Nursing Against the Odds - The Workers' View
"Nursing Against the Odds: How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care,"
by Suzanne Gordon
Cornell University Press, 450 pages.
March 14, 2005
Nurses. Nurses. Nurses. Already I've guaranteed that more people will find this article on the internet who are searching for pornography than who are searching for answers to our health care crisis or insights into one of the most demanding professions there is.
Outside of sexual fantasies, our most common image of a nurse is of an angel. Hospital campaigns to recruit more nurses depict them with wings. Their work is described as caring and compassionate. Skill is never mentioned, medical expertise blurred over, life-saving and cost-saving insight and awareness deeply buried.
What nurses actually do is invisible to us, even to patients, even to nurses themselves. We think in terms of 19th century stereotypes. We picture nurses in hats that no living nurse has worn. We imagine them as the unskilled humanizing assistants to doctors who do all the scientific thinking. We imagine that only women can be nurses -- and only women who lack intelligence and ambition. Being a nurse, like being a teacher, is a second-best career perhaps because its aim is not the advancement of scientific knowledge. Never mind that nurses contribute as much as doctors to medical knowledge or that there are purposes more noble in life than the accumulation of knowledge.
Gordon's book is a masterful depiction and analysis of a career we generally fail to understand, and which health care corporations have clearly failed to come to terms with. In this country, nurses do much of the work done by doctors in some countries. They are constantly observing and diagnosing. They often speak in terms that give doctors credit for their work, but if nurses always waited for doctors to analyze the raw data they collect, many lives would be lost. Entering a hospital that really functioned like that would carry a greater risk to patients than entering a war zone.
How ever skilled your doctor may be, a stay in a hospital without nurses competent in the fields relevant to your illness means a serious risk to your health. So does a stay in a hospital in which doctors will not condescend to listen to nurses. The stories Gordon tells of nurses' warnings being ignored, and needless deaths resulting, are heartbreaking and frustrating. Surely we should be beyond such petty egotism and class distinctions in a profession as long established as health care. Apparently we are not. Gordon devotes much of the first 150 pages of her book to the dysfunctional relationships in our hospitals.
She devotes the next 75 pages to the media's portrayal of nurses. She finds the work of nurses largely absent and nurses almost never quoted in the media on health care issues. Nurses appear in the news media only when there is an extreme shortage of them and a campaign to recruit them, or when they are on strike, or when a nurse is blamed for a patient's death. Gordon gives some of the blame for this situation to nurses. They hide from the media and even from patients. They are often reluctant to let anyone know their last names. Rather than wearing professional uniforms with name tags and introducing themselves as Nurse Smith or Nurse Taylor, they often wear cutesie pajamas and call themselves Kimmy or Nancy. They may have extensive medical knowledge, but when you meet them you can't even be sure they're a nurse.
By the time you reach page 227 of Gordon's book, you have an extremely troubled picture of nursing. The reasons seem very clear for the shortage of nurses; you only wonder why it isn't more severe. Who would want to work in a thankless profession in which blame is available, but credit not, in which verbal and physical abuse by doctors is common, in which filthy and gory work is combined with extreme risk and pressure, plus dangerous chores such as lifting well-fed Americans off tables? Why voluntarily train and study to work in a career with a high rate of injuries, an intense demand for concentration, and a near universal attitude of condescension, albeit in the form of appreciation for how sweet and compassionate you are?
The next 223 pages present the situation as 100 times worse. This is the story of cost-cutting hospital "reform." Because nurses have no important skills, HMO bean counters see cost savings available if they cut back on nurses and make them more flexible, shuffling them around from this wing of the hospital to that as needed. Never mind that some of them have no education in the area they are assigned to on a given day. Never mind that eight nurses on eight days cannot observe a patient's changing state the way one nurse could. The important thing is cost savings. Get the patients in later and send them home quicker and sicker. Give each nurse more patients at a time, and never mind that all of the patients are seriously ill, whereas the nurse's workload used to include some patients who were recovering and in need of less assistance.
Of course, most of the "reforms" that have been imposed on our health care have made worse whatever they were supposed to address. Average patient stays are shorter, but costs are higher. And nurses' workloads are greater, but it's become harder to find enough nurses to go around. Hiring freelance or "travel" nurses from temp agencies allows flexibility, but hospitals pay them at such a higher rate that staff nurses often resent their temporary colleagues. In growing numbers, underpaid staff nurses quit and join the contingent workforce. Of course, this leads to fewer nurses having a stake in the future of the hospitals where they work.
Not only does the future look grim for nurses in the United States (and in many of the other countries discussed in this book), but our chances of having enough nurses at all are dwindling. The nursing shortage is being addressed at least for now -- by recruitment from abroad, at a time when many Americans desperately want work but don't want to work as nurses.
One thing that I think could change that would be for current nurses and young people to read this book. Here, in the end, is a picture of a noble career that offers truly meaningful and challenging work that directly benefits and can be rewarded with intense gratitude. Reading this book would also help encourage nurses to speak up on their own behalf and on behalf of everyone who needs decent and affordable health care.
The final section of the book offers Gordon's recommendations. Given the depth of scholarship and understanding displayed in this text, her recommendations are worth taking very seriously. One thing she advocates for is legislating safe staffing ratios, so that by law a minimum number of nurses is required for a given number of patients. This approach has been tried in many places, including the Australian state of Victoria and the US state of California. Thirty other US state legislatures are considering the idea.
Gordon also recommends requiring a four-year degree for nursing, arguing that there is too much to be learned in less time, and even citing a study that finds a correlation between educational preparation of nurses and mortality rates.
Gordon presents similarly strong arguments for shorter and more predictable hours combined with better pay and a more powerful voice in the workplace. All of which means: the ability to form a union and the will to do so. In nursing, as in every industry in the U.S., serious obstacles, both legal and technically illegal, are placed in the way of unionizing. But in addition, many nurses need to understand better the importance of a union to improving their working conditions. They need to learn to accept a union as not demeaning but enhancing to their professional status.
Ultimately, if not very surprisingly, Gordon recognizes that the establishment of single-payer health care is needed to solve numerous problems in our health care system. Among the contributions of this book are international comparisons suggesting that single-payer alone, while necessary, will be far from sufficient in addressing the problems facing nursing.
Gordon encourages nurses to play a more outspoken role in the public debate over single-payer and other health care questions. But this book is not just for nurses. Every profession should have a book like this one. And every one of us should read each of those books. Working class solidarity is built by understanding the work our brothers and sisters do, and this book is a wonderful contribution toward that end.
David Swanson is a writer and activist. His website is http://davidswanson.org. He can be heard every Monday on the Thom Hartmann Show.
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