Tag: Health

Nursing Ambivalence

The Poor Poet, by Carl Spitzweg, 1839. (Neue P...
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As Phillip Lopate says, “If you have ambivalence, you already have two paragraphs.”

I have always been ambivalent about nursing: more than two paragraphs worth of ambivalence. There have been numerous times in my life when I have listed out the pros and cons of nursing. It started, of course, when I first began contemplating nursing as a viable career option, when I found myself a Harvard graduate school dropout and without job prospects. My ambivalence accelerated greatly while I was in nursing school: I despised nursing school and almost flunked out until I got to the graduate nursing school part where people—and their testing methods—were somewhat saner. It has continued throughout my 27 years as a nurse. The unexamined life is not worth living. Unexamined nursing is not worth doing.

Recently, my ambivalence about nursing increased. I sought career counseling with an excellent expert in this area. Three sessions and five standardized career tests later, her conclusion was that I have neither the aptitude nor the personality to be a nurse. According to the test results and her interpretation of them, I was meant to be an artist—an activist artist to be precise. My mother, who was an artist, turned over in her grave with this news. As I spent a lot of hard-earned money on the career counseling, I decided to take it seriously. But with a son in graduate school, I have no intention of chucking nursing to become a starving artist. So I am back to sorting out the pros and cons of nursing.

Here’s my current list, in no particular order.

Positives of nursing: I like nursing’s emphasis on caring vs. curing. I like the down-to-earth, no-nonsense aspect of it—the dirtiness and realness of it as opposed to the loftier, detached way that doctoring can have. I especially like public health/community nursing, working with underserved populations where they live. I like that nursing is generally closer socio-economically to “real” people than is medicine. Solidarity can ward off disdain. I like the diversity of working opportunities—the range of what you can do with a nursing degree. I like that it is easier to move into various different jobs and roles and even to get out of working as a nurse, and still have the nursing part inform other work. I like that nursing is generally well regarded by the public—at least in terms of trustworthiness. I like that it requires less time and money to become a nurse (compared with becoming a physician).

Negatives of nursing: There are too many women in nursing: cat fights, back-stabbing, high school-type bullying gossip (and yes, even in nursing education). Too much estrogen is not a healthy thing. We need more men in nursing for so many reasons. I don’t like the sanctimonious, dogmatic, missionary, religious, preachy, bossy ways of nursing. I don’t like the Pollyanna-propensity of nursing. I don’t like the servant role it assumes in reference to physicians and even to patients—the self-effacing, self-sacrificing, subservient way of nursing. I dislike this more than I do the sexy naughty nurse/angel in white motif (Not politically correct, but I also see the humor in these—a future blog post topic). I think I am enough of a feminist to see through these gendered stereotypes. But I am also enough of a feminist to recognize that traditional female roles are not something to reject out of hand—that it is possible to be a feminist nurse, just as it is possible to be a feminist mother, or a feminist teacher, or a feminist flight attendant. I don’t like the anti-intellectualism of much of nursing. I dislike the dominant discourse/narrative within nursing of whining victim—the inferiority complex. I dislike that nursing has developed its identity around the medical model, that it compares itself to and tries to differentiate itself from the physician role. This can lead to some bizarre and flakey things like nursing care plans, nursing diagnoses (“alteration in bowel elimination” instead of “diarrhea” anyone?), and therapeutic touch. It also has reinforced an emphasis on hospital-based nursing, and the rigid health care hierarchy inherent in that factory type model—keeping nurses in the ‘functional doer’ role.

For me, measured in sheer number of words in my lists, the cons of nursing win.

Early in my career as a nurse practitioner, I interviewed for a job with a crusty but astute psychiatrist, an expert in substance abuse disorders at a public east-coast university hospital. He interviewed me three times over the course of more than a month. I didn’t get the job and I couldn’t figure out why. A physician friend of mine who worked with the psychiatrist told me he’d concluded, “She’s not enough of a nurse to be a nurse practitioner.” It hurt my feelings at the time, and is a rankling statement that has stayed with me over the years. At the time, I thought he meant that I hadn’t been a nurse long enough to merit becoming a nurse practitioner. I was overly sensitive to that sort of thing since I had gone straight through nursing school to become a nurse practitioner. It was the only type of nurse I wanted to be—but I caught flack for it by other nurse practitioners, other nurses, and physicians. It wasn’t as common a track as it is now, although my accelerated nursing program students tell me they still get hassled about their lack of experience as nurses. But now I am wondering if what the psychiatrist really meant was that I did not have the personality of a nurse—that I was too ambivalent about nursing in general—to make a good nurse for his research project.

