The December issue of the International Nursing Review, the official journal of the International Council of Nurses, has the following editorial that I wrote.http://onlinelibrary.wiley.com/doi/10.1111/j.1466-7657.2010.00862.x/full
Nursing Needs a New Image
Empowerment. Patient advocacy. These are some of the most commonly heard words in nursing. No matter where I go and no matter with whom I talk, nurses argue that one of their primary missions is to advocate for patients. They also acknowledge that patient advocacy is hardly easy. That is because genuine advocacy is not just wishing the patient well. All too often it involves taking a risk, speaking out in public, and/or explaining what nurses do and why it is so important for politicians and policy makers to allocate resources to support nursing care.
A decade’s worth of research has documented the crucial connection between nursing care and patient outcomes. Whether it is in the hospital, home, nursing home, school, rehabilitation facility, or the community, nursing can be a matter of life and death. The concept of ‘failure to rescue,’ developed by physician Jeffrey Silber and his colleagues at the University of Pennsylvania School of Medicine (Silber et al. 1992), and elaborated on by Linda Aiken and her colleagues at the same university’s School of Nursing, clearly connects nursing care to patient rescue. Rescue, these researchers show, is dependent on having enough educated eyes on the patient enough of the time to detect subtle change in the patient’s condition that could signal a catastrophe about to happen. It turns out that, in many instances, those educated eyes belong to nurses.
Educated eyes, however, are not enough to affect rescue. Rescue also depends on the individual or team’s ability to mobilize institutional resources to avert catastrophe. And herein lies the rub. In many institutions, and in many societies, social or institutional devaluation of nursing has long constrained nurses’ ability to mobilize resources to save patients. I would also argue that nurses are further constrained by a professional discourse that, with the best intensions, belittles and trivializes nurses’ knowledge and skill, depicts nurses as juvenile and sometimes even silly, and thus subtly dissuades nurses from speaking out and acting in the policy arena.
What do I mean by a trivializing, sometimes almost ‘juvenilizing’ discourse? It is what I characterize in my new edited collection, When Chicken Soup Isn’t Enough: Stories of Nurses Standing Up for Themselves, Their Patients and Their Profession, as the ‘chicken soup’ narrative of contemporary nursing. Or what Sioban Nelson and I have termed the ‘virtue script’ in nursing (Gordon & Nelson 2005). In both books and images, nurses and nursing organizations all over the world depict nurses as either sugar-coated, sentimental women (and men) or in ways that almost suggest that they are children. Instead of utilizing images and words that capture the critical research that has been done about nursing, many national and international public relations campaigns, as well as nursing organizations themselves, depict nursing as the work of modern angels endowed with extraordinary powers of empathy and compassion. Their role is to be soothing and reassuring. As they hold hands, hug patients and their families, give back rubs and smile beatifically at patients, almost everything that could really empower nurses is left out of the picture.
Many campaigns conducted by nursing organizations and public relations done by hospitals or governments fail to highlight that nursing requires technical, medical, and pharmacological – to mention only a few – knowledge and expertise. What is even more disturbing is that the public rarely learns that effective caring and compassion requires education and expertise. In other words, even the most emotional, psychosocial work that nurses do is an example of the mind at work, not the heart. That is because in nursing effective heart work is, in reality, guided by brainwork.
With all due respect to the organizations involved, let me give some international examples of what I mean. Several years ago, when celebrating its anniversary, a nursing organization urged its members to purchase a commemorative poster depicting two white child angels. At the turn of the 21st century, francophone nurses from all over the world gathered for a conference focused on the theme Nursing: An Expertise of the Heart. In some countries, nursing groups give out prizes of stuffed kittens or teddy bears wearing nursing caps, to nurses.
