o n to the p h e n o m e n o n of n u r s i n g layoffs. But the story is rarely f r a m e d as a n i m p o r t a n t public h e a l t h issue. Rather it is generally d e p i c t e d as a l a b o r - m a n a g e m e n t conflict. N u r s i n g u n i o n s are b a t t l i n g w i t h m a n a g e m e n t . Nurses say this, hospital a d m i n i s t r a t o r s claim that. Who c a n you believe?
Gordon/JOURNAL O1: EMERGENCYNURSING
Or worse still, this crucial i s s u e m a y be c o u c h e d in the worst s t e r e o t y p e s of n u r s i n g / w o m e n ' s work. A typical e x a m p l e a p p e a r e d on NBC Nightly News. T h e p r o g r a m ran a story a b o u t t h e serious p r o b l e m s r e s u l t i n g from r e p l a c i n g n u r s e s w i t h u n l i c e n s e d assistive p e r s o n n e l . The a n c h o r i n t r o d u c e d it as "a n e w a n d controversial w a y of a d m i n i s t e r i n g TLC." I m a g i n e h o w reporters w o u l d c h a r a c t e r i z e t h e story if 20% to 50% of p h y s i c i a n staff w e r e e l i m i n a t e d i n t h o u s a n d s of A m e r i c a n hospitals. Would it n o t b e front-page n e w s , a major public health c a t a s t r o p h e ? P a t i e n t s all over the c o u n t r y w o u l d b e terrified to e n t e r hospitals. Yet, w e learn a b o u t the n u r s i n g e q u i v a l e n t w i t h only a m i n i m u m of concern. If t h e only p r o b l e m w i t h laying off t h o u s a n d s of n u r s e s is t h e loss of a little TLC, w h a t difference does it m a k e if a n aide r e p l a c e s a n u r s e ? But n u r s i n g is n o t a m a t t e r of TLC. It's a m a t t e r of life a n d death. In the hospitals w h e r e 66% of n u r s es work, n u r s e s are the o n e s w h o m o n i t o r a n d evaluate a p a t i e n t ' s c o n d i t i o n before, during, a n d after h i g h - t e c h m e d i c a l procedures. It is t h e n u r s e w h o will a d j u s t m e d i c a t i o n s , m a n a g e pain, a n d side effects of t r e a t m e n t , act i n s t a n t l y to i n t e r v e n e if t h e r e are l i f e - t h r e a t e n i n g c h a n g e s in a p a t i e n t condition, or alert p h y s i c i a n s so t h a t t h e y c a n p r o t e c t t h e i r patients. N u r s e s like N a n c y Rumplik, J e a n n i e Chaisson, a n d Ellen K i t c h e n are c o n s t a n t l y e n g a g e d in w h a t a p p e a r to b e s e e m i n g l y simple i n t e r a c t i o n s - - a d m i n i s t e r i n g a m e d i c a t i o n , g i v i n g a bath, e m p t y i n g a b e d pan, c h e c k i n g a p a t i e n t ' s m e d i c a t i o n box, m a k i n g sure his refrigerator is well stocked. But there is n o t h i n g simple a b o u t t h e s e e x c h a n g e s . T h e y are s o m e of t h e t h r e a d s w i t h w h i c h their t a p e s t r y of care is w o v e n a n d are critical to n u r s e s ' k n o w l e d g e of a n d r e l a t i o n s h i p s w i t h patients. T h e s e e n c o u n t e r s allow n u r s e s to develop a s e n s e of p a t i e n t s - - w h a t t h e y refer to as the p a t i e n t ' s "baseline." This p e r m i t s t h e m to know, often at a glance, w h e n a n i m p o r t a n t c h a n g e in a p a t i e n t ' s c o n d i t i o n h a s occurred e v e n before t h a t c h a n g e is r e g i s t e r e d in a falling blood pressure, r i s i n g t e m p e r a t u r e , or labored b r e a t h i n g . In a c a n c e r ward, n u r s e s c a t c h a serious r e a c t i o n to m e d i c a t i o n almost before it happens. In a n operati n g room, n u r s e s m a k e sure t h e right p a t i e n t is b e i n g o p e r a t e d on, or t h a t the right p r o c e d u r e is b e i n g performed on t h e right limb or organ. O n a n ICU or in h o m e care, n u r s e s q u e s t i o n w h y a p a t i e n t is g e t t i n g a n o t h e r painful d i a g n o s t i c t e s t t h a t m a y reveal little useful information; w h y a d e q u a t e p a i n m e d i c a t i o n is n o t g i v e n after surgery; w h y a p a t i e n t is b e i n g disc h a r g e d too quickly; w h e t h e r s o m e o n e is available to take care of t h e m in the home; a n d at t h e e n d of life,
w h y e x p e n s i v e , heroic t r e a t m e n t t h a t will only prolong d e a t h is p r e s e n t e d as the only option. In t h e self-enclosed world of t h e h i g h - t e c h hospital, w h e r e ordinary m e n a n d w o m e n a n d children are c o n f r o n t e d w i t h people w h o wear alien c o s t u m e s , a d h e r e to peculiar c u s t o m s , a n d e v e n s p e a k their o w n l a n g u a g e , n u r s e s help p a t i e n t s deal with their fear a n d a n x i e t y - - n o t only of their d i s e a s e s b u t of the people w h o are s u p p o s e d to cure t h e m . W a t c h Nancy, J e a n n i e , a n d Ellen a n d you see h o w i m p o r t a n t this is to f r i g h t e n e d p a t i e n t s a n d family m e m b e r s .
Imagine how reporters would c h a r a c t e r i z e t h e s t o r y if 20% to 50% of p h y s i c i a n staff w e r e e l i m i n a t e d in t h o u s a n d s of A m e r i c a n hospitals.
