Nursing and the Perils of Success
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.
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Precisely why preventative medicine (which is something that NPs and PAs do best) has not really caught on. People do not demand what they can not see or feel. They demand antibiotics when they don’t need them, they demand magic weight loss pills instead of exercising. They demand pain pills instead of trying meditation. Patients/consumers/clients want instant results.
Preventing a stroke is not sexy, saving the patient with the stroke is thanked by the patient and their family.
And let’s all work towards getting reimbursement for preventative care. If nurses really want to change things
payment for prevention must become a mantra.
Dave
We work very hard at the science of nursing, but the art of nursing is what patients and their families see. When the art of nursing is present it is a beautiful thing. There are so many little things we constantly make sure are present before, during and after we care for our patients. I may not love my job, but I love being a nurse, because an employer may not see the innumerable times we help a patient prevent a setback. Our actions (or lack thereof) can really put a patient at risk of permanent injury and death. We fight daily mini battles with life and death, and we win 99.9999% of the time.
Yes and yet, the essence of our profession is our ability to communicate with the patients when no one else can or will. Isn’t it amazing that the most basic skill of our profession, requires us to deliver all sorts of “news”, including the most frightening or technical, in language the patient and their family will understand and we can’t (don’t) communicate our contribution to the health and wellness of the world so that others understand.
Excellent commentary, Suzanne, as usual. We are lucky to have such an articulate non-nurse in our corner. Yes, we will be phased out if the public does not come to realize our worth. I can’t help but think of the myriad disasters we divert in a single shift. We’ve got to do a better job of tooting our horns. Thank you for tooting it for us in the meantime.
As usual, Suzanne, you have said this more clearly than anyone else could! You are spot-on and I agree with your comments completely. Thanks for sharing your unique view on this topic and pointing out another area where nurses must use their voices in a more powerful way.
Your words ring true l & your interest & perseverance is inspiring. I have felt the thrill & satisfaction of rescue @ the bedside & been bone-tired but happy to be a nurse.
Recent developments in the concept of ‘surveillance’ seem to have created a foundation from which we can more clearly communicate info re nursing capacity to provide safe care. Very encouraging to read about the development of a surveillance profile in the following article:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906760/?tool=pubmed
Suzanne, I read your prevention piece with interest and agree it is an unappreciated segment of health care by RN’s. I do monthly Blood Pressure Clinics for the hospital in low income Senior Housing buildings in Princeton and one church(nutrition site).
In addition to checking pt’s bp, I check; meds and do med teaching, assess visible signs/symptoms of problems (ankle edema, petechia,cough, skin) and ask if they have had any med changes, recent falls/changes in health status, or even if they have a doctor.I make referrals to the hospital clinics when appropriate.i.e.” My sugars have been high this past month,now I’m out of testing strips.”I’ll refer this pt to our diabetic clinic for f.u. and teaching. I address pt questions,they save them uo for me! It’s amazing what I find, BP’s so high they are@stroke level with never a symptom. I send them to their Dr or the ER. if appropriate and BEFORE they have a stroke. I instruct pts in an individual exercise and nutrition program. I may ask them to keep a log of intake or exercise so they can show me the next month. Most people know they should eat a good diet and exercise but they need someone to encourage and motivate them and to cheer their progress. RN’s do this well.
These clinics are about prevention in chronic elderly population and I know it prevents potential disasters. I am at the clinic for 2 hours and paid an hourly rate of $32.50, so, it is very affordable.
Carol
From your blog to nurses’ ears! If we don’t spread the word about what we do, and the education behind the power to do it, nobody will.
Because nobody knows like nurses…
And that would make a great post title – thanks for the inspiration! : )
Suzanne:
Thank you for such a great post! I have enjoyed your work and I own From Silence to Voice after reading it in nursing school.
I am a newer nurse who worked in the business world for years and I too am sometimes horribly baffled as to why nursing does not toot it’s own horn.
I am so convinced of the ability we have to implement surveillance and prevent complications, that I have even gotten certification in my specialty. Why? It gives credence to what I do, and gives another dimension of professionalism to my work.
Some of my coworkers blow it off as just the ability “to take tests and pass”, but I think we need to expand our range of knowledge to more than just our little worlds, and also, be willing to expand our communication skills to let the light in on what really happens in nursing.
We are not handmaidens…in my state we are officially “Registered Professional Nurses”. Why not be professional and be able to explain that at the same time?
We need to tell ALL our stories – both the science (just-in-time critical thinking skills and vast knowledge base) and the art (the moments our connection makes the therapeutic difference). We can start by telling each other – we don’t even do that because the pace is so busy and the cultural grain runs agains it. As Marchall Ganz says, these stores connect humans to their values because of affective learning.
The real problem is what this society values. There is no biling code for saving a patient’s life by intervening when the MD writes an order on the wrong chart or orders a drug that the patient is allergic to. There is no biling code for being present with a patient who has no family so they don’t die alone or giving someone the will to live….or holding their hand while they learn if their cancer is in remission. ALL of these things are free – not just some. As long as we come with the room charge and keep our stories to ourselves, nurses will always be the biggest bargain on earth.
Hello Suzanne,
As always enjoy your blog. I’m including a quote from it in my book too. Every word I write I have more and more respect for writers and marathon runners. Writers, because it is a skill I envy, and marathon runners for having the mental ability to keep going even when they are tired, but no where near finished.
Hope to talk sometime soon,
Rob
Ms Gordon,
I’ve had your book Nursing against the Odds sitting on my bookshelf for about 2 years. This October I started back to school and in an effort to avoid schoolwork picked up your book. I’m sorry I didn’t read it sooner. I never (honestly) had a book make such an impression on me. I have notes all through the book, and have used quotes to make points on our discussion board for class. Thank you for ripping my perceptions of my own career apart, changes are being made, and I’m excited.
Suzanne,
Thank you for your accurate but sad commentary on the “invisibility” of nursing. I have just finished our 7th International Neonatal Nursing Conference in Durban, South Africa where the Council of International Neonatal Nurses (COINN) and world leaders in maternal child health discussed the key role neonatal nurses have in impacting child mortality including prevention. Over and over again the discussion came back to the fact that as nurses we have not talked about the value we bring to health care. We do not do a good job of telling our story! During our conference we had a press conference, press releases, and interviews. Each time we had to refocus the pitch to include nursing’s contribution. We need to be as you say articulate with our patients and families, tell our stories, and not just say we were only doing our jobs. Those of us in leadership roles in professional organizations also need to make sure we also carry the message about nurses and nursing’s role in health care globally.
Thank you for writing this. I really appreciate it. I am so glad my book made a difference and you can finally dance and enjoy it.