WHAT DO NURSES DO? --help me respond to this question

Here is an article from Advance Practice in Nursing eJournal. It can be found at http://www.medscape.com/viewarticle/520714 but I quoted the entire article here. The section most pertinent to your question is underlined. (By me, not in the original article.) We can make task lists all day long, but that will never explain what nurses really do. This comes closer...

What Do Nurses Really Do?

Suzanne GordonTopics in Advanced Practice Nursing eJournal. 2006;6(1) ©2006 Medscape

Posted 02/02/2006

A Vow of Silence?

Several weeks ago, I was invited to speak to a group of undergraduate students who had been asked to read my new book, Nursing Against the Odds, for their history of science class at Harvard University. During the hour-and-a-half discussion, one question that kept popping up was: "What do nurses really do?" As I left the room, I pondered, as I often do, why the public has so little understanding of the consequential nature of nursing practice. Clearly, it's because of traditional stereotypes about nursing. But it's also because nurses have been socialized to be silent about their work or to talk about it in ways that fail to reverse these traditional stereotypes.

When I ask nurses to describe their work, many respond: "Oh it's too hard to talk about. It's too diffuse, too vague, too indefinable." But I have written thousands of pages about nursing and I am not a writer of fiction. I've been able to write about nursing because I've observed nurses at work and asked them a lot of questions about their practice.

What Nurses Do

Here is what I think nurses do. Using their considerable knowledge, they protect patients from the risks and consequences of illness, disability, and infirmity, as well as from the risks and consequences of the treatment of illness. They also protect patients from the risks that occur when illness and vulnerability make it difficult, impossible, or even lethal for patients to perform the activities of daily living -- ordinary acts like breathing, turning, going to the toilet, coughing, or swallowing.

Even the most emotional work nurses do is a form of rescue. When nurses construct a relationship with patients or their families, they are rescuing patients from social isolation, terror, or the stigma of illness or helping family members cope with their loved ones' illnesses.

What do nurses do? They save lives, prevent complications, prevent suffering, and save money.

Why do nurses have a hard time explaining such compelling facts and acts? As Sioban Nelson and I have argued in a recent article in the American Journal of Nursing,[1] it's because they've been educated and socialized to focus on their virtues rather than their knowledge and their concrete everyday practice. They've been taught to wear their hearts and not their brains on their sleeves as they memorize and then reheorifice the virtue script of modern nursing.

If you analyze the words and images of campaigns used to recruit nurses into the profession or listen carefully to the stories nurses tell about their work, nurses may not use the available research to fully explain why what they do is so critical to patient outcomes. Although many studies, conducted by nursing, medical, and public health researchers, have documented the links between nursing care and lower rates of nosocomial infections, falls, pressure ulcers, deep vein thrombosis, pulmonary embolism, and deaths, most promotional campaigns and many stories nurses themselves tell about their work ignore these data.

Instead, nurses focus on their honesty and trustworthiness, their holism and humanism, their compassion, and their caring. The problem is that when they focus on caring, they often sentimentalize and trivialize the complex skills they must acquire through education and experience. They often fail to explain that caring is a learned skill and not simply a result of hormones or individual inclination. After all, knowing when to talk to a patient about a difficult issue, when to provide sensitive information, when to move in close to hold a hand or move away at a respectful distance all are complex decisions a nurse makes. To make these decisions, nurses use equally complex skills and knowledge they have mastered. But all too often nurses make these skills and knowledge invisible or describe nursing practice in terms that are far too limited.

Nurses are still talking about themselves -- or allowing themselves to be talked about -- in the most highly gendered, almost religious terms and allowing themselves to be portrayed with the most highly gendered, almost religious images. Indeed, as Nelson and I argue, with the best intentions in the world, many modern nursing organizations and nurses reproduce and reinforce traditional images of nursing as self-sacrificing, devotional, altruistic, anonymous, and silent work.[1] Just think of one of the jingles in the recent Johnson & Johnson image campaign:

Historical Images of Nursing and Nurses

Unfortunately, like those above, many of the images and words nurses mobilize reflect the religious origins of the profession. Nurses in religious orders were socialized to sacrifice every shred of their individual identity, to be obedient members of an anonymous mass. Religious nurses were taught not to claim credit for their work and accomplishments but were instead supposed to view themselves as divine instruments who willingly assigned the credit for their accomplishments to God, the Bishop, the Abbot, or the Mother Superior.

Most importantly, these images reflect a time when nurses were taught to Say Little and Do Much because to talk about a good deed was to turn it into a bad one -- to exhibit the sin of pride. What nurses could accept were compliments for their deferential behavior and angelic virtues. What they could talk about was self-sacrifice and devotion and the outside agents they served.

If you look closely at the history of the problem of nursing visibility, you see that this religious depiction of nursing was not only a relic of the origins of nursing in Christian penitential practice but was also a legacy of the 19th century movement to professionalize nursing. In the 19th century, religious and social reformers like Florence Nightingale adapted the religious template to help women who wanted and/or needed to work outside of the home find purposeful paid work. In a society where gender roles were very rigid and people prized modesty and innocence, reformers needed to make it safe for female nurses to work in public spaces with strangers -- mostly strange men.

Nurse reformers helped respectable women affect this passage by borrowing religious images, costumes, language, and metaphors. The nun's cornette was transformed into the nurse's cap. In English-speaking countries, nurses were called "sisters."

Nurse reformers tried to desexualize nurses just as nuns (women who weren't really women) had been desexualized before them. Nursing students wore ugly uniforms, were not allowed to marry, and were sheltered in cloister-like dormitories in or near the hospital. Nurses were said to be self-sacrificing and morally superior and would thus create order out of the chaos of the 19th century hospital.