In our h i g h - t e c h m e d i c a l system, n u r s e s are the o n e s w h o care for the b o d y a n d the soul. No m a t t e r h o w sensitive, caring, a n d a t t e n t i v e p h y s i c i a n s are, in b o t h t h e hospital a n d home, n u r s e s are often closer to p a t i e n t n e e d s a n d w i s h e s t h a n p h y s i c i a n s . T h a t ' s n o t b e c a u s e n u r s e s are i n h e r e n t l y more c a r i n g t h a n doctors, b u t b e c a u s e t h e y s p e n d far more t i m e w i t h p a t i e n t s a n d m a y g e t to k n o w t h e m better. This t i m e a n d k n o w l e d g e allows n u r s e s to save lives. But n u r s e s also help people a d j u s t to the lives they m u s t live after t h e y h a v e b e e n saved. A n d w h e n d e a t h c a n no longer b e delayed, n u r s e s help p a t i e n t s confront their o w n mortality with at least s o m e m e a s u r e of grace a n d dignity. T h e t a p e s t r y of care t h a t n u r s e s w e a v e w o u l d b e m u c h s t r e n g t h e n e d if p h y s i c i a n s a n d n u r s e s cons t r u c t e d it t o g e t h e r a n d if b o t h groups h a d a n equal voice i n health care i n s t i t u t i o n s a n d in the health care s y s t e m as a whole. In m a n y i n s t a n c e s , b o t h in this book a n d in the health care system, doctors a n d n u r s e s do cooperate effectively. But, in general, the history of m e d i c i n e a n d n u r s i n g a n d c o n t e m p o r a r y physician and nurse relationships preclude g e n u i n e collaboration. In spite of their i m p o r t a n t work, n u r s e s - m e m b e r s of a q u i n t e s s e n t i a l l y female profession (95% of all n u r s e s are f e m a l e ) - - h a v e long b e e n subord i n a t e d to the q u i n t e s s e n t i a l l y male profession of m e d i c i n e . In the A m e r i c a n m e d i c a l s y s t e m , rigid, g e n d e r - r i d d e n hierarchies m a k e it difficult for doctors a n d n u r s e s to relate as colleagues. T h u s today m a n y
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d o c t o r s - - m a l e a n d female a l i k e - - s t i l l c o n s i d e r n u r s es to b e their h a n d m a i d e n s . This has serious c o n s e q u e n c e s for p a t i e n t s a n d for t h e health care s y s t e m as a whole. W h e n doctors d o n ' t listen to n u r s e s t h e y c a n ' t hear their patients. In 1995, The Journal of the American Medical Association (JAMA) r e l e a s e d t h e highly p u b l i c i z e d SUPPORT study. The S t u d y to U n d e r s t a n d Prognoses a n d P r e f e r e n c e s for O u t c o m e s a n d T r e a t m e n t s f o c u s e d on p a t i e n t s ' suffering at the e n d of life. Over the course of 5 years, t h e s t u d y tracked t h e experie n c e s of 9105 d y i n g p a t i e n t s i n five major m e d i c a l centers. To help p a t i e n t s die w i t h less a g g r e s s i v e t r e a t m e n t a n d in greater comfort, doctors were prov i d e d with u p - t o - d a t e information on p a t i e n t prognoses. Expert n u r s e s c o m m u n i c a t e d w i t h p a t i e n t s a n d families a n d relayed information a b o u t p a t i e n t w i s h e s to p h y s i c i a n s , a n d great a t t e n t i o n w a s paid to p a i n control. Yet the results w e r e abysmal. P h y s i c i a n s did n o t u n d e r s t a n d or h e e d p a t i e n t s ' wishes, too m a n y p a t i e n t s s p e n t too m u c h t i m e on ICUs, a n d too m a n y died in pain. W h y did this w e l l - i n t e n t i o n e d project go w r o n g ? As Dr. Bernard Lo, w h o wrote a JAMA editorial on t h e study, told t h e m e d i a (and one of t h e n u r s e s involved in t h e s t u d y told me), doctors are notoriously u n w i l l i n g to listen to n u r s e s . Should w e b e surprised then, w h e n the result for p a t i e n t s is less t h a n satisfactory? We m u s t do m o r e t h a n t e a c h doctors h o w to listen to p a t i e n t s . We m u s t t e a c h t h e m h o w to learn from a n d collaborate w i t h nurses. A n d in a n era w h e n more a n d more m e m b e r s of the p u b l i c are worried a b o u t h o w t h e y will die, t h e y m u s t u n d e r s t a n d the role n u r s e s c a n play in h e l p i n g t h e m cope w i t h p a i n a n d suffering a n d find a good e n o u g h death. There is a n o t h e r r e a s o n n u r s e s ' work so often goes u n r e c o g n i z e d . E v e n s o m e of the p a t i e n t s who h a v e b e n e f i t e d t h e m o s t from n u r s e s ' critical care are u n a b l e to publicly credit its importance_ B e c a u s e n u r s e s share a n d cusi~ion w h a t Oliver~.,~Sadks has called h u m a n b e i n g s ' radical fall into sickness, n u r s es are a living r e m i n d e r of t h e pain, fear, vulnerability, a n d loss of control adults find it so difficult to tolerate a n d t h u s openly discuss. A m a n w h o has just h a d a s u c c e s s f u l b y p a s s operation will b o a s t of his s u r g e o n ' s a c c o m p l i s h m e n t s to his friends at a d i n n e r party. A w o m a n w h o has just s u r v i v e d a b o n e m a r r o w t r a n s p l a n t will extol her oncologist's t r i u m p h in the war a g a i n s t c a n c e r to her friends a n d relatives. But w h a t n u r s e s did for t h o s e two i n d i v i d u a l s will rarely b e m e n t i o n e d . It w a s a n u r s e w h o b a t h e d t h e cardiac p a t i e n t , a n d comforted this g r o w n m a n
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while he s t r u g g l e d w i t h the terror of n o t k n o w i n g if he w o u l d live or die. It w a s a n u r s e who held t h e plastic dish u n d e r the c a n c e r p a t i e n t ' s lips as she w a s w r a c k e d w i t h n a u s e a a n d who w i p e d a b o t t o m r a w from diarrhea. As Claire F a g i n a n d D o n n a Diers h a v e e x p l a i n e d in a n e l o q u e n t e s s a y e n t i t l e d " N u r s i n g As Metaphor," n u r s e s are a m e t a p h o r for intimacy. T h e y are our s e c r e t sharers. E v e n t h o u g h they are p a t i e n t s ' lifelines d u r i n g illness, w h e n control is restored the r e s i d u e of our a n x i e t y a n d mortality clings to t h e m like d u s t a n d w e flee t h e memory. B e c a u s e w e w o u l d prefer to forget t h e realities of illness, w e grasp on to t h e f a n t a s y t h a t m e d i c i n e c a n t r i u m p h over the h u m a n condition. In d e f i n i n g h e a l t h care as m e d i c a l care, w e ' v e c o m e to t h i n k of illness as a n event. You get sick. You go to a doctor. He or she gives you a diagnosis, a n d t r e a t m e n t plan. You follow it a n d hopefully you are cured. But illness is a p r o c e s s not a n e v e n t - - o n e t h a t requires care b o t h before, during, a n d after t h e m e d ical e n c o u n t e r s t h a t p u n c t u a t e it. Rather t h a n forcing n u r s i n g into the b i o m e d i c a l mode] of d i a g n o s i s treatm e n t a n d cure, think of n u r s i n g as a tapestry of care w o v e n from countless threads into a n intricate whole. At one m o m e n t , a n u r s e like N a n c y Rurnplik, J e a n n i e Chaisson, or Ellen Kitchen m a y b e involved in a sophisticated clinical procedure that d e m a n d s expert judgm e n t a n d a d v a n c e d t r a i n i n g in the latest technology. The n e x t m o m e n t , or e v e n at the s a m e time, she m a y do w h a t m a n y people consider trivial or m e n i a l work, s u c h as e m p t y i n g a b e d p a n , giving a bedbath, a d m i n istering medication, feeding, or walking a patient. T h e fact t h a t n u r s e s ' work is i n t e r s p e r s e d w i t h m a n y so-called m e n i a l tasks is n o t a r e a s o n to d e m e a n their work or, as is h a p p e n i n g today, a n d to replace n u r s e s w i t h less skilled workers. It's this h a n d s - o n care t h a t allows n u r s e s to explore p a t i e n t s ' p h y s i c a l c o n d i t i o n a n d register their a n x i e t y a n d fear. It is this t h a t allows t h e m to save lives a n d to ascert a i n w h e n it's appropriate to help p a t i e n t s die. A n d it is only in w a t c h i n g t h e m w e a v e t h e t a p e s t r y of care t h a t w e grasp its i n t e g r i t y a n d its m e a n i n g for a society t h a t too easily forgets the value of t h i n g s t h a t are b e y o n d price.