And the irony, of course, is that I teach nursing. Luckily, I have yet to be asked to teach any courses that require nursing care plans, nursing diagnoses, or therapeutic touch. As with teaching nursing research, I’d have to decline. I’d rather be a starving artist.

Hell is Paved With Good Intentions

Human test subjects from the Tuskegee Syphilis...
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Recently I worked in an occupational health setting, at a clinic for employees of a call-center: a warehouse of a building filled with rows of Dilbert-like low cubicles with people on telephones, fielding customer complaints. Women workers would come in to clinic with bladder infections from not wanting to take bathroom breaks. They have to clock out for bathroom breaks and they get penalty points if they take too many bathroom breaks during one shift. Too many points and they get fired. Taking a diuretic for high blood pressure, or being pregnant, can be bad for job security at this site. Not surprisingly, stress-related health problems like headaches, heart palpitations, and depression are commonly diagnosed at this employee clinic. The purpose of work-site clinics such as this one is to maximize the bottom line for the company—keep workers as healthy as possible, and then fire them when they aren’t healthy anymore. The clinic is also designed to reduce the overall health care cost to the company. The irony, of course, is that many of the employees say they have to keep their jobs to keep their health benefits so that they can get health care for job-induced health problems. These are all issues not unique to this particular company.

This is much different work for me than all the clinical work I’ve done within the health care safety net. Although there are overlaps. For one thing, many of my homeless young adult patients worked for call centers like this when they were transitioning out of homelessness. These are the sorts of low-wage, low-skill, entry-level jobs available to people without a college degree, without work experience. Working at the call center has increased my understanding of what my homeless young adult patients meant when they spoke about such work: it’s a job, it pays the bills, but it’s depressing work because almost everyone is angry at you on the phone and you have to be nice to them or you’ll get fired. It has given me a new appreciation for how stressful it can be for all of those anonymous help desk people I have to deal with at times.

Ours is the only country in the world to primarily tie health care to work. Blame Rosie the Riveter. Employer-sponsored health care started in our country during WWII, when the scarcity of workers, combined with a national wage freeze, made the benefit package—including health care—a way for companies to attract and retain employees. It continued even after the war—and wage freezes—ended. People came to expect it.

What started off as a good idea has turned into a bad one. Employer-sponsored health care drags down our national economy. It does this by limiting entrepreneurship—people are less likely to strike out on their own to start a small business if they can’t afford health insurance in the private market. It is also a drain on the national economy since we have more disgruntled—and therefore less efficient—workers staying in jobs they hate just to keep their health benefits. It contributes to the fracturing of the US health care system due to multiple health insurance companies vying for business with companies offering health plans—and drives up overall health care costs through increased insurance company administrative costs. Some of these problems are addressed in the Affordable Care Act, but since our health care system is a highly complex adaptive system, powerful interest groups such as insurance companies have already plotted ways to circumvent these changes and continue making huge profits.

To use another famous quote from George Bernard Shaw’s “Maxims for Revolutionists”: “Hell is paved with good intentions, not bad ones.” I am always wary of occupational health programs due to the complex ethical issues involved: role conflict, invasion of privacy, and paternalism/coercion related to health promotion activities. I also remember that the notorious Tuskegee Syphilis Study had its roots in an otherwise well-meaning occupational health program. It began in 1932 in Macon County, Alabama, still one of the poorest counties in the US. Funded by a Northern philanthropist family and operated through a local Agricultural Extension program, it provided comprehensive mobile health care—including screening and treatment for syphilis (commonly called ‘bad blood’)—to poor black farm workers. These men had access to very little health care. Well-planned and well intentioned, the occupational health program was a success until the Great Depression forced a major scale-back of the program.

The rest of this is perhaps a familiar story, but one worth repeating. The US Public Health Service, and subsequently the CDC, stepped in to take over the program, under the guise of a treatment and research project for syphilis. The doctors told the study participants, all poor and mostly illiterate black men, that they were receiving first-rate medical care—including treatment for bad blood—for free. Eunice Rivers, a black public health nurse from the area, helped recruit and retain participants. She did community-based outreach to black churches and schools. At her suggestion, the researchers offered the men free burial. This was highly valued since the greatest disgrace was to die so poor you couldn’t get a proper burial. The men were deceived and received no treatment for syphilis, even though penicillin was available as an easy cure. The study continued until 1972, when a San Francisco-based journalist—tipped off by an internal CDC whistleblower—persevered to bring the public’s attention to the awful facts of the study. Some of the white male doctors and researchers involved still see nothing unethical in what they did. Eunice Rivers needed a job and she sincerely thought she was providing good nursing care to “her men.”