Focusing on nurses' virtues also helped nurses in their long battle with medicine for what became, in the 19th century, the highly contested terrain of the hospital. Before the 19th century, very few doctors had ever set foot in a hospital. In the 19th century, scientifically oriented doctors were moving into the hospital in greater numbers and wanted to control the hospital. They were not pleased to see a group of women who wanted authority and education competing for a sphere of influence (even a separate female sphere) inside the hospital.

Doctors were happy to have trained nurses but only if they were their servants. They wanted nurses to know what to do and how to do it but not why they were doing it. They didn't want anyone to know if a nurse had acquired scientific, medical, or technical mastery. Because nursing at this time was feminized, women with no political, legal, economic, or social power had to make a deal with medicine, and the deal was that nurses could have virtues but not knowledge.

In the 19th century, nursing was thus constructed as self-sacrificing, anonymous, devotional, altruistic work. While this was a functional bargain to make over a century ago, this template reigns today in spite of the fact that things have changed dramatically for women -- which is why it's time for a change.

Now Is the Time for Change

I believe the public knows that nurses are kind, caring, and compassionate and that they provide patients with more information than doctors do. People don't know, however, that nurses have medical knowledge, participate in medical cures, and have technological know-how. I believe nurses can advance knowledge of their profession if they amplify their caring stories and include anecdotes that help us understand that doctors don't do all the curing.

The public needs to know that nurses -- regular, ordinary bedside nurses, not just nurse practitioners or advanced practice nurses -- are constantly participating in the act of medical diagnosis, prescription, and treatment and thus make a real difference in medical outcomes. Nurses can help the public understand that nursing is a package of medical, technical, caring, nursing know-how -- that nurses save lives, prevent suffering, and save money. If nurses wear not only their hearts, but also their brains on their sleeves, perhaps the public, like those students at Harvard, will finally understand what nurses know and do.

References

1. Gordon S, Nelson S. An end to angels. Am J Nurs. 2005;105:62-69.

Suzanne Gordon, Assistant Adjunct Professor, School of Nursing, University of California at San Francisco; journalist, Arlington, Massachusetts; author, Nursing Against the Odds: How Health Care Cost-Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care (Cornell University Press, 2005)

Disclosure: Suzanne Gordon has disclosed no relevant financial relationships.

You're always there when someone needs you

You work your magic quietly

You're not in it for the glory

The care you give comes naturally.

This just makes me ill. No wonder we can't make any headway when we have to fight against this sort of dreck.

Yes, I care. But I didn't take a vow of poverty, a vow to destroy my health, forsake myself for everyone else, etc.

Nursing is not martyrdom.

[/indent]

That is absolutely right

I love what I do, but it enables me to pretend to be what I want to be

Jack the Giant Killer

Well, I hate to sound jaded, but this sounds exactly like the kind of thing a student would say. For those of us who have been in the trenches for decades, we know exactly what this sort of exercise means. We've seen it before, many times, in many forms. Just wait until you've got a few years behind you; you'll see.

I find it stretches credulity that someone could grasp complex disease processes and their respective treatments, work alongside nurses who care for their patients and carry out those treatments they order, yet then they claim with wide-eyed innocence that they have no idea "what nurses do." Sorry, that just doesn't pass the smell test. Then it's the nurses' responsibility to make the doctors a list? No way--that sort of intellectual laziness is inexcusable. If they really want to know, they can jolly well seek out the nurses--it's not like we're that hard to find--and educate themselves.

Amen! But it sounds more like a teacher - someone who's never been in the trenches - or has been out so long they don't remember. Honestly, I do think this NM is trying to educate the doctors after one of them made an off-hand remark about "well, what do they do anyway?" - but was never sincerely interested in knowing. I have never - NEVER worked with a doctor who had either the least idea of what we did or of learning what we do. I was in school 22 years ago after wanting to be a nurse since age 5. My dream became a reality when I passed my NCLEX at age 36 and my dream died during my 36th year. I have continued to work as an RN and tried to just focus on helping my mentally ill clients - but I've been blackmailed by doctors (withholding needed med orders until I apologized to him for reporting him after he was not available for 3 hours during a medical emergency when he was on-call) accused of "making me discharge people" (doctor who would discharge no one who hadn't been on the acute care unit a min. of 14 days), told I was not a patient advocate and was not to act like one- by a PhD director of services, etc. etc, etc........ the list goes on.........

Now I'm counting the days - 2 years and 132 days until I can retire. Do I sound bitter? You better believe it. But I had 4 children to raise alone and very occasionally a patient actually was better for my having been there.

Now planning to become a small engine mechanic. Lord help the doctor who needs his mower or chain saw repaired. None of my children are working in healthcare and I would not encourage it. I know those not all doctors are as bad as what I've met, but I don't know the good ones.

This just makes me ill. No wonder we can't make any headway when we have to fight against this sort of dreck.

Yes, I care. But I didn't take a vow of poverty, a vow to destroy my health, forsake myself for everyone else, etc.

Nursing is not martyrdom.

[/indent]

That's why I support The Center for Nursing Advocacy. I think they sometimes need to choose their battles, but over all they are doing important work to change the image of nursing. I highly recommend that you check them out and write letters as they suggest. They do the work, all we have to do to support them is sign and send letters and emails. Especially check out their info on Gov. Corzine and the DOT spot. Talk about nauseating...

Most people miss what we do because it is often subtle. Talking to a patient about the weather involves observing the patient's affect, his orientation, his speech patterns, and his overall attitude. Looking at him we note skin color, moisture, turgor, patency of all tubes, condition of observable wounds and dressings, condition of bed linen, and (during the day) nutrition, and teaching him about the reason we are there. This is in a 2 minute interaction during a med pass. We are there 12 hours and we are working all the time and THAT is what nurses do.