Contributions for this" column sbould be sent to Gall P i s a r c i k Lenehan, RN, EdD, CS, c/o Managing Editog ENA, 216 Higgins Rd., Park Ridge, IL 60068-5736,. phone (847) 698-9400.
Gordon, BA, Arlington, Massachusetts
For t h r e e years, j o u r n a l i s t S u z a n n e Gordon o b s e r v e d three n u r s e s - - N a n c y Rumplik, a n u r s e in the H e m a t o l o g y / O n c o l o g y O u t p a t i e n t Clinic; J e a n n i e Chaisson, a m e d i c a l clinical n u r s e specialist on a general m e d i c a l unit, a n d Ellen Kitchen, a geriatric n u r s e practitioner m h o m e c a r e - - a t a B o s t o n teachi n g hospital. Using their e x p e r i e n c e s with patients, nurses, p h y s i c i a n s , and other colleagues as a p r i s m to look at n u r s i n g practice, history, n u r s e - p h y s i c i a n relationships, a n d nursing's future, Gordon h a s written Life Support: T h r e e N u r s e s on t h e Frontlines. This b o o k is an a t t e m p t to s h o w the A m e r i c a n p u b l i c the i m p o r t a n c e o f n u r s i n g practice. In today's health care climate, w h e r e c o s t c u t t i n g is directly targeting caregiving, it a r g u e s that n u r s e s are a p r e c i o u s r e s o u r c e w e m u s t p r e s e r v e a n d defend. This e x c e r p t is from Life Support.* A
p o s t e r d e c o r a t e s t h e wall of m y study. P a i n t e d in t o n e s of sepia, f a d e d teal, rust, a n d pewter, it shows a medieval woman, worried and attentive, h o l d i n g on h e r lap a pale, g l a s s y - e y e d child. A t her s i d e sits an e a r t h e n w a r e p i t c h e r which, w e a s s u m e , h o l d s a m e d i c i n a l potion. T h e p a i n t i n g , d a t e d 1660, is from a D u t c h m a s t e r G a b r i e l M e t s u (cc 1660) a n d is entitled, "The Sick Child." U n d e r n e a t h , is t h e title of t h e e x h i b i t i o n a n d b o o k t h a t it i n t r o d u c e d , Nursing: The Oldest Art. It m a y b e t h e oldest, b u t in t h e c o n t e m p o r a r y world, it is also one of t h e m o s t invisible. O n e of t h e m o s t invisible arts, s c i e n c e s , a n d c e r t a i n l y one of t h e m o s t invisible p a r t s of our h e a l t h c a r e s y s t e m . W h e n w e h e a r t h e w o r d s hospital, m e d i c i n e , a n d health care, i m a g e s of t e c h n o I o g y a n d - s c i e n t i f i c i n v e n t i o n often s p r i n g to mind. Mecharf~babventilatots, d i a l y s i s m a c h i n e s , i n t r a v e n o u s pumps;"Jbiomedical r e s e a r c h , surgery, m e d i c a t i o n . T h e s e , m a n y believe, are t h e life s u p p o r t s in our h e a l t h care syst e m . It is this s c i e n c e a n d t e c h n o l o g y t h a t k e e p s p e o ple alive, t h a t h e l p s t h e m c u r e a n d heal. In fact, t h e r e are other equally i m p o r t a n t life s u p *From Life S u p p o r t : T h r e e N u r s e s on t h e F r o n t l i n e s by Suzanne Gordon, w i t h an introduction by Claire M. Fagin, RN, PhD, FAAN, ©1997. Reprinted by permission of Little, Brown & Company. Available at your local bookstore, or to order a copy call 1-800-236-READ.
