On Respecting Nurses
Posted on November 10, 2008
Filed Under Medical ethics |
Here’s a Podcast of this post:
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DrRich commends to his readers Dr. Val’s new blog, Getting Better with Dr. Val. Val is taking the good work she did on her former site at Revolution Health, and lifting it to new heights.
In particular, DrRich suggests you make yourself a nice cup of tea and listen to her 30 minute podcast on what’s ailing American nurses today. This is a patented Dr.Val well-known-people interview, this time with three eminent blogging nurses, all of whom are very thoughtful and very articulate about their profession.
DrRich has been a great admirer of nurses for 35 years, ever since a head nurse went out of her way to (diplomatically) save DrRich’s intern *ss when he was about to do something stupid to a patient. DrRich worked very closely with colleagues who were nurses during his entire clinical career, and considers many of these people to be the finest medical professionals he has ever known. More recently, DrRich has come to admire and respect the nursing profession as possibly the last bastion of real medical ethics. (The physicians’ new ethical precepts have largely thrown patients under the bus. Nurses haven’t done that yet.)
Much of what Gina (Code Blog), Strong One (My Strong Medicine), and Mother Jones (Nurse Ratched’s Place) have to say about the nursing profession is not all that surprising. That nurses are often disrespected and stereotyped by god-like doctors and poorly-informed patients is, sadly, an old story. But DrRich is struck by two things in Val’s podcast.
First is that there is a long, long waiting list for entrance to nursing school. DrRich had no idea. He finds it uplifting that so many young Americans are lining up to enter this still-noble profession, especially at a time when nurses are so needed. It seems likely that at least some of this enthusiasm reflects the fact (and it is a fact) that the nursing profession is entering an era where the stereotypes and the disrespect seem ready to be torn down. While he has no special insight into the matter, DrRich finds it very likely that nursing school slots will be rapidly expanded (and nursing instructors will be adequately rewarded to staff these new slots), simply because there will be little other choice for our healthcare system.
Second, it is striking that nurses seem to have figured out already that taking over primary care medicine from the rapidly-dwindling primary care physicians is a losing proposition. They are avoiding the opportunity in droves.
That, if nothing else, should tell us how smart nurses really are.
Thanks to a) the growing nursing shortage, b) the inability to accommodate all the people who want to enter nursing, and c) the fact that those who have made it into the nursing profession are very smart people with “disturbingly” high ethical standards, we find that the healthcare system will soon need to re-evaluate its strategy in regard to primary care medicine.
Our healthcare system has taken exquisite pains to make primary care medicine an untenable proposition for American doctors. Not only is their pay (which, by the way, is determined the same way it was determined for workers in the old Soviet collectives) low, but also their autonomy as physicians has been wrecked by arbitrary guidelines; their clinical activities are closely monitored and second-guessed by stone-witted bureaucrats; they have been limited to 7.5 minutes per “patient encounter” and the stuff they must accomplish during those 7.5 minutes is determined by Pay for Performance checklists; they have been charged with operating flawlessly under a system of hundreds of thousands of pages of federal rules, regulations and guidelines whose meaning is not merely unclear, but is fundamentally indeterminate, like Schrodinger’s cat, and (also like Schrodinger’s cat) which remains fundamentally unknowable until the “box is opened” through criminal prosecution (whereupon doctors who had been practicing in good faith have at least a 50- 50 chance of learning that they are actually professionally dead); and finally, they have been charged with the duty of covertly rationing their patients’ healthcare at the bedside by the healthcare bureaucracy, by the United States Supreme Court, and by the new-age ethical precepts of their own profession.
The healthcare system has done all this precisely to drive physicians out of the primary care business, for the explicit purpose of opening the primary-care doors to a profession it believes is more tractable than physicians - namely, the nurses. The healthcare system sees nurses as professionals who (once they are duly certified in primary care medicine through respected testing organizations), will have just enough training to diagnose and treat the average patient (i.e., the ones with high blood, low blood, fat blood and sugar), and who will cheerfully, unquestioningly follow whatever guidelines are handed down to them from on high. And they will do all this for less pay and with less lip than the now-obsolete physician PCPs. These new practitioners of primary care medicine will be a perfect fit.