It's why the greatest predictor of a good outcome for a patient is a nurse at the bedside.

this is going to vary depending on the type of nursing you are involved in.I think the nursing article covers the basic things all nurses need to use to be a good nurse.But as an example what i encounter and have to handle working in long term care is different than the hospital nurse.I still have to assess my residents and when their sick send them out to hospital,take care of their pain,Listen to their concerns and their FAMILIES,encourage to eat and drink when the appetite is gone,assist in adl's and ambulation,be at bedside when they are dying and support them so they can leave this world the way they want with diginity.We are the eyes,ears,and hands for the doctors in long termcare.I would say that 90% of the doctors I have contact with know that and appreciate nurses.I did have one doctor tell me he did not like coming to a nursing home because it was like watering dead flowers.I told him that he shouldn't come-we did not need any gardners here.His associate came after that and he never returned.The rest of the doctors count on us to fill them in on their residents and their needs and show us respect.I know this did not help with your request but it will give you a different view of what is out there from a nurse of 40 years

I have, and for several years was a supporter. Regrettably, I can no longer give them my support.

That's why I support The Center for Nursing Advocacy. I think they sometimes need to choose their battles, but over all they are doing important work to change the image of nursing. I highly recommend that you check them out and write letters as they suggest. They do the work, all we have to do to support them is sign and send letters and emails. Especially check out their info on Gov. Corzine and the DOT spot. Talk about nauseating...

I find it disheartening that your NM, who i will assume was a nurse at one time, is unable to tell a physician what the nurses do. Are they so far removed that they are unable to remember and must ask the individuals that they manage, what exactly the do in the course of their day. SOME ONE SHOULD ASK THEM HOW THEY ARE QUALIFIED FOR THEIR JOB.

The doctors need to know what nurses do?

That's one line. Nurses keep doctors out of court.

Who cares about the rest from the doctor's standpoint?

I feel that nurses oversee what the Doc orders and makes sure orders are followed along with alot of things we nurses think of and the pt may need, we get orders from the doc, and yes we do keep doctors out of court!

Oopsy Doopsy, see the next post!

here is an article from advance practice in nursing ejournal. it can be found at http://www.medscape.com/viewarticle/520714 but i quoted the entire article here. the section most pertinent to your question is underlined. (by me, not in the original article.) we can make task lists all day long, but that will never explain what nurses really do. this comes closer...

what do nurses really do?

suzanne gordontopics in advanced practice nursing ejournal. 2006;6(1) ©2006 medscape.

http://www.nursingadvocacy.org/media/books/nursing_against_odds.html

nursing against the odds: how health care cost-cutting, media stereotypes, and medical hubris undermine nursing and patient care (2005)

by suzanne gordon

cornell university press

nursing rating

artistic rating

suzanne gordon's nursing against the odds is a searing indictment of the denursification of developed world health care and the associated nursing shortage. gordon (a member of the center's advisory panel) links the nursing crisis to the three factors cited in her subtitle, which presents a handy executive summary of the book. she uses research and anecdotes to explain why skilled nursing is vital to patient outcomes, and she spares virtually no one with responsibility for the crisis, including nurses themselves. the book could be more balanced. parts seem to reflect a lack of respect for nurses who do not work at the "bedside" and for some key nursing principles. the book suggests that nurses are essentially physician "subordinates" with no real autonomy, and that nurses' embrace of holism and patient advocacy is largely bogus. but this well-written, generally persuasive account of nursing in the managed care era is still one of the most important books published about the profession in recent times. and despite the bleakness of much of its analysis, the book makes a serious effort to point the way forward, offering concrete and far-reaching policy ideas to alleviate the crisis and avert the looming health catastrophe.

nurses in a physician's world

in the first of her book's three major sections, gordon examines how nursing's dysfunctional relationship with physicians has developed into a huge problem for everyone, including patients. she explains that 19th century reformers professionalized nursing, establishing a respectable job for women outside the home. they used a combination of the "virtue script" (first christian, later civic) and assurances that nurses would not challenge physicians' authority over patient care or their scope of practice. the male physicians' competitive fear of the supposedly inferior female nurses is remarkable, and the book's suggestion that nurses' historic oppression by physicians parallels the oppression of women by men is convincing.

over time, gordon contends, nursing developed a complex system of deference to physicians, one which concealed nurses' true mastery of health care, as well as the key roles nurses played in patient outcomes and "medical" research. nurses came to feel that they would meet a wall of physician resistance to their own care goals unless they subtly manipulated the physicians, whose fragile egos seemed to require that significant care be all their idea. gordon argues that nurses even developed their own obfuscatory language to ensure that they were not perceived as "diagnosing," "treating" or "curing" patients, which could mean encroaching on "medical" turf. the tentative, bureaucratic nature of such language could be absurdly self-defeating, as reflected in nurses' notes stating that a patient in pain had an "alteration in comfort."

today, the book argues, this "subordinate" relationship continues, as nurses are socialized to behave like battered women, either accepting or overadapting to physicians' refusal to listen, as well as their verbal and even physical abuse. sadly, the increase in female physicians seems to have made little difference. poor communication between the professions is common, and bad relations with physicians are a major factor in nurse burnout. the modern care system is often inclined to tolerate this not only because of traditional gender bias, but because physicians are viewed as powerful revenue generators, nurses as burdensome cost centers. gordon makes clear the tragic results of this "fatal synergy" with examples of errors and fatalities linked to nurses' inability to have their concerns heeded by physicians or administrators, and in many cases, nurses' reluctance to speak up at all, given the powerful disincentives. one notorious case involved nurses' efforts to address the gross incompetence of a young surgeon in winnipeg in the 1990's. because nurses' warnings were ignored, many children died. though gordon overstates nurses' "subordination" and is too quick to dismiss the profession's patient advocacy focus as a delusion, her basic points here are well-taken. she argues that nurses should stop overadapting: they must start respecting themselves, and vocally assert their true importance in patient care.