Suzanne Gordon is a journalist and author of Lifo Support: Three Nurses on the Front Lines. J Emerg Nuts 199'7;23:148-52. 18/9/79837
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p o r t s in our h e a l t h c a r e s y s t e m . T h e s e a r e t h e 2.2 million n u r s e s in A m e r i c a w h o m a k e u p t h e l a r g e s t prof e s s i o n in h e a l t h care, t h e l a r g e s t f e m a l e p r o f e s s i o n in A m e r i c a , a n d t h e s e c o n d - l a r g e s t profession. T h e s e w o m e n - - a n d m e n - - w e a v e a t a p e s t r y of care, k n o w l e d g e , r e l a t i o n s h i p , a n d t r u s t t h a t is c r i t i c a l to p a t i e n t s ' survival. This b o o k is t h e story of t h r e e of t h o s e n u r s e s p r a c t i c i n g on t h e frontlines of n u r s i n g , of t e c h n o l o g y , a n d of t h e m a n y c h a n g e s in our h e a l t h c a r e s y s t e m . N a n c y Rumplik, J e a n n i e C h a i s s o n , a n d Ellen K i t c h e n have, b e t w e e n t h e m , m o r e t h a n five d e c a d e s of e x p e I i e n c e c a r i n g for t h e sick. T h e y w o r k in a n a c u t e c a r e h o s p i t a l - - o n e of H a r v a r d M e d i c a l S c h o o l ' s t e a c h i n g hospitals. T h e Beth Israel is n o t only k n o w n for t h e q u a l i t y of its p a t i e n t care, it is also w o r l d - r e n o w n e d for t h e quality of its n u r s i n g staff a n d its i n s t i t u t i o n a l c o m m i t m e n t to n u r s i n g . I n s i d e Beth Israel, N a n c y Rumplik, J e a n n i e C h a i s s o n , a n d Ellen K i t c h e n are also r e c o g n i z e d for t h e i r e x p e r t i s e . N a n c y R u m p l i k is a n o u t p a t i e n t n u r s e w h o w o r k s in a n a m b u l a t o r y c a n c e r clinic; J e a n n i e C h a i s s o n is a m e d i c a l clinical n u r s e s p e c i a l i s t on a g e n e r a l m e d i c a l floor; a n d Ellen K i t c h e n is a n u r s e p r a c t i t i o n e r w h o delivers h o m e c a r e services. Their w o r k t h u s s p a n s t h e s p e c t r u m of w h a t n u r s e s do on i n p a t i e n t h o s p i t a l w a r d s , o u t p a t i e n t s e r v i c e s , a n d in t h e h o m e a n d community. A s y o u w a t c h t h e s e n u r s e s wor k w i t h p a t i e n t s , it m i g h t b e e a s y to c o n c l u d e t h a t t h e k n o w l e d g e , skill, a n d e m p a t h y t h e y d i s p l a y are extraordinary. In fact, t h e r e are h u n d r e d s of t h o u s a n d s of e x p e r t n u r s e s like t h e m w o r k i n g in hospitals, n u r s i n g h o m e s , r e h a b i l i t a t i o n facilities, p s y c h i a t r i c i n s t i t u t i o n s a n d m e n t a l h e a l t h clinics, rural a n d u r b a n h e a l t h clinics, p u b l i c health, h o m e care, a n d h o s p i c e c a r e all a c r o s s t h e nation. W i t h o u t their c a r e of t h e body, p a t i e n t s w o u l d n o t r e c o v e r a n d heal. W i t h o u t their c a r e of t i l e soul, p a t i e n t s w o u l d b e u n a b l e to w i t h s t a n d t h e a r d u o u s h i g h - t e c h t r e a t m e n t s on w h i c h our m o d e r n m e d i c a l s y s t e m d e p e n d . W i t h o u t their a c c e p t a n c e of d e a t h , our d e a t h - d e n y i n g m e d i c a l s y s t e m w o u l d e x a c t e v e n m o r e suffering from p a t i e n t s a n d their families. A l t h o u g h n u r s e s are s o m e of t h e m o s t c o s t - e f f e c tive professionals, t h e for-profit, m a r k e t - d r i v e n h e a l t h c a r e t h a t is s w e e p i n g this n a t i o n - - a n d m a n y othe r s - i s t h r e a t e n i n g t h i s v a l u a b l e r e s o u r c e . To g a i n an a d v a n t a g e in t h e c o m p e t i t i v e n e w h e a l t h c a r e m a r k e t p l a c e , h o s p i t a l s all over t h e c o u n t r y a r e t r y i n g to
Gordon/JOURNAL OF EMERGENCY NURSING
c u t their costs. O n e popular c o s t - c u t t i n g s t r a t e g y is l a y i n g off n u r s e s . T h r e e f o u r t h s of all A m e r i c a n h o s p i t a l s a r e e n g a g e d in or d e v e l o p i n g p l a n s for "restructuring" a n d m a n y are l a y i n g off m o r e t h a n 20% to 50% of t h e i r n u r s i n g staff. For t h e first t i m e in a d e c a d e , m a n y n u r s e s feel t h e i r p a t i e n t s are in danger. With g r e a t sadness and distress, they say that hospitals and i n s u r e r s will n o t allow t h e m to deliver t h e k i n d of q u a l i t y c a r e t h e y h a v e b e e n e d u c a t e d to g i v e p a t i e n t s a n d families. Yet this v e r y r e s t r u c t u r i n g a n d d o w n s i z i n g of h e a l t h care i n s t i t u t i o n s is t o u t e d as o n e of t h e w a y s to cure our s y s t e m ' s s e r i o u s defects. T h e latter a r e well known. T h e A m e r i c a n h e a l t h c a r e s y s t e m suffers from lack of a c c e s s , too m u c h f r a g m e n t e d , e x p e n s i v e h i g h - t e c h t r e a t m e n t , not e n o u g h a t t e n t i o n to h e a l t h m a i n t e n a n c e a n d d i s e a s e p r e v e n t i o n , a n d failure to a t t e n d to p a t i e n t s ' e m o t i o n a l a n d social n e e d s , as well a s their p a i n a n d suffering. R e d u c i n g t h e n u m b e r of e x p e r i e n c e d , e d u c a t e d n u r s e s hardly solves t h e s e p r o b l e m s . A l t h o u g h A m e r i c a n h o s p i t a l s a l r e a d y u s e 20% fewer n u r s e s t h a n a n u m b e r of other i n d u s t r i a l i z e d countries, h o s p i t a l a d m i n i s t r a t o r s a n d s o m e n u r s i n g e x e c u t i v e s n o w a r g u e t h a t u n i t s staffed w i t h e d u c a t ed, e x p e r i e n c e d n u r s e s are a luxury w e c a n no l o n g e r afford. Yet, in 1992, t h e a v e r a g e staff n u r s e e a r n e d a little less t h a n $33,000 a year, t h e a v e r a g e clinical n u r s e s p e c i a l i s t e a r n e d a b o u t $41,000 a year, a n d t h e a v e r a g e n u r s e p r a c t i t i o n e r e a r n e d slightly less t h a n $44,000 a year. (At a major t e a c h i n g h o s p i t a l like t h o s e in Boston, staff n u r s e s in a u n i o n - b a r g a i n i n g unit c a n e a r n u p to $67,000 w h i l e a clinical n u r s e s p e cialist or n u r s e p r a c t i t i o n e r c a n e a r n m o r e t h a n $80,000). N u r s e s ' salaries a n d b e n e f i t s c o m p r i s e only a b o u t 16% of h o s p i t a l ' s total costs. Compare this with the average income of physicians. A c c o r d i n g to Modern Healthcare's 1996 physician compensation report, average physicians compensation in internal m e d i c i n e is $135,755, in family practice $128,096, in anesthesiology $193,242, oncology $164,621, and in general surgery $199,342. Some s p e c i a l i s t p h y s i cians e a r n up to several million dollars a year. A s u r v e y c o n d u c t e d in 1995 b y Hospitals" & Health Networks, t h e m a g a z i n e of t h e A m e r i c a n Hospital Association, stated that the average base salary a n d total c a s h c o m p e n s a t i o n for h o s p i t a l CEOs w a s $188,600. In a large h o s p i t a l t h a t w e n t u p to $280,900. A n d in a for-profit c h a i n it's far higher. In 1995, at a g e 43, Richard Scott, CEO of C o l u m b i a / H C A H e a l t h c a r e C o r p o r a t i o n , r e c e i v e d a s a l a r y of $2,093,844. H e p e r s o n a l l y c o n t r o l s s h a r e s in C o l u m b i a / H C A w o r t h $359.5 million.
