Nurses Go Where Doctors Don’t

Mary Breckinridge Statue
Mary Breckinridge Statue (Photo credit: jimmywayne)

One of the most e-mailed NYTarticles/blog posts over the past twenty-four hours was Tina Rosenberg’s Opinionator/Fixes post “The Family Doctor, Minus the M.D.” (10-24-12). In her online article, Ms. Rosenberg focuses on the expanding role of nurse practitioners in providing cost-effective, accessible, comprehensive, and quality primary health care—especially in rural and underserved urban areas of the U.S. where physicians typically do not want to work. There is already a severe shortage of primary care physicians in the U.S., a shortage slated to grow with the ‘perfect storm’ of the aging/chronic disease-challenged population combined with Obamacare’s expanded coverage of previously uninsured patients.

Ms. Rosenberg, who is a journalist and contributing writer for the NYT Magazine (and not a nurse), points out that nurses “take a different approach to patient care than doctors(…)”—and that nurses’ more holistic approach to patient care is particularly useful in the management of chronic disease, especially in patients with complex socio-economic barriers to care. She included organized physician resistance to nurse practitioner-run clinics, citing a recent position statement by the American Academy of Family Physicians in which they oppose independent practice by nurse practitioners. Ms. Rosenberg points out that in sixteen states plus Washington, D.C, nurse practitioners have complete independence. (Of course, what she left out is the fact that nurse practitioners have to maintain their RN license; as RNs they are independent practitioners within commonly accepted nursing functions.)

It is a well-researched and well-written article. Perhaps equally interesting are the reader comments—all 295 of them. Unlike local newspapers, the NYT carefully moderates all reader comments. They screen them before allowing posting of only the “thoughtful, civil and articulate” ones. Most of the comments to this article were on-topic. There were the usual vitriolic negative comments by some physicians about care by nurse practitioners being “second rate care,” and how nurse practitioners were dangerous unless “under the direction of a fully trained and clinically seasoned M.D. or D.O.” There were the physician assistants weighing in with “what about me?!” and saying that since they were trained under the medical model they provided superior health care compared with nurse practitioners. There were patient testimonials (for and against) care they received by nurse practitioners. There was an off-topic comment about how all nurses are into narcotic diversion and are addicted (Nurse Jackie, you brought on this misconception). And there were more than a few comments about how professional “turf wars are only hurting the patients and the nation.” I agree with that sentiment. I also am glad to see a healthy debate about the need for more primary care providers in the U.S., as well as about the important role that nurses can (and do) play in our health care system.

In (Nurses) We Trust

An oil lamp, the symbol of nursing in many cou...
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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?