Except for one thing. The nurses want no part of it.
The nurses interviewed by Dr. Val speak of the relatively low pay primary care nursing practitioners receive, especially compared to what specialist nurses can make working in hospitals. They also seem to understand the real downsides of primary care nursing. There is an inherent lack of respect toward primary care in the U.S., which is clearly expressed by both specialist doctors and patients, no matter who is delivering it. Primary care nurses will also be saddled with the same guidelines, intrusive bureaucratic oversight, time limits, threats of a federal fraud rap if they misinterpret a rule, and the same bedside rationing expectations that have ruined the careers of primary care doctors. They will be accountable for their patients 24/7, and will be subject to malpractice suits beyond most nurses’ imagining. And the fact that primary care practitioners have been maneuvered into owing their chief allegiance to third party payers instead of to patients will be perhaps even more insulting to nurses than it turned out to be for doctors.
The notion that nurses will jump at this opportunity is absurd. That the healthcare system appears to blithely assume they will happily do so is perhaps the greatest disrespect being perpetrated on the nursing profession today.
For what it’s worth, DrRich supports the nursing profession in saying “no” to the healthcare bureaucracy. They should not engage in primary care until they can do so without compromising their principles and their commitment to patients. He prays they will stick to their strong ethical ideals, and keep their patients first, and tell the system that if they want to treat patients like widgets, then go find somebody else to do it. Had doctors given this answer the medical profession would not be in such sad shape today.
Nurses may not magically garner instant respect from doctors and patients if they take this stand, but they’ll at least maintain their own self-respect. And anyone who doesn’t think this is the most important kind of respect, just ask someone who has lost theirs - you might want to start with some of the doctors.
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What a terrific blog post! Thanks for enjoying my podcast (with a cup of tea)… hope you’ll come back for more. I’m so pleased to be embraced by the nurse bloggers - they’re the salt of the earth, I tell you.
KUDOS to you on a fine blog post. I (and all nurses) appreciate your support and your honesty.
It’s physician’s like yourself that absolutely wash away the ‘other’ bad experiences we have all had.
A professional handshake for you.
Thank you.
My comment may be a post hijack. Please delete or edit it if you find it so.
As you know, I’m a disaffected nurse, doctorally educated as a nursing administrator and blacklisted for whistle-blowing in advocating for nurses and patients. I’ve taught in undergraduate nursing programs, and I also practiced critical care nursing. I’ve straddled the academic and clinical arenas, and my administrative positions gave me a fairly broad view of hospital and community health operations.
All of that makes me atypical, but I hope, fairly tuned in to the profession’s challenges and opportunities across clinical, academic, research and administrative nursing specialties.
I am not a fan of Val, and she is well aware of it. However, I admire her for following through on a blog request I made a year or so ago which was to have physicians and nurses engage in conversations about their perspectives of their own profession’s issues and to explore mutual opportunities to collaborate and support one another. So huzzahs to Val and the nurses she interviewed, one of whom wrote some fairly scathing things about my blogging.
To address your points, DrRich, I’m going to start with that of imprecise language. Nurses practice nursing and adhere (or not) to nursing ethics. I was educated to be respectful of and to recognize the distinct separateness of medical ethics and practice from nursing ethics and practice. I don’t use the terms interchangeably, and I hope you might consider them as different entities, as well. While they have so many similarities, they differ enough around key precepts that it is useful to identify them by their uniqueness.
By statute and by ethics (the Nurses Code of Ethics with interpretive statements may be found on the American Nurses Association website. It is to their discredit that they only allow viewing of the Code online, and they sell hard copies instead of making the document freely available to the public and interested parties.)