N u r s e s ' salaries s e e m particularly paltry w h e n c o m p a r e d w i t h s o m e of t h e m o s t e g r e g i o u s w a s t e in the system~he i n c o m e of t h e CEOs of for-profit HMOs. In 1994, t h e e x e c u t i v e c o m p e n s a t i o n p a c k a g e s of t h e CEOS of t h e s e v e n l a r g e s t for-profit H M O s a v e r a g e d $7.9 million. E v e n t h o s e in t h e not-for-profit s e c t o r of i n s u r a n c e e a r n s t a r t l i n g s u m s . In 1995, J o h n Burry Jr., c h a i r m a n a n d CEO of t h e nonprofit Ohio Blue C r o s s Blue Shield, w a s p a i d $1.6 million. A c c o r d i n g to a r e p o r t in Modern Healthcare, a prop o s e d m e r g e r w i t h t h e for-profit C o l u m b i a / H C A H e a l t h c a r e Corporation w o u l d h a v e p a i d h i m $3 million "for a d e c a d e - l o n g , n o - c o m p e t e c o n t r a c t . . , a n d u p to s e v e n million for t w o c o n s u l t i n g a g r e e m e n t s . "
R e d u c i n g t h e n u m b e r of experienced, educated n u r s e s hardly s o l v e s these problems.
N u r s e s are clearly not t h e c o s t e s c a l a t o r s in t h e s y s t e m . Quite t h e contrary. Their c a r e s a v e s not only lives b u t money. Over t h e p a s t 20 years, this fact h a s b e e n confirmed in s t u d y after study. In major s t u d i e s c o n d u c t e d in 1976, 1986, 1989, 1994, a n d 1995, m e d i c a l a n d n u r s i n g r e s e a r c h e r s directly linked t h e n u m b e r a n d e d u c a t i o n a l qualifications of r e g i s t e r e d n u r s e s on h o s p i t a l u n i t s to lower m o r t a l i t y r a t e s a n d d e c r e a s e d l e n g t h s of h o s p i t a l stay. R e d u c i n g t h e n u m b e r of e x p e r t n u r s e s in t h e hospital, c o m m u n i t y , a n d h o m e h e e d l e s s l y e n d a n g e t s p a t i e n t s ' lives a n d w a s t e s s c a r c e r e s o u r c e s . N u r s e s h a v e also h e l p e d to i n c r e a s e a c c e s s to our h e a l t h care s y s t e m . M a n y p r o v i d e s e r v i c e s to s o m e of t h e 41 million A m e r i c a n s w h o h a v e no h e a l t h i n s u r a n c e or to A m e r i c a n s w h o live in a r e a s t h a t p h y s i c i a n s t e n d to avoid. It is Ellen K i t c h e n a n d her c o l l e a g u e s w h o g i v e h e a l t h c a r e to poor, m i n o r i t y w o m e n a n d their n e w b o r n s , w h o staff rural h e a l t h clinics in w h i c h few d o c t o r s c h o o s e to p r a c t i c e , or w h o go into t h e h o m e s of t h e elderly a n d h o m e b o u n d allowing t h e m to live on their o w n for as long as p o s sible. A g a i n , b y h e l p i n g elderly c i t i z e n s to live at h o m e , r a t h e r t h a n in a n u r s i n g home, this k i n d of c a r e s a v e s billions. C h o o s i n g to s a v e m o n e y b y r e d u c i n g n u r s i n g
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care a g g r a v a t e s t h e i m p e r s o n a l i t y a n d i n h u m a n i t y of a m e d i c a l s y s t e m t h a t t e n d s to t u r n h u m a n b e i n g s into their d i s e a s e s a n d t h e doctors who care for t h e m into s o p h i s t i c a t e d clinical m a c h i n e s . W h e n t h e y ' r e sick, p a t i e n t s do n o t only ask w h a t pills t h e y should take, or w h a t o p e r a t i o n s t h e y should have. T h e y are p r e o c c u p i e d w i t h q u e s t i o n s like, "Why m e ? Why now? How c a n I deal w i t h this? How c a n we, as a family, c o p e ? W h e r e is h o p e ? Is there m e a n i n g ? Is there God?" B e c a u s e of their history, a n d their daily work, n u r s e s live t h r o u g h this day-by-day, m i n u t e - b y m i n u t e attack o n the soul. T h e y k n o w that, for the patient, there is n o t only a sick or infirm body, b u t a life, a family, a c o m m u n i t y , a society t h a t has b e e n disrupted a n d t h a t n e e d s to heal.