“The hallmark of the Tuskegee Study, and a key to its 40 year life, was its culturally-sensitive, community-based approach,” wrote Stephen Thomas in his article “The Legacy of Tuskegee: AIDs and African-Americans” (Jan/Feb 2000, Body Positive Magazine.) This is a good reminder of how good intentions—and good approaches to health care—can go to hell.

I feel uneasy about working in an occupational health setting, and I doubt I’ll return to work at that employee clinic. I didn’t feel right patching the workers up to return to their high-stress, low-paying jobs, sitting in the endless rows of cubicles under flickering fluorescent lights. But this means that I am rapidly running out of morally acceptable (to me) places to work within the US health care system. Perhaps next I will try jail health.

Those Who Can’t, Teach

swamp

A familiar phrase, and one that I think about often as I teach. It is appropriately humbling, an antidote to hubris. The phrase originates from George Bernard Shaw’s play “Man and Superman: A Comedy and a Philosophy,” from the main character’s “Maxims for Revolutionists.” The phrase is included in a section on education and reads, “He who can, does. He who cannot, teaches.” It is accompanied by: “A fool’s brain digests philosophy into folly, science into superstition, and art into pedantry. Hence, a university education.”  In his lengthy introduction to the play, Shaw writes, “(…) what we call education and culture is for the most part nothing but the substitution of reading for experience, of literature for life (…).” Shaw had a very unhappy childhood educational experience in Dublin, Ireland, was largely self-taught while living in London, and became a life-long ardent believer in socialist reforms.

In a practice discipline such as nursing, the tension between education and practice—between teaching and doing—is ever present. Further complicating this tension is the emphasis on nursing research in university-based nursing schools. Nursing is considered a minor (or wanna be) profession. As Patricia Benner and her co-authors state in their book Educating Nurses: A Call for Radical Transformation (Jossey-Bass, 2009), for the past thirty years nursing faculty and administrators have focused most of their attention on developing nursing research. Benner attributes this to the pressure to increase the prestige of nursing within academic settings. I am still unclear just what “nursing research” does to increase the prestige of nursing—or even what it means. Is nursing research any research having to do with nursing practice or workforce issues? Is it any research having to do with anything as long as it is led by a nurse?  I gave up teaching nursing research because I felt like a hypocrite since I didn’t understand or value it. In my experience, research methods classes taught in schools of nursing are not very rigorous, especially when compared with research methods courses in schools of public health or psychology.

Now nursing practice I do understand and value. I am an accidental nursing educator, and an occasional health services researcher. My first and real love is clinical work as a nurse practitioner. To apply Shaw’s maxim: I can and I do, but I also can’t and I teach. While my students value this clinical relevance, it isn’t valued within my school of nursing. This isn’t unique, as I hear a similar lament from my nurse educator colleagues at other top-rated schools of nursing. It also isn’t unique to nursing, as my academic physician friends tell me the same thing happens in schools of medicine.

Both the Educating Nurses and the IOM Future of Nursing Report emphasize the need for lessening the existing disconnect between classroom theory and clinical practice in nursing education. They point out that many nurse educators have not practiced nursing in many years and, therefore, have a hard time including appropriate classroom experiential learning. Much of nursing theory courses are taught with an overreliance on endless PPTs, busy work, and an emphasis on rote memorization. Nurse educators teach the way they were taught. It is not teaching; it is torture.

One of the most influential books on my own teaching of nursing is Donald Shon’s Educating the Reflective Practitioner (Jossey-Bass, 1987).  It doesn’t mention nursing at all, but is nonetheless applicable to nursing education. In the book he talks about professional practice as more of an art that a science, and emphasizes the teaching of reflection-in-action, a sort of higher-level critical thinking.

Here is his opening paragraph from the book:

“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique. In the swampy lowland, messy, confusing problems defy technical solution. The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest might be, while in the swamp lie the problems of greatest human concern. The practitioner must choose. Shall he remain on the high ground where he can solve relatively unimportant problems according to prevailing standards of rigor, or shall he descend to the swamp of important problems and nonrigorous inquiry?”

