Code Green, has anyone read this?

[lee1]

Posted on Sun, Aug. 24, 2003

Philadelphia Inquirer

Carlin Romano | Health care in U.S.: Good night, nurse!

By Carlin Romano

Inquirer Book Critic

Code Green

Money-Driven Hospitals and the Dismantling of Nursing

By Dana Beth Weinberg

Cornell University Press. 213 pp. $25

Try naming a superstar nurse since Clara Barton and Florence Nightingale.

Stumped? It speaks volumes about how we view nursing. Just imagine the number of heroes that embarrassing century-plus gap leaves out, the many saints it misses.

Nurses do the dirty work - doctors and administrators rake in the prestige and top-tier bucks. Nurses do the soothing and hand-holding - doctors too often shoot in and out, condescending to everyone in the room who's not a doctor. Nurses race at the flash of the call button, refusing to cut back on service to frightened, lonely patients despite the imperatives of profit-driven "managed care" (better described as "poorly managed care").

Meanwhile, in today's fungible corporate suites, M.B.A.-

equipped hospital administrators may well consider Hippocrates a preexisting condition of the obese, one that insurance companies will never pay for.

No, in a media world that tracks every sighting and cliche of doltish actresses, addled rock stars, and sentence-challenged jocks, no one cares what nurses do, say or think. They should simply be there when we desperately need them. Nurses should make no mistakes, no matter how overtired. Most unfair of all, nurses should treat our health as the most important thing in the world - to them, mind you - the moment we get sick, even though we don't give a damn about them on a day-to-day basis.

Dana Beth Weinberg's acerbically titled Code Green, a piercing study of the degradation of contemporary American nursing achieved by managed-care consultants, should be absorbed by every health professional. The project began, Weinberg explains, after her graduate school adviser emerged from hospitalization and days of heartfelt conversations with attendants at Beth Israel-Deaconess Medical Center (BIDMC), a Massachusetts institution formed by the merger of two smaller hospitals. Find out something, the adviser asked Weinberg: "Why are the nurses crying?"

Weinberg has. Increased patient loads. Increased replacement of registered nurses and licensed practical nurses by aides. Decreased perks and benefits. Decreased decision-making autonomy. Declining status and administrative authority within hospitals. Not enough time to monitor patients. Not enough time to get to know patients and evaluate their needs.

Nurses as a percentage of the overall hospital work force in the United States dropped 8 percent from the early '80s to the early '90s, according to one study, and the trend continues. Everywhere, the author reports, nurses complain "about not having enough time or support to care for patients."

Unlike journalist Suzanne Gordon's excellent Life Support (Gordon contributes an incisive introduction to this volume), Code Green doesn't offer action portraits of nurses at work. Rather, Weinberg, a health professions scholar at Brandeis University, zeroes in on the institutional forces damaging nursing today. While she laces detail and nurses' voices throughout the book, she focuses on the big picture, which she outlines with calm but pointed clarity.

Weinberg's method is to treat BIDMC as a case study of what's wrong with managed care. Before the merger, Weinberg explains, Beth Israel ranked as an international "gold standard" of nursing, a Harvard teaching hospital that drew professionals from around the world to study its practice of "primary nursing, in which each nurse became responsible for the care of particular patients from admission to discharge."

Beth Israel paid nurses salaries, not by the hour, and offered them opportunities for promotion while remaining active nurses. It "placed their notes and care plans in the medical record alongside those of physicians," instead of devaluing them by filing them separately. It "treated nurses not as doctors' handmaidens but as professionals with crucial knowledge and skills to contribute to patient care."

After Beth Israel merged with New England Deaconess Hospital in 1996, however, and started losing $1 million a week, "market medicine" began to change all that. Weinberg writes that by the time she shadowed nurses at BIDMC for nine months in 1999, she "never once saw a nurse sit down and talk with her patients or their families - not even for five minutes, let alone half an hour."

Weinberg shows exceptional fairness in regularly citing the "hospital administrator's" side of recent trends. Many characterize nurses' concerns about quality "as mere resistance to change." A few accuse nurses of falsely confusing the quality of patient care in tough economic times with their own working conditions. "Nurses need to adjust their standards," one administrator tells Weinberg. "We can't go back to the way we did things before."