A specialty organization dedicated to advancing nursing education, clinical practice and research in the field of cardiology, undermines its serious mission with its logo: a childlike drawing of stick figures holding a fluttering ribbon and connected with a childlike drawing of a heart. When another nursing organization decided to launch a public campaign to make nursing more visible to the public, its slogan was Quiet Power– a message that contradicted the outspoken and knowledgeable nurses who appeared in the organization’s video and in magazine and newspaper articles.
Finally, when you walk into a hospital and check out the photos of nurses in hospital photos, recruitment material or publications, some of them put out by departments of nursing, you find two predominant images: nurses holding the hands of a patient or nurses smiling at the camera, at the patient, or even at machines. (In direct contrast, institutional photographs of doctors always show them either looking authoritative or like they know something.) If you look at the faces of real nurses doing their work, more often than not, their expression is one of concentration, of concern, a look that conveys that they are thinking.
Are nurses really angels? Are they kittens? Teddy bears? Do patients need ‘quiet’ nurses? (I for one want a really noisy nurse to intervene if a physician prescribed the wrong drug, or the pharmacy delivers the wrong dose). Why do organizations with serious missions choose childlike images that completely contradict the seriousness of nurses’ work? Would physicians, lawyers, stockbrokers, pharmacists, or physical therapists mobilize similar words and images to depict their work? (Hint, they would not and do not). In a world where nursing is often dismissed as mere ‘hand-holding’ or TLC and nurses are devalued as either kind but not very bright, or worse, as sex kittens, why do nurses themselves perpetuate these images? And in 2010, no less?
I would argue that whenever nurses mobilize this kind of discourse, they are not only shooting themselves in the proverbial foot with the public, but also limiting their ability to mobilize their forces to fight for the kinds of policy changes upon which effective nursing depends. Nursing as a profession is an organized, institutional intervention. Just as rescuing patients in the hospital depends on nurses’ ability to mobilize institutional resources, so too rescuing the broader health care system and nurses’ role in it depends on nurses’ ability to mobilize societal resources to affect change. Many nurses and nursing groups have done this to wonderful effect. But their job is made much harder by a discourse that I believe demobilizes nurses – and can often end up demoralizing them as well.
In 2010, as the world faces an on-going global recession, and governments and private payers try to cut back on nursing care, nursing really does need a new image – one that not only encourages empathy but activism as well. If nurses are to advocate for patients, they must learn to better advocate for themselves. This means risking moving away from the comfortable image of the sweet and kind nurse and telling the world what nurses really know and what they really do.
Since the Institute of Medicine’s by now famous report To Err Is Human was published in 1999, there has been enormous public attention and huge public and private resources devoted to patient safety. All kinds of things have been promoted as silver bullets that will supposedly prevent thousands of patients from dying or suffering from preventable complications. Billions have been spent on health care information technology (HIT) as well as initiatives to get health care staff to wash their hands, pay attention to which leg they are amputating, and make sure they are giving the right patient the right drug. In spite of all this effort, time and money, things are not improving for patients. In Mid April, of 2010, the Agency for Healthcare Research and Quality, released a report that compared rates of bloodstream infections between 2009 and 2010. The 2010 rate of bloodstream infections, the agency reported, increased by 8 percent in one year, while, in the same time period, catheter associated urinary tract infections had likewise increased (by 4 percent). There was good news, e.g., pneumonias were down.
In June, 2010, only two months later, two professors from Case Western Reserve published an article in The Berkeley Technology Law Journal with even more distressing news. Doctors, the authors, warned should be wary of the promise of electronic medical records. Software bugs, lack of adequate training in complex technology, incessant warnings of drug interactions with no real threats, and errors that generate the wrong output, all can create significant patient safety hazards for which physicians may be held liable. In the late summer, Rhode Island hospital was again cited for performing a wrong site surgery — one of several in a short span of time. http://www.ri.gov/press/view/12476 And just last week, the New England Journal of Medicine published a sobering report by Christopher Landrigan and his colleagues. http://www.nejm.org/doi/full/10.1056/NEJMsa1004404 Landrigan who is a pioneer in the study of the impact of physician lack of sleep on both doctors and their patients, was the principle investigator on a study that looked at the progress of protecting patients from harm. To assess this progress, the investigators looked at hospitals in North Carolina — a state that has demonstrated, as the authors put it, a “high level of engagement in efforts to improve patient safety.”