Contrast this with an unfortunate statement in Educating Nurses: “Critical thinking alone cannot develop students’ perceptual acuity of clinical imagination; and cynicism and excessive doubt are often the by-product of the over-use of critical thinking.” The authors have obviously misunderstood the definition of “critical” as applied to critical thinking, where “critical” is understood to be the “exercising of careful judgment or observation.” It is having an inquisitive spirit, questioning underlying assumptions—including one’s own assumptions—of being able to think about thinking. Critical thinking is the opposite of Shaw’s fool’s brain and is necessary for effective swamp work, the terrain of most nursing practice.

Hope is grammar. Hope Dies Last.

Don Quixote and Sancho Panza by Honoré Daumier
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These are two of my favorite aphorisms on hope. The first is from the literary critic George Steiner. The second is from the title of Studs Turkel’s book Hope Dies Last: Keeping the Faith in Difficult Times (The New Press: 2003), and is a phrase he attributes to Jessie de la Cruz, a co-worker of Cesar Chaves. I have been re-reading Terkel’s book, concurrently with Cervante’s Don Quixote Of The Mancha—Shelton’s English translation version from 1611. They go together well.

In the Introduction to Hope Dies Last, Terkel writes: “Hope has never trickled down. It has always sprung up.” He points out that positive change, transforming despair into hope, has always been a bottom up, not a top down affair and is often initiated by groups of troublemakers: activists. The rest of his book is a series of oral histories of a variety of current activists in the US. In one chapter, Linda Stout, the Executive Director of the Amherst-based Peace Development Fund is quoted saying, “Our big challenge is the people’s spirit of helplessness. Power corrupts absolutely, but so does powerlessness.”

Not to make this a Hallmark moment, but I have to bring in a very concrete source of hope I have for the future of nursing. Graduation. Yesterday I had the great honor of seeing many of my most amazing students graduate from our nursing school. I got to hood three newly minted Doctor of Nursing Practice/FNP students who I know are going on to change their parts of the world. One did his research work on both maternal survival and HIV care at the Hope Center in Nairobi, Kenya. Another did her research on cervical cancer prevention in rural Costa Rica. A third did her research on CAM/Integrative Medicine modalities in academic research medical centers in the US. Another student I was blessed to work with did her master’s research on kidney disease and kidney transplants in African-Americans. She’s now on her way to start in a terrific FNP program in the South. And the crop of new BSN students—well, hopefully you will get to read some of their essays they wrote for my health policy class in Narrative Matters sometime soon. Including an excellent essay on men in nursing by a man in nursing. There are many hidden and not-so-hidden nurse activists in the graduation class of 2011. Godspeed! And remember what Don Quixote said (OK—it was really what Peter O’Toole said in Wasserman’s screenplay The Man from La Mancha): “When life itself seems lunatic, who knows where madness lies? To surrender dreams—this may be madness; to seek treasure where there is only trash. Too much sanity may be madness! But maddest of all: to see life as it is and not as it should be.” Go change the world. And health care. And nursing.

Nurses’ Health Study: Lipstick Counts

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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.

Re-scripting Code Pink

Marching in 2004.
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I worked at a community health clinic that was housed in an old restored firehouse with old plumbing designed for a few firefighters and not for hundreds of patients each day. We fairly regularly had “Code Brown” called over the clinic loudspeaker when the sewer system backed up into clinic areas. Sometimes they closed the clinic until it was cleared. Sometimes we worked around it. That’s community health.

I have never worked where they called “Code Pink” and I think I am glad of that. It sounds as if it should be a mammogram emergency. According to nursing leadership expert, former Dean of the Kansas School of Nursing, and current hospital mystery writer Eleanor Sullivan, Code Pink is called by a nurse in a hospital who is being bullied by physicians or others. In her letter to the NYT editor in today’s paper (Sunday May 15th), she writes, “The word is passed nurse to nurse, and colleagues gather around the beleaguered nurse. Few physicians can stand the scrutiny of neutral-faced nurses standing silent beside one of their own.” Somehow I don’t picture the nurses as neutral-faced. All four letters today in “When Doctors Humiliate Nurses” were supportive of Theresa Brown’s Op-ed article “Physician Heel Thyself.” All four letters were relatively bland, especially compared with the responses to her article found elsewhere.

