Call the Midwife! The Hobby Lobby Won

Call_The_Midwife_2433160b“A woman’s right to control her own body is taken for granted now, and younger people can scarcely believe that abortion used to be a criminal offense, punishable by a prison sentence for the woman and the abortionist,” wrote Jennifer Worth in her article ‘A Deadly Trade’ (The Guardian, 1-5-2005).

Jennifer Worth worked as a midwife and district nurse in London’s impoverished East Side neighborhoods during the 1950s. She lived with and worked alongside the Anglican nuns/midwives from the Community of Saint John the Divine (the Midwives of Saint Raymund Nonnatus in both her memoir and BBC series Call the Midwife.) In this time before effective birth control and legal abortions, the women she cared for had multiple, closely-spaced, and often unplanned/unwanted pregnancies. Of course, women from higher socioeconomic levels had access to to safe (if not legal) abortions. From what I have read, through her work as a district nurse and midwife, Jennifer Worth became a deeply committed Christian as well as an outspoken supporter of women’s reproductive freedoms, including the right to safe, legal abortions. Showing that these do not need to be mutually exclusive.

I am currently besotted by both the BBC series Call the Midwife and the trilogy of Jenifer Worth’s memoirs (Call the Midwife, Shadows of the Workhouse, and Farewell to the East End). I plan to use some of the Season 1 episodes of Call the Midwife next week for the summer quarter narrative medicine course I am teaching, and I envision using some of the episodes in future community health nursing courses. The series depicts many of the same–or similar–community health nursing issues that are still pertinent today and within the U.S. context. Of course, the Call the Midwife series also includes some of the early developments of Britain’s National Health Service, which for us in the U.S. seem oh so progressive (or is it oh so socialist?)

How is it that women’s reproductive rights in our country seem to be going backwards–oh so retro?

I just turned 54 and am blessed with having ‘come of age’ during a time of reasonably decent access to effective birth control and safe, legal abortion services. Similar to my belief in the germ theory, I took it as a given that these same (or better: more male methods of birth control anyone?) advancements would be available to my children and all future generations. Sure, I’ve had the mass mailing dire prediction/requests for donations from Planned Parenthood, and I’ve followed the legal retrogressive shenanigans in many of the Bible Belt states, but I never thought it could really touch me all the way out here at the far edge of North America, in the true blue area of Seattle. Until this week’s news of the Supreme Court ruling in favor of the (seriously–where did they get this name?) Hobby Lobby. To paraphrase Martin Niemoller: “First they came for the poor women of Texas—and I didn’t speak out.” Shame on me.

My U.S. Senator Patty Murray sent me an e-mail saying she’s furious about the Supreme Court ruling and vows to fight it, although I’m not exactly sure how she plans to do this. But I gave her some money, perhaps so she can buy another pair of tennis shoes to march through the halls of Congress and kick some butt. You go girl! I am very happy to live in a state with so many women in key government positions. Our country would be better off with more women in key government positions.

The American Nurses Association issued a statement condemning the Hobby Lobby ruling, stating:

“The Affordable Care Act sought to provide millions of Americans access to basic health care and preventive services, including contraception, and essential component to women’s health. However, this ruling places an unfair burden on women, particularly those with lower incomes, who may not be able to access medically appropriate contraceptive care due to the additional expense.”

Julie Rovner wrote a nice, yet disturbingly Kafkaesque,  article “Did the Supreme Court Tip Its Hand on Contraceptive Cases Yet to Come?” yesterday for Kaiser Health News.

What will you do when the Hobby Lobby (or the Conservative male Supreme Court Justices) come for you–or your loved ones? Calling the midwife won’t work by then.

Addendum: The National Women’s Law Center launched the CoverHer hotline to help women who are having trouble getting access to women’s preventive health services – especially contraception – at no cost to them. The user-friendly hotline provides personalized instructions on how to navigate the health insurance process to ensure women get the coverage for preventive services they are guaranteed under the health care law and includes critical follow-up to track the results.

