Nursing against the Odds

How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care

Suzanne Gordon

• Publisher: ILR Press
• Year: 2012
• eBook ISBN: 9780801465000
• Topic: Medicine
• Subtopic: Nursing

In the United States and throughout the industrialized world, just as the population of older and sicker patients is about to explode, we have a major shortage of nurses. Why are so many RNs dropping out of health care's largest profession? How will the lack of skilled, experienced caregivers affect patients? These are some of the questions addressed by Suzanne Gordon's definitive account of the world's nursing crisis. In Nursing against the Odds, one of North America's leading health care journalists draws on in-depth interviews, research studies, and extensive firsthand reporting to help readers better understand the myriad causes of and possible solutions to the current crisis.

Gordon examines how health care cost cutting and hospital restructuring undermine the working conditions necessary for quality care. She shows how the historically troubled workplace relationships between RNs and physicians become even more dysfunctional in modern hospitals. In Gordon's view, the public image of nurses continues to suffer from negative media stereotyping in medical shows on television and from shoddy press coverage of the important role RNs play in the delivery of health care.

Gordon also identifies the class and status divisions within the profession that hinder a much-needed defense of bedside nursing. She explains why some policy panaceas—hiring more temporary workers, importing RNs from less-developed countries—fail to address the forces that drive nurses out of their workplaces. To promote better care, Gordon calls for a broad agenda that includes safer staffing, improved scheduling, and other policy changes that would give nurses a greater voice at work. She explores how doctors and nurses can collaborate more effectively and what medical and nursing education must do to foster such cooperation. Finally, Gordon outlines ways in which RNs can successfully take their case to the public while campaigning for health care system reform that actually funds necessary nursing care.

PART ONE

NURSES AND DOCTORS AT WORK

As the daughter of a doctor, I was steeped in the realities of “doctor-nurse relationships” long before I began to view them from the perspective of a journalist. From the time I was a young child in the 1950s, I watched how my father—a well-known ophthalmologist, researcher, and eye surgeon— related to the nurses in his office and at Cornell University Medical School/New York Hospital.

With my attention firmly focused on my father and his physician colleagues, the nurses at New York Hospital seemed always to blend into the background. I remember them as trim women who glided silently by, posture erect, faces stern, dressed in the ubiquitous starched white uniform, wearing stumpy shoes, white hose, and that forbidding yet reassuring white cap. We never mingled with “the nurses.” I can’t remember if they stood to attention when my father entered the room, but they were definitely not of his status. This message was conveyed by the fact that my father never seemed to greet them or stop to talk to them when I went with him to his office in the hospital. And it was underscored by the fact that, whenever we ate a meal in the hospital, we went directly to the “doctors’ only” dining room. Where the nurses ate I have no idea.

When my father moved his office out of the hospital to a space just across York Avenue on Sixty-eighth Street, he of course had a nurse who worked for him—but very definitely not with him. “My nurse” was how he referred to her. She was a middle-aged, plump, kindly figure who seemed part secretary, part technical assistant. When I overheard her calling a patient, she would, like my mother—who always introduced herself as Mrs. Dan Gordon—begin the conversation with “Hello, this is Mss Collins, Dr. Gordon’s nurse.”

When I was a teenager, I used to come into my father’s office in Manhattan on Saturday mornings. After waiting while he saw his patients, I would get the ultimate treat—lunch at some fancy New York restaurant. While I waited for my father, I would overhear Mss Collins respond to patients’ questions or requests with “I don’t know, you’ll have to ask the doctor.” Hearing that over and over, I absorbed the idea that a nurse was someone whose knowledge was limited and who relied on the doctor, who obviously knew it all. Until I began to write about nursing, I had no idea that Mss Collins might, in fact, have known quite a bit more than I thought she did and that her demurrals were part of a carefully stitched costume she donned to play a particular role in relation to my father.

Almost forty years later, when I first began observing nurses at the Beth Israel Hospital for my book Life Support, I was struck by the way doctors treated nurses even in a hospital that purported to be a model of nurse influence and state-of-the-art nurse-physician relationships. Nurses consistently were denied—or denied themselves—opportunities to form productive, constructive professional partnerships with doctors. Unintentionally physicians sent subtle messages to nurses about who was important in the hospital.

Nurses were regularly kept out of what I’ve come to think of as the circle of concern that doctors routinely formed as they discussed patients on a floor or unit. Each day on the clinical units, attendings or residents would stand in a circle or semicircle discussing a patient issue. If a physician walked up to the group, the circle would expand and allow him or her to enter. If a nurse walked up to this group, rather than moving out to expand the circle so it could accommodate the nurse, the physicians would continue to talk, ignoring her presence as if she did not exist. If the nurse was a woman and the physicians were women, the circle would often remain as closed as if the physicians were all males. Sometimes, if the nurse was a man (and very few were at that time), it would shift. But even this depended on the particular players, how well they knew one another, and how assertive the male nurse was. Similarly, if the female nurse was particularly assertive, she could force the circle to expand and the physicians to acknowledge her presence and patient concerns. Most often, however, she would stand outside the circle, listen to the conversation the doctors directed, and inject her views from the periphery. Sometimes she would simply give up and walk away. This image, of doctors talking to one another while the nurse made her comments to their backs, became for me a symbol of the sorry state of nursing and medical relationships.