the media's "medical superstar narrative"

in the book's second major section, gordon rightly argues that the media is critical to nursing's future because of its proven influence on how people regard the profession and health care in general. she stresses that the media must help the public understand nursing's true nature and value. unfortunately, the media now tends to ignore, trivialize or demonize the profession.

in recent fictional media, gordon notes, it is generally physicians who matter--and even perform key nursing tasks--while nurses are peripheral subordinates. though "china beach" did feature a fairly strong military nurse, recent u.s. dramatic television has basically been all physicians, all the time. "er," the leading hospital drama of the last decade, presents nurses as skilled handmaidens to the dominant physicians, who provide all significant care. in recent films, gordon finds nurse characters tending toward "sexpots," sadists, or dimwits. examples include the archetypal nurse ratched of "one flew over the cuckoo's nest," the "kind but dumb" image of "nurse betty," and what gordon accurately terms the "dress for success" feminism of movies like "living out loud," in which--as on "er"--nurses achieve by moving up to medicine. gordon finds some of the best recent fictional portrayals of nursing in drama, notably in margaret edson's "wit" and tony kushner's monumental "angels in america," which features the formidable aids nurse belize. in modern fiction, gordon praises the powerful depiction of nurse hester latterly in anne perry's victorian era mystery novels.

turning to nonfiction products, gordon observes that hospital marketing tends to promote physicians, and that the media in turn generally ignores nurses' role in health research. when nurses do appear in the media, it is rarely as experts, but more likely as angels, emotional "heroes," victims, or killers. documentaries that give a real sense of nursing practice, like discovery health channel's recent "nurses" series, are the exception. most promote what gordon aptly terms the "medical superstar narrative." even patients, such as the late christopher reeve, tend to marginalize or stereotype nursing in recounting their experiences.

gordon zeroes in on nurses' own role in all this, noting that because of their socialization in the "virtue script," most display a bone-deep self-effacement and fear of controversy. she argues that nurses must overcome their fears, and stop disrupting their own "definitional claims" by reinforcing stereotypes. as examples, she cites the difficulty a new york times reporter had in getting a nurse to explain the critical nursing role in caring for victims of a recent nightclub fire, and the national student nurse association's unfortunate efforts to help promote "nurse betty." public respect, gordon asserts, is the only way nursing will become attractive to career-seekers and gain the power to resist the threats posed by managed care.

the book's survey of the media is instructive, and it includes some very good insights. it is a huge topic, and there are omissions, including discussion of overseas media, advertising, pop music, and fictional television other than scripted drama. at times, the book's analysis is debatable. it seems not to fully recognize "meet the parents"' clear rejection of anti-male nurse bigotry. on the other hand, though highly critical of "er," the book actually grants the show a little too much credit even in suggesting that it occasionally portrays nursing managers and addresses nurses' real workplace problems. the show's actual (and deeply flawed) attention to such matters, in its hundreds of hours of screen time, could fit into a short highlight segment.

although the book provides examples of the nonfiction media's failure to portray nurses accurately, there is little indication that the creators of this media bear much responsibility. instead, it seems from the book that the problems are pretty much the fault of fearful nurses and heedless hospitals, who must do more to promote nursing. in fact, the handmaiden stereotyping that permeates most of the journalistic community, including its elite and "feminist" sectors, is also a major factor in the media's failure to present nursing accurately. the press is supposed to investigate and observe, not just rely on assumptions and bias. even those who solicit press attention for substantive nursing achievements are often ignored. of course, it is ironic that gordon does not seem to expect her press colleagues to match the high standard of self-education about nursing that she herself has set.

denursification in the managed care era

the book's third and largest section explores the tragic effects of managed care--"mangled care" to gordon--on nursing since the 1990's. during that decade, health care providers came under increasing pressure to reduce spiraling costs, and to compete in an increasingly market-oriented system. many hospitals responded with cuts and restructuring plans that drastically increased the workloads of individual nurses, even as the cost pressures also meant the average hospital patient was sicker and the average stay shorter, so the patient actually needed far more care. hospital executives reduced the influence of nursing management, and many facilities eliminated resources for nurses' professional development, including continuing education programs and clinical nurse specialist positions that were vital to nursing practice. this was especially harmful because of the lack of formal nursing apprenticeships comparable to physician residencies. gordon reserves special contempt for the consultants who advised the hospitals to make these changes and for the hospital managers who implemented them. both categories included nurses. gordon identifies several nurse consultants as myopic supporters of these market shifts, supplying quotes in which the nurses argue that the changes were inevitable and would actually enhance nurses' status and ability to coordinate care. most of these quotes seem to be from the mid-1990's, before the crisis had fully developed, and gordon might have provided more recent material. she argues that nurses were targeted because of traditional handmaiden assumptions and because, as noted above, they were viewed as "cost centers" that hospitals could control, unlike physicians, who were seen as powerful revenue generators. the results were nursing deprofessionalization, burnout, bad patient care, and a massive shortage. the "bottom line" system gordon depicts clearly does not understand or value nursing, and she argues that the current shortage has been driven by the flawed application of market theories to health care.

these changes meant that many nurses were now responsible for "enforcing throughput" of patients according to "patient acuity systems" that often failed to provide an accurate measure of what care giving actually required. nurses faced what gordon calls an "epidemic of overwork": unmanageable patient loads, longer shifts, forced overtime, "floating" to units for which they were not prepared, and "flexing" on or off duty according to the hour-to-hour demands of factory-like care systems, as if nurses were robots who did not need rest, food, regular schedules, or any sense that they were meeting their professional obligations. new nurses confronted chaos and hostility from harried veterans who did not have time to train or mentor them. while nurses were trying to cope with all this, they were also absorbing blame from many patients and physicians who saw only that nurses were not available to provide needed care.

