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Based on more than ten years' field research, Beyond Caring is filled with eyewitness accounts and personal stories demonstrating how nurses turn the awesome into the routine. It shows how patients, many weak and helpless, too often become objects of the bureaucratic machinery of the health care system and how ethics decisions, once the dilemmas of troubled individuals, become the setting for political turf battles between occupational interest groups. The result is a compelling combination of realism and a powerful theoretical argument about moral life in large organizations.
The Routinization of Disaster
The moral system of the nurse's world, the hospital, is quite different from that of the lay world. In the hospital it is the good people, not the bad, who take knives and cut people open; here the good stick others with needles and push fingers into rectums and vaginas, tubes into urethras, needles into the scalp of a baby; here the good, doing good, peel dead skin from a screaming burn victim's body and tell strangers to take off their clothes. Here, in the words of an old joke, the healthy take money from the sick, and the most skilled cut up old ladies and get paid for it. The layperson's horrible fantasies here become the professional's stock in trade. Some people believe, reasonably, that nurses' work must, therefore, be terribly stressful. "How do they cope with it?" is a question I am frequently asked. But the layperson has not seen the routinization of activities and the parallel flattening of emotion that takes place as one becomes a nurse. Nursing is stressful, to be sure, but not in the way the layperson imagines. Intravenous lines started, meds delivered, baths given, trays passed out, vital signs taken, a nonstop round of filling out forms, of writing reports, sending off blood samples—this fills the nurse's day, routine tasks done dozens of times. The moral ambiguity of any one task becomes utterly lost in the pile of repeated events; the routine blurs the moral difficulties.
Problems arise against this background of routine. In the large medical center, deaths occur every day. Only a few of them become "ethics problems" for the staff: a patient wants to die, and the staff won't let her; when the staff does let her die, then the family doesn't understand why. Tests and procedures cause pain, but few tests and procedures are challenged on moral grounds. Privacy is violated in the most egregious ways, all the time; but usually the violation is unhappily accepted by the suffering patient, who understands that the professional is just doing her job.
This chapter will detail how the routinization of this abnormal world occurs; Chapter Two will show how, even in the face of chaos, the routine is maintained.
THE HOSPITAL SETTING
As a formal organization, the hospital can be readily described, in objective terms, as a professional bureaucracy. For readers unfamiliar with general hospitals, a brief description of the organization, and some key terms describing its structure, will be useful.
Consider Northern General, one of the hospitals where this research was conducted. Northern General is a major medical care center for its region. It provides services to walk-in patients and accepts referrals from physicians in the surrounding communities and beyond. Some 70 percent of its patients are from the immediate urban area, 28 percent from the rest of the state in which it is located, and the remainder from the greater United States and even outside the country. They are drawn to Northern by the reputation of the hospital and its staff.
The hospital provides an impressive array of health care services. Its Emergency Room (ER) alone treats over 100,000 patients a year. Next door to the ER is a Primary Care Center (PCC) where regular patients come to see their assigned physicians for routine checkups and minor procedures. In the building rising over the ER and the PCC are housed many clinics for outpatient services—Eye Clinic, Radiation Clinic, Dental Clinic, and others. In the basement below, there is the Poison Control Center, a Rape Crisis Center, and a Cancer Hotline. The hospital also has a special staff which deals with child and spouse abuse. And these are only outpatient services, provided to people who are not staying overnight in the hospital. The inpatient floors rising beyond the clinics, in several buildings, house nearly 1,000 patients and the nurses who support their basic medical care in surgical, pediatric, internal medicine, obstetrics and gynecology, psychiatric, and other specialties. The hospital, of course, owns CAT scanners, MRI devices, a linear accelerator, and what are now the entire array of technologies. Pediatricians here treat relatively rare diseases such as Reye's syndrome and Cooley's anemia, and the hospital boasts one of the nation's oldest and most renowned Newborn Intensive Care Units.
With such magnificent facilities, it is no wonder that Northern General is a major training center for physicians, nurses, technicians, and other health care workers. It is one of the 900 or so "teaching hospitals" in the nation directly affiliated with a major medical school. There is a steep hierarchy of physicians, typical of such hospitals. The medical staff includes, first, senior physicians who hold positions as professors in the university's medical school as well as physicians from the community. These doctors are the "attending" physicians of the hospital and hold the top rank in the medical hierarchy. Just below the attendings are "Fellows," doctors at an advanced stage of training in specialized fields such as renal disease or endocrinology. Below these come the "house staff." They are employed by the hospital, not by the patients, as attendings are, and they work long hours (thirty-six-hour shifts perhaps twice a week, twelve hours other days). House staff are physicians, M.D.s, who are still in training; they are also called "residents." In their first year of training residents are usually called "interns." Most of the day-to-day medical decision making in the hospital is in the hands of the house staff; they are the physicians who are in the hospital handling the emergencies that come up at any time of the day or night.