I was also struck by the assiduous maintenance of social distance between physicians and nurses. Although the doctor’s dining room of my childhood is largely an artifact of the past, nurses and doctors seem to recreate it in hospital cafeterias all over the world. People who work together on a daily basis on the floors and in the hospital clinics rarely seem to join one another when they have the time for a quick cup of coffee or lunch or dinner. In hospital cafeterias, I have watched doctors sit together. When nurses they knew walked in, they rarely asked them to join the group. Nor did nurses tend to challenge status hierarchies by joining the physicians. Watching this go on day after day, I became convinced that it was a symptom of a larger problem—the professional distance that prevents doctors and nurses from consulting with one another about vital patient care issues.

When it comes to doctor-nurse relationships, what’s even more interesting is how nurses themselves have adapted to—and thus reinforce—the structured inequality of the medical system. After listening to nurses over the years, I realize that nurse-doctor relationships are a kind of chronic illness to which the profession may have adapted but which has nonetheless caused persistent dysfunction. Some nurses adjust to these relationships; others find indirect means to resist their imperatives or openly rebel against them. In any event, no serious discussion of the nursing crisis can ignore the problems that nurses encounter when they work with or around physicians.

1

Manufacturing the Dominant Doctor

It was the first week in July at the Beth Israel Hospital in Boston and a new crop of interns has just arrived in the teaching hospital. A nurse named Deborah Madison* was taking care of Ella, a forty-two-year-old woman with pancreatic cancer who was about to begin her first round of chemotherapy. Madison had worked on this cancer unit for the past five years. When she examined her patient, she found that Ella was anxious about the chemotherapy and was also in excruciating pain from the cancer.

As Ella’s primary nurse, Madison had great deal of experience diagnosing and treating cancer pain. She immediately recognized that Ella needed intravenous morphine to control her suffering. But she worked in a system where doctors—even doctors with as little experience as interns beginning their residency training—were the only ones permitted to diagnose, treat, and prescribe. Indeed, for internal medicine services, newly minted doctors, under the supervision of residents, fellows, and attending physicians, were nominally in charge of hospitalized patients—and also of their nurses.

Reassuring Ella that she would do something to ease her pain, Madison walked down to the nurses’ station in search of the intern in charge of the case. The young man, upon whose orders much of her work depended, was in his late twenties, tall, clean-shaven, with close-cropped black hair. He listened as Madison explained the problem and related her treatment recommendation.

“I don’t know,” the intern said nervously. “I don’t think the patient is really in pain. I think she’s just anxious about the chemo she’ll be getting tomorrow. I’ll write an order for Xanax (a tranquilizer) and that should do it.”

Cognizant that she was there not only to care for patients, but also to teach novice physicians, Madison calmly repeated that the patient was having cancer pain. Xanax, while useful to treat any anxiety she might have also been feeling, would not alleviate her cancer pain. Morphine would. The intern, who like many novice physicians was extremely wary of narcotics, resisted the suggestion. No, he said adamantly, adding that he would go and see the patient.

About five minutes later, if that, he returned.

The patient, he informed Madison, was not in pain. It was just as he thought. She was anxious about her chemo.

“Did she say that?” Madison asked.

“No,” he said, “the patient complained of pain.” “But,” he added, as he wrote the order for the Xanax, “she can’t really be in pain because people who are in pain don’t smile at their doctors.”

Although frustrated that this young physician seemed unaware that, as one recent federal report documented, “patients may be experiencing excruciating pain even while smiling and using laughter as coping mechanisms,” Madison once again tried to teach the young man about cancer pain as well as patients’ responses to vulnerability and dependence.1 Patients, she counseled, often smile at their doctors and may not be assertive about their complaints, because they don’t want to bother, contradict, or potentially alienate someone upon whom they depend for their very lives.

The intern was unmovable.

Over the course of the next two hours, Madison shifted tactics. Following the appropriate channels, she paged the resident who ranked above this intern in the medical chain of command. She would try to convince him to talk to the novice doctor and secure pain medication for her patient. When the resident responded to the page, he agreed with Madison. Morphine was just what the intern should order. The two went off to find the intern and the resident repeated to the young man exactly, almost word for word, what Madison had said about the rationale for this particular choice of drug. Listening to the senior doctor and ignoring the nurse, the intern nodded and dutifully wrote the order for the narcotic.

Madison went back to the patient and told her that the doctor had ordered the drug. She then administered the medication and monitored its effectiveness. Ella was finally able to relax. Although Madison diagnosed the patient’s problem and recommended the correct treatment for it, when the interaction was recorded in the patient’s chart, the intern was given credit for both making the diagnosis and ordering the medication. When Ella was about to leave the hospital several days later, she wrote notes to thank her caregivers. Although she jotted a short thank-you note to her nurses, there was no mention of what the nurse did to help relieve her pain. In fact, she saved most of her gratitude for her doctors. “Thank you so much,” she told the intern, “for all you did for me.”