the effects on nurses were profound. having brought order to care settings over the past century and a half, gordon notes, nurses were now forced back into disorder, unable to provide the clinical care they knew their patients needed to regain health, and undergoing severe stress and burnout. nurses experienced increasing conflicts with physicians, increasing workplace hazards, and less ability to empathize, work as a team, or develop their professional skills. they became alienated from patients, who came to represent the legitimate needs they could not meet. at the same time, gordon argues, nurses were poorly placed to resist the changes because they had been socialized to accept unfair demands and avoid collective advocacy. (she suggests that u.s. nursing schools discourage union activity because of a misguided view that it is not "professional.") this "perfect storm" of stressors has led to increased health problems for nurses themselves, including depression and anxiety. indeed, a reasonable reader might wonder why any nurses with other options remain at the bedside.

gordon steps back from that bedside to examine the full scope of the crisis. she reports that in the industrialized west, no geographic location, no practice setting, from the ed to home care, and no level of nursing has been spared the effects of the changes wrought by the financial pressures of this era. in hospitals and other clinical settings, nursing managers themselves eventually became victims of the cuts and shifts they had been asked to implement, losing organizational authority and resources, and in some cases their jobs. this resulted in a full blown nursing management crisis. gordon describes the severe nursing faculty shortage, which she links to overwork and inadequate pay. on the other hand, she is critical of many nursing academics' apparent view that better educated nurses will automatically empower nursing, and of what she seems to regard as the academic nurses' disdain for bedside nurses. gordon fears that not enough of the new nurses the academics want to train will actually stay at the bedside long.

gordon briefly surveys the situation in other industrialized western nations that have faced similar cost pressures, despite universal health financing systems and far higher rates of nursing unionization. she reports that poor working conditions, especially heavier workloads, have fueled nursing burnout, protests and shortages in canada, the united kingdom, australia, and norway. gordon notes that the erosion of nursing power extends even to global health entities like the world health organization, in which nurses are severely underrepresented.

the book also addresses the explosion in nursing migration, a serious consequence of the crisis that gordon calls "management by churn." this migration has national and international dimensions. in the u.s., gordon reports, the crisis has fueled huge growth in the use of travel and temporary nurses, as hospitals desperate for nurses pay agencies steep fees to supply nurses for limited contracts. the attractions of travel nursing to the nurses are clear: high pay, perks, flexibility, a sense of adventure, and a built-in escape from any bad work conditions. and despite the up-front costs, gordon reports that many hospitals apparently value the flexibility and relief from long term obligations and employee benefits that is associated with the use of agency nurses. she notes, however, that predicted long term savings for hospitals have not materialized.

gordon believes that the travel trend raises concerns for patients and nursing as a whole. these include fragmentation of the nursing work force, the likelihood that travelers will not have the same inclination or ability to raise concerns about work conditions and patient safety, and concerns that travelers may have difficulty acclimating quickly to varied and increasingly complex hospital care systems. gordon also decries the internal migration of bedside nurses to non-bedside roles, especially advanced practice. the book includes a limited description of international migration, focusing on the situation of filipina nurses, whom gordon contends are effectively forced overseas by a combination of local "push" factors (bad work and living conditions) and "pull" factors (the enticements of aggressive rich nation recruiters). employers in developed nations may see benefits to recruiting foreign nurses who may be understandably less inclined to act assertively. but the developing nations that have devoted precious resources to train these nurses are losing many of their most highly skilled professionals, and now they are facing huge challenges in maintaining already weakened care systems.

gordon concludes that nurse staffing is a serious public safety issue. she describes in some detail what nurses actually do--if they are permitted--to improve patient outcomes. she notes that they are health care's early intervention, warning and action system, preventing adverse events like infections, blood clots and medical errors, and providing pain relief, therapy, patient education and emotional support that is essential to recovery from illness. but a growing body of research, as well as accounts from savvy patients, show that nurses in the wake of the recent cost-cutting are increasingly unable to perform these vital tasks. the result is worsening patient outcomes, an ironic increase in care costs due to complications and errors that nurses could have prevented, and of course, an exodus of burned out nurses away from the bedside.

some concerns

nursing against the odds has several problematic aspects. perhaps the most troubling is its apparent contempt for key aspects of nursing theory and for non-bedside nurses. these problems may reflect a strong ideological perspective, an understandable alarm at the current crisis at the bedside, and perhaps an impatience borne of years of struggling to get nurses to see and present themselves as serious health professionals.

the book gives the impression that nurses are formally subordinate to physicians, and that nursing's key tenets of patient advocacy and holistic care are largely feel-good platitudes that developed to mask nursing's key role in hard-core "medicine." nurses and physicians do work together, and their professions overlap to a significant extent. but nursing is an autonomous discipline, with its own scholarship, training and scientific scope. and it has many key features of autonomous practice, including independent licensing, regulation, malpractice liability, ethical duties, and nursing management. nurses tend to have less practical power than physicians, but that does not make them formally subordinate, any more than india is formally subordinate to the united states. indeed, nursing encompasses a range of independent care giving that physicians would not even be qualified to assess. nor would most of the book's readers understand that physicians do not formally have the final say on patient care issues. nurses are ethically obliged not to implement care plans they do not believe are in a patient's interest. unfortunately, gordon seems to regard nursing ethical codes as little more than virtue script moralizing, rather than a definition of the basic nature and scope of the profession.

