Q: What Scares Nurses? A: Who Cares?

May 14, 2006 -- Last week two prominent U.S. news entities ran pieces whose basic theme was that not even health professionals are safe from the health threats posed by...hospitals. TIME magazine's May 1 issue featured a cover story by Nancy Gibbs and Amanda Bower called "Q: What Scares Doctors? A: Being the Patient." The piece's all-physician vision of hospital care, based on expert comment by 12 physicians, excludes nurses so completely that readers can be forgiven for wondering if nursing is in the final stages of being phased out. At one point, the piece plaintively asks who will be the "sentinels" and "advocates" in hospitals now that family physicians have been excluded from the role. Meanwhile, Rosalind Feldman, RN, DNSc, published a good piece in The Washington Post on May 2 describing the inept, surly and dangerous care she received at the hands of her fellow nurses and others when she was hospitalized for a femur break. Unlike the TIME piece, Feldman's "Get Me Out Alive" provides a balanced account of the actual nature and risks of a hospital stay, with comments on nurses, physicians, physical therapists, nursing assistants, and the "independent sitters" whose use is driven by short-staffing. We commend Dr. Feldman and the Post. But the TIME cover story, following the vast but nurse-free "Medical Heroes" feature the magazine ran late last year, suggests that the leading U.S. news weekly remains in thrall to an extreme "heroic physician" narrative that is misleading millions of readers. Of course, TIME is hardly alone; major stories in today's New York Times and Baltimore Sun display a similar lack of regard for nurses' expertise and central role in health care.

The TIME feature is an example of two trends in health news stories. First, it's part of the "What Doctors Want You to Know About ____" school of health journalism. This type of reporting occupies a big part of the national health news landscape, but it has no comparable nursing counterpart, despite the valiant efforts of nurses like Pat Carroll, Donna Cardillo, Diana Mason, Barbara Glickstein, and Barbara Ficarra. The TIME piece is also a part of the smaller but still significant category of stories that ask: "What Happens When Doctors Get Sick?" For instance, a lengthy April 6, 2006 National Public Radio story was entitled "When Physicians Get Cancer." In these stories, health journalists typically highlight the irony and drama of the perceived masters of health actually getting sick themselves. These media products also use the expertise of the sick physicians to present special insights about the experience of illness. However, we are aware of no major journalist-driven U.S. news story (as opposed to the kind of memoir/advocacy piece Feldman wrote) based on the theme: "When Nurses Get Sick."

The assumption underlying virtually all of the TIME story is that only physicians matter in hospital care. The reporters, seemingly astonished that even physicians and their loved ones get poor care, explore some of the risks that U.S. hospitals present. These include insurance nightmares, overtreatment, poor communication, technology glitches, post-surgical complications, the relative merits of older and younger physicians, the relative merits of different physician training models, July syndrome, which occurs in the month new interns start each year, medication errors, and physician errors generally. The piece relies on extensive expert comment and personal anecdotes from no less than 11 named physicians, as well as a sidebar ("The Doctor's View") by physician Scott Haig entitled "What Makes a Good Patient?" In the cover story's 11 solid pages (no ads), there is room for six large photos of these physicians. Yet not a single nurse is named or quoted, despite the fact that hospitals exist mainly to provide nursing care.

But the TIME piece does not just ignore nurses' expertise on a subject--hospitals--about which they know at least as much as anyone else. That would hardly be novel; indeed, yesterday The New York Times ran yet another in a seemingly endless string of major media pieces that focus on the supposed risks of nurse practitioner-staffed "quick clinics" at retail stores without quoting a single nurse. But whereas the quick clinic pieces cannot effectively present physician criticism of quick clinics without at least admitting that nurses staff them, the TIME piece manages to overlook the fact that nurses play any significant role in hospital care. Indeed, the only references to "nurses" in the entire feature are: (1) in the "How to Survive Technology" section, we learn that when hospitals introduce more computers, "you can hear the sound of nurses growling," and that "a nurse" brought one physician's hospitalized wife a specific medication each day for two weeks after it had been discontinued "by a physician's order;" (2) Haig's sidebar says that "[d]octors and nurses...know when to respect an educated opinion" about treatment options, and it pays nurses the dubious compliment that they "tend to be better patients" than physicians because they are "adept at following doctors' orders."   

The only real indication that nurses might have anything to do with key care tasks is the unexplained medication error, which readers may assume was a computer glitch that had little to do with the nurse. He or she was probably just "following doctors' orders," and it's not like a nurse is going to question what someone in authority says to do, right? The piece makes no effort to explore why these physicians and their families experienced so many medication errors. What about the countless potentially lethal medication errors that nurses catch each year by declining to mechanically "follow doctor's orders?" Why were the nurses apparently not doing that here? Were they short-staffed? Poorly trained? Was the work environment one in which their concerns about care were heeded? What about research suggesting that the staffing and educational levels of nurses are factors in post-op mortality? Could this have anything to do with the ongoing nursing crisis?

When the piece describes hospital events in which nurses play a major role, the passive voice is often used; these things simply occur, with no actor. This is consistent with the common media presentation of the major health players as physicians and hospitals. In this piece, one section is called "How to Find the Right Doctor;" the next is "How To Find the Right Hospital." In the "hospital" section, the word "nurse" does not appear. Hospitals are evidently an undifferentiated mass of facilities and bureaucrats who provide backup, so physicians can provide health care. In the "How to Survive July" section, the word "nurse" does not appear. It would seem that the only thing relevant to the quality of hospital care, and to patient survival, is the quality of the physicians.

