AT four o'clock on a Friday afternoon the hematology-oncology clinic at Boston's Beth Israel Hospital is quiet. Paddy Connelly and Frances Kiel, two of the eleven nurses who work in the unit, sit at the nurses' station -- an island consisting of two long desks equipped with phones, which ring constantly, and computers. They are encircled by thirteen blue-leather reclining chairs, in which patients may spend only a brief time, for a short chemotherapy infusion, or an entire afternoon, to receive more complicated chemotherapy or blood products. At one of the chairs Nancy Rumplik is starting to administer chemotherapy to a man in his mid-fifties who has colon cancer.
Rumplik is forty-two and has been a nurse on the unit for seven years. She stands next to the wan-looking man and begins to hang the intravenous drugs that will treat his cancer. As the solution drips through the tubing and into his vein, she sits by his side, watching to make sure that he has no adverse reaction.
Today she is acting as triage nurse -- the person responsible for patients who walk in without an appointment, for patients who call with a problem but can't reach their primary nurse, for the smooth functioning of the unit, and, of course, for responding to any emergencies. Rumplik's eyes thus constantly sweep the room to check on the other patients. She focuses for a moment on a heavy-set African-American woman in her mid-forties, dressed in a pair of navy slacks and a brightly colored shirt, who is sitting in the opposite corner. Her sister, who is younger and heavier, is by her side. The patient seems fine, so Rumplik returns her attention to the man next to her. Several minutes later she looks up again, checks the woman, and stiffens. There is now a look of anxiety on the woman's face. Rumplik, leaning forward in her chair, stares at her.
"What's she getting?" she mouths to Kiel.
Looking at the patient's chart, Frances Kiel names a drug that has been known to cause severe allergic reactions. In that brief moment, as the two nurses confer, the woman suddenly clasps her chest. Her look of anxiety turns to terror. Her mouth opens and shuts in silent panic. Rumplik leaps up from her chair, as do Kiel and Connelly, and sprints across the room.
"I can't breathe," the woman sputters when Rumplik is at her side. Her eyes bulging, she grasps Rumplik's hand tightly; her eyes roll back as her head slips to the side. Realizing that the patient is having an anaphylactic reaction (her airway is swelling and closing), Rumplik immediately turns a small spigot on the IV tubing to shut off the drip. At the same instant Kiel calls a physician and the emergency-response team. By this time the woman is struggling for breath.
Kiel slips an oxygen mask over the woman's head and wraps a blood-pressure cuff around her arm. Connelly administers an antihistamine to stop the allergic reaction, and cortisone to decrease the inflammation blocking her airway. The physician, an oncology fellow, arrives within minutes. He assesses the situation and then notices the woman's sister standing paralyzed, watching the scene. "Get out of here!" he commands sharply. The woman moves away as if she had been slapped.
Just as the emergency team arrives, the woman's breathing returns to normal and the look of terror fades from her face. Taking Rumplik's hand again, she looks up and says, "I couldn't breathe. I just couldn't breathe." Rumplik gently explains that she has had an allergic reaction to a drug and reassures her that it has stopped.
After a few minutes, when the physician is certain that the patient is stable, he and the emergency-response team walk out of the treatment area, but the nurses continue to comfort the shaken woman. Rumplik then crosses the room to talk with her male patient, who is ashen-faced at this reminder of the potentially lethal effects of the medication that he and others are receiving. Responding to his unspoken fears, Rumplik says quietly, "It's frightening to see something like that. But it's under control."
He nods silently, closes his eyes, and leans his head back against the chair. Rumplik goes over to the desk where Connelly and Kiel are breathing a joint sigh of relief. One of the nurses comments on the physician's treatment of the patient's sister. "Did you hear him? He just told her to get out."
Wincing with distress, Rumplik looks around for the sister. She goes into the waiting room, where the woman is sitting in a corner, looking bereft and frightened. Rumplik sits down next to her, explains what happened, and suggests that the patient could probably benefit from some overnight company. Then she adds, "I'm sorry the doctor talked to you like that. You know, it's a very anxious time for all of us."
At this gesture of respect and recognition the woman, who has every strike -- race, class, and sex -- against her when dealing with elite white professionals in this downtown hospital, smiles solemnly. "I understand. Thank you."