Dr. Kevin Pho on his popular blog KevinMD.com, has already written two posts on Theresa Brown’s article. In his first blog post entitled “Theresa Brown unfairly blames doctors for hospital bullying” he states, “Brown has a prominent media platform in the New York Times, and, in a way, she wields it here to metaphorically bully the entire physician profession.” Many self-identified physicians who responded to Dr. Pho’s blog post were supportive of his read of Ms. Brown’s articles, although most stated they refused to (literally) read anything she writes… One person identified as “David MD” did the math, dismissed Ms. Brown as a neophyte nurse since she has a pre-existing PhD and pre-existing children, and admonished her for “extracurricular writing” that “must have violated the terms of her employment at Shadyside Hospital.” He concludes, “From the tone of her other blogs, she must be an absolute nightmare to work with.” David MD stated that he had written a letter to the editor of the NYT in protest of her article.

In his follow-up blog post, “Doctor bashing and confronting physicians in the media,” Dr. Pho admitted that Ms. Brown’s article had brought the topic of hospital bullying into the national health care conversation. He applauded her for bringing up such a difficult topic in the NYT. But he still takes issue with her method, calling it an “adversarial approach,” and alluding to it as “doctor bashing.” He even likens it to the case of the Seattle nurse Kim Hiatt being fired by Children’s Hospital for a medication error, stating that neither will solve larger systemic issues within health care. Instead, for physician bullying, he places blame on the medical education system for perpetuating the socialization of arrogance and bad manners in medical students. That line of reasoning makes no sense to me: Medical education is by and for physicians.

What I find fascinating in many of the physician blog posts and comments to Ms. Brown’s article, is the resentment that, 1) she is a nurse and she can write well, and 2) she has a national media platform through the NYT. In his second blog post on Ms. Brown’s article, Dr. Pho writes, “Brown is a former English professor, and it’s no wonder that the framing of the piece is masterful.” Some of the posts by physicians call for her hospital administration to silence her. In Ms. Brown’s recent article entitled “Nurse as Writer, Writer as Nurse” published in the Clinical Journal of Oncology Nursing (April 2011), she acknowledges that dealing with hospital management has been tricky when it comes to her writing. She never identifies the hospital where she works, although as she says it’s easy enough to figure out who her employer is. She states that when she first started writing, the hospital management wanted editorial control over everything she wrote. “Knowing this was a request they could not legally make, I said, ‘No,’ and have had to repeat this refusal more than once. It’s not always easy, and at times I wasn’t sure I was tough enough to stand up to the healthcare corporation I work for.” I do not know what sorts of blowback Ms. Brown is currently getting from her hospital administration over her NYT Op-ed article “Physician, Heel Thyself.” But if she is feeling this heat, perhaps she could call a Code Pink of the Dr. Sullivan type. I contend that she has done vastly more through her ‘popular press’ writing to effect positive change in nursing and health care than any amount of academic journal articles or IOM reports or White Papers.

For those of you in the Seattle-area, Theresa Brown will be speaking at a public event next week at the University of Washington. Sponsored by Poets and Writers and the School of Nursing, Ms. Brown will give a talk entitled “Nurse as Writer, Writer as Nurse,” UW Health Sciences, Room T-625, Thursday May 26th 10:30-12:20pm. The following is the blurb I wrote to describe the event:

Theresa Brown is an oncology nurse, author of Critical Care: A New Nurse Faces Death, Life, and Everything in Between (harperstudio, 2010), and is a regular contributor to the New York Times’ Well blog. In a recent article entitled “Nurse as Writer, Writer as Nurse” in the Clinical Journal of Oncology Nursing, Ms. Brown addresses the most common questions people ask her, such as, “What about patient confidentiality?” “Do you take notes at work?” and “How do your coworkers (and employer) feel about your writing?” A former English professor who found her true calling as a nurse, Ms. Brown will talk about her dual paths as writer and as nurse.

KOMO News Problem Makers

Original cast of the show (1994-1995)
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Tracy Vedder with our Seattle-based TV KOMO News Problem Solvers should have been at our panel discussion yesterday on med errors and the consequences for nurses. Perhaps she could have learned something. But instead she was hot on the case of two Seattle Children’s Hospital nurses who were charged with professional misconduct yesterday by the Washington State Nursing Commission. Last night she aired a news piece that sensationalizes and distorts the facts.