TIME's suggestions that things like post-operative mortality depend entirely on physicians are bad enough. But one passage in the "Technology" section actually says this:

Until proper safeguards are built into the system, what a patient needs most, many doctors agree, is a sentinel--someone to take notice, be an advocate, ask questions. Now that the family doctor has been squeezed out of that role, someone else has to step in. But even a doctor-family member may not be able to counter the complexity of the system.

Of course, nurses are the "sentinels" in hospitals, the skilled professionals who monitor patients 24/7 and guide them through complex systems and wide-ranging threats. And patient advocacy plays a central role in nurses' work. If permitted by staffing levels and other aspects of the workplace, nurses work with families and others on the health care team to address just the issues the article identifies. However, it is difficult for nurses to do that effectively when the importance of their work remains largely unknown to major elements of the news media and the decision-makers who rely on that media.

Although TIME is certainly one of the worst and most influential media offenders in ignoring nurses' contributions in service to an all-physician vision, it is just one of many. Today's Baltimore Sun, for instance, including a lengthy front page story, David Kohn's "City Full of Patients, Devoid of Doctors," that clearly tells readers that the only health practitioners who matter in the shattered New Orleans health system are physicians. Countless elements in the story suggest that physicians provide hospital and primary care by themselves, at least eight physicians are quoted, and three of them appear in enormous photographs--but as far as we can see, the word nurse does not appear once. The basic theme is that the departure of many physicians in Katrina's wake poses a grave health threat, but whether that is true of nurses is of no significance whatsoever.

Rosalind Feldman's May 2 piece in the Washington Post has the sub-head: "As a Nurse, She Knew the System. Then She Became a Patient." It seems to have run on the front page of the Post's weekly health section. Feldman says she accidentally broke her femur, and spent 10 days in suburban Maryland hospitals, half in acute care, half in rehab. Right away, we have a different picture from the TIME piece, which suggested that the important elements of hospital care are the relatively brief periods patients spend with physicians, especially for diagnosis, formulating medical plans, and surgery (just like on TV!). Two days into her hospital experience, Feldman says, she just wanted to survive the inadequate care of some hospital staff, and then to speak out about the problems she found, so that they could be addressed. Such system-wide reform is patient advocacy, a cornerstone of nursing.

Here again, the contrast with the TIME piece is striking. The news magazine's focus was clearly to help the individual reader play the existing system like a physician; its sub-head was "What Insiders Know About Our Health Care System That the Rest of Us Need to Learn." Fixing that system did not seem to be a priority, certainly not in the hard copy feature. (In fairness, in a short related sidebar that appeared only on the magazine's web site, a 13th physician, Donald Berwick, did address "How to Fix the System," and the sixth of his seven proposed reforms was "Re-Energize Primary Care and Nursing.")

Feldman's Post article does not suggest that any one group of health workers did everything that mattered during her hospital stay. Instead, she gives us a sense of the full hospital experience: the kindness of the ED staff who removed her dress rather than cutting it off; the nurse who scolded her for not eating, even though she was scheduled for surgery, since the nurse had her confused with another patient; the nurse who gave her a urinary tract infection by improperly inserting a Foley catheter; the nurses she had to repeatedly ask to reposition her, so that she could avoid blood clots and bed sores; the "independent sitters" of her room-mates, one of whom swore at her when she pressed a call bell, another of whom was anti-Semitic; the rehab physician who was good at diagnosing the UTI and the bed sores the first hospital gave her; the nurses who used faulty equipment; the overmedicating "fill-in physician" at the rehab hospital; the physical therapy staff who provided fine care without being pressed--except on the weekend; and the physicians who disregarded patient confidentiality, discussing her roommate's history of herpes within her hearing.

We saw two curious omissions. First, the piece has nothing about those who performed Feldman's surgery. Of course, this supports our point that surgery is not the whole hospital experience, but we would not suggest it is irrelevant. Since the surgical team, physicians and nurses, obviously played a key (if relatively brief) role in Feldman's overall hospital experience and in the ultimate outcome, they would seem to merit some comment.

Moreover, Feldman says nothing good about any particular nurse, though presumably her description of the ED staff referred primarily to nurses. Perhaps she has very high standards for her own profession. But none of her complaints seem unreasonable, and some involve major threats to her health. Maybe she never actually had any nurses she felt deserved recognition after the ED, and given her measured praise for some of the other professionals, this is cause for concern. Why didn't her nurses seem to meet some of the basic standards for infection control, hygiene, accurate monitoring, and so on?

Feldman does address these issues, at least by implication, in her very good final section, "Rx for change." There she pulls no punches in making suggestions for systemic reforms. Among her ideas:

• Hospitals should devote more resources to re-evaluating nurses' skills and providing continuing education;
   
• Nursing supervisors should "test regularly on basic skills such as ascertaining patient identity and following treatment protocols;"
     
• Hospitals should have more full-time nursing personnel;
  
• Hospitals should devote more resources to basic hygiene supplies, like bed linens and toilet seat covers;
   
• Hospitals should have "quality improvement programs and education departments;"
   
• State and voluntary agencies that accredit hospitals should step up site visits, and Medicare should diligently investigate complaints about hospital care.

Most if not all of these ideas would require resources to implement, as Feldman seems to recognize in wishing that hospitals were "as committed to patient well-being as to the balance sheet." Perhaps the central issue in health care today is where we will get the money for the care we need. Feldman's take on that would have been useful. Of course, recent research has suggested that improving nurse staffing could actually save money by producing better patient outcomes, at least under some scenarios.

We commend Feldman and the Post for this helpful article.

Please send a short letter to the editor of TIME magazine at letters@time.com (and please blind copy us at letters@nursingadvocacy.org). Thank you!

Send your note of thanks to Rosalind Feldman and The Washington Post at health@washpost.com and please copy us at letters@nursingadvocacy.org

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