Every year or so, a nursing organization or some polling group commissions a poll on which profession ranks highest in the public’s esteem. And each year, nurses win the trust, ethics and honesty sweepstakes. Just the other day I received yet another press release– this one from the American Nurses Association — entitled “Public Ranks Nurses as Most Trusted Profession–11th Year in Number One Slot in Gallup Poll” telling me how much the public values nurses. http://www.gallup.com/poll/112264/nurses-shine-while-bankers-slump-ethics-ratings.aspx. It was one in a long string of such announcements. With the exception of a poll commissioned post 9/11, in which fire fighters ranked number one, nurses always head the list. And immediately, nursing organizations like the American Nurses Association send out press releases announcing that nurses have once again won the trust sweepstakes. And many nurses smile happily because they believe they are trusted by the public.
You may sense a certain skepticism in my tone. And indeed, you are right. I am getting tired of these trust rankings. In fact, I’ve come to think of them as THE TRUST TRAP or THE TRUST PARADOX. Why a trap? Why a paradox? Because these rankings may lull nurses into believing that they really don’t have to inform the public about their work, because everybody trusts them. So they don’t have to go out of their way to do what my colleague Bernice Buresh and I have written about in our book, From Silence to Voice: What Nurses Know and Must Communicate to the Public, http://www.amazon.com/Silence-Voice-Nurses-Communicate-Public/dp/080147258X/ref=sr_1_1?ie=UTF8&s=books&qid=1291934526&sr=1-1 which is to talk, in detail, about what they do in their daily work. Indeed, people have told us that they don’t think they need to work harder to communicate their work to the public because they are so highly trusted. So that’s the trap.
Now here’s the paradox. If you’re a nurse, ask yourself the following two questions. Do you really believe the public trusts nurses? If you reply in the positive, then ask yourself the following question. Do you think members of the public — the same folks whosay they trust nurses — understand what nurses do? Really. If you answer in the negative, as many nurses do when I ask them those two questions, then you’ve stumbled over the paradox. I believe it’s true that many members of the public think nurses are trustworthy, ethical and honest. I also believe very strongly that most members of the public don’t have a clue what nurses do. So if people don’t know what nurses do, but think they are hyper trustworthy, why do they trust them? Because they are nice? Because they are, as nursing organizations constantly proclaim, “always there?” Like the chair? Or because they are a matter of life and death, the difference between hope and despair, because they are critical to patient rescue, coping, recovery, or a decent death? Because they are knowledge workers or because they are sentimental workers?
I am getting tired of these polls that try to assuage nurses and stroke them and make them feel better. Why? Because the very same people who apparently believe that nurses are so trustworthy, ethical, and honest also seem willing to tolerate consistent and relentless attacks on the profession. In every country I know, nursing is continually fighting both rear and front guard actions against assaults on nurses ability to do their work. In the US, hospitals aren’t hiring new grads and claim that the nursing shortage is over even if they have nurse-patient ratios of 1-6, 1-7, or even higher. They don’t want the public to understand that you can fill all your FTEs at those ratios and patients can still experience a shortage of nursing care. In Canada, provinces are instituting new — actually old — models of care, where they are replacing RNs with LPNs. But everyone still loves and trusts nurses.
I think it’s time we moved beyond trust and asked the public — and particularly health policy makers and administrators –to put their money and resources where their trust is. Trust is a great foundation upon which to build an accurate understanding of the importance of nursing but without that understanding, trust is definitely not enough. Nursing organizations have to move way beyond trust and so do nurses. They’ve got to go out and tell the public what they do so that patients can actually get the benefit of their expert care.
As I said earlier, nurses and patient advocates all over the country may be tempted to breathe a huge sigh of relief after news that a Texas jury acquitted nurse Anne Winkler after she was arrested and tried for reporting physician misconduct to the Texas Medical Board. The case had drawn national attention, because, Mitchell’s conviction as the Texas Medical Board argued, would have had a “significant chilling impact” on health care workers’ willingness to report unsafe medical practice. With last Thursday’s verdict it seems the chill is gone.
Not so fast.
Although this acquittal is very good news indeed, serious issues still remain unaddressed. Namely the fact that Mitchell, like many other nurses and lower level health care workers, was fired when patient safety concerns that involved those higher up on the medical ladder. Like many other nurses, she is still without a job, and this verdict doesn’t alter an all too typical hospital industry response one iota.
This particular case – which is by no means an isolated one – began last spring when two experienced nurses who had worked at the hospital for decades –Anne Mitchell and her colleague Vickilyn Galle — became concerned about a physician, Rolando G. Arafiles Jr. at their hospital, Winkler County Hospital in West Texas. Arafiles, who had joined the staff in 2008, was performing surgical procedures without having surgical admitting privileges, had been prescribing medications improperly, and was trying to sell patients herbal supplements. They talked to their the administrators of their public hospital, and were told that the administrators were too concerned about their ability to recruit physicians to rural institutions to act on them. Since both Mitchell and Galle worked in patient safety roles, they felt they had no choice but to report their concerns to the state board of medicine.
The Sheriff of Winkler County – a former patient and personal friend of the Arafiles – got hold of what should have been anonymous Medical Board documents and then arrested the RNs involved for utilizing official documents for non-official purposes, a felony in the state of Texas. Fortunately the jury recognized that the subsequent trial wrecked of conflicts of interest – not to mention violations of Texas Whistleblower protection statute. Unfortunately, the acquittal does not address the fact that the default position of Winkler County Hospital was when in doubt fire or muzzle the nurse.
This default position seems to be an industry standard. Hospitals seem to worry more about keeping doctors happy no matter what happens to the other employees who are also critical to the delivery of safe patient care.
In 2002, an experienced nurse at Huntington Memorial Hospital in Pasadena, California dared to disagree with a first year doctor in training about a patient safety issue. When he complained about her “insubordination,” the hospital, which has signed on to major patient safety initiatives, fired her. She was also reported to the state Board of Nursing, which fined her $8000 and put her on probation for two years. Massachusetts has passed a whistlblower protection law – after Barry Adams, a nurse at Youville Hospital was fired for reporting problems that led to patient deaths. Nonetheless many nurses still face management retaliation when reporting concerns about a hospital higher up. The same is also true in other countries. In Australia and Canada, nurses were practically hounded out of their professions when they reported physicians whose incompetence or malpractice was responsible for the deaths of dozens of patients.
Even though, Anne Mitchell was acquitted, nurses and other hospital employees may still be too intimidated by the possibility of retaliation to risk publically advocating for patients. Texas has a whistleblower statute, but Winkler County Hospital’s action has hardly reinforced the message that whistleblowers will be protected. Mitchell and Galle are now suing the hospital, sheriff and county attorney. But will this acquittal, followed by a private lawsuit be enough to convince hospitals to support any and every employee who tries to protect patients from harm?