The waits for nursing education placement are largely a factor of two restrictions: available faculty, who are compensated below that of two year technical associate degree program graduates in clinical practice and the lack of educational facilities which incur larger expenses than traditional liberal arts majors due to the small student to faculty ratios and clinical practice hours which are costly. When I was on the serfdom track (tenure)in an underfunded state university, I had to fight for every single MINUTE of clinical contact hours for students. All of my students worked at least twenty hours per week. Most were parents or heads of households. Only one or two fit the traditional notion of the college undergrad: living in a dorm, studying full time and not working. Everyone else was doing three or more major life activities. Yikes!
Back to faculty and student problems: in nursing, faculty rarely, if ever, have the opportunity to enjoy joint appointments. In my own case, I was teaching in a new program fulltime with both clinical and didactic courses to develop and approve curriculum and content, then to teach and evaluate that curriculum, publish, engage in research, pursue doctoral study full time, and - oh - to remain clinically competent, I worked a weekend position as a critical care nurse in an unaffiliated academic teaching medical center twenty four hours each week. I also advised 15 students and “served” time as the faculty mentor in the nursing lab. Plus other duties as assigned. Ha. Ha. Ha. Sleeping was optional. The faculty pay didn’t even match my very first time new graduate clinical wage. My weekend job covered my expenses.
Nursing faculty average age now is in the late forties, and faculty are fleeing via retirement and when they can, for greener pastures with better working conditions.
Later, I served as a hospital advisor for a well-regarded associate degree nursing program which provided excellent technical education for Appalachian students. it had such a long wait list for assignment into the clinical portion of the program that many students’ federal financial aid expired while they were waiting. This disconnect between acceptance and program progression/completion is a key reason that excellent prospective nurses are lost.
But without joint appointments, clinical nurses don’t get routine exposure to advanced practice, research and doctorally prepared nurses. Because of the nature of nursing practice, nurses remain siloed and isolated from their colleagues practicing in other settings and with other patient populations. They end up divided against themselves and their own professional interests. Mostly, nurses do not read the professional peer-reviewed literature, and they don’t engage in nursing research and collegial education. In hospitals, most “education” isn’t nursing education, but rather, CME to which nurses have been invited. CME and CNE are two entirely different animals (I served as continuing educ. nursing and medical faculty, and so have some notion about the differences between the two). There is no mandatory formal education ofter nurses pass the entry licensure examination. It then falls to nurse employers to provide for entry into practice education and support. This ranges from fly by the seat of the pants orientation to full fledged formal nursing internships. It desperately needs to be standardized so that all nurses are protected and guided while they learn to transition from student to independent professional nurse.
The second point you raise about nurses and their role in primary care points to a lack of understanding on the interviewed nurses’ part. None of them is an advanced practice nurse. I don’t know their credentials (I’ll look for them when I have time later) so I’m guessing that none of them has formal nursing education beyond their entry into practice program which could be anything form a two year associate degree to a three year hospital based diploma program to a four year baccalaureate education. The American Association of Colleges of Nursing is mandating that all nurse practitioners have an earned DNP degree (doctor of nursing practice) within the next ten years. The AACN website is an excellent resources for the profession’s demographics, education, the FAQ around the and for the DNP and nurses’ role in primary care.
I don’t have a dog in the DNP fight. I am not an advanced practice nurse as my grad. work is in nursing administration. But I’m not overly worried about the DNP nurses in primary care for several reasons.
One is that patients are satisfied with nurse practitioners, and nurses tend to go into this role because workplace conditions for clinical nurses are so unsatisfactory and dangerous that this provides more control, autonomy and direct interaction with patients - the same reasons that physicians like the field.
The dissatisfiers for both physicians and nurses are similar and just as you listed.
So in my view, we need to find ways to identify opportunities for mutual interest and benefit for nurses and physicians that combine a return of professional autonomy and satisfactory and SAFE patient case loads with the same patient goal: excellent access to affordable, quality primary care - nursing and medical.