for its assertions of nursing subordination, the book relies on sociologists, as if nurses could not be trusted to define the parameters of their own profession. of course, the complex mix of nursing's autonomy and its relatively low level of power is less dramatic than the notion of a group of subordinate female workers who are relentlessly oppressed by the man. but nurses do not always do what physicians want, and their views often prevail even in direct interactions on care issues. this is not to dispute the book's view that many nurses feel impotent in the managed care era, and that this is a factor in nursing burnout. however, repeated claims of nursing subordination are unhelpful in the same way as it is unhelpful to stress that someone has no rights simply because her rights are not being fully respected. the first step toward enjoying a right is asserting that you have it.

gordon is plainly impatient with the idea of "patient advocacy." the book notes that nurses "claim" this principle is an important aspect of their practice, but it suggests that claim is dubious because many nurses are unable or unwilling to act as true advocates. once again, the book does not convey that nurses regularly change the course of patient care by raising concerns with physicians directly, rather than through the subtle manipulation of a servant. certainly many nurses are inhibited by power issues, as in the winnipeg case, and indirect manipulation is common. but gordon claims that the failure of many nurses to advocate effectively for their patients "exposes the limits of nursing advocacy." really? would we say that the failure of many mothers to protect their children from abuse "exposes the limits" of maternal protection? moreover, contrary to the book's assertions, nursing's focus on patient advocacy as a key ethical duty is more than a misguided effort by nurses to claim the moral high ground at the expense of clinical expertise. clinical expertise is the basis of most patient advocacy, and many nurses actually know it.

likewise, the book dismisses nursing's emphasis on holistic care as "fashionable nursing jargon" that makes nurses feel special but devalues the profession's actual scientific basis. gordon is right to stress that nursing holism must include technical expertise, and no doubt some nurses do understate the importance of that expertise. but the book is wrong to suggest that the point is lost on nurses generally, and to imply that holism should therefore be de-emphasized. in fact, most nurses understand that "holism" refers to a bio-psycho-social model of care that encompasses the myriad effects an illness or injury has on the patient and her family.

gordon's willingness to engage in frank criticism of the nurses who count her as a staunch ally is a great virtue. but the book presents an unduly negative vision of non-bedside nurses generally, especially advanced practice nurses, nursing academics, and nursing managers, a vision that might be seen as a kind of bedpan chic. the book generally portrays nursing managers as misguided figures who waived any right to be considered professional leaders by failing to realize the extent of the damage that managed care would cause, and failing to stand firm against the changes, to the point of going to the press and losing their jobs, if not their careers. at times, it's not clear if gordon considers non-bedside nurses to be nurses at all. however, to see nursing as essentially confined to the bedside understates the importance of nurses who work in policy, research, education, advanced practice and public health. readers are also given the impression that nursing academics are largely management-side elitists who have contempt for bedside nurses and are indifferent to the staffing crisis. at times the book seems to miss that most highly educated nurses are not just focused on theory that is marginally relevant to the bedside. in fact, they help shape the scientific foundation and the policy environment of bedside practice. and many nurses who do not work "at the bedside" still advocate strongly both for patients and for nurses who do work at the bedside. one recent example is australian head nurse toni ellen hoffman , whose relentless efforts to protect patients from an allegedly inept surgeon led to the surgeon's departure from a hospital where he has been linked to dozens of deaths.

perhaps most striking is the book's dim view of advanced practice nurses (aprns). despite a few brief, grudging acknowledgements of the value of aprns, the book gives readers the sense that most aprns today get little or no clinical experience, that they have contempt for bedside nurses, and that they mainly represent society's failure to value bedside nursing. in part gordon seems to be reacting to the tendency of some non-nurses to regard aprns as an utterly new breed of nurses they can finally respect, and to the worrying migration away from the bedside, which in many cases does lead nurses to advanced practice. she also questions the wisdom of graduate programs that fast-track non-nurses into advanced practice roles with minimal bedside training.

but those legitimate concerns do not justify an unbalanced attack on aprns as a whole, nor the implication that aprns provide no benefit to bedside nurses. in fact, many aprns are highly experienced clinical nursing leaders who directly teach and mentor bedside nurses, and whose research informs bedside practice. gordon is right to decry nurses who look down on those with less education. but aprns often have far better clinical relations with bedside nurses than physicians do, and they often provide key clinical support to bedside nurses. aprns also provide a huge health benefit to society by bringing their preventative, holistic approach to primary care and other settings that are in desperate need of it. the focus of many aprns on community health and on underserved urban and rural communities stands in stark contrast to the book's implications of self-serving elitism. this distorted view of aprns is especially unfortunate given the book's calls for nurses to move beyond the class and other divisions that have held the profession back.

the book's treatment of non-bedside nurses is indicative of a somewhat unbalanced overall quality. gordon presents little data that conflicts with her views, and generally readers do not get much sense of how consultants, hospitals, physicians, or managed care figures might respond to her criticisms. by contrast, the views of union representatives are generally presented as expressions of simple truth, though gordon does gently disagree with the unions' apparent opposition to a bachelor's degree entry requirement for registered nurses. gordon might note that the objects of her criticism have ample opportunities to present their views elsewhere. but her arguments might be more persuasive if readers got a better idea of the debate. in addition, the book might have given readers some sense that despite being up "against the odds," nurses today do still manage to pioneer and implement critical, life-saving health care innovations in a wide range of settings. she might also have done a bit more to acknowledge that there are some good depictions of nurses in the non-fiction media, especially the print press. of course, the book's overall goal is to sound the alarm, which it does very well.

though the book makes an admirable effort to assess the situation beyond the united states, it might have done more to address global nursing issues. it does discuss cost-cutting in western europe, australia, and canada, and it includes some description of nurse migration from the philippines. but there is little treatment of nurse-physician relations or the media outside of north america, including in the industrializing east. nor does the book deal with the devastating effects of the crisis on the developing world as a whole, especially africa, which is now struggling with the loss of many of its most highly skilled nurses as the aids epidemic threatens to overwhelm local health systems. even a relatively brief survey of the effects of the shortage on various nations and regions, such as that contained in the november 2004 international council of nurses report (pdf), might have helped readers see the interconnected global nature of the crisis and the fundamental changes that will be needed to address it.