Nurses, by contrast, see a causal connection between reduced staffing and patient health, and Weinberg's examples support the nurses' position: Fewer nurses, stretched too thin, inevitably harms the health of patients. According to Weinberg, "To protect patient health, nurses paid with their own health and well-being."

Their voices here tell the story. "We're talking seconds," says one, "but seconds count a lot to save a person's life." Another, a Beth Israel veteran, makes a poignant point, citing the growing need for nurses to endlessly say "I'm sorry" to emergency patients because the patient has to wait for this, wait for that, wait in the hallway, wait for a doctor too busy to call back. The only comforting thing, she notes, "is that they're still saying it."

Code Green offers many lessons. One, Weinberg observes, is that doctors should fight for nurses and their interests. In the current corporate environment, it's simple logic based on Pastor Niemöller's old warning about where lack of another kind of solidarity leads: "First they came for the... and I did nothing."

More broadly, Code Green shows that in a modern technological age, health care, like electrical power, needs strict governmental regulation. Last week's blackout demonstrated the same economic truth as Code Green, the same one that explains why the FAA (in theory) tightly regulates airlines. In the 21st century, when dependence on mass corporate systems is a life-and-death matter, unregulated utilities inevitably do things on the cheap out of money-driven self-interest. In electricity, in airlines, in hospitals, uncreative managers, often lacking the entrepreneurial talent to bring in revenue by any idea except cutting costs and investments, inevitably produce a shoddier product.

With nonessential items, consumers in an unregulated market can simply refuse to buy shoddy goods, which is why bad restaurants and publications fold. But health care, like electricity and air travel, rarely offers the consumer much genuine choice. It's too important to be left to bottom-line consultants and the stock market.

As Weinberg reports, a Joint Commission on the Accreditation of Healthcare Organizations opposed greater regulation. What a surprise. I wonder how many nurses made it onto the commission. The sooner government ties the hands of hospital administrators, denying them accreditation unless they staff their hospitals and honor their nurses properly, the sooner we'll be proud of American health care again.

Contact book critic Carlin Romano at 215-854-5615 or [email protected].

[mdfog10]

Yes,I read it and enjoyed it. I was able to relate to many issues relating to a hospital merger and demerger. I believe we must work for some kind of universal health insurance to take the evil profiters out of health care.

[lee1]

Yes,I read it and enjoyed it. I was able to relate to many issues relating to a hospital merger and demerger. I believe we must work for some kind of universal health insurance to take the evil profiters out of health care.

I am reading it now and YES can certainly relate as my hospital is getting ready to start RN layoffs because supposedly they overestimated the number of beds they needed. Hired those nurses to fill the beds, now the census is down and they want to lay them off. Profit is KING it seems. In the mean time floating, harrassment, increased ratios, reduction of ancillary staff has all affected nursing and probably patient care. This in a once proud hospital that wanted to offer high standards of care also. OOPS, still wants to but make the nurses crazy so that more will leave the profession.

[RoxyBen]

Try naming a superstar nurse since Clara Barton and Florence Nightingale.

Ummm...Clara Barton wasn't a nurse. Head of the Red Cross but not a nurse.

[roxannekkb]

Try naming a superstar nurse since Clara Barton and Florence Nightingale.

Ummm...Clara Barton wasn't a nurse. Head of the Red Cross but not a nurse.

Yes, that's very true. Barton is often called the "American Florence Nightingale" but in reality, Barton had no real interest in nursing. She was a teacher, and then a patent clerk working in Washington DC when the Civil War broke out. She took supplies out to the battlefield, because she became fed up with the red tape in getting them to the soldiers. She assisted the field doctors, but as soon as the war ended, she was out of there. Barton never trained as a nurse, and never thought of herself as a nurse.

On the other hand, writers Walt Whitman and Louisa May Alcott volunteered as nurses during the Civil War. Both have written about their experiences.

[caroladybelle, BSN, RN]

Dorothy Dix

[P_RN, ADN, RN]

That's a great review. I'm going to see about reading this one.