Nancy Rumplik returns to her patient.
"I AM READY TO DIE"
IT is 6:00 P.M. Today Jeannie Chaisson, a clinical nurse specialist, arrived at her general medical unit at seven in the morning and cared for patients until three-thirty in the afternoon. At home now, she makes herself a pot of coffee and sits down in the living room, cradling her cup. Just as she is shedding the strain of the day, the phone rings.
It's the husband of one of Chaisson's patients -- a sixty-three-year-old woman suffering from terminal multiple myeloma, a cancer of the bone marrow. When Chaisson left the hospital, she knew the family was in crisis. Having endured the cancer for several years, the woman is exhausted from the pain, from the effects of the disease and failed treatments, and from the pain medication on which she has become increasingly dependent. Chaisson knows she is ready to let death take her. But her husband and daughter are not.
Now the crisis that was brewing has exploded. Chaisson's caller is breathless, frantic with anxiety, as he relays his wife's pleas. She wants to die. She is prepared to die. She says the pain is too much. "You've got to do something," he implores Chaisson. "Keep her going -- stop her from doing this."
Chaisson knows that it is indeed time for her to do something -- but, sadly, not what the anguished husband wishes. "Be calm," she tells him. "Please hold on. We'll all talk together. I'm coming right in." Leaving a note for her family, she gets into her car and drives back to the hospital.
When Chaisson walks into the patient's room, she is not surprised by what she finds. Seated next to the bed is the visibly distraught husband. Behind him the patient's twenty-five-year-old daughter paces in front of a picture window with a view across Boston. The patient is lying in a state somewhere between consciousness and coma, shrunken by pain and devoured by the cancer's progress. Chaisson has seen scenes like this many times before in her fifteen-year career as a nurse.
As she looks at the woman, she can understand why her husband and her daughter are so resistant. They remember her as she first appeared to Chaisson, three years ago -- a bright, feisty sixty-year-old woman, her nails tapered and polished, her hair sleekly sculpted into a perfect silver pouf. Chaisson remembers the day, during the first of many admissions to the unit, when she asked the woman if she wanted her hair washed.
The woman replied in astonishment, "I do not wash my hair. I have it done. Once a week."
Now her hair is unkempt, glued to her face with sweat. Her nails are no longer polished. Their main work these days is to dig into her flesh when the pain becomes too acute. The disease has slowly bored into her bones. Simply to stand is painful and could even be an invitation to a fracture. Her pelvis is disintegrating. The nurses have inserted an indwelling catheter, because having a bedpan slipped underneath her causes agony, but she has developed a urinary-tract infection. Because removing the catheter will make the infection easier to treat, doctors suggest this course of action. Yet if the catheter is removed, the pain will be intolerable each time she has to urinate.
When the residents and interns argued that failure to treat the infection could mean the patient would die, Chaisson responded, "She's dying anyway. It's her disease that is killing her, not a urinary-tract infection." They relented.
Now the family must confront this reality.
Chaisson goes to the woman's bed and gently wakes her. Smiling at her nurse, the woman tries to muster the energy to explain to her husband and her daughter that the pain is too great and she can no longer attain that delicate balance, so crucial to dying patients, between fighting off pain and remaining alert for at least some of the day. Only when she is practically comatose from drugs can she find relief.
"I am ready to die," she whispers weakly.
Her husband and daughter contradict her -- there is still hope.
Jeannie Chaisson stands silent during this exchange and then intervenes, asking them to try to take in what their loved one is telling them. Then she repeats the basic facts about the disease and its course. "At this point there is no treatment for the disease," she explains, "but there is treatment for the pain, to make the patient comfortable and ease her suffering." Chaisson spends another hour sitting with them, answering their questions and allowing them to feel supported. Finally the family is able to heed the patient's wishes -- leave the catheter in and do not resuscitate her if she suffers a cardiac arrest. Give her enough morphine to stop the pain. Let her go.
The woman visibly relaxes, lies back, and closes her eyes. Chaisson approaches the husband and the daughter, with whom she has worked for so long, and hugs them both. Then she goes out to talk to the medical team.