The Center will use the aggregated data it collects from CoverHer to identify systemic problems with implementation of the ACA’s birth control and other preventive health benefits and will use its advocacy and outreach efforts to overcome these obstacles. CoverHer builds off of the Center’s former Pills4Us hotline, which helped hundreds of women obtain the birth control that they needed.


Hotline number: 1-866-745-5487





The (Very Public) Case of Amanda Trujillo

State Seal of Arizona.
State Seal of Arizona. (Photo credit: Wikipedia)

The Truth About Nursing had a post yesterday, “Amanda Trujillo: Fired for Educating A Patient?” Briefly, it is reported that in April 2011 the hospital administration where Ms. Trujillo was employed filed a complaint against her with the Arizona Board of Nursing (BON) and also fired her. The firing and BON complaint were allegedly for Ms. Trujillo referring her patient with end-stage liver disease to have a hospice consult—when the patient’s surgeon had already scheduled the patient for a liver transplant. As stated in the Truth About Nursing post, the Arizona BON was scheduled to decide on the case at its meeting at the end of March, but there are no public reports of their decision.

What I find most interesting about this case is the level of social media presence about the issue, and much of it directly from Ms. Trujillo. Unless there is someone posing as her, she appears to weigh in with details about her case on high profile forums such as KevinMD (see guest post by a semi-anonymous ‘J. Doe’, RN. “Why Physicians Should Care About Amanda Trujillo” date unstated). Ms. Trujillo set up an online legal defense fund to help defray the costs of retaining a personal lawyer to assist with her case with the Arizona BON.  A psychiatric nurse who goes by the name Mother Jones and blogs under Nurse Ratched’s Place, has a link to the NurseUp! nursing advocacy website that reports having raised $1,700 in additional support for Amanda Trujillo. Mother Jones speculates in April 25th blog post that the case is headed to the court system, and that this is why there is no public information on the Arizona BON decision. There have been numerous letter-writing campaigns to the Arizona BON and the Arizona Nurses Association, as well as to various state officials and even to the ANA. There were allegations of close ties between the Arizona BON and the hospital which filed a complaint against Ms. Trujillo. There have even been calls to boycott the Arizona tourism industry in protest of the Arizona BON in the their handling of the case of Amanda Trujillo. Maybe boycotting Arizona’s hospitals would have made more sense?

I continue to be dismayed by the lack of understanding by nurses (and the general public) of just how corrupt and inefficient our state-level health professions regulatory system is. It will be interesting to see if higher profile cases such as Amanda Trujillo help bring much needed reform to this system. (see my previous post “Not Just Culture” 11-19-11 for more information on the health professions regulatory system and its relation to nursing and public health.).

Happy (#192) Birthday Flo!

Cover of "Notes on Nursing"
Cover of Notes on Nursing

Happy International Nurses’ Day and happy end of National Nurses (no apostrophe, I don’t know why) Week, celebrated May 6-May 12th every year since 1990, thanks to the American Nurses Association—seemingly in conjunction with Hallmark. Is it a strange coincidence that National Nurses Week, National Administrative Professional’s (or Secretary’s) Day, National Teacher Day, and National Mother’s Day are all clustered around the same weeks?

In the interest of research, I recently bought and watched Season Three of the TV show, Nurse Jackie. According to Nurse Jackie (Episode 11: Batting Practice), “(Nurses) Appreciation week is patronizing. It’s for the overworked and underpaid.” To which her co-worker, male nurse Thor chimes in, “Secretaries. Teachers. Us.” Jackie responds, “It’s bullshit and we don’t celebrate it.” And my favorite character on the show—the pink Crocs and teddy bear scrubs wearing new nurse Zoe—says, “That’s crazy! It’s our week, and if we don’t celebrate it, who will?”