finally, though gordon stresses the importance of language, the book itself has a few troubling aspects in this regard. it rightly recommends that the care language in nursing and medicine should be made compatible, which may mean adjusting some of the indirect language that nursing has developed to avoid stepping on physicians' toes. and it notes that phrases like "doctor's orders" should be abandoned; in fact, many nurses use more accurate terms like "care plans." in this same spirit, the book might have employed the term "physician," rather than "doctor," to avoid suggesting that only physicians receive doctorates. the book suggests that nursing cannot gain respect until it is known that nurses engage in "medicine." but the problem is that few people understand that nursing requires real technical skill, whether many aspects of the profession could also be described as "medicine" or not. moreover, if nurses are seen as being engaged in "medicine," it may encourage the public to continue to equate "medicine" with all health care, a practice that devalues nursing. at times, gordon's impatience with nursing's care locutions seems excessive, as when she "simply refuse" to use the key nursing term "intervention" rather than "treatment," apparently because she regards the former as a dysfunctional euphemism that few understand. "assessment" and "intervention" may be less familiar than "diagnosis" and "treatment," but they do not mean the same thing as the medical terms gordon favors, since the nursing terms encompass the profession's broader, more holistic patient care focus. perhaps nursing can find catchier terms, but accuracy would seem to be an important consideration as well.

fight the future

nursing against the odds is not just a litany of pain and failure. gordon has a vision, and in the book's excellent final section, she proposes eight key reforms and many more ideas that may offer a way out of the nursing crisis. gordon argues that only systemic change will really have an impact; otherwise, there will simply be more frantic recruitment campaigns without retention.

first, gordon stresses that staffing ratio legislation similar to the laws in california and victoria (australia) is needed at all governmental levels. a global solution is required, she asserts, because otherwise mass nursing migration will continue. she rebuts arguments that such ratios are inflexible and too costly, noting that they actually save money by reducing turnover, decreasing the costly use of temporary nurses, and improving care. she finds proposed alternatives inadequate, though she does not seem to recognize the important role measures like disclosure and reporting could play in the enforcement of ratios, as they do in comparable regulatory structures in other fields. gordon briefly discusses magnet hospitals, which are recognized by an american nurses association-affiliated body as meeting high standards of nursing care and empowerment. gordon regards the magnet program as an important effort, but she questions how well it really works, suggesting that many of its voluntary guidelines may offer only the illusion of empowerment. actually, given the withering criticism leveled at the magnet program by anti-ana nursing unions--who contend it is little more than a corrupt, jcaho-style hospital promotion tool--gordon's approach is surprisingly measured.

gordon argues for other major reforms in the regulation of nursing practice. she favors measures to control shift length and eliminate mandatory overtime, which would provide greater schedule predictability, adequate opportunities for rest and learning, a reduction in the use of temporary nurses, and better utilization of the skills of very senior nurses. gordon also argues for better pay for nurses based on education and experience, citing the example of teachers who use such systems with good results. and she recommends a bachelor's degree entry requirement for nursing, despite the divisiveness of the issue, noting that comparable health professionals all need it, and nurses will have a hard time being treated as professionals without it--a powerful real-world point. gordon notes that imposing such an entry requirement has helped teachers gain many benefits in recent decades. gordon might have done more to address concerns that implementing such a requirement is impractical during a critical shortage that has actually pushed the profession hard in the other direction--toward aggressive streamlining and acceleration of educational programs. she might have done so by returning to her own basic point that only fundamental reforms can really resolve the crisis in the long run. gordon also supports formal nursing residencies, pointing to an ongoing american association of colleges of nursing pilot program. such residencies seems like an excellent and long overdue idea. and gordon correctly notes that federal funding for nursing education as a whole is tiny compared to that devoted to medical education.

gordon argues that nurses' collective action--especially union activity--is a critical way for the profession to gain strength and advocate for patients. she stresses that union nurses have the strongest influence on patient care and have been the driving force behind legislation as to safe staffing and whistleblower protection. she reports that although union membership is common among nurses in developed nations, only 17% of u.s. nurses are union members, a fact she links to anti-union attitudes in nursing schools and other nursing bodies. countering views that union activity is "unprofessional," gordon notes that many other professionals (such as journalists) are union members. she calls for unity among nursing unions, professional organizations and academics as critical to furthering patient care goals.

to aid in "reconciling" physicians with nurses, gordon advocates promising ideas to improve the dysfunctional "heirarchical" relationship between the professions. she argues that this will not only benefit nurses, but also improve care, for instance by reducing errors. gordon explains how interdisciplinary training could improve the way the professions communicate and resolve conflicts, using successful reforms in the airline industry as an example. other ideas include having all health professionals shadow each other in clinical settings in order to improve understanding, unifying care language, and insisting that nurses be presented--and present themselves--as serious members of the health care team, even if that means greater formality and less colorful uniforms.

to improve the nursing image, gordon focuses primarily on things nurses themselves can do. she urges nurses to work on their communications skills and assertiveness. she also argues that the virtue script--with its emphasis on emotion and sacrifice over intellect and skill--must go. nurses should present to the public clear, concrete descriptions of what nursing actually is and does, with emphasis on education, research and critical thinking. as an example of what not to do, gordon provides a devastating deconstruction of the recent johnson & johnson "dare to care" campaign, which--despite the input of nurses--featured highly gendered angel themes, and did little to convey nurses' real clinical importance. gordon also argues that hospitals must start to promote nursing in order to educate the media. once again, the book is too easy on the news media, which bears significant responsibility for nursing's poor image and must act affirmatively to address its own biased coverage, not just wait for nurses and hospitals to make things easy.

gordon's final proposal is that nurses take a leading role in achieving universal health care in the u.s., and in strengthening it in the rest of the industrialized world. gordon sees this as a critical way for nurses to help themselves by helping society. she argues that ending the extraordinary waste and chaos of the managed care era could free up tremendous resources to enable nursing to meet its responsibilities to patients, and at the same time empower nursing and improve its image. she asserts that single payer is not a pipe dream in the u.s., despite the opposition of powerful economic interests, because the current system is crumbling--an argument she is not alone in making.

in summing up, gordon presents the central problem we face as how to find enough nurses in a world where women have many options, most men are still not interested, and the population is living longer with more chronic and acute health needs. the world must work hard to understand and value nurses if it is to overcome the endless cycles of shortage, she argues, and if we are to have the qualified, satisfied nurses we need to care for us in the 21st century.