Before leaving for home, Chaisson again visits her patient. The husband and the daughter have gone for a cup of coffee. The woman is quiet. Chaisson sits down at the side of her bed and takes her hand. The woman opens her eyes. Too exhausted to say a word, she merely squeezes the nurse's hand in gratitude. For the past three years Chaisson has helped her to fight her disease and live as long as possible. Now she is here to help her die.
THE ENDANGERED RN
WHEN we hear the word "hospital," technology and scientific invention spring to mind: mechanical ventilators, dialysis machines, intravenous pumps, biomedical research, surgery, medication. These, many believe, are the life supports in our health-care system. This technology keeps people alive, and helps to cure and heal them.
In fact there are other, equally important life supports in our health-care system: the 2.2 million nurses who make up the largest profession in health care, the profession with the highest percentage of women, and the second largest profession after teaching. These women and men weave a tapestry of care, knowledge, and trust that is critical to patients' survival.
Nancy Rumplik and Jeannie Chaisson have between them more than a quarter century's experience caring for the sick. They work in an acute-care hospital, one of Harvard Medical School's teaching hospitals. Beth Israel not only is known for the quality of its patient care but also is world-renowned for the quality of its nursing staff and its institutional commitment to nursing.
The for-profit, market-driven health care that is sweeping the nation is threatening this valuable group of professionals. To gain an advantage in the competitive new health-care marketplace, hospitals all over the country are trying to cut their costs. One popular strategy is to lay off nurses and replace them with lower-paid, less-skilled workers.
American hospitals already use 20 percent fewer nurses than their counterparts in other industrialized countries. Nursing does provide attractive middle-income salaries. In 1992 staff nurses earned, on average, $33,000 a year. Clinical nurse specialists, who have advanced education and specialize in a particular field, earned an average of $41,000, and nurse practitioners, who generally have a master's degree and provide primary-care services, earned just under $44,000. Yet RN salaries and benefits altogether represent only about 16 percent of total hospital costs.
Nevertheless, nurses are a major target of hospital "restructuring" plans, which in some cases have called for a reduction of 20 to 50 percent in registered nursing staff.
The process of job elimination, de-skilling, and downgrading seriously erodes opportunities for stable middle-class employment in nursing as in other industries. However, as the late David Gordon documented in his book Fat and Mean: The Corporate Squeeze of Working Americans and the Myth of Managerial "Downsizing," reduced "head counts" among production or service workers don't necessarily mean that higher-level jobs (and the pay and perquisites associated with them) are being chopped as well. In fact, Gordon argued, many headline-grabbing exercises in corporate cost-cutting leave executive compensation untouched, along with other forms of managerial "bloat."
Even in this era of managed-care limits on physicians' compensation, nurses' pay is relatively quite modest. And the managers of care themselves -- particularly hospital administrators and health-maintenance-organization executives -- are doing so well that even doctors look underpaid by comparison.
According to the business magazine Modern Healthcare's 1996 physician-compensation report, the average salary in family practice is $128,096, in internal medicine $135,755, in oncology $164,621, in anesthesiology $193,242, and in general surgery $199,342. Some specialists earn more than a million dollars a year.
A survey conducted in 1995 by Hospitals & Health Networks, the magazine of the American Hospital Association, found that the average total cash compensation for hospital CEOs was $188,500. In large hospitals the figure went up to $280,900, and in for-profit chains far higher. In 1995, at age forty-three, Richard Scott, the CEO of Columbia/Healthcare Corporation, received a salary of $2,093,844. He controlled shares in Columbia/HCA worth $359.5 million.
In 1994 compensation for the CEOs of the seven largest for-profit HMOs averaged $7 million. Even those in the not-for-profit sector of insurance earn startling sums: in 1995 John Burry Jr., the chairman and CEO of Ohio Blue Cross and Blue Shield, was paid $1.6 million. According to a report in Modern Healthcare, a proposed merger with the for-profit Columbia/HCA would have paid him $3 million "for a decade-long no-compete contract. . . . [and] up to $7 million for two consulting agreements."