Doctors o n E.R. are c o n s t a n t l y barking out the simplest commands--" get a blood pressure, a Chem-13 (blood chemistries), type a n d c r o s s a n d call t h e OR, or call r e s p i r a t o r y t h e r a p y " - to e x p e r i e n c e d ED n u r s e s . Although n u r s e s help u s live a n d die, i n the p u b lic depiction of health care, p a t i e n t s s e e m to e m e r g e from hospitals w i t h o u t ever h a v i n g b e n e f i t e d from their assistance. W h e t h e r p a t i e n t s are t r e a t e d in a n e m e r g e n c y d e p a r t m e n t i n a few short hours, or on a critical care u n i t for m o n t h s on end, w e s e e m c e r t a i n that p h y s i c i a n s are r e s p o n s i b l e for all t h e s u c c e s s e s - - o r f a i l u r e s - - i n our m e d i c a l system. In_fact, w e s e e m to believe t h a t t h e y are r e s p o n s i b l e h-et.o~ly for all of the c u r i n g b u t for m o s t of t h e caring. - ,;' Nurses, on t h e other h a n d , r e m a i n s h a d o w y figures m o v i n g m y s t e r i o u s l y in t h e b a c k g r o u n d . On television series, n u r s e s often a p p e a r as c o m i c figures. In TV s h o w s like t h e short-lived Nightingales, the sit-com Nurses, or t h e m e d i c a l d r a m a Chicago Hope, n u r s e s are far too b u s y p i n i n g after doctors or racing off to aerobics classes to actually care for patients. The n e w hit E.R. gives n u r s e s more promin e n c e t h a n m a n y other doctor shows. N o n e t h e l e s s , doctors on E.R. are c o n s t a n t l y b a r k i n g out the simplest c o m m a n d s - - " g e t a blood pressure, a Chem-13 (blood chemistries), t y p e a n d cross a n d call t h e OR, or call respiratory t h e r a p y " - - t o e x p e r i e n c e d ED nurses.
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In reality, t h e s e n u r s e s w o u l d h a v e t h o u g h t of all this before t h e doctor. In a n e m e r g e n c y d e p a r t m e n t as b u s y a n d s o p h i s t i c a t e d as t h e one on E.R. (this is, after all, a level I t r a u m a center), t h e first c l i n i c i a n a p a t i e n t w o u l d see is a triage n u r s e w h o w o u l d a s s e s s a p a t i e n t a n d d i c t a t e w h a t he or s h e n e e d s , w h o will see h i m or her, a n d w h e n . E x p e r i e n c e d n u r s e s will, i n fact, direct less e x p e r i e n c e d residents, s u g g e s t i n g a m e d i c a t i o n , test, c o n s u l t a t i o n w i t h a specialist, or transfer to t h e o p e r a t i n g room. The great irony of E.R. is t h a t Carol Hathaway, t h e n u r s e in c h a r g e - - a n d t h u s one of the key figures in a n y real e m e r g e n c y r o o m - - i s generally r e l e g a t e d to comforting a child or following p h y s i c i a n direction rather t h a n h e l p i n g to direct t h e staff in s a v i n g lives. Not only do doctors d o m i n a t e television, t h e y are also t h e focus of m o s t hard n e w s health care coverage. Reporters rarely cover n u r s i n g i n n o v a t i o n s , u s e n u r s e s as sources, or report on n u r s i n g research. W h e n reporters a n d politicians c o n s u l t w i t h h e a l t h care experts a n d report on their r e c o m m e n d a t i o n s , or their r e s p o n s e s to reform proposals, t h e y i n v a r i a b l y i n t e r v i e w p h y s i c i a n s , r e p r e s e n t a t i v e s of p h y s i c i a n organizations, or health care policy specialists w h o t e n d to look at health care either t h r o u g h t h e p r i s m of m e d i c i n e or t h r o u g h e c o n o m i c s . T h u s a 1990 study, "Who C o u n t s in N e w s Coverage of Health Care?", of t h e h e a l t h care c o v e r a g e i n three A m e r i c a n n e w s p a pers of record--The N e w York Times, Los Angeles igmes, a n d The Washington Post--documented t h a t out of 908 q u o t e s t h a t a p p e a r e d in 3 m o n t h s ' w o r t h of health care stories, n u r s e s were q u o t e d exactly 10 times. C o n v e n t i o n a l w i s d o m has held t h a t w h e n m o r e w o m e n e n t e r e d the n a t i o n ' s n e w s r o o m s , t h e y w o u l d p a y greater a t t e n t i o n to t h e varied c o n t r i b u t i o n s of w o m e n in society. This h a s n ' t h e l p e d t h o s e w o m e n w h o are n u r s e s . Of the 119 articles w o m e n journalists clearly authored, there w a s a larger p e r c e n t a g e of female m a i n sources (23.53%) t h a n in t h o s e a u t h o r e d b y m e n (16.01%). F e m a l e journalists t e n d e d to q u o t e m o r e female p h y s i c i a n s , h o s p i t a l a d m i n i s t r a t o r s , o r g a n i z a t i o n a l s p o k e s p e r s o n s , politicians, a n d policy makers. But female reporters did n o t seek out n u r s e s for s o u r c e s of i n f o r m a t i o n or expertise a n y more freq u e n t l y t h a n their male counterparts. Today, t h e revolution in health care h a s b e c o m e b i g n e w s . Occasionally reporters t u r n their a t t e n t i o n to the p h e n o m e n o n of n u r s i n g layoffs. But the story is rarely f r a m e d as a n i m p o r t a n t public h e a l t h issue. Rather it is generally d e p i c t e d as a l a b o r - m a n a g e m e n t conflict. N u r s i n g u n i o n s are b a t t l i n g w i t h m a n a g e m e n t . Nurses say this, hospital a d m i n i s t r a t o r s claim that. Who c a n you believe?
