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Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care / Edition 1

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Overview

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 doctorsand 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.


About the Author:
Suzanne Gordon is an award-winning journalist. She is the author of Life Support: Three Nurses on the Front Lines, the coauthor of From Silence to Voice: What Nurses Know and Must Communicate to the Public (also from Cornell), and has written for the New York Times, the Boston Globe, and the Toronto Globe and Mail, among many other publications. Gordon is also Assistant Adjunct Professor at the University of California San Francisco School of Nursing and was a health care commentator on Public Radio International's Marketplace.

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Editorial Reviews

From the Publisher

"One of the most comprehensive and insightful discussions . . . of the complex set of relationships that have developed over the years between doctors and nurses. Nursing against the Odds should be required reading for all nurses, doctors, and nursing and medical students, . . . who will find this book both provocative and enlightening."—New England Journal of Medicine, 29 September 2005

"Exhausted by heavy work, mandatory overtime, and the stress of looking after hospital patients who are sicker, frailer, and in need of ever more high-tech intervention, nurses are leaving the bedside faster than they can be replaced. . . . People who are interested in the health care system or in their own health care should pay attention to the issues Ms. Gordon raises in this book. But nurses especially should read it."—Cornelia Dean, New York Times, 17 May 2005

"Gordon uses anecdotes, research findings, and statistics to develop the list of contributing factors and potential resolutions to the current nursing shortage in more developed countries. She offers a comprehensive, international overview of the key issues."—Ellen Zupa, The Lancet, 27 August 2005

"Gordon's detailed information in the form of interviews, documented research, groundbreaking advances and setbacks, statistics, and opinions about the state of nursing are compelling. . . . You will recognize that there isn't any issue related to nurses and nursing that Gordon hasn't examined. . . . This book isn't just for nurses. It is a comprehensive depiction of how nursing is indeed working against the odds to provide a safe, caring environment for patients. Nurses hold the key to the solutions. Gordon gives us the data and talking points to move to the action stage."—Kay Bensing, Advance for Nurses, 1 August 2005

"Suzanne Gordon, a national award-winning journalist, author, and adjunct professor, is an advocate for all nurses. Gordon isn't a nurse, but believes nursing to be an honorable profession and the backbone of our health care system. . . . This book addresses the main forces that drive nurses out of their workplace; the crucial issues that deprive communities of adequate care of the sick, and the class and status divisions within the profession. But Gordon doesn't focus only on the problems, past and present, facing the nursing profession, but the remedies as well."—Terry Ratner, RN, MFA, Nurseweek, 9 May 2005

"The nurses Gordon describes in multiple anecdotes are almost always clinically astute and are frequently the first, occasionally the only, professionals to observe, interpret, and respond appropriately to signs and symptoms that foretell disaster for the patient. Despite the horror stories of disasters and averted disasters, Gordon fortunately places the issues of nurses and doctors at work in a larger historical and sociological context."—Barbara A. Mark, Ph.D., RN, FAAN, Journal of the American Medical Association, 17 August 2005

"The nursing profession lacks many things, like decent working conditions, recognition, and respect on the job. But, with Suzanne Gordon, it has something other professions can only envy—a skilled reporter, brilliant analyst, and steadfast advocate."—Barbara Ehrenreich

"Nursing is one of the most honorable professions I know. I'm proud of the service I provided during my nursing days. I learned so much about my beliefs, values, and passions as well as learning about others. Anyone who has spent time in a hospital knows that nurses are the true caregivers, the backbone of our health care system. Most doctors spend only a few minutes with their patients while nurses are there around the clock. This is an important book and needs to be required reading in all our medical schools."—Naomi Judd, RN

"The shocking real-life stories Gordon describes in Nursing against the Odds echo what our members experience every day. Readers will not only learn how the nursing profession has suffered over the years due to the many pressures of the nation's evolving health care system-they'll understand exactly what needs to be done to meet the challenges nurses and patients continue to face today. Gordon takes a candid look at the current nursing shortage and paints a vivid picture of how nurses are uniting throughout the profession to raise patient-care standards. This book is a must-read for anyone involved in the healthcare industry."—Andrew Stern, SEIU International President

"Nursing against the Odds is a brilliant and long-overdue assessment of nursing at a time of crisis in health care-what has gone wrong and what can be done to restore this once-esteemed profession to a position of equality with doctors. It should be read by anyone interested in the hierarchy of medicine, and the reasons why the nurse is becoming an endangered species."—Richard Selzer, MD, author of Letters to a Young Doctor

"Suzanne Gordon's book contains a wealth of ideas for legislators and policymakers who want to protect patients from the consequences of managed care and hospital restructuring. Gordon shows that real health care reform requires strong coalitions between nurses and the communities they serve."—U.S. Representative Bernard Sanders (I-VT)

"Suzanne Gordon provides new and important insights into the complexities involved in the current nursing shortage. Nursing against the Odds contains the right mixture of patient/nurse anecdotes and scientific evidence for the conclusions reached and finishes with constructive suggestions for steps that can be taken to correct the situation."—Margaret L. McClure, RN, EdD, FAAN

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Product Details

Meet the Author

Suzanne Gordon is coeditor of the Cornell University Press series, The Culture and Politics of Health Care Work, and was program leader of the Robert Wood Johnson-funded Nurse Manager in Action Program.

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Read an Excerpt

NURSING AGAINST THE ODDS

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

ILR Press

Copyright © 2005 Suzanne Gordon
All right reserved.