The online link to the video news portion is bookended by an ad for UNICEF. A mop-headed sad-faced boy says, “22,000 children die every day for reasons the world has the power to prevent.” It then cuts to the two newscasters sitting behind a desk with a large screen in front stating in large letters: “Nurses Charged”. Then Tracy Vedder is shown in front of the Washington State Department of Health, and states that two Children’s Hospital nurses were charged with unprofessional conduct—with SERIOUS conduct violations (her head spins around to emphasize ‘serious’). She goes on to name the two nurses several times. She describes the transport nurse as giving three medications “without any doctor’s orders” and says the baby in that case died. She states the ER nurse gave an adult patient epinephrine by IV instead of IM. The patient had arrhythmias but was stabilized.

Ms. Vedder fails to mention that the medications the transport nurse gave were appropriate ones, that the medical examiner determined the baby died of natural causes, and that both state and federal authorities cited Children’s Hospital with a lack of clear guidelines for transport staff.  Tracy Vedder also fails to report that in the case of the ER nurse, an ER doctor incorrectly prescribed the epinephrine to be given IV, but was not charged because he “didn’t intend any harm.”  All of this information is in easily obtained publicly available documents, including official written statements by Dr. David Fisher, Medical Director for Seattle Children’s Hospital.

By contrast, Carol Ostrom (please note, this is her correct name–not Tracy Ostrom–apologies Carol!) of the Seattle Times has a remarkably balanced and insightful article today about the nurses being charged. She was at our panel discussion yesterday, but I draw no cause and effect conclusions. I think it was a case of selection bias. Yesterday in the panel discussion, NPR’s Joanne Silburner encouraged the audience to be responsible consumers of news media, and to recognize the limitations of TV news. She also encouraged nurses in the audience to speak out more, to know which newspaper reporters are professional (including ethical), and to talk with those reporters when given the opportunity. I would add: stop watching TV news. Lead by example.

The other lesson I learned yesterday: Kim Hiatt’s suicide should be a “never again” event, and all of us have a responsibility to ensure that is the case. Two of our nurses in Seattle are being publicly fried by KOMO News and others. Let’s not be silent about that. In whatever ways we can, we should each offer appropriate support to these two nurses—and to all of the ‘collateral damage’ nurses who know and have worked with them.

Poverty Medicine: Why we need the poor and the uninsured

Establishment of rural rehabilitation camps fo...
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This past weekend at the Tacoma Dome, 1,500 uninsured people were seen for free health care by 1,400 volunteer doctors, nurse practitioners, nurses, dentists and others. They saw all of the patients in eight hours, and provided 3,000 free prescription medications for things like diabetes and hypertension. The National Association of Free Clinics and the Washington Free Clinic Association were joint sponsors of the event. Nicole Lamoureux, the Executive Director of the National Association of Free Clinics told the volunteers, “This event will change your life.” (KOMO News, 4-30-11).

I watched the KOMO TV news footage of this event, and besides spotting a few of my nursing students who were volunteers (way to go!), I noticed that the newscaster kept emphasizing that the patients that day were the working poor. They interviewed an older white woman who said she’d worked all her life but didn’t have health insurance and was too young to qualify for Medicare. She did not appear to have a serious mental illness or a substance abuse problem. The message was that they were only providing free health care to the deserving poor.

There are many useful debates as to the utility of such large-scale one-off medical missions (whether or not they are explicitly faith-based). That is old territory and I won’t address it here. What I am interested in is what these sorts of free clinics—and of poverty medicine in general—say about us as a society. Why are they a seemingly permanent part of our health care safety net and of our country?

Poverty medicine, by the way, seems to have been coined by a US family physician, David Hilfiker. I met him back in the 1980s when he was living and working with homeless people in Washington, DC at Christ House. As he states on his website, many people seek “life with the dispossessed as a pathway toward intimacy with God.” That can either be viewed as laudable or slightly sadomasochistic. Christianity does have a long tradition along those lines. Dr. Hilfiker is quite open about the fact that he was prone to severe burnout and deep depression through this work. He stopped work as a physician altogether many decades ago.

Besides possible feel good, life changing, spiritual awakening (or burnout and depression) by those providing poverty medicine sort of care, what other functions does it serve?

I reflect back on the sociologist Herbert Gans’ “The Positive Functions of Poverty” (AJN, 1972).  Among his many suggested positive functions of poverty, the following have pertinence to poverty medicine:

1)   Poverty makes possible the existence and expansion of respectable jobs, including social work and public health (and I would add poverty medicine).

2)   The poor support medical innovation by being “practice” patients at public hospitals and by being guinea pigs in medical experiments.

