Cutting Down on Care|
Suzanne Gordon gives a first-hand account from the front lines of nursing -- a profession that is gravely threatened by the restructuring of our medical system
March 19, 1997
The mythology of medicine revolves around doctors -- they are the ones who are usually credited if a patient is cured. Yet it is nurses who make up the largest profession in health care and who spend the most time with patients. Their story is rarely told, but in Life Support: Three Nurses on the Front Lines, health specialist Suzanne Gordon follows nurses at the Beth Israel Hospital in Boston as they go on their rounds and shows how crucial their roles are.
In this era of managed care, many health-care providers are scrambling to cut their budgets, and the nursing profession has been hit hard. Many trained nurses no longer provide direct care for their patients; instead, they oversee unlicensed personnel who have not attended nursing school and who have as little as a few weeks of training. Gordon believes that most people do not realize how vitally important nurses are in our health-care system. Life Support is a wake-up call.
Gordon spoke recently with Atlantic Unbound's Katie Bacon.
"What Nurses Stand For," an excerpt from Life
Support from the February, 1997, Atlantic
Related articles from The Atlantic's archive
See Flashback: Markets and Medicine. Michael Crichton and Arnold S. Relman on the commercialization of health care.
You argue in Life Support that medicine and
nursing are fundamentally different disciplines: medicine's mission is to fight
disease and nursing's is to acknowledge and deal with illnesses' effects on
patients' lives. Should or can the "culture of cure" and the "culture of care"
I wouldn't say that medicine and nursing are fundamentally incompatible, but the focus of medicine, particularly in the mid- to late-twentieth century, has moved further and further away from care giving. Before doctors had an armamentarium of high-tech cures, they really had to talk to and listen to their patients. There has been an increasing focus on disease as opposed to the person who has the disease.
If you look at the average hospital, you see very clearly why this has come about. A doctor may visit a patient for five minutes a day, while nurses have been with that patient and lived through the illness eight, ten, twelve hours a day. Nevertheless, doctors really view health care as theirs, and they talk about nurses in what I call the "Adam's Rib" view of nursing. They call nurses "non-physician providers," "physician extenders," "mid-level practitioners." The physicians have simply been taught to look at nurses as inferior. Given this context of medical domination, nurses have often tried to carve out caring as their niche. But the "doctors cure, nurses care" distinction is invidious, because nurses do an awful lot of curing, as I make clear in my book. What I'm trying to say is that there is a lot of room for overlap. What we really need, as you suggest in your question, is for the culture of cure and the culture of care to be combined.
I once asked a young medical student what he'd learned about nursing. He said, "The nurses call the doctors when something goes wrong, and the doctor comes in and fixes it." That is a very problematic view of nursing, but it is also a very problematic view of medicine. What happens when that doctor can't cure or fix his patient, as is often the case? A lot of doctors feel so frustrated and impotent and powerless in that situation that they abandon their patients -- not because they're callous people, but because they simply don't know how to be caregivers. Caring is not something you're born with. It's a skill that you learn -- a skill of involvement, a skill of engagement. The nurses I profiled have honed this skill very carefully, and I think that doctors can, too. We've created divisions between the roles of doctors and nurses rather than encouraging collaboration, and we've made a hierarchy in which doctors give "orders" to nurses -- and by extension, to patients -- rather than creating teams of health-care professionals that can work together and share their insights. The Beth Israel is an excellent model of this sort of collaboration, but even it has enormous limitations. This is something that should matter to patients. It's a bit like a family: if the father and mother don't get along it can be really difficult for the kid. The patient is the dependent variable in this equation.
What made you decide to write this book? Do you have a background in medicine?
No, I don't have a background in medicine. My father was a famous ophthalmologist, though, so I had some familiarity with the field. I decided to write the book because in writing another book, called Prisoners of Men's Dreams, I stumbled onto nursing. It was the mid-eighties at the height of the nursing shortage, and as a journalist I began to wonder why there was a shortage. At a feminist study program at Boston College I met a nurse who talked very eloquently to me about what it was like to give care. I was deeply moved by her description, and I started exploring the nursing profession, which not many people have written about.
Is there a better way to organize the education of doctors and nurses so that they can work together more effectively?
I think doctors should learn a lot more about nursing in medical school. They should learn what nurses do, they should be taught by nurses, and they should learn with nursing students in some instances. When doctors go into hospitals as residents, they should get orientations from nurses, they should collaborate with nurses, and they should go on rounds with nurses. That should be the norm in all hospitals, but it isn't. There's very little discussion between doctors and nurses in hospitals, and patients should be very worried and concerned about this.
You argue that nurses rather than doctors are the ones who help patients face death, yet neither nurses nor doctors are trained at this skill. Why are nurses so much better at it, or at least more willing to do it?
There are many doctors who help patients deal with death, of course. But as a profession medicine has not taught its practitioners to help patients navigate the last days of life. Doctors are taught to fight disease, and many feel that it is a personal failure if their patient dies. There is a growing band of physicians in the field of providing palliative care. But doctors have been very resistant in learning about the care of the dying. They consider it baby sitting. They've been taught to believe that the challenges in medicine are biomedical.