The nursing administration is larger but a bit simpler. All nurses are employed by the hospital, and the nursing hierarchy performs a large part of the hospital's administrative work. At the top of the Northern General nursing staff is a vice president for nursing of the hospital; below her are a half-dozen directors of nursing for different medical services of the hospital, for example, pediatrics, internal medicine, surgical nursing, etc. The next level is of supervisors who oversee a number of discrete floors or units. Each "floor" consists of a number (probably twenty to thirty) of patient beds and is headed by a head nurse. The head nurse, like a foreman of a work crew, directs the work of the bedside, or "staff," nurses. There are perhaps twenty to forty staff nurses under each head nurse, divided into three shifts (or two twelve-hour shifts in some ICUs). There are some twenty-five floors and a half-dozen units making up the hospital. The head nurse has the immediate daily responsibility for the floor or unit (the generic term for Intensive Care Units). Finally, at the bottom there are nursing students from the university's nursing school, who study for four years to receive a Bachelor of Science degree in nursing. Students typically will work in the hospital for one or two days a week, devoting the rest of their time to classroom studies. While working in the hospital, they usually care for a smaller number of patients than the full-time staff nurse, but the student nurse may well have many of the same responsibilities and tasks that a full-time R.N. does.
Physically, hospital floors look much like those on television soap operas: long hallways with rooms on either side, with the halls intersecting at a nurses' station, a configuration of boothlike desks behind which are clerks and nurses filling out the forms, answering the telephones, checking computer monitors, and taking care of the endless administrative tasks which consume as much of the nurse's time as does patient care. There is also a vast array of supplies and materials. On the desks in the nurse's station are polyurethane stackable boxes holding dozens and dozens (fifty or more) of multicopy forms for ordering all sorts of tests and procedures, billing forms, permission forms, order forms. On supply shelves, stacked to the ceiling, or jamming closets, or filling the walls of a pantrylike room in the hall, are adhesive tape, packaged needles, boxes of syringes, from 1 cubic centimeter (tiny), to 30, 40, 50 cc (a huge thing, the size of a baby's arm, used to deliver food in tube feedings), stacks of sterile isolation gowns in plastic wrappers, rubber bands, blood pressure cuffs, plastic jugs of microbial soap, bottles of saline solution, swabs, scales (for weighing patients' stools), large red plastic disposal jugs for used needles, plastic garbage bags, packaged kits of needles, sterile paper, syringes, and medications for doing lumbar puncture procedures, Foley urinary catheter insertion kits, intravenous kits, arterial catheter lines, and on, and on. The range and volume of visible, usable, disposable equipment is astonishing.
In the Intensive Care Units the equipment is multiplied with red "crash carts" carrying defibrillating machines and the wide range of drugs used for cardiac resuscitation; bottles of drugs like atropine, sodium bicarbonate, and epinephrine wedged into boxes on the fronts of patients' doors, ready to be used in an instant to juice up a failing heart; ring binders, several for each patient, with records of everything that is done to or for him or her. The equipment, the forms, the variety of supplies in themselves reflect the complexity of the organizations in which they are used, which provide and use them. Hospitals are complex, hierarchial organizations, and in that sense are like many other organizations in our society.
HOW THE HOSPITAL IS DIFFERENT
Much here is the same as in other organizations: the daily round of paper processing, answering the phone, making staffing decisions, collecting bills, ordering supplies, stocking equipment rooms; there are fights between departments, arguments with the boss, workers going home tired or satisfied. And medical sociology has made much of these similarities, using its research to create broader theories of, for instance, deviance or of the structure of professions.
But in one crucial respect the hospital remains dramatically different from other organizations: in hospitals, as a normal part of the routine, people suffer and die. This is unusual. "[A] good working definition of a hospital is that place where death occurs and no one notices; or, more sharply, the place where others agree to notice death as a social fact only so far as it fits their particular purposes." Only combat military forces share this feature. To be complete, theories of hospital life need to acknowledge this crucial difference, since adapting themselves to pain and death is for hospital workers the most distinctive feature of their work. It is that which most separates them from the rest of us. In building theories of organizational life, sociologists must try to see how hospitals resemble other organizations—indeed, eventually that is what I am trying to do in this book—but we should not make a premature leap to the commonalities before appreciating the unique features of hospitals that make a nurse's task so different from that of a teacher or a businessman or a bureaucrat.
A quick survey of typical patients in one Surgical Intensive Care Unit on one Saturday evening should make the point. The words in brackets are additions to my original field notes:
Room 1. 64-year-old white woman with an aortic valve replacement; five separate IMEDs [intravenous drip-control devices] feeding in nitroglycerine, vasopressors, Versed [a pain killer which also blocks memory]. Chest tube [to drain off fluids]. On ventilator [breathing machine], Foley [catheter in the bladder], a pulse oximeter on her finger, a[rterial monitoring] line. Diabetic. In one 30-second period during the night, her blood pressure dropped from 160/72 to 95/50, then to 53/36, before the nurse was able to control the drop. N[urse]s consider her "basically healthy."