Gordon/JOURNAL O1: EMERGENCYNURSING
Or worse still, this crucial i s s u e m a y be c o u c h e d in the worst s t e r e o t y p e s of n u r s i n g / w o m e n ' s work. A typical e x a m p l e a p p e a r e d on NBC Nightly News. T h e p r o g r a m ran a story a b o u t t h e serious p r o b l e m s r e s u l t i n g from r e p l a c i n g n u r s e s w i t h u n l i c e n s e d assistive p e r s o n n e l . The a n c h o r i n t r o d u c e d it as "a n e w a n d controversial w a y of a d m i n i s t e r i n g TLC." I m a g i n e h o w reporters w o u l d c h a r a c t e r i z e t h e story if 20% to 50% of p h y s i c i a n staff w e r e e l i m i n a t e d i n t h o u s a n d s of A m e r i c a n hospitals. Would it n o t b e front-page n e w s , a major public health c a t a s t r o p h e ? P a t i e n t s all over the c o u n t r y w o u l d b e terrified to e n t e r hospitals. Yet, w e learn a b o u t the n u r s i n g e q u i v a l e n t w i t h only a m i n i m u m of concern. If t h e only p r o b l e m w i t h laying off t h o u s a n d s of n u r s e s is t h e loss of a little TLC, w h a t difference does it m a k e if a n aide r e p l a c e s a n u r s e ? But n u r s i n g is n o t a m a t t e r of TLC. It's a m a t t e r of life a n d death. In the hospitals w h e r e 66% of n u r s es work, n u r s e s are the o n e s w h o m o n i t o r a n d evaluate a p a t i e n t ' s c o n d i t i o n before, during, a n d after h i g h - t e c h m e d i c a l procedures. It is t h e n u r s e w h o will a d j u s t m e d i c a t i o n s , m a n a g e pain, a n d side effects of t r e a t m e n t , act i n s t a n t l y to i n t e r v e n e if t h e r e are l i f e - t h r e a t e n i n g c h a n g e s in a p a t i e n t condition, or alert p h y s i c i a n s so t h a t t h e y c a n p r o t e c t t h e i r patients. N u r s e s like N a n c y Rumplik, J e a n n i e Chaisson, a n d Ellen K i t c h e n are c o n s t a n t l y e n g a g e d in w h a t a p p e a r to b e s e e m i n g l y simple i n t e r a c t i o n s - - a d m i n i s t e r i n g a m e d i c a t i o n , g i v i n g a bath, e m p t y i n g a b e d pan, c h e c k i n g a p a t i e n t ' s m e d i c a t i o n box, m a k i n g sure his refrigerator is well stocked. But there is n o t h i n g simple a b o u t t h e s e e x c h a n g e s . T h e y are s o m e of t h e t h r e a d s w i t h w h i c h their t a p e s t r y of care is w o v e n a n d are critical to n u r s e s ' k n o w l e d g e of a n d r e l a t i o n s h i p s w i t h patients. T h e s e e n c o u n t e r s allow n u r s e s to develop a s e n s e of p a t i e n t s - - w h a t t h e y refer to as the p a t i e n t ' s "baseline." This p e r m i t s t h e m to know, often at a glance, w h e n a n i m p o r t a n t c h a n g e in a p a t i e n t ' s c o n d i t i o n h a s occurred e v e n before t h a t c h a n g e is r e g i s t e r e d in a falling blood pressure, r i s i n g t e m p e r a t u r e , or labored b r e a t h i n g . In a c a n c e r ward, n u r s e s c a t c h a serious r e a c t i o n to m e d i c a t i o n almost before it happens. In a n operati n g room, n u r s e s m a k e sure t h e right p a t i e n t is b e i n g o p e r a t e d on, or t h a t the right p r o c e d u r e is b e i n g performed on t h e right limb or organ. O n a n ICU or in h o m e care, n u r s e s q u e s t i o n w h y a p a t i e n t is g e t t i n g a n o t h e r painful d i a g n o s t i c t e s t t h a t m a y reveal little useful information; w h y a d e q u a t e p a i n m e d i c a t i o n is n o t g i v e n after surgery; w h y a p a t i e n t is b e i n g disc h a r g e d too quickly; w h e t h e r s o m e o n e is available to take care of t h e m in the home; a n d at t h e e n d of life,
w h y e x p e n s i v e , heroic t r e a t m e n t t h a t will only prolong d e a t h is p r e s e n t e d as the only option. In t h e self-enclosed world of t h e h i g h - t e c h hospital, w h e r e ordinary m e n a n d w o m e n a n d children are c o n f r o n t e d w i t h people w h o wear alien c o s t u m e s , a d h e r e to peculiar c u s t o m s , a n d e v e n s p e a k their o w n l a n g u a g e , n u r s e s help p a t i e n t s deal with their fear a n d a n x i e t y - - n o t only of their d i s e a s e s b u t of the people w h o are s u p p o s e d to cure t h e m . W a t c h Nancy, J e a n n i e , a n d Ellen a n d you see h o w i m p o r t a n t this is to f r i g h t e n e d p a t i e n t s a n d family m e m b e r s .
Imagine how reporters would c h a r a c t e r i z e t h e s t o r y if 20% to 50% of p h y s i c i a n staff w e r e e l i m i n a t e d in t h o u s a n d s of A m e r i c a n hospitals.
In our h i g h - t e c h m e d i c a l system, n u r s e s are the o n e s w h o care for the b o d y a n d the soul. No m a t t e r h o w sensitive, caring, a n d a t t e n t i v e p h y s i c i a n s are, in b o t h t h e hospital a n d home, n u r s e s are often closer to p a t i e n t n e e d s a n d w i s h e s t h a n p h y s i c i a n s . T h a t ' s n o t b e c a u s e n u r s e s are i n h e r e n t l y more c a r i n g t h a n doctors, b u t b e c a u s e t h e y s p e n d far more t i m e w i t h p a t i e n t s a n d m a y g e t to k n o w t h e m better. This t i m e a n d k n o w l e d g e allows n u r s e s to save lives. But n u r s e s also help people a d j u s t to the lives they m u s t live after t h e y h a v e b e e n saved. A n d w h e n d e a t h c a n no longer b e delayed, n u r s e s help p a t i e n t s confront their o w n mortality with at least s o m e m e a s u r e of grace a n d dignity. T h e t a p e s t r y of care t h a t n u r s e s w e a v e w o u l d b e m u c h s t r e n g t h e n e d if p h y s i c i a n s a n d n u r s e s cons t r u c t e d it t o g e t h e r a n d if b o t h groups h a d a n equal voice i n health care i n s t i t u t i o n s a n d in the health care s y s t e m as a whole. In m a n y i n s t a n c e s , b o t h in this book a n d in the health care system, doctors a n d n u r s e s do cooperate effectively. But, in general, the history of m e d i c i n e a n d n u r s i n g a n d c o n t e m p o r a r y physician and nurse relationships preclude g e n u i n e collaboration. In spite of their i m p o r t a n t work, n u r s e s - m e m b e r s of a q u i n t e s s e n t i a l l y female profession (95% of all n u r s e s are f e m a l e ) - - h a v e long b e e n subord i n a t e d to the q u i n t e s s e n t i a l l y male profession of m e d i c i n e . In the A m e r i c a n m e d i c a l s y s t e m , rigid, g e n d e r - r i d d e n hierarchies m a k e it difficult for doctors a n d n u r s e s to relate as colleagues. T h u s today m a n y