At the other end of the new health-care salary spread are "unlicensed assistive personnel" (UAPs), who are now being used instead of nurses. They usually have little background in health care and only rudimentary training. Yet UAPs may insert catheters, read EKGs, suction tracheotomy tubes, change sterile dressings, and perform other traditional nursing functions. To keep patients from becoming unduly alarmed about -- or even aware of -- this development, some hospitals now prohibit nurses from wearing any badges that identify them as RNs. Thus everyone at the bedside is some kind of generic "patient-care technician" -- regardless of how much or how little training and experience she or he has.
In some health-care facilities other nonprofessional staff -- janitors, housekeepers, security guards, and aides -- are also being "cross-trained" and transformed into "multi-skilled" workers who can be assigned to nursing duties. One such employee was so concerned about the impact of this on patient care that he recently wrote a letter to Timothy McCall, M.D., a critic of multi-skilling, after reading a magazine article the latter had written on the subject.
I am an employee of a 95-bed, long-term care facility. My position is that of a security guard. Ninety-five percent of my job consists of maintenance, housekeeping, admitting persons into clinical lab to pick-up & leave specimens. Now a class, 45 minutes, is being given so employees can feed, give bedpans & move patients. My expertise is in law enforcement & security, 25 years. I am not trained or licensed in patient care, maintenance, lab work, etc. . . .This scares me. Having untrained, unlicensed people performing jobs, in my opinion, is dangerous.
Training of RN replacements is indeed almost never regulated by state licensing boards. There are no minimum requirements governing the amount of training that aides or cross-trained workers must have before they can be redeployed to do various types of nursing work. Training periods can range from a few hours to six weeks. One 1994 study cited in a 1996 report by the Institute of Medicine on nursing staffing found that
99 percent of the hospitals in California reported less than 120 hours of on-the-job training for newly hired ancillary nursing personnel. Only 20 percent of the hospitals required a high school diploma. The majority of hospitals (59 percent) provided less than 20 hours of classroom instruction and 88 percent provided 40 hours or less of instruction time.
Because the rapidly accelerating UAP trend is so new, its impact on patient care has not yet been fully documented. However, in a series of major studies over the past twenty years researchers have directly linked higher numbers and greater qualifications of registered nurses on hospital units to lower mortality rates and decreased lengths of hospital stay. Reducing the number of expert nurses in the hospital, the community, and homes endangers patients' lives and wastes scarce resources. Choosing to save money by reducing nursing care aggravates the impersonality of a medical system that tends to turn human beings into their diseases and the doctors who care for them into sophisticated clinical machines. When they're sick, patients do not ask only what pills they should take or what operations they should have. They are preoccupied with questions such as Why me? Why now? Nurses are there through this day-by-day, minute-by-minute attack on the soul. They know that for the patient not only a sick or infirm body but also a life, a family, a community, a society, needs to heal.
ALTHOUGH nurses help us to live and die, in the public depiction of health care patients seem to emerge from hospitals without ever having benefited from their assistance. Whether patients are treated in an emergency room in a few short hours or on a critical-care unit for months on end, we seem to assume that physicians are responsible for all the successes -- and failures -- in our medical system. In fact, we seem to believe that they are responsible not only for all of the curing but also for much of the caring.
Nurses remain shadowy figures moving mysteriously in the background. In television series they often appear as comic figures. On TV's short-lived Nightingales, on the sitcom Nurses, and on the medical drama Chicago Hope nurses are far too busy pining after doctors or racing off to aerobics classes to care for patients.
gives nurses more prominence than many other hospital shows, but doctors on ER are constantly barking out commands to perform the simplest duties -- get a blood pressure, call the OR -- to experienced emergency-room nurses. In reality the nurses would have thought of all this before the doctor arrived. In an emergency room as busy and sophisticated as the one on ER, the first clinician a patient sees is a triage nurse, who assesses the patient and dictates what he needs, who will see him, and when. Experienced nurses will direct less-experienced residents (and have sometimes done so on ER), suggesting a medication, a test, consultation with a specialist, or transfer to the operating room. The great irony of ER is that Carol Hathaway, the nurse in charge, is generally relegated to comforting a child or following a physician's orders rather than, as would occur in real life, helping to direct the staff in saving lives.