The vehicle I would advocate for is that of self-governed professional practice groups for nurses and for physicians. And I would re-design the US health care system from the ground up instead of from the high tech, high cost, high acuity top down.
This is where nurses ROI should be taken into account. Community health clinic settings would allow baccalaureate prepared nurses (about one third of the US nurse population) to serve as primary case managers, triage patient needs, coordinate physician services (notice I didn’t say control) and other health services and provide care where patients are: home, community, workplace, school.
Hospitals employ about 60% of practicing nurses, but a large segment practice in home, community, school and occupational settings. This is where I’d invest in more infrastructure, providers and essential services. The more that patient case loads can be controlled, and that patients can receive preventive and primary care, chronic disease management and health education and can stay out of hospitals and emergency departments, the more that hospitals can stay afloat and should be able to address fundamental workplace conditions deficits. I blogged about this in more detail today, coincidentally.
I’m so sorry - this is much too long and yet it doesn’t sufficiently answer your questions and address the complex issues. Thanks for your indulgence, and please, edit/delete as you desire.
Your post and Dr. Val’s podcast convey much of the disappointment that many nurses feel towards our healthcare system (if it can be called a system).
Due to a scheduling conflict, I was unable to participate in the podcast, but what you say in this post covers much of what I believe.
Our healthcare system is beset by an almost endless list of problems. Healthcare is America’s Achilles Heel.
As for the shortage of willing nurses, I don’t know what solutions are needed. Nurses have been saddled burdens that aren’t even related to their primary responsibilities. The nursing profession is in the middle of a positive feedback loop. It’s been circling the drain for some time.
Still, I’m hopeful that if enough of the medical community pulls together, we can avert a catastrophic collapse (although I wonder if we’ve past an event horizon). We need champions.
I’m glad to hear the profound and acknowledging words expressed in your post. I hope we can continue the conversation.
Thank you for your great post, and for supporting the nursing profession.
MJ
A concern I have as an RN and as a clinical instructor is that many of the peoplelined up to enter nursing are no longer doing this because it is a “noble and respected” profession. they are doing it for job security (reading so much about the nursing shortage), AND they are doing it for the bucks.
A sad commentary, as I am so proud of being a nurse, and living my life long dream. Yet I see nurses being hired onto our unit who very clearly care little for the patients or their families, but they are eager to rack up the hours and and the overtime. As an insturctor, I see that the lottery system is imposed in order to stay within the guidelines of state funding and “equal access” to the deleterious effect of qualified, gifted and inspired aspiring nurses being denied admission to a nursing program because thier lottery number was not picked.
We are encouraging a new breed of nurse…one looking for a guaranteed job and guaranteed, fat pay check.
Another part of overhauling healthcare should be to instill standards and screening practices for nursing schools.
Thanks. You have great insight - an absolutely fabulous read.
From another nurse who wants no part of it.
Annie, thank you so much for putting it into words that people can understand. I have been a nurse for 30 years and a nurse practitioner for 10. I have seen so many changes in the profession and in the new nurses coming out of schools. The hospital nursing staff is averaging a complete turnover of nurses about every 12-16 months because 1. not enough supervision and training after graduation especially in the speciality areas. 2. Supervisors that are being pressured from the admin staff to cut corners and decrease their budgets to a point that a new graduate can only have 6 weeks training instead of 6 months. and 3. Being completely ridiculed and written up for making a mistake that they probably would not have made if they had been properly trained.
Animals that eat their young have nothing on the nursing profession.
As far as the DNP degree, I applied and was accepted to a DNP program but after really looking into it, I beleive the ANA requirement for this degree is only there to help the colleges that offer the degree. Of all the companies, hospital and practices I have called talked to, having a DNP will not be worth any more than a MSN degree and the money spent on this degree will never been recouped in the real world. I can do allot more with 45,000.00 then spent it on a degree that will not improve my standing any more than what I have now.
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