In (Nurses) We Trust

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Nurses did it again: topped Gallop’s annual Honesty and Ethics of professions survey for the twelfth straight year. In fact, nursing has topped the Gallop survey every year except one since nursing was added to the list in 1999. Nursing was eclipsed by firefighters in the 2001 poll, which was conducted two months after 911. It is interesting to note that Gallop started the Honesty and Ethics survey in 1976, and nursing wasn’t included until 1999. Prior to 1999 pharmacists or clergy were rated #1.

The 2011 Gallop Honesty and Ethics poll was based on a telephone (landline and cell) survey conducted November 28-December 1st from a random sample of 1,012 adults representing all 50 states and Washington, DC. The survey question was, “Please tell me how you would rate the honesty and ethical standards of people in these different fields—very high, high, average, low, or very low?” Rankings of the professions by overall results are done based on the percentage of respondents answering either ‘very high’ or ‘high.’ This year 84% of those surveyed rated nurses as very high/high (and only 1% rated nurses ‘very low/low). Pharmacists were the next highest medical profession in the ranking, 73%, very high/high, followed by medical doctors at 70%. Military officers and high school teachers rank higher than doctors.

The phrase, “nursing is the most trusted profession in the US” is inserted into many public speeches—by nursing leaders ,of course—but also by politicians pandering to the nursing vote. It is almost taken for granted that nurses are trusted. But why are we so trusted?

First, you can’t trust nursing leaders for the full answer to this question. They have a vested interest in positive spin, such as this recent statement by ANA’s President Karen Daley: “The public’s continued trust in nurses is well-placed, and reflects appreciation for the many ways nurses provide expert care and advocacy.” Well, yes, but isn’t there more to it than that?

If you dig into analysis by the Gallop researchers, they point out that the medical professions as a whole are generally highly trusted in our society, and that stability is the norm in American’s rating of professions. However, American’s opinions do shift in response to real-world events (e.g.: 911 and firefighters), and mostly to large scandals that reflect poorly on a profession. For instance, the clergy took a tumble in ratings in the wake of the Catholic priest sex abuse scandals (as well as the Evangelical sex scandals such as Jim Bakker/closets, etc). For whatever reason (relative low-profile/low power and prestige perhaps?) nurses and pharmacists have been able to avoid widespread scandals.

Sandy Summers (a nurse) on her The Truth About Nursing website states, “The reason the ‘most trusted’ poll results don’t do too much for us is that this public view often goes hand in hand with the prevailing vision of nurses as devoted, angelic handmaidens.” And Suzanne Gordon (a journalist/not a nurse, but rather a die-hard nurse advocate) goes even further, writing on her blog last year, “I am getting tired of these polls that try to assuage nurses and stroke them and make them feel better.” Both Sally and Suzanne point out that trust does not equal respect, and that many people may trust nurses but have little idea what they really do. But I’m not convinced that you have to understand what someone does to be able to trust them.

I find it intriguing that the four most highly trusted professions (listed in order) are nurses, military officers, pharmacists, and grade school teachers. All four have strict codes of ethics and standards of practice, and all—for the most part—work within rigid hierarchies for ‘the man’ or ‘the woman.’ They don’t typically work on their own as physicians can and often do. They all, in various ways, take orders. And they aren’t exactly the highest paid professions around—although the average pharmacist salary now tops six figures. So—taking orders within a rigid hierarchy and not profiting in a huge way would seem to be related to high public trust. The lowest ranked professions on the trust survey are members of congress, car salespeople, telemarketers, and lobbyists. The lesson here for our country? Perhaps more nurses should become members of congress?

Poverty Medicine: Why we need the poor and the uninsured

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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.