Florence Nightingale, the somewhat tarnished icon of modern nursing, was born 192 years ago today. Of all that has been written about Florence Nightingale, Lyton Strachey’s is my favorite. He calls Florence’s Notes on Nursing, “… that classical compendium of the besetting sins of the sisterhood…”  Here is what Lyton Strachey writes about Florence Nightingale in his entertaining book Eminent Victorians (1918/The Albion Press/Oxford England):

“Every one knows the popular conception of Florence Nightingale. The saintly, self-sacrificing woman, the delicate maiden of high degree who threw aside the pleasures of a life of ease to succour the afflicted, the Lady with the Lamp, gliding through the horrors of the hospital at Scutari, and consecrating with the radiance of her goodness the dying soldier’s couch—the vision is familiar to all. The Miss Nightingale of fact was not as facile fancy painted her. She worked in another fashion, and towards another end; she moved under the stress of an impetus which finds no place in the popular imagination. A Demon possessed her. Now demons, whatever else they may be, are full of interest. And so it happens that in the real Miss Nightingale there was more that was interesting than in the legendary one; there was also less that was agreeable.” (pg 73)

Roxanne Nelson, in her Washington Post (4-29, 2003) article entitled “Good Night, Florence,” reports that Unison, Britain’s largest trade organization representing nurses, declared they were ditching Florence Nightingale because she “represents the negative and backwards elements of nursing.” (during their 1999 annual conference). In her article, Ms. Nelson reminds us that Miss Nightingale worked as a nurse for less than three years, including the time she managed a British hospital in Turkey during the Crimean War. After the war—and for the last fifty years of her life—she basically took to her bed with what historians now suspect was a combination of Malta Fever (brucellosis—probably from infected milk products) and depression. While an invalid, she wrote Notes of Nursing, oversaw the opening of the Nightingale Training School for nurses, and worked on hospital reform of the British military. Florence insisted that nursing was a calling and not a profession.

Those funny Brits across the pond. They know how to celebrate the history and influence of Florence Nightingale. They have the Florence Nightingale museum in London, complete with a stuffed owl—the remains of her pet owl Athena—and a Turkish lantern like the one used during the Crimean War. In their online store you can buy a teddy bear dressed as a nurse and holding a Turkish lantern, or a resin bust of the Iron Maiden, or a hot pink lapel pin with the interesting statement, “Nursing is an art.”

Of cheese, erectile dysfunction, and health reform

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And jewelry.

Those were the main take-away messages of yesterday’s nurse practitioner conference at the Washington State Convention Center. There was a lot of mention of the role of nutrition in health, and of individual responsibility for health in some of the sessions I attended—and in the booths at the vendor section. I saw very few obese attendants at this conference—are nurse practitioners skinner on average than their RN counterparts, and if so, why?

The Washington State Dairy Association had free cheese sticks and food pyramids or food Great Walls of China, or whatever architectural wonders they are using now to rank food groups. At a session on health care reform, the speaker spent a lot of time talking about the nutritional content of ‘fast foods’—the winner of the junk-food hall of fame seems to be Baskin Robbins’ Oreo Milkshake at a gazillion calories. As if that is the cause of the dismal health outcomes in our country.

This was at a workshop session by Louise Kaplan, a nurse practitioner who has her doctorate in health policy. She is past president of the Washington State Nurses Association, founder of the first Washington State Nurse Lobby Day in 1984 (in serious need of reform itself–see previous blog post The Nurse Lobby Day That Wasn’t–Feb 15th, 2011), and currently is a Senior Policy Fellow at the American Nurses Association. Besides the information on the Oreo Milkshake, she said we didn’t have health care reform, we had health insurance reform. This statement got applause from the audience, but not from me. This is a profound statement? This is news to anyone? And health insurance in the US is not a significant part of our health care system?

After her talk I asked her if the ANA was looking at reform of the health professions regulatory system in the US. She asked me what I see as the problem with this system—what is in need of reform. I told her in 20 words or less—including that it is not effective in protecting the health of the public, that it drives up health care costs and worsens health inequities. She replied that it was up to each individual state to regulate health professions, and that the ANA would have nothing to say about that—only what the IOM Future of Nursing Report recommended in terms of a consensus on scope of practice for nurses and nurse practitioners. Her response did not surprise me, but I was disappointed in the stock reply.