Did those efforts pay off?
Sadly not much.
Do the investigators think patient safety efforts around the country are working?
The investigators conducted a six year study of ten hospitals in the state and sifted through 2300 randomly selected medical records of patients admitted to the hospital. Too many patients suffered from harm. Out of the 2300, 588 instances of harm were found, including, 14 deaths, 50 life threatening incidents and 17 instances of permanent problems. Over the six year period, there was no significant reduction in harm to patients — this in spite of myriad patient safety initiatives. Although the study focused only on North Carolina, the authors believe they can be applied to the rest of the country.
The conclusions of the study are worth everyone’s attention. The investigators write that there has been so little progress because of lack of “penetration of best practices” into the health care context, as well as failure to implement even basic electronic medical record keeping . A critical contributor to patient harm to which the authors point is the fact that “Physicians in training and nurses alike routinely work hours in excess of those proven to be safe. Compliance with even simple interventions such as hand-washing is poor in many centers.”
I would add to this list that nurses and doctors all shoulder too high patient loads. I know of nurses in North Carolina and other states who routinely care for 6,8 or even more patients and at night the workload skyrockets. Doctors too are seeing too many patients for too short a time. And, many patient safety initiatives are poorly designed because they fail to include front line workers in the design, planning, implementation, evaluation and refinement phases.
These issues and more are the subject of a book that I am editing with medical sociologist Ross Koppel. Koppel and I asked a number of patient safety experts — Christopher Landrigan among them – to contribute essays on the “Inconvenient Issues in Patient Safety.” The book will be out in the spring of 2012.
But don’t wait till 2012. Read the Landrigan article and think about your own work if you are a health care worker or professional. What is going on in your institution? Do you get enough sleep? Is your patient load too high? Do you have time to think? Do you have time to recover from an emergency? Or an upset? Or a patient death? Do you have time for teamwork? Are you fried when you leave the workplace? We need to hear from you about all this and more. If health care workers don’t talk about what is going on in the workplace more patients will be hurt. Sadly, but inevitably, more will die.
For years, I have been encouraging nurses to talk concretely about their work. Bernice Buresh and I have given nurses a primer in how to do this in our book From Silence to Voice: What Nurses Know and Must Communicate to the Public. As I think about nurses’ work, I continue to be convinced that nurses are not articulating their work and putting their brains — as opposed to their hearts — in the fore front of their conversation. In thinking about the nursing communication dilemma, I believe it’s important to consider what I call the perils of success. When I encourage them to talk about their work, many nurses tell me that it isn’t necessary. Patients understand what they do. They understand how important nurses are and how complex their work is. Well, I’m not so sure.
One of the problems is that a great deal of the work nurses do –whereever they practice — is preventive work. Nurses prevent bad things — or worse things as the case may be — from happening. When nurses work outside the hospital they may practice primary prevention. That is they stop people from getting sick in the first place. In the hospital, or home, or clinic, or rehab facility, nurses deal with people who are sick already. Nonetheless, they prevent worse things from happening to these patients. The person may already have diabetes, or a heart condition, or hypertension, or cancer, but that doesn’t mean that they can’t suffer from preventable complications — a medication error, a UTI, a bedsore, a DVT. It’s the nurses’ job to prevent those complications.
But ask yourself. When you prevent something, what happens? Think for a moment…….
What happens is nothing. Nothing happens when you act successfully to prevent it. And therein lies the perils of success. The danger is that a lot of people think that nothing happened to make that nothing happen, when in fact something happened to make nothing happen. If nurses do not talk about the something then people can easily think they do little or nothing. The more that nothing happens, the more people think, well, gee, who needs nurses. Nothing is happening.
