NURSING AGAINST THE ODDS
How Health Care Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care
By SUZANNE GORDON ILR Press
Copyright © 2005 Suzanne Gordon
All right reserved. ISBN: 0-8014-3976-0
Chapter One
It was the first week in July at the Beth Israel Hospital in Boston and a new crop of interns has just arrived in the teaching hospital. A nurse named Deborah Madison was taking care of Ella, a forty-two-year-old woman with pancreatic cancer who was about to begin her first round of chemotherapy. Madison had worked on this cancer unit for the past five years. When she examined her patient, she found that Ella was anxious about the chemotherapy and was also in excruciating pain from the cancer.
As Ella's primary nurse, Madison had great deal of experience diagnosing and treating cancer pain. She immediately recognized that Ella needed intravenous morphine to control her suffering. But she worked in a system where doctors-even doctors with as little experience as interns beginning their residency training-were the only ones permitted to diagnose, treat, and prescribe. Indeed, for internal medicine services, newly minted doctors, under the supervision of residents, fellows, and attending physicians, were nominally in charge of hospitalized patients-and also of their nurses.
Reassuring Ella that she would do something to ease her pain, Madison walked down to the nurses' station in search of the intern in charge of the case. The young man, upon whose orders much of her work depended, was in his late twenties, tall, clean-shaven, with close-cropped black hair. He listened as Madison explained the problem and related her treatment recommendation.
"I don't know," the intern said nervously. "I don't think the patient is really in pain. I think she's just anxious about the chemo she'll be getting tomorrow. I'll write an order for Xanax (a tranquilizer) and that should do it."
Cognizant that she was there not only to care for patients, but also to teach novice physicians, Madison calmly repeated that the patient was having cancer pain. Xanax, while useful to treat any anxiety she might have also been feeling, would not alleviate her cancer pain. Morphine would. The intern, who like many novice physicians was extremely wary of narcotics, resisted the suggestion. No, he said adamantly, adding that he would go and see the patient.
About five minutes later, if that, he returned.
The patient, he informed Madison, was not in pain. It was just as he thought. She was anxious about her chemo.
"Did she say that?" Madison asked.
"No," he said, "the patient complained of pain." "But," he added, as he wrote the order for the Xanax, "she can't really be in pain because people who are in pain don't smile at their doctors."
Although frustrated that this young physician seemed unaware that, as one recent federal report documented, "patients may be experiencing excruciating pain even while smiling and using laughter as coping mechanisms," Madison once again tried to teach the young man about cancer pain as well as patients' responses to vulnerability and dependence. Patients, she counseled, often smile at their doctors and may not be assertive about their complaints, because they don't want to bother, contradict, or potentially alienate someone upon whom they depend for their very lives.
The intern was unmovable.
Over the course of the next two hours, Madison shifted tactics. Following the appropriate channels, she paged the resident who ranked above this intern in the medical chain of command. She would try to convince him to talk to the novice doctor and secure pain medication for her patient. When the resident responded to the page, he agreed with Madison. Morphine was just what the intern should order. The two went off to find the intern and the resident repeated to the young man exactly, almost word for word, what Madison had said about the rationale for this particular choice of drug. Listening to the senior doctor and ignoring the nurse, the intern nodded and dutifully wrote the order for the narcotic.
Madison went back to the patient and told her that the doctor had ordered the drug. She then administered the medication and monitored its effectiveness. Ella was finally able to relax. Although Madison diagnosed the patient's problem and recommended the correct treatment for it, when the interaction was recorded in the patient's chart, the intern was given credit for both making the diagnosis and ordering the medication. When Ella was about to leave the hospital several days later, she wrote notes to thank her caregivers. Although she jotted a short thank-you note to her nurses, there was no mention of what the nurse did to help relieve her pain. In fact, she saved most of her gratitude for her doctors. "Thank you so much," she told the intern, "for all you did for me."
When nurses go to work in a hospital or other health care institution, they expect to confront a certain number of predictable risks. They may injure their backs if they try to turn a patient without help, or lift a patient who's fallen in the cramped space of a hospital bathroom. They may stick themselves with an infected needle because another hospital worker has failed to dispose of it correctly or because some hospital administrators do not purchase safe needles. They may contract a new and mysterious disease like SARS. They may be verbally or physically attacked by a mentally ill patient who becomes violent or by a patient or family member frustrated with an increasingly impersonal health care system. Through a variety of workplace and legislative measures, nurses try to minimize these risks.