I loved the vendor area because it was so informative about the role of nurse practitioners in our health care system. Somehow it felt like reading People Magazine—as Paul Farmer says, it is a cultural touchstone. There were many of the major drug company’s represented, including Lilly’s erectile dysfunction “weekend pill” that seemed popular among the ladies. The Washington State Nursing Quality Care Commission had a booth that included a 10-question survey on knowledge of the role/responsibilities of the Commission. There were many booths for local educational programs for nurses, as well as Seattle-area employment agencies/hospitals—and farther afield employment opportunities—the US Navy, the Federal Prisons, Alaska Native American clinics.

But what astounded me was that the most popular booth in the vendor area was a jewelry store. Not fine jewelry, not jewelry for a cause—like for healthcare in Haiti—just glitzy, glittery costume jewelry. Really? There are some things about nursing I am convinced I will never understand.

Nurses’ Health Study: Lipstick Counts

pink ribbon
Image via Wikipedia

Continuing on with my Code Pink theme from earlier this week, I want to comment on the Nurses’ Health Study (female nurses only—sorry guys there is no male nurses’ health study that I know of). Today I was invited to join Nurses’ Health Study III by Karen Daley, President of the American Nurses Association.

If you don’t already know, the Nurses’ Health Study was started in 1976 by epidemiologists from the Harvard Medical School and Brigham and Women’s Hospital. Originally it was a prospective cohort study looking at the possible risks of oral contraceptives for development of ovarian and breast cancer in women. Funded by the NIH, the researchers targeted nurses because they were mostly female, they knew enough medical terminology to be able to answer questionnaires with accuracy, and they were likely to be compliant with research study parameters. Expanded in 1989 with the Nurses’ Health Study II, they have 238,000 “dedicated nurse participants” and have had a 90% follow-up rate. The questionnaires include questions on reproductive health, family history, environmental exposure, diet/supplement use, physical activity, screening history, disease outcome, medication use and psychosocial issues. A scan of the questionnaire/long form reveals these interesting questions: 1) how often (each day) do you apply lipstick?, 2) how many natural teeth do you have?, 3) how many moles do you have on your left arm >3mm?, and 4) how do you feel about your social standing in US society and in your community? (picture a ladder, where participant is asked to mark the rung on which they perceive themselves to be, once for US and community). According to the study website, quality of life questions were added in 1992 at the request of nurse participants. The questions include social support, perceived support by job supervisors, participation in religious activities, shift work, and global rating of overall health.

More than 100 scholarly journal articles are published every year based on results from this study. As the ANA President says, “These studies have taught us much of what we currently know about how foods, exercise, and medications can affect women’s risk of developing cancer and other serious health conditions.” She goes on to say, “However, there is still a great deal that we do not know, especially among women from diverse ethnic backgrounds.

 The goal of the Nurses’ Health Study 3 is to investigate how women’s lifestyles (including diet, exercise, birth control, pregnancy, work exposures etc.) during their 20’s, 30’s and 40’s can influence their health and disease risk later in life.” They started to recruit female nurse participants in the Summer 2010 and have a goal of recruiting 100,000 nurses.

I did a PubMed search on all of the published journal articles related to the Nurses’ Health Study. They are listed in the categories of breast cancer, diabetes, cardiovascular disease, physical activity and vitamins. I found no published journal articles related to job stress, perceived social standing and health outcomes. The closest are studies linking night shift work and bone loss and/or pregnancy loss. To make sure I wasn’t missing something, I asked Dr. Susan Hankinson, RN, ScD, Principal Investigator for the study if she knew of any current/unpublished studies on these issues. She told me that they have some new people looking at the relationships between stress and ovarian cancer and diabetes, but that it will be a few more years before they have those results. She added in a follow-up e-mail that they were looking at the relationship between stress (experience with violence and PTSD) and health (asthma, diabetes, coronary heart disease).