Of course, what they aren’t thinking about is the thought, action, knowledge and skill went into that nothing. And that may be because nurseds are so busy talking about their compassion and niceness that they don’t talk about the skill and knowledge it takes to protect patients from the myraid dangers they will confront when they are sick. Administrators and politicians and journalists may even begin to imagine that hospitals are a lot safer than they are and that they don’t really need as many nurses because nurses are so successful at prevention.
If you doubt how seductive is this illusion just think back to Y2K. Remember, just ten years ago, when 1999 was about to turn into 2000 and we learned that all the computers in the world might fail and that at the stroke of midnight Jan 1, 2000, we would all turn into scullery maids like Cinderella and our amazing technological society would turn into a giant, global pumpkin. Newspapers were filled with stories of computer programmers frantically working to make sure that didn’t happen. But just in case it did, we were advised to stock up on water, canned food and plenty of cash (since the ATM machines would no longer be spewing out dollar bills, or Euros or Yen.)
Maybe you followed that advice. I certainly did and worried anxiously at a New Year’s Eve party about what would happen at that particular stroke of midnight. And what did happen? One big nothing. And what was my response over the next couple of days? I felt tricked,bamboozled. “What was all the fuss about? “, I thought. “Here we were chugging along just like we did throughout the latter part of the 20th century. It’s the media,” I thought, “once again making a mountain out of a molehill.” And, fortunately, then I thought again. Actually, it was because of all those people who were working on that mountain that it became a molehill. It was because of all the fuss that there was no more fuss, because of all that preventive work that our glass carriage did not turn into a giant orange vegetable.
Nursing is like Y2K everyday. If nurses do not explain to patients that they prevent any number of things, patients will never ever know. How could they? Nothing happened.
As I write this blog post, I do so in the shadow of the dramatic rescue of those 22 Chilean miners in the Atacama desert in South America. Wow, what a spectable! What a miracle! What drama! We are in love with the drama of rescue. But imagine if mine owners practiced the routine, daily, boring work of prevention, as the rescued miners keep reminding us in their post-rescue comments? And remember, for every miner rescued, hundreds are killed in preventable accidents. The point is, we cannot put our faith in the drama of rescue. We must put it into the everyday reality of prevention. And nurses must tell their patients precisely how they are practicing the science of prevention while they are practicing it. If they don’t there will be no practice, and that means patients will die.
Sometime last year, I received a request to blurb a new book by a nurse. This is not uncommon and I am usually quite happy to take a look at the book. But I have to admit, that most of the time, I refuse, because alot of books by nurses — well intentioned as they are — are not particularly compelling. So I didn’t hold out a lot of hope for this one. I was totally wrong. Theresa Brown’s book, entitled Critical Care: A New Nurse Faces Death, Life, and Everything in Between was stunning. Brown does everything right. Instead of focusing on the sappy and sentimental, she tells it like it is. In fact, what she talks about is not the kind of critical care one might think, since she’s not an ICU nurse, but instead an oncology nurse. But her no nonsense discussion of what it means to be a nurse focuses precisely on the right thing — the skill, knowledge, intelligence, know-how, and self-mastery involved in being a nurse.
Brown’s story is really interesting. She started out as a PhD in English and was actually an English professor for many years. Then she decided to become a nurse. Her book relays that journey and what she learned along the way. She got her start writing by reaching out to the New York Times Health Section and doing a short article for the Times. That led to a book contract and she now is a regular contributor to the Times Well Blog where you can find her about once a month. After meaning to talk to her since I agreed to blurb her book, I finally called her up and we began what I hope will be a long telephone conversation. What I found most interesting in talking to Theresa was how committed she is to bedside nursing and how little support she gets for that commitment. She told me that her non-nurse friends are always saying things like, well now since you’ve gotten a book published, you’re surely going to stop being a bedside nurse. (Can you imagine anyone asking Atul Gawande, or Jerome Groopman, the equivalent: “So now that you’re published in The New Yorker, surely you’ll stop being a surgeon or an oncologist?) What’s worse is that Theresa gets this from nursing. When, nursing academics ask her, are you going to become an NP? When are you going to leave the bedside and become an academic? I hear this and want to weep.