Not only do doctors dominate on television but they are the focus of most hard-news health-care coverage. Reporters rarely cover innovations in nursing, use nurses as sources, or report on nursing research. The health-care experts whom reporters or politicians consult are invariably physicians, representatives of physician organizations, or policy specialists who tend to look at health care through the prism of economics. "Who Counts in News Coverage of Health Care?," a 1990 study by the Women, Press & Politics Project, in Cambridge, Massachusetts, of health-care coverage in The New York Times, the Los Angeles Times, and The Washington Post, found that out of 908 quotations that appeared in three months' worth of health-care stories, nurses were the sources for ten.
The revolution in health care has become big news. Occasionally reporters will turn their attention to layoffs in nursing, but the story is rarely framed as an important public-health issue. Rather, it is generally depicted as a labor-management conflict. Nursing unions are battling with management. Nurses say this; hospital administrators claim that. Whom can you believe?
Worse still, this important issue may be couched in the stereotypes of nursing or of women's work in general. A typical example appeared on NBC Nightly News in September of 1994. The show ran a story that involved a discussion of the serious problems, including deaths, resulting from replacing nurses with unlicensed aides. The anchor introduced it as "a new and controversial way of administering TLC." Imagine how the issue would be characterized if 20 to 50 percent of staff physicians were eliminated in thousands of American hospitals. Would it not be front-page news, a major public-health catastrophe? Patients all over the country would be terrified to enter hospitals. Yet we learn about the equivalent in nursing with only a minimum of concern. If laying off thousands of nurses results only in the loss of a little TLC, what difference does it make if an aide replaces a nurse?
Nursing is not simply a matter of TLC. It's a matter of life and death. In hospitals, which employ 66 percent of America's nurses, nurses monitor a patient's condition before, during, and after high-tech medical procedures. They adjust medications, manage pain and the side effects of treatment, and instantly intervene if a life-threatening change occurs in a patient's condition.
In our high-tech medical system nurses care for the body and the soul. No matter how sensitive, caring, and attentive physicians are, nurses are often closer to the patient's needs and wishes. That's not because they are inherently more caring but because they spend far more time with patients and are likely to know them better. This time and knowledge allows them to save lives. Nurses also help people to adjust to the lives they must live after they have recovered. And when death can no longer be delayed, nurses help patients confront their own mortality with at least some measure of grace and dignity.
THE STIGMA OF SICKNESS
THERE is another reason that nurses' work so often goes unrecognized. Even some of the patients who have benefited the most from nurses' critical care are unable to credit its importance publicly. Because nurses observe and cushion what the physician and writer Oliver Sacks has called human beings' falling "radically into sickness," they are a reminder of the pain, fear, vulnerability, and loss of control that adults find difficult to tolerate and thus to discuss. A man who has had a successful heart bypass will boast of his surgeon's accomplishments to friends at a dinner party. A woman who has survived a bone-marrow transplant will extol her oncologist's triumph in the war against cancer to her friends and relatives. But what nurses did for those two patients will rarely be mentioned. It was a nurse who bathed the cardiac patient and comforted him while he struggled with the terror of possible death. It was a nurse who held the plastic dish under the cancer patient's lips as she was wracked with nausea, and who wiped a bottom raw from diarrhea. As Claire Fagin and Donna Diers have explained in an eloquent essay titled "Nursing as Metaphor," nurses stand for intimacy. They are our secret sharers. Even though they are lifelines during illness, when control is restored the residue of our anxiety and mortality clings to them like dust, and we flee the memory.
At one moment a nurse like Nancy Rumplik or Jeannie Chaisson may be involved in a sophisticated clinical procedure that demands expert judgment and advanced training in the latest technology. The next moment she may do what many people consider trivial or menial work, such as emptying a bedpan, giving a sponge bath, administering medication, or feeding or walking a patient.
The fact that nurses' work incorporates many so-called menial tasks that don't demand total attention is not a reason to replace nurses with less-skilled workers. This hands-on care allows nurses to explore patients' physical condition and to register their anxiety and fear. It allows them to save lives and to ascertain when it's appropriate to help patients die. It is only in watching nurses weave the tapestry of care that we grasp its integrity and its meaning for a society that too easily forgets the value of things that are beyond price.
Illustrations by Kamil Vojnar
The Atlantic Monthly; February 1997; What Nurses Stand For; Volume 279, No. 2; pages 81 - 88.
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