3)   The poor—the uninsured who have to turn to free clinics like the Tacoma Dome—make the rest of us feel better about our social standing: at least we aren’t that poor. Yet.

4)   And here’s one of Herbert Gans’ positive functions of the poor that can really make us squirm: “They also provide incomes for doctors, lawyers, teachers, and others who are too old, poorly trained, or incompetent to attract more affluent clients.” (p 280)

I have worked as a health care safety net provider for almost thirty years, so I am one of those people ‘supported’ by the existence of poor people. Thanks poor people. I made a purposeful crossover into “yuppie medicine” for several years just to see what it was like. In Bellevue, Washington I treated Microsoft lawyers with stress-related health problems and bizarre sports injuries from extreme yuppie sports like underwater hockey. I reassured the worried well and tried to talk them out of total body MRIs. I burned out on yuppie medicine and went back to working with homeless teens at a community health clinic. But then I began to realize that perhaps by working in the health care safety net I was just helping to perpetuate the problem. Nothing has changed in the thirty years I’ve been doing health care for the poor—if anything, things have gotten worse. I do still believe that the mirage of the safety net is better than nothing, but it also prevents us from making the fundamental overhaul of our health care system that is needed.

To Forgive, Divine: Medical Errors and the Consequences for Nurses, Part II

Alexander Pope dying; from the title page to W...
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“Good-nature and good-sense must ever join; To err is human; to forgive, divine.”~Alexander Pope, Essay on Criticism

The topic of my last post “To Err Is Human” hit a raw nerve for many people. Since the post, I have heard directly from numerous former co-workers and parents of NICU patients of Kim Hiatt’s who are devastated by the news of her suicide. Many other people who did not know her personally are distressed over her death, and seek to understand what went wrong at a systems level—what we can do to prevent this from happening to other nurses.  I am struck by the inadequacy, irony, and inaccuracy of the Seattle Times article last week, “Nurse’s Suicide Follows Tragedy.” Her suicide is part of the tragedy; her suicide does not follow the tragedy. The role of local media—not only the Seattle Times but more importantly KOMO News—in this tragedy is a topic I do not possess the psychic distance to be able to address.  Of course, we the news-munching public are also culpable, since we engorge ourselves on ambulance-chasing, witch-hunting, tabloid-line blurring ‘news’ stories.

I try to keep my personal blog separate from my life as a faculty member at the University of Washington School of Nursing. But on this topic the lines blur. I listened to some of my current nursing students, as well as some very wise local nurses outside of the UW, and—with the blessing and assistance of many of my UW colleagues—we are offering a forum/panel discussion on Tuesday May 10th, 3-5pm Hogness Auditorium, UW Health Sciences Building. It is open to the public, so please join us if you can. The tentative title is the title of my last blog post, “To Err is Human: Medical Errors and the Consequences for Nurses” because—well, that is what the panel discussion will be about. So far for the panel we have top-ranking representatives from the Washington State Nursing Care Quality Assurance Commission, the Washington State Nursing Association, an area suicide prevention program for health care professionals, and Joanne Silberner from the UW Department of Communications (to discuss the role/responsibilities of the media). For those of you who don’t know, May 10th is during National Nurses Week.

As I told my students this week, the news of the suicide of Kim Hiatt has re-opened wounds of my own. The topic of a future post (and a chapter in a book I am writing), I experienced the fallout in my own life of an investigation/threatened suspension of my nursing license early in my career. It was due to a (still) anonymous complaint about the scope of my practice back when the nurse practitioner role was very new and in a more conservative state than Washington. I was (I think) eventually cleared of any wrongdoing, but the stress of that time cascaded into my divorce, loss of my job, episodes of homelessness, and a bitter vow to leave nursing. The overwhelming feelings of shame, isolation, betrayal/loss of trust in the health regulatory system, led me to contemplate suicide. I did not have the media hounding me. It has taken me 25 years to be able to process those events and be able to talk about it with other nurses. Silence can be deadly.