The standard definition of nursing, on the other hand, includes helping patients deal with death. According to nursing scholar Virginia Henderson a nurse's purpose is to "assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge." Nurses are taught that the challenges are not just biomedical but also emotional and spiritual. We're a culture that prefers to believe that illness is an affront and death is optional. Nurses know the truth, but we don't like to acknowledge them or that truth.
You write that "the history of nursing education is one of the longest-running feminist struggles in any profession in America." What has been the reaction of feminists to the recent trend of replacing registered nurses with less-skilled, less-educated workers?
The deprofessionalization of nursing, the layoffs of nurses, and the dehospitalization of patients so that they can't get appropriate medical care are all very big women's issues. More and more women are having to take time off from work to take care of family members who have been discharged from the hospital too early. There's a real intersection between what happens to nurses in health-care institutions and what happens to women at home and in the workplace.
To the extent that there's a feminist movement in America -- and I'm not sure there really is today -- I don't think that it's paying enough attention to what's happening to the largest profession in health care. It's interesting to me that, for example, a book like Susan Faludi's Backlash had not a word about nurses in it. The backlash in hospitals against nurses trying to get more authority, trying to get more autonomy, trying to have a greater voice in health care is really extraordinary.
Many feminists believe that it would be progress if women nurses became doctors rather than remaining in nursing but gaining better recognition and better financial reward. A lot of people feel that a liberated woman is a doctor, a lawyer, a junk-bond dealer, whatever. But not a nurse. Many feminists have argued that if a profession is better-paid, more men will go into it, but that is simply not true of nursing. Nurses make on average $33,000 a year -- and even earn up to $80,000 dollars a year in some urban areas, -- but the profession is still 95-97 percent female. There is a real prejudice factor at work here.
During the 1960s nurse practitioners started to take on the responsibilities of primary physicians, especially in poor or rural areas where there weren't enough doctors to go around. "During this brief period," you explain, "the American Medical Association was controlled by physicians who felt that medicine's main mission was to serve a broad public." What is their main mission now? Why has it changed?
The American Medical Association has tended to be extremely conservative; it has fought national health insurance and has torpedoed attempts to create a rational health-care system in this country for decades. It tends to be very narrowly focused on specialist physicians and their incomes. It has been very turf-conscious. In the 1993-1994 health-care-reform debate, when Clinton proposed using more nurse practitioners the AMA went ballistic and ran horribly sexist and very nasty ads about this issue. The AMA is confused about what the mission of medicine should be. Should it be to help physicians make a great deal of money or should it be to help provide a human service? The American health-care service has suffered from this confusion for quite some time.
The tragedy of the marketplace model of medicine is that it pits people against one another. In health care you have the generalist physicians against the specialists, the primary-care doctor against the nurse practitioner, and the nurse practitioner against the bedside nurses. This is the meaning of competition in the adversarial marketplace model of health care. Americans just don't seem to get that this is not an appropriate model for dealing with the vulnerable, sick, and dying.
What are the practical ramifications of nurses being replaced by less-expensive patient-care technicians?
I think it's a very serious problem to give "techs" nursing-care duties. If they're going to be doing nursing, they should be paid and educated like nurses. We consistently refuse to pay for care-giving in this country, and this is the latest iteration of that problem. The techs are very well-intentioned: they perform enormously important work in health care, but they are not qualified or educated to interpret patients' illnesses. A lot of people think that nursing is just taking a patient's vital signs and then reporting them to a doctor. But what nurses do with that information is to put it in the context of the patient and interpret its significance. Over and over again I have seen nurses rescuing their patients because they knew that something was wrong, even though the objective measures didn't register any change. This often creates conflict with doctors, who are trained to ask "What are the objective measures?" Nurses will say, "Their temperature isn't up, their blood pressure is the same, their blood-saturation level hasn't changed, but I know that there's something wrong with the patient." And they will be right.
What do you think of recent efforts by President Clinton to legislate how long hospitals must keep patients after giving birth or having a mastectomy? What does this say about our health-care system?
You can't legislate on a disease-by-disease basis. We've focused on breast cancer and on labor and delivery but the issue is so much bigger. Every single person who goes into a hospital is hustled out quicker and often sicker. We're focusing on compelling cases and ignoring other, equally compelling cases. Corporate-driven managed care is managing care right out of the system. If we want care we're going to have to pay for it. One way to pay for it is to stop corporations from taking twenty to thirty percent off the top of our health-care dollar. You cannot take those kind of profits out of the health-care system and still have nurses at your bedside when you need them. Right now there's a big fight between the California Nurses' Association and Kaiser Permanente (the largest non-profit HMO in the country). Kaiser is being ruthless in its attempts to cut its nursing care. They've cut home-care nursing and home-care services, and they're trying to get some registered nurses to take a fifteen percent pay cut -- at a period when Kaiser is extremely profitable and is spending large sums of money on advertising and marketing and consultants. A lot of the future of nursing and health care really depends on citizens saying no to this. People really need to become much more active, to find out more about nursing care, and to ask their doctors and hospitals about what kind of nursing care they're going to get.
Copyright © 1997 by The Atlantic Monthly Company. All rights reserved.