"nursing against the odds" is an important tool in that struggle.

review by harry jacobs summers

nursing editor: sandy summers, msn, mph, rn

reviewed july 19, 2005

the views expressed herein do not necessarily reflect those of the board members or advisory panel of the center for nursing advocacy.

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http://http://www.nytimes.com/2005/05/17/health/17books.html?_r=1&adxnnl=1&oref=slogin&adxnnlx=1190593506-ko2ion5d3ujcnnpbfxhigq&pagewanted=print

may 17, 2005

nursing in america: a portrait of a profession in critical condition

by cornelia dean

"nursing against the odds: how health care cost cutting, media stereotypes and medical hubris undermine nurses and patient care," by suzanne gordon. 489 pages. cornell university press. $29.95.

exhausted by heavy work, mandatory overtime and the stress of looking after hospital patients who are sicker, frailer and in need of ever more high-tech intervention, nurses are leaving the bedside faster than they can be replaced.

the situation is so bad, ms. gordon writes in this gloomy assessment of american nursing, that even nursing educators, the people we rely on to train the next generation of nurses, are leaving the field, so nursing schools cannot accommodate declining numbers of would-be students.

ms. gordon, a journalist who specializes in nursing issues, is hardly the first person to make these points. the cost-cutting of managed care has been notoriously hard on nurses, whose salaries loom large on the hospital bottom line.

but these are not the only issues in her book. issues of respect and regard must also be dealt with if the nursing crisis she sees is to be addressed. and these issues, she writes, will never be solved unless nursing as a profession comes to grips with them.

true, some problems can be solved with simple infusions of cash - money for more staff members brings vast improvement in performance and morale, ms. gordon writes. and she cites growing evidence that spending more money on nursing is cost-effective, since it reduces complications like urinary tract infections, bedsores or costly posthospital misadventures.

but other major problems are less amenable to fiscal fixes. for example, she writes, nursing as a profession does not answer with one voice this basic question: who is a registered nurse?

recipients of associate degrees, graduates of diploma programs in hospitals, students who earn bachelor's degrees in nursing and liberal arts graduates who complete master's programs in advanced practice, like anesthetists, all can be registered nurses.

but their training is far different. liberal arts graduates who train for advanced practice nursing may lack crucial bedside skills, or may even denigrate such skills as mere "technical" nursing, even though ms. gordon cites numerous cases in which a nurse's bedside experience meant life or death to a failing patient.

on the other hand, and as other experts on nursing have argued, it is difficult to make the case that registered nurses deserve respect as fellow professionals when they can enter the field without a bachelor's degree. this is a question nursing must confront, ms. gordon argues.

ms. gordon is also obviously irritated by nursing's collective embrace of what she calls a "language of virtue" to describe the noble self-sacrifices of caring nurses who dedicate themselves to the welfare of others with little thought of themselves.

this tradition is one reason nursing typically scores so well in surveys of the most respected professions. ms. gordon offers many examples of nurses who live up to this high standard.

but, she writes, similarly dedicated people in other fields demand - and get - reasonable working conditions, reasonable pay and other compensation for their skill and dedication. until nursing makes these demands, she argues, nurses will not get the respect they deserve.

she adds that, speaking of respect, the abandonment of starched whites, perky caps and "scrunchy" shoes may have made life easier for nurses, but their wholesale embrace of pastel or flowered scrub suits is not helping their image.

all of this is reflected in the news media, in which nursing's role as a linchpin of medicine goes largely unreported. here again, ms. gordon indicts the culture of nursing - in particular, its habitual deference to doctors and collective unwillingness to promote itself. as an example, ms. gordon cites the difficulty a journalist faced when the new york times assigned her to report on the care of people injured in a rhode island nightclub fire. it proved almost impossible to find a nurse to interview, even though arduous, meticulous bedside care is crucial to burn patients' recovery.

perhaps as a result, ms. gordon writes, nurses on television or in the movies are with few exceptions missing in action, or "an ill-distinguished mass of busy hands" or objects of Mediaographic fantasy.

idealistic, hardworking and intelligent nurses like colleen mcmurphy of "china beach," or belize of "angels in america," are rare exceptions.

if nurses hoped the arrival of large numbers of women into the ranks of physicians would change the deference equation between them, they were disappointed, ms. gordon adds. now that women make up half the students in medical schools, she writes, women who decide to become nurses are sometimes assumed to lack the ambition or ability to become doctors. and, ms. gordon adds, nursing has not done well in attracting men to its ranks.

many unexpected health crises occur not when technology fails but when a patient's condition changes and no one notices. a doctor who parachutes in for five-minute visits once or twice a day may think a patient is stable or even improving. sometimes, it is only the nurse at the bedside who knows whether the patient is recovering steadily or teetering on the edge. so people who are interested in the health care system or in their own health care should pay attention to the issues ms. gordon raises in this book.

but nurses especially should read it. in many ways, ms. gordon's message is directed at them.

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