To Err is Human: Medical Errors and the Consequences for Nurses

The Neonatal Intensive Care Unit.
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That medical care can be harmful to your health or even deadly, is not necessarily news to many people. The extent of it within the US health care system and the impact of it on health care providers are not well known. The IOM Report To Err Is Human: Building a Safer Health System (2000) highlighted serious patient safety issues in our health care system and outlines approaches to patient safety improvement. This report emphasized that the vast majority of adverse patient events were the direct result of bad systems and not of bad health care providers. “The focus must shift from blaming individuals for past errors to a focus on preventing future errors by designing safety into the system.” They pointed to the aviation industry as a model for safety design at the systems level. Root cause analysis was applied to understand and try to prevent adverse events. “Never events” were identified as sentinel patient safety events for monitoring purposes in hospitals (these include surgical removal of the wrong body part and inpatient suicides). National level patient safety monitoring databases were developed. Eleven years later where are we in terms of progress on patient safety?

In the April edition of the journal Health Affairs, indications are that we have not improved much and may actually have worsened. A study by Classen, et al reveals that serious preventable adverse events occur in one out of every three hospital admissions. Another study estimates a $17.1 billion annual cost of measurable medical errors in the US.  They point out that the risk of harmful errors in health care in the US is increasing due to the increasing complexity of care and of medical devices and medications. What to do about this? The Agency for Healthcare Research and Quality is putting an emphasis on educating patients on ways to advocate for their own patient safety (or parents of pediatric patients). But as Donald Berwick points out in the April 15th Health Affairs Health Policy Brief on improving quality and safety, “Commercial air travel didn’t get safer by exhorting pilots to please not crash. It got safer by designing planes and air travel systems that support pilots and others to succeed in a very, very complex environment. We can do that in healthcare, too.”

I have been thinking about the issue of patient safety and the consequences for nurses because of the recent news of the suicide of a respected local RN, Kimberly Hiatt. She died April 3rd at the age of 50. She had worked as a NICU nurse at Seattle Children’s Hospital for almost the past thirty years. I did not know her personally, but by all accounts she was a devoted and highly capable and compassionate nurse. In fact, Megan Moreno, a pediatrician who did her fellowship at Seattle Children’s Hospital and whose daughter Fiona died in the NICU of congenital health problems describes Kimberly Hiatt in an article published in the Archives of Pediatric and Adolescent Medicine (January 2006). She writes, “Our favorite nurse was assigned to us the next day, and she helped us through the difficult task of extubating Fiona.” At the end of the article she expresses particular gratitude to Kim Hiatt, RN, along with her neonatologist.

Kimberly Hiatt committed suicide because of a cascade of adverse events that happened to her in the aftermath of a medication error that resulted in an infant’s death in the NICU at Children’s. This happened in September, 2010 just months after a highly publicized death of a 15 year old autistic boy after routine dental surgery at Children’s, which resulted from an incorrect dose of a Fentanyl patch (a powerful narcotic) prescribed by the dentist. Children’s Hospital changed its policies on the prescribing of narcotics after this incident, but the dentist was not disciplined. Around the same time, an ER doctor at Children’s incorrectly administered a drug to a critically ill patient by IV instead of by an injection in the muscle, and the patient had to be transferred to another hospital because of the complications. The physician was not disciplined.

In contrast, Kimberly Hiatt was fired soon after the infant’s death. Also soon after the infant’s death, Children’s Hospital changed its policies to require stricter control and checks on the administration of the specific medication, calcium chloride, which is considered an especially dangerous drug  in medically fragile infants.  Dr. Hanson, the Medical Director of Children’s Hospital said that it was important that all staff feel safe to report mistakes. The Washington State Nursing Commission put restrictions on her nursing license with a four-year probationary period; with these restrictions no one would hire her to work as a nurse. According to a Seattle Times article (4-20-11), many hundreds of former patients and their family members, as well as nursing colleagues attended her funeral. In the Seattle Times Editorial and Opinion pages today, F. Norman Hamilton, a retired anesthesiologist writes, “The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error. (…) If we fire every person in medicine who makes an error, we will soon have no providers. (…) It is my belief that if the nurse had been dealt with appropriately—with compassion and insight—that she, today, would be a valuable and happy nurse.”

So I am left with many questions. Why was the nurse treated so differently from the   dentist or physician at the same hospital for similarly serious medication errors? If one in three hospital patients in the US experiences serious preventable adverse events and we know that it’s “the system, stupid,” why are most of our efforts put into educating patients to advocate for safer care? If nurses are simultaneously being told by hospital administrators to report errors and then facing serious retribution for making honest unintentional mistakes—and usually due to unsafe staffing levels they have no control over—what do I teach my students to do? If the suicide of a hospital patient is considered a sentinel “never event,” shouldn’t the suicide of a nurse such as Kimberly Hiatt due to systems errors be considered a “never event?”