Room 2. Man with pulmonary atresia, pulmonary valvotomy [heart surgery].
Room 3. Woman with CABG [coronary artery bypass graft; a "bypass operation"]. Bleeding out [i.e., hemorrhaging] badly at one point during the night, they sent her back to the OR [Operating Room]. On heavy vasopressors [to keep blood pressure up].
Room 4. Older woman with tumor from her neck up to her temple. In OR from 7 A.M. until 2 A.M. the next morning having it removed. Infarct [dead tissue] in the brain.
Room 5. 23-year-old woman, MVA [motor vehicle accident]. ICP [intracranial pressure—a measure of brain swelling] measured—terrible. Maybe organ donor. [Patient died next day.]
Room 6. Don't know.
Room 7. Abdominal sepsis, possibly from surgery. DNR [Do Not Resuscitate] today.
Room 8. Big belly guy [an old man with a horribly distended abdomen, uncontrollable. Staff says it's from poor sterile technique in surgery by Doctor M., who is notoriously sloppy. This patient died within the week.] [Field Notes]
This is a typical patient load for an Intensive Care Unit. Eight beds, three patients dead in a matter of days. "Patients and their visitors often find the ICU to be a disturbing, even terrifying place. Constant artificial light, ceaseless activity, frequent emergencies, and the ever-present threat of death create an atmosphere that can unnerve even the most phlegmatic of patients. Some are so sick that they are unaware of their surroundings or simply forget the experience, but for others the ICU is a nightmare remembered all too well." On floors—the larger, less critical care wards of the hospital—fatalities are less common, and patients are not so sick; even so, one-third of the patients may have AIDS, another one-third have cancer, and the rest suffer a variety of serious if not immediately lethal diseases. The ICUs just get patients whose deaths are imminent.
It is interesting that this density of disease presents one of the positive attractions of nursing. People don't become nurses to avoid seeing suffering or to have a quiet day. Every day nurses respond to and share the most intense emotions with total strangers. "People you don't know are going through the most horrible things, and you are supposed to help them. That's intense," says one nurse. And another enthuses about coming home as the sun is coming up; the rest of the world thinks things are just starting, and here you're coming off a big emergency that lasted half the night: "[T]here's a real adrenaline kick in all this stuff. If you deny that, you're denying a big part of [nursing]."
The abnormality of the hospital scene liberates the staff from some niceties of everyday life and allows them a certain freedom. This will be treated in much fuller detail later in this book, but for now, two small, even silly, examples may illustrate the point. (1) Many nurses wear scrub suits—the pajama-like pants and tops worn in operating rooms and on some units. Written on the suits are phone numbers, vital statistics, or even doodles drawn during surgery. It's more convenient than finding a piece of paper. One observer, Judith André, has commented, "It's like a childhood fantasy" to scribble things on your clothes. (2) During a "code," as a patient was being resuscitated, one nurse who was having her period began to leak menstrual fluid. She ran into the patient's bathroom to change her sanitary pad. When she came out, another nurse, seeing the stain on her pants, yelled, "Well, J. got her period!"—a comment unthinkable in the everyday world. But this isn't the everyday world. As Everett Hughes wrote, "All occupations—most of all those considered professions and perhaps those of the underworld—include as part of their very being a licence to deviate in some measure from common modes of behavior." In this sense, the hospital is like a war zone, in which common niceties and rules of decorum are discarded in the pursuit of some more immediate, desperate objective. There is an excitement, and a pressure, that frees hospital workers in the "combat zone" from an array of normal constraints on what they say and do.
And yet, for them their work has become normal, routine. On a medical floor, with perhaps two-thirds of the patients suffering eventually fatal diseases, I say to a nurse, "What's happening?" and she replies, walking on down the hall, "Same ol' same ol'." Nothing new, nothing exciting. Or in an Intensive Care Unit in the same hospital, "What's going on?" The resident replies, with a little shrug of the shoulders, "People are living, people are dying." Again, no surprises, nothing new. The routine goes on.
As other writers have noted, the professional treats routinely what for the patient is obviously not routine. For the health worker, medical procedures happen to patients every day, and the hospital setting is quite comfortable: "The staff nurse ... belongs to a world of relative health, youth, and bustling activity. She may not yet have experienced hospitalization herself for more than the removal of tonsils or the repair of a minor injury. Although she works in an environment of continuous sickness, she has been so conditioned to its external aspects that she often expresses surprise when someone suggests that the environment must be anxiety evoking." Everett Hughes's formulation of this divergence of experience is classic: "In many occupations, the workers or practitioners ... deal routinely with what are emergencies to the people who receive their services. This is a source of chronic tension between the two." Or, more precisely, "[O]ne man's routine of work is made up of the emergencies of other people."
Excerpted from Beyond Caring by Daniel F. Chambliss. Copyright © 1996 The University of Chicago. Excerpted by permission of The University of Chicago Press.
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