Risky Business

When nurses go to work in a hospital or other health care institution, they expect to confront a certain number of predictable risks. They may injure their backs if they try to turn a patient without help, or lift a patient who’s fallen in the cramped space of a hospital bathroom. They may stick themselves with an infected needle because another hospital worker has failed to dispose of it correctly or because some hospital administrators do not purchase safe needles. They may contract a new and mysterious disease like SARS. They may be verbally or physically attacked by a mentally ill patient who becomes violent or by a patient or family member frustrated with an increasingly impersonal health care system. Through a variety of workplace and legislative measures, nurses try to minimize these risks.

Other less publicized risks that nurses encounter jeopardize their patients. On a daily basis, nurses work with physicians who fail to communicate with them about critical clinical issues, deny them access to needed information and resources, subject them to verbal abuse when they try to do their job, and misinterpret collegial disagreements about clinical issues as challenges to medical authority and hierarchy. Some physicians rudely overrule nurses’ clinical concerns and subject nurses to verbal abuse and humiliation. In rarer cases, some physicians physically abuse RNs. Added to this is the fact that the medical system often gives physicians credit for nurses’ contributions. This means nurses have little experience with positive credit but have a great deal of experience with negative accountability. All of these patterns of communication and behavior make nursing a very risky job, and not only for the so-called uppity nurse who refuses to couch her questions and concerns in the demure rituals of medical dominance.

Even nurses who work hard at staying in their assigned place by observing the accepted rules of deference may find that MD-RN relationships can be hazardous to their professional self-esteem, as well as to their personal health and well-being. The incident I described above, for example, happened at a hospital in which nurses received a great deal of credit for their work. It occurred during the heyday of nurse empowerment in the early 1990s. But no matter how much institutional support nurses had—support that has, we shall see, largely disappeared today— they were still stuck in a medical system characterized by rigid inequality. While there is increasing attention to the problem of “disruptive physicians”—who often bully those they consider to be inferiors—little systematic attention is paid to the fact that the medical system as a whole is a disruptive, sometimes toxic environment for many who work in it.

Relationship Interruptus

Over the past thirty years, many articles have been written about this structured inequality. Two of the most famous—“The Doctor-Nurse Game” and “The Doctor-Nurse Game Revisited,” published in 1967 and 1990 respectively—were written by the psychiatrist Leonard Stein.2 The original article analyzed why doctors failed to consult with nurses and why nurses adopted indirect or even passive-aggressive strategies to deal with doctors. Then in 1990, during the last nursing shortage, Stein and two other physicians reexamined the state of nurse-physician relationships. The authors argued that the women’s and civil-rights movements had fomented a rebellion among nurses. More nurses, the authors insisted, were socialized outside the old hospital schools, had advanced degrees, and wanted to be viewed as “autonomous,” “independent” professionals. The “new” nurse was more than willing to make direct recommendations. In fact, many bluntly challenged physicians. Others exhibited outright hostility to MDs. Some seemed to want to replace physicians and claim, as their own “domain,” disease prevention, patient education, management of chronic illness, and holistic care or “treatment of the whole person”—things which doctors should do but too often ignore.

The “Doctor-Nurse Game Revisited” suggested that nurse-physician relationships were improving, because nurses were no longer tolerating medicine’s traditional dominance. Twelve years later, however, one of the only systematic, quantitative studies of the impact of physician-nurse relationships on nurse retention painted a much more sobering picture. The principal investigator on the study, which was published in the American Journal of Nursing, was Alan H. Rosenstein, a physician and vice president and medical director of the VHA’s West Coast hospitals.3 He and his coinvestigators sent out surveys to RNs and MDs in the VHA, which runs a quarter of the community-owned hospitals in the United States and is the largest employer of RNs in the country. The survey was designed to determine how physicians and nurses in the VHA system “viewed nurse-physician relationships, disruptive physician behavior, the institutional response to such behavior, and how such behavior affected nurse satisfaction, morale, and retention.” The article reported on preliminary findings from the first 1,200 responses analyzed. Of these, 720 were from nurses and 173 from physicians from eighty-four different hospitals.

Respondents reported that nurse-physician relationships, which seemed less of an issue to physicians, were extremely important to nurses. Almost all nurses had experienced or witnessed some form of “disruptive physician behavior,” which included screaming, berating of colleagues or patients, use of abusive language, and other instances of disrespect or condescension toward nurse colleagues. Nurses believed that disruptive physician behavior had a serious impact on morale and nurse retention. Many respondents cited examples of nurses who had, because of such problems, left a hospital ...

Table of contents

• Preface
• Introduction
• PART ONE: NURSES AND DOCTORS AT WORK
• PART TWO: THE MEDIA AND NURSING
• PART THREE: HOSPITALS AND NURSING
• Conclusion: Changing the Odds
• Notes