Theresa Brown, RN has a new NYT monthly opinion piece column called “Bedside.” In a recent e-mail, Theresa describes her column as, “…a nurse’s eye view on ways to make health care better and more humane.” In her debut piece “Money or Your Life” (6-23-12/print version 6-24-12 in Sunday Week in Review section), she argues for the Affordable Care Act (ACA) based on her work as a hospital-based oncology nurse. She describes working with an uninsured male patient with leukemia who asked her about death panels, hoping they existed. It seemed he wanted to be put out of his misery, while avoiding bankrupting his family. Ms. Brown then does a good job of describing some of the complexities of–and the argument for–the individual mandate component of the ACA. This, of course, is a key element of the ACA, and one before the US Supreme Court as to its constitutionality. Their decision is due out this week.
Congratulations Theresa Brown! And thanks NYT editors for recognizing and including a nursing perspective on the continuing health care debate in our country.
Since this is a blog, and since Theresa Brown asked for feedback on her new column, I offer a few reflections. The name “Bedside,” as in bedside nursing, implies direct patient care in an inpatient hospital setting. As such, it is descriptive of the type of nursing Theresa Brown is involved with. But bedside nursing is a term often used as code for “real nursing,” as if community/public health, home health, school and occupational health, and nursing home nurses are somehow not real nurses. The name “Bedside” also perpetuates the notion that nurses spend the most time with patients of any health care team member, and are, therefore, in the best position to advocate for patient’s needs. This belief undermines patient care and safety by working against good health care team communication. It is a paternalistic (maternalistic?) belief that undermines the patient autonomy and agency central to patient-centered care. The belief is also not supported by facts.
Recent studies indicate that hospital-based nurses consistently (and significantly) overestimate the amount of time they spend on direct patient care. Whereas many nurses ‘guesstimate’ they spend over half their time during a given shift on direct patient care, national studies (sophisticated versions of time/motion studies) indicate that hospital nurses spend just 15% of their time in direct patient care. (see RWJ study by Hendrich, et al, “A 36-hospital time and motion study: how do medical-surgical nurses spend their time?” The Permanente Journal, Summer 2008) The largest percentage of their time was spent on charting and other administrative tasks. And a recent study found that physician hospitalists also spent 15% of their time in direct patient care (“Hospitalist time useage and cyclicality: opportunities to improve efficiency” Kim, et al. Journal of Hospital Medicine, July/Aug 2010). So nurses’ time-honored claim to spending the most time at a patient’s bedside is no longer true.
Then there is the fact that hospital-based jobs for nurses are rapidly disappearing as hospital administrators reduce their nursing staff, and as more hospitals merge or close altogether. Some experts claim that one-third of all hospitals in the US will close by 2020 (see David Houle and Jonathan Fleece’s post on KevinMD. 3-15-12)
Bedside nursing is probably a term that needs to be, well, put to sleep.
The last time I worked in a hospital was about 15 years ago–it was a surgical floor—cardio-thoracic, vascular, general surgery requiring telemetry and medical overflow–a hodge podge. The hospital was still trying to keep an all RN staff–so few CNAs–a lot of hands on. The routine was to walk everyone who could twice a shift–that meant a minimum of 15 minutes per patient times 6 patients times 2 per shift to equal THREE HOURS of just ambulating them–no assessments, no meds, no IVs, no dressings, no teaching–just walking with them. I estimate I spent about 90 percent of my time at the bedside.
Well maybe it was not bedside nursing but is was HALLWAY nursing.
Looking back, I don’t know how I and my colleagues did it–yes I do –no dinner ever and bladders bursting at the end of shift.