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d o c t o r s - - m a l e a n d female a l i k e - - s t i l l c o n s i d e r n u r s es to b e their h a n d m a i d e n s . This has serious c o n s e q u e n c e s for p a t i e n t s a n d for t h e health care s y s t e m as a whole. W h e n doctors d o n ' t listen to n u r s e s t h e y c a n ' t hear their patients. In 1995, The Journal of the American Medical Association (JAMA) r e l e a s e d t h e highly p u b l i c i z e d SUPPORT study. The S t u d y to U n d e r s t a n d Prognoses a n d P r e f e r e n c e s for O u t c o m e s a n d T r e a t m e n t s f o c u s e d on p a t i e n t s ' suffering at the e n d of life. Over the course of 5 years, t h e s t u d y tracked t h e experie n c e s of 9105 d y i n g p a t i e n t s i n five major m e d i c a l centers. To help p a t i e n t s die w i t h less a g g r e s s i v e t r e a t m e n t a n d in greater comfort, doctors were prov i d e d with u p - t o - d a t e information on p a t i e n t prognoses. Expert n u r s e s c o m m u n i c a t e d w i t h p a t i e n t s a n d families a n d relayed information a b o u t p a t i e n t w i s h e s to p h y s i c i a n s , a n d great a t t e n t i o n w a s paid to p a i n control. Yet the results w e r e abysmal. P h y s i c i a n s did n o t u n d e r s t a n d or h e e d p a t i e n t s ' wishes, too m a n y p a t i e n t s s p e n t too m u c h t i m e on ICUs, a n d too m a n y died in pain. W h y did this w e l l - i n t e n t i o n e d project go w r o n g ? As Dr. Bernard Lo, w h o wrote a JAMA editorial on t h e study, told t h e m e d i a (and one of t h e n u r s e s involved in t h e s t u d y told me), doctors are notoriously u n w i l l i n g to listen to n u r s e s . Should w e b e surprised then, w h e n the result for p a t i e n t s is less t h a n satisfactory? We m u s t do m o r e t h a n t e a c h doctors h o w to listen to p a t i e n t s . We m u s t t e a c h t h e m h o w to learn from a n d collaborate w i t h nurses. A n d in a n era w h e n more a n d more m e m b e r s of the p u b l i c are worried a b o u t h o w t h e y will die, t h e y m u s t u n d e r s t a n d the role n u r s e s c a n play in h e l p i n g t h e m cope w i t h p a i n a n d suffering a n d find a good e n o u g h death. There is a n o t h e r r e a s o n n u r s e s ' work so often goes u n r e c o g n i z e d . E v e n s o m e of the p a t i e n t s who h a v e b e n e f i t e d t h e m o s t from n u r s e s ' critical care are u n a b l e to publicly credit its importance_ B e c a u s e n u r s e s share a n d cusi~ion w h a t Oliver~.,~Sadks has called h u m a n b e i n g s ' radical fall into sickness, n u r s es are a living r e m i n d e r of t h e pain, fear, vulnerability, a n d loss of control adults find it so difficult to tolerate a n d t h u s openly discuss. A m a n w h o has just h a d a s u c c e s s f u l b y p a s s operation will b o a s t of his s u r g e o n ' s a c c o m p l i s h m e n t s to his friends at a d i n n e r party. A w o m a n w h o has just s u r v i v e d a b o n e m a r r o w t r a n s p l a n t will extol her oncologist's t r i u m p h in the war a g a i n s t c a n c e r to her friends a n d relatives. But w h a t n u r s e s did for t h o s e two i n d i v i d u a l s will rarely b e m e n t i o n e d . It w a s a n u r s e w h o b a t h e d t h e cardiac p a t i e n t , a n d comforted this g r o w n m a n
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while he s t r u g g l e d w i t h the terror of n o t k n o w i n g if he w o u l d live or die. It w a s a n u r s e who held t h e plastic dish u n d e r the c a n c e r p a t i e n t ' s lips as she w a s w r a c k e d w i t h n a u s e a a n d who w i p e d a b o t t o m r a w from diarrhea. As Claire F a g i n a n d D o n n a Diers h a v e e x p l a i n e d in a n e l o q u e n t e s s a y e n t i t l e d " N u r s i n g As Metaphor," n u r s e s are a m e t a p h o r for intimacy. T h e y are our s e c r e t sharers. E v e n t h o u g h they are p a t i e n t s ' lifelines d u r i n g illness, w h e n control is restored the r e s i d u e of our a n x i e t y a n d mortality clings to t h e m like d u s t a n d w e flee t h e memory. B e c a u s e w e w o u l d prefer to forget t h e realities of illness, w e grasp on to t h e f a n t a s y t h a t m e d i c i n e c a n t r i u m p h over the h u m a n condition. In d e f i n i n g h e a l t h care as m e d i c a l care, w e ' v e c o m e to t h i n k of illness as a n event. You get sick. You go to a doctor. He or she gives you a diagnosis, a n d t r e a t m e n t plan. You follow it a n d hopefully you are cured. But illness is a p r o c e s s not a n e v e n t - - o n e t h a t requires care b o t h before, during, a n d after t h e m e d ical e n c o u n t e r s t h a t p u n c t u a t e it. Rather t h a n forcing n u r s i n g into the b i o m e d i c a l mode] of d i a g n o s i s treatm e n t a n d cure, think of n u r s i n g as a tapestry of care w o v e n from countless threads into a n intricate whole. At one m o m e n t , a n u r s e like N a n c y Rurnplik, J e a n n i e Chaisson, or Ellen Kitchen m a y b e involved in a sophisticated clinical procedure that d e m a n d s expert judgm e n t a n d a d v a n c e d t r a i n i n g in the latest technology. The n e x t m o m e n t , or e v e n at the s a m e time, she m a y do w h a t m a n y people consider trivial or m e n i a l work, s u c h as e m p t y i n g a b e d p a n , giving a bedbath, a d m i n istering medication, feeding, or walking a patient. T h e fact t h a t n u r s e s ' work is i n t e r s p e r s e d w i t h m a n y so-called m e n i a l tasks is n o t a r e a s o n to d e m e a n their work or, as is h a p p e n i n g today, a n d to replace n u r s e s w i t h less skilled workers. It's this h a n d s - o n care t h a t allows n u r s e s to explore p a t i e n t s ' p h y s i c a l c o n d i t i o n a n d register their a n x i e t y a n d fear. It is this t h a t allows t h e m to save lives a n d to ascert a i n w h e n it's appropriate to help p a t i e n t s die. A n d it is only in w a t c h i n g t h e m w e a v e t h e t a p e s t r y of care t h a t w e grasp its i n t e g r i t y a n d its m e a n i n g for a society t h a t too easily forgets the value of t h i n g s t h a t are b e y o n d price.
Contributions for this" column sbould be sent to Gall P i s a r c i k Lenehan, RN, EdD, CS, c/o Managing Editog ENA, 216 Higgins Rd., Park Ridge, IL 60068-5736,. phone (847) 698-9400.