Here is a smart, articulate woman who gave her a professorship to become a nurse. She is committed to bedside nursing. She would like to do it, at least for now. And everyone is urging her to leave the bedside and do something (you can’t ignore the explicit message) better. Well, as far as I am concerned, nothing is better and I hope she stays. She is just the kind of nurse we need. I hope, when, knock wood, I get sick and old (I am having an I made it to Medicare party in only a month), someone like Theresa Brown will be at my bedside. Read her book and you will agree, that she’s the kind of nurse you will want to. So can we just agree — finally — to stop bad mouthing bedside nurses and give them a break. Sure we need NPs. Yes, we need more nursing academics. But if someone wants to remain at the bedside over the long term, why can’t nurses encourage them to stay there. Why can’t nurses applaud them. What we need to ask the Theresa Browns of the world is not “where are you going next,” but “what book — about bedside nursing — do you plan to write next and when can I look forward to purchasing it?”
On Monday, Labor Day, September 6, The New York Times ran a shocking article everyone should read. The headline read “Corporations Seek Favor from Lawmakers through Donations to Their Charities,” http://washingtonindependent.com/96741/corporations-seek-favor-from-lawmakers-through-donations-to-their-charities explains why our health care system and so much of our society is now under the kind of corporate domination that makes the threat of so-called “government pale in comparison. Why do pharmaceutical benefit management companies get to dictate what meds doctors prescribe? Why do insurance companies get to tell RNs and MDs how long patients stay in hospitals? Why do banks get bailed out when middle class home owners don’t? Why are there no strings on tax loopholes for corporations and tax cuts for hugely wealthy people? Why aren’t tax advantages awarded to people who create jobs for others rather than cash for themselves?
Of course we all know about the influence of money on politics. But this story reveals that that trend has been taken to a whole new level. Politicians of both parties — think Representative Charles B. Rangel Democrat and Senator Orrin G. Hatch Republican — get away with setting up foundations to which corporations contribute unlimited funds. The whole scheme is insidious. Orrin Hatch sets up a foundation called Utah Families Foundation. To fund it, he solicits money from corporations — who, if they donate $20,000, get to meet privately with Hatch. He then passes on this corporate money to constituents or their groups, thus bribing them to vote for him. So those who can afford to spend $20,000 or more get to bribe Hatch, who then turns around and bribes the voters. This on top of the fact that, failure to create national or state financing of elections, and to set spending limits on candidates means you get the super rich fighting it out with their own money, makes a total mockery of democracy.
This reminds me of the rotten boroughs that were outlawed in England in 1832. http://en.wikipedia.org/wiki/Rotten_and_pocket_boroughsThey were boroughs that were essentially bought and paid for by the rich.
What we need is a Reform Act here in the US too. Or, if that’s not possible why not just go straight for the gold. Forget the fiction that our lawmakers aren’t bought and paid for. Or that they aren’t themselves just buying their own seats. Just cut right to the chase. Instead of having two men (or women) fight it out let’s just assign seats to corporations. We could have the Walmart seat, the Staples seat, the Pfizer or Merck seat. We could have Big Pharma fighting it out with the insurance industry, or oil pitching against wind energy. At least, that way our choices would be clear. Of course, the companies would need politicians to represent them. So it would be like the Tour de France or any big sports competition where the stadium is plastered with corporate logos — the man or woman running would always wear the tee shirt or colors of the company he or she represents. The company logo would be on all their campaign material. This way you’d know which corporate interests your guy or girl represents. You don’t like the drug companies, vote the hospital association candidate, you hate the corporate agriculture, go Whole Foods.
Hey, I think I’m on to something. Maybe I can start my own PR company and cash in.