Other less publicized risks that nurses encounter jeopardize their patients. On a daily basis, nurses work with physicians who fail to communicate with them about critical clinical issues, deny them access to needed information and resources, subject them to verbal abuse when they try to do their job, and misinterpret collegial disagreements about clinical issues as challenges to medical authority and hierarchy. Some physicians rudely overrule nurses' clinical concerns and subject nurses to verbal abuse and humiliation. In rarer cases, some physicians physically abuse RNs. Added to this is the fact that the medical system often gives physicians credit for nurses' contributions. This means nurses have little experience with positive credit but have a great deal of experience with negative accountability. All of these patterns of communication and behavior make nursing a very risky job, and not only for the so-called uppity nurse who refuses to couch her questions and concerns in the demure rituals of medical dominance.
Even nurses who work hard at staying in their assigned place by observing the accepted rules of deference may find that MD-RN relationships can be hazardous to their professional self-esteem, as well as to their personal health and well-being. The incident I described above, for example, happened at a hospital in which nurses received a great deal of credit for their work. It occurred during the heyday of nurse empowerment in the early 1990s. But no matter how much institutional support nurses had-support that has, we shall see, largely disappeared today-they were still stuck in a medical system characterized by rigid inequality. While there is increasing attention to the problem of "disruptive physicians"-who often bully those they consider to be inferiors-little systematic attention is paid to the fact that the medical system as a whole is a disruptive, sometimes toxic environment for many who work in it.
Relationship Interruptus
Over the past thirty years, many articles have been written about this structured inequality. Two of the most famous-"The Doctor-Nurse Game" and "The Doctor-Nurse Game Revisited," published in 1967 and 1990 respectively-were written by the psychiatrist Leonard Stein. The original article analyzed why doctors failed to consult with nurses and why nurses adopted indirect or even passive-aggressive strategies to deal with doctors. Then in 1990, during the last nursing shortage, Stein and two other physicians reexamined the state of nurse-physician relationships. The authors argued that the women's and civil-rights movements had fomented a rebellion among nurses. More nurses, the authors insisted, were socialized outside the old hospital schools, had advanced degrees, and wanted to be viewed as "autonomous," "independent" professionals. The "new" nurse was more than willing to make direct recommendations. In fact, many bluntly challenged physicians. Others exhibited outright hostility to MDs. Some seemed to want to replace physicians and claim, as their own "domain," disease prevention, patient education, management of chronic illness, and holistic care or "treatment of the whole person"-things which doctors should do but too often ignore.
The "Doctor-Nurse Game Revisited" suggested that nurse-physician relationships were improving, because nurses were no longer tolerating medicine's traditional dominance. Twelve years later, however, one of the only systematic, quantitative studies of the impact of physician-nurse relationships on nurse retention painted a much more sobering picture. The principal investigator on the study, which was published in the American Journal of Nursing, was Alan H. Rosenstein, a physician and vice president and medical director of the VHA's West Coast hospitals. He and his coinvestigators sent out surveys to RNs and MDs in the VHA, which runs a quarter of the community-owned hospitals in the United States and is the largest employer of RNs in the country. The survey was designed to determine how physicians and nurses in the VHA system "viewed nurse-physician relationships, disruptive physician behavior, the institutional response to such behavior, and how such behavior affected nurse satisfaction, morale, and retention." The article reported on preliminary findings from the first 1,200 responses analyzed. Of these, 720 were from nurses and 173 from physicians from eighty-four different hospitals.
Respondents reported that nurse-physician relationships, which seemed less of an issue to physicians, were extremely important to nurses. Almost all nurses had experienced or witnessed some form of "disruptive physician behavior," which included screaming, berating of colleagues or patients, use of abusive language, and other instances of disrespect or condescension toward nurse colleagues. Nurses believed that disruptive physician behavior had a serious impact on morale and nurse retention. Many respondents cited examples of nurses who had, because of such problems, left a hospital or asked to be switched from a unit or shift because of them. Nurses also felt that physicians did not give them enough respect or understand the impact of their behavior. Most nurses stated that their institution did not deal effectively with the problem.
The psychologist Larry Harmon is the codirector of the Physicians' Development Program in Miami, which evaluates, educates, and monitors physicians and nurses and other health care providers. Harmon defines "disruptive behavior" as "any behavior which results in diminishing team members' ability to do their best work." He classifies such behavior as verbal, physical, and indirect behavior.