ISBN: 0-8014-3976-0


Chapter One

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. 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."

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. 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. 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 or asked to be switched from a unit or shift because of them. Nurses also felt that physicians did not give them enough respect or understand the impact of their behavior. Most nurses stated that their institution did not deal effectively with the problem.

The psychologist Larry Harmon is the codirector of the Physicians' Development Program in Miami, which evaluates, educates, and monitors physicians and nurses and other health care providers. Harmon defines "disruptive behavior" as "any behavior which results in diminishing team members' ability to do their best work." He classifies such behavior as verbal, physical, and indirect behavior.

"Disruptive verbal behavior," Harmon explains, "includes sarcastic comments, snapping at others when frustrated, or talking down to people. Physical disruption occurs when doctors throw small objects when angry, raise their fists at someone, give someone the finger, or actually strike or assault someone." Indirect disruptive behavior includes things like criticizing people behind their back, spreading rumors, or pouting or intentional selective ignoring. "For example," Harmon says, "the physician won't talk to one particular nurse as a way of punishing him or her."

This kind of behavior has become such a problem that, in its 2002 alert about the nursing shortage, the Joint Commission on the Accreditation of Health Care Organizations (JCAHCO) also raised the issue of nurse-physician relationships. "Incidents of verbal abuse of nurses, typically by physicians, are unfortunately well known, even commonplace," the report stated. It called for a voluntary policy of zero tolerance in the workplace and suggested that medical societies develop guidelines to deal with abusive physicians.

In Canada, the Status of Women Sector of the Quebec Federation of Nurses conducted research to ascertain the level of violence against nurses in Quebec. Nurses told of being humiliated, screamed at, and subjected to temper tantrums as well as physical abuse. Ninety percent of the union's members said they'd been "victims of at least one act of assault or aggression during their career." Among abusers of nurses, doctors figured prominently. The number of incidents, the union said, indicated "that doctors can express their anger against their closest workers as they see fit."

In my interviews with nurses, their most common complaints were that physicians do not understand what role nurses play in the health care system, misunderstand whom nurses serve, do not value the knowledge and skill that nurses have amassed during their careers, and fail to appreciate that collaborative, cooperative, collegial relationships between physicians and nurses are central to quality patient care. Most nurses feel that although nurses work closely with doctors and respect their training, skill, and expertise, doctors do not reciprocate.

In his study of the hospital workplace, the sociologist Daniel Chambliss recorded similar complaints. "If there is a single dominant theme of nurses' complaints about their work, it is the lack of respect they feel, from laypersons, from coworkers, and especially from physicians. It is nearly universally felt and resented. 'The docs never listen to us,' they say, 'you don't get any recognition from doctors'; doctors don't read the nurse's notes in the patients' chart, don't ask her what she has seen or what she thinks, they don't take her seriously." Chambliss, who spent over ten years observing nurses and physicians interact, agreed with the nurses. The "daily evidence" of physician disregard, he wrote, was "truly pervasive; I was genuinely surprised at how common the obvious disrespect is."

When I was recently in Adelaide, Australia, a nurse manager of a cardiac unit related an illustrative incident. Because of the closure of an oncology service in the area, cardiac nurses were being asked to treat oncology patients at a cardiac unit that was being prepared to take on an extra load of cancer patients. The nurses were given a quick course to teach them how to deal with oncology patients. Before their hasty tutorial was even complete, an oncologist in the hospital admitted a patient to the unit. When the nurse manager told the physician that the RNs didn't yet know how to deal with chemotherapy drugs, and had not mastered the complexities of inserting needles into porta catheters (devices that are surgically inserted into the subclavian vein to allow easier, and over time less painful, access for chemotherapy and blood tests), he became irate. No oncologist would ever imagine that a cardiologist could simply stroll in and replace him. Nonetheless, this physician insisted that a cardiac nurse could easily replace an oncology nurse. "Surely someone around here can manage this. You are nurses after all," he fumed.

See One, Do One, Teach One

In medical schools, doctors in training are taught to do procedures through the process of "see one, do one, teach one." That also seems to be the way novice physicians are taught to look down on nurses. Listen to John E. Heffner, MD, medical director of the Medical University of South Carolina, "complimenting" nurses in the introduction he wrote in 2002 to a brochure about nursing that the hospital distributed for Nurses Week:

"We physicians at MUSC have much to appreciate in working with our nursing staff. Nurses amplify by their extended bedside presence the value of our brief daily patient encounters. The expertise and personal touch of our nurses drive much of the community's perception of our health care facilities. And the vigilance and judgment of our nurse permit us to travel to our daily duties yet still respond to any sudden clinical event.

(Continues...)



Excerpted from NURSING AGAINST THE ODDS by SUZANNE GORDON Copyright © 2005 by Suzanne Gordon. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Pt. 1 Nurses and doctors at work 17
1 Manufacturing the dominant doctor 21
2 Designing the doctor-nurse game 55
3 The disruptive medical system 76
4 Fatal synergy 95
5 Making matters worse 121
Pt. 2 The media and nursing 147
6 Dropped from the picture 151
7 Missing from the news 173
8 Unavailable for comment 200
Pt. 3 Hospitals and nursing 227
9 Mangling care 233
10 The new nursing universe 253
11 Nurses on the ropes 284
12 No nurse left behind 312
13 Management by churn 351
14 Failure to rescue 384
Conclusion : changing the odds 401
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