A missed opportunity. First, let me state clearly that I applaud this study and have personally benefited from it. For instance, when I was in my late 20s, I was reassured by study results indicating that use of oral contraceptives was not likely to increase my risk of breast or ovarian cancer. However, I am struck by the lack of research attention on stress—and particularly on work-related stress for women (and nurses in this case) on health outcomes. Gender and class issues come to mind here. As does the fact that for the first time in recorded US history, female life expectancy rates in parts of the US have started to decline. Majid Ezzati and colleagues in 2008 published an article, “The Reversal of Fortunes, Trends in County Mortality and Cross-County Mortality Disparities in the United States.” Between 1982-2001 they found that for 19% of the US female population there was a significant decline or stagnation in overall life expectancy. This reversal of the epidemiologic transition was most apparent for low-income white women in Appalachia and the Mississippi Valley. I wonder how many of these women are nurses and how many are reflected in the Nurses’ Health Study.

There is growing recognition that social determinants of health have a much bigger part to play in terms of health inequities than do behavioral health factors like diet and exercise. The socioeconomic ladder is strongly associated with gradations in health outcomes. The Nurses’ Study asks about perceived social standing, which I would imagine has a close association with nurses’ socioeconomic ranking. I hope that some researchers begin to examine these data, as well as the relationship between work-related stress and overall perceived health status. So, all of you female nurses ages 22-45, consider joining the Nurses’ Health Study III and count how many times per day you apply lipstick. And all of you epidemiologists please consider looking at the social determinants of health—including work-related stress—for female nurses.

Truth-tellers and nursing leadership

Image via Wikipedia

“Tell all the truth but tell it slant–” (Emily Dickenson) I have been re-reading Dickenson’s poem as well as Foucalt’s “Fearless Speech” series of lectures while thinking about the state of truth-telling in nursing leadership. Truth-telling  to me connotes honesty, integrity and courage, which are all essential ingredients of good leadership. Truth-telling in the classical sense involves self-reflection and truth-telling to oneself. There is an art to good truth-telling. I believe that the current nursing leadership in our country has a lot to learn in all of these areas of truth-telling.

First though, just who are nurse leaders? My working definition of “nurse leader” is anyone who is a nurse of some sort who has the power and position, or the power of position to be able to effect change on systems–whether the system is a hospital unit, an entire hospital, some other health-related agency public or private, a public health program, a unit of or an entire school of nursing. Perhaps they are the nurses chosen (by other nurse leaders) to be part of the RWJ Nurse Executive Nurse Fellows Program, or chosen (by other nurse leader/fellows) to be a Fellow of the American Academy of Nursing (FAAN). Do you notice a pattern here at all? The inner circle, the “old girls’ network of nurse leaders chooses who to let into the inner circle. This, of course, is human nature, and nursing is no different in many ways from say, medicine. Except that it is significantly different from medicine in terms of power and prestige–not essential ingredients to truth-telling, but they help in being heard and not being killed in the process.

The Dean of my school of nursing, Marla Salmon, ScD, RN, FAAN recently said that the focus in nurse leadership should not be about increasing the status of nursing as a goal, but rather to have nursing be partners in leading improvements in health care: It’s not just about nursing getting in the door, but it’s what happens when they’re at the table. I like this, but I like thinking about this table not as a sandbox with people (and nurses especially) “playing nice” and not throwing sand in Jimmy’s face–but rather thinking of the table as the Ancient Greek marketplace where truth-telling, open debate and reflection were encouraged.

We do not practice or encourage truth-telling in our profession of nursing. As nurse educators we actively discourage our students from voicing different viewpoints from our own, or from the accepted Cannon of Sacred Nursing. I recently read a document on revising the BSN essentials (e.g.: the most important things we want BSN-prepared RNs to be ‘taught’) and it stated that we should not teach/practice critical thinking “because it is too critical.” And in the practice of nursing it is obvious that nurse leaders shoot the messenger when line staff RNs “speak the truth” about patient safety issues.How is any of this going to change if the existing nurse leaders don’t start modeling more truth-telling in all of it’s ancient connotations?