"Disruptive verbal behavior," Harmon explains, "includes sarcastic comments, snapping at others when frustrated, or talking down to people. Physical disruption occurs when doctors throw small objects when angry, raise their fists at someone, give someone the finger, or actually strike or assault someone." Indirect disruptive behavior includes things like criticizing people behind their back, spreading rumors, or pouting or intentional selective ignoring. "For example," Harmon says, "the physician won't talk to one particular nurse as a way of punishing him or her."
This kind of behavior has become such a problem that, in its 2002 alert about the nursing shortage, the Joint Commission on the Accreditation of Health Care Organizations (JCAHCO) also raised the issue of nurse-physician relationships. "Incidents of verbal abuse of nurses, typically by physicians, are unfortunately well known, even commonplace," the report stated. It called for a voluntary policy of zero tolerance in the workplace and suggested that medical societies develop guidelines to deal with abusive physicians.
In Canada, the Status of Women Sector of the Quebec Federation of Nurses conducted research to ascertain the level of violence against nurses in Quebec. Nurses told of being humiliated, screamed at, and subjected to temper tantrums as well as physical abuse. Ninety percent of the union's members said they'd been "victims of at least one act of assault or aggression during their career." Among abusers of nurses, doctors figured prominently. The number of incidents, the union said, indicated "that doctors can express their anger against their closest workers as they see fit."
In my interviews with nurses, their most common complaints were that physicians do not understand what role nurses play in the health care system, misunderstand whom nurses serve, do not value the knowledge and skill that nurses have amassed during their careers, and fail to appreciate that collaborative, cooperative, collegial relationships between physicians and nurses are central to quality patient care. Most nurses feel that although nurses work closely with doctors and respect their training, skill, and expertise, doctors do not reciprocate.
In his study of the hospital workplace, the sociologist Daniel Chambliss recorded similar complaints. "If there is a single dominant theme of nurses' complaints about their work, it is the lack of respect they feel, from laypersons, from coworkers, and especially from physicians. It is nearly universally felt and resented. 'The docs never listen to us,' they say, 'you don't get any recognition from doctors'; doctors don't read the nurse's notes in the patients' chart, don't ask her what she has seen or what she thinks, they don't take her seriously." Chambliss, who spent over ten years observing nurses and physicians interact, agreed with the nurses. The "daily evidence" of physician disregard, he wrote, was "truly pervasive; I was genuinely surprised at how common the obvious disrespect is."
When I was recently in Adelaide, Australia, a nurse manager of a cardiac unit related an illustrative incident. Because of the closure of an oncology service in the area, cardiac nurses were being asked to treat oncology patients at a cardiac unit that was being prepared to take on an extra load of cancer patients. The nurses were given a quick course to teach them how to deal with oncology patients. Before their hasty tutorial was even complete, an oncologist in the hospital admitted a patient to the unit. When the nurse manager told the physician that the RNs didn't yet know how to deal with chemotherapy drugs, and had not mastered the complexities of inserting needles into porta catheters (devices that are surgically inserted into the subclavian vein to allow easier, and over time less painful, access for chemotherapy and blood tests), he became irate. No oncologist would ever imagine that a cardiologist could simply stroll in and replace him. Nonetheless, this physician insisted that a cardiac nurse could easily replace an oncology nurse. "Surely someone around here can manage this. You are nurses after all," he fumed.
See One, Do One, Teach One
In medical schools, doctors in training are taught to do procedures through the process of "see one, do one, teach one." That also seems to be the way novice physicians are taught to look down on nurses. Listen to John E. Heffner, MD, medical director of the Medical University of South Carolina, "complimenting" nurses in the introduction he wrote in 2002 to a brochure about nursing that the hospital distributed for Nurses Week:
"We physicians at MUSC have much to appreciate in working with our nursing staff. Nurses amplify by their extended bedside presence the value of our brief daily patient encounters. The expertise and personal touch of our nurses drive much of the community's perception of our health care facilities. And the vigilance and judgment of our nurse permit us to travel to our daily duties yet still respond to any sudden clinical event.
(Continues...)
Excerpted from NURSING AGAINST THE ODDS by SUZANNE GORDON Copyright © 2005 by Suzanne Gordon. Excerpted by permission.
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