Life Support: Three Nurses on the Front Lines
By Suzanne Gordon
Little, Brown and Company, Boston, 352 pages.
It’s a tough time to be a nurse. My downstairs neighbor, a registered nurse, drags herself home from work most days exhausted and disgusted. As a result of nursing layoffs at her hospital, she cares for eight patients on most shifts, and given insurers’ pressure to discharge patients quicker, those are eight very sick people. Her only support is one aide who also assists the other nurse on her unit, who has eight patients to care for.
My neighbor says she can’t give her patients the kind of care they deserve, and now management has announced the need for another million dollars in cuts–some of which will come from the nursing budget. “I wouldn’t advise anyone to go to nursing school the way things are now,” she says, gloomily. After 15 years, she is ready to leave the profession.
My neighbor’s experience and sentiments are typical. A survey of 7,500 nurses, published in November in the American Nursing Journal, reveals a profession demoralized by cut-backs and speed-up. A majority of the 7,500 nurses in the study say that the increasing use of aides and technicians and growing reliance on part-time nurses compromise patient care. Nurses report that they are working harder than ever and nearly one-quarter of those surveyed say it is unlikely that they will stay in the field.
The 2.1 million nurses in this country comprise the single largest profession in health care. Anyone who has ever been hospitalized or sick enough to need home health care, knows that the face of health care is a nurse’s face. Even the best doctors see their patients for only a few minutes a day; the nurses are there around the clock.
And yet, in the debate about America’s rapidly changing health care system there has been virtual silence on the impact on nursing. Nurses are almost never quoted in media stories about managed care or hospital mergers. Nurses are rarely part of the corporate teams that are running–and downsizing–hospitals and other health care facilities. In other words, nursing is still being treated as the obedient handmaiden.
Suzanne Gordon’s new book argues that nursing is actually the bedrock of health care and that corporate cost containment strategies that cut and downgrade nursing positions pose a serious threat to the care of the sick. Cuts in nursing even harm the sacrosanct bottom line, she reports; several studies have shown that adequate staffing by qualified registered nurses is correlated with lower mortality rates and decreased lengths of hospital stay.
The “Life Support” of Gordon’s title has nothing to do with high-tech medical machines usually associated with that term, but to the largely unseen and unacknowledged care that nurses provide to the sick, the infirm, and the dying. The book contains a raft of facts and figures that demonstrate how cuts in nursing pose potential dangers to patient well-being, and how the under-valuation of nursing as a profession by physicians compromises the quality of health care. There’s also a fascinating historical overview woven through the book, spanning Florence Nightingale’s “invention” of modern nursing in the Crimean War of 1854, Lillian Wald’s pioneering work as a public health nurse at the Henry Street Settlement House on New York City’s Lower East Side in the 1890s, and the professionalization of the field in this century, which peaked in the 1980s with the introduction of advanced practice nurses and nurse practitioners.
Gordon describes nursing as a “tapestry of care, knowledge, relationship, and trust that is critical to patient survival.” Her book is not, unfortunately, a seamless tapestry. Awkward descriptions and misplaced first-person comments sometimes get in the way, and there are moments when her polemical style feels like finger-wagging to even the most sympathetic reader. However, in the vignettes describing the “Three Nurses on the Front Line,” Gordon makes a persuasive, and indeed, heart-rending case.
Gordon shadowed three exemplary nurses in Boston’s Beth Israel Hospital: Nancy Rumplik, an outpatient nurse in an ambulatory cancer clinic, Ellen Kitchen, a geriatric nurse practitioner who provides home care, and Jeannie Chaisson, a “clinical nurse specialist” who teaches and acts as a mentor to younger nurses, and also spends two or three days a week caring for patients on a general medical floor. Watching these women work allows the reader to see the best of nursing practice–intelligent, compassionate, and skilled. It’s also a lesson in how complex a job nursing is–even at its most apparently mundane.
For example, Gordon devotes nearly four pages to Jeannie Chaisson feeding breakfast to an elderly stroke victim. On the face of it, feeding a patient might sound like a task that could be safely entrusted to a less-trained (and thus less expensive) aide or technician. But because of Chaisson’s training and experience, the “simple” act of feeding is revealed as a diagnostic process, a therapeutic intervention, and a compassionate human interaction.
Mrs. Cohen (a pseudonym) was admitted from a nursing home to the hospital for “aspiration pneumonia,” a potentially life-threatening inflammation of the lungs that is not uncommon among people who have difficulty swallowing and thus may inhale their food. Swallowing, as Chaisson knows, is a complicated process that involves six nerves and 25 muscles. Brain damage from stroke can compromise this process in many ways, even to the extent of shutting off the gag reflex and permitting food to go directly into the lungs where it causes infection. Thus, when Chaisson feeds Mrs. Cohen, she monitors the patient’s color to make sure she doesn’t inhale her food.
When Mrs. Cohen starts to cough, Chaisson says, “Some might think she’s coughing because she’s aspirating. But in fact, she’s just bringing up the phlegm which I then have to suction out.” After breakfast, Chaisson places an oxygen mask over Mrs. Cohen’s mouth and nose to deliver a mist that will loosen secretions in the lungs and encourage her to cough more.
Despite the fact that her patient never says a word and gives no indication that she knows what’s going on, Chaisson talks to her, explaining what she is doing and why. She takes the time to treat Mrs. Cohen carefully and with respect, and in the process notices a small red spot that might turn into a bedsore and decides to turn her on her side later, to prevent any further breakdown of the skin.
Gordon notes that since the treatment of bedsores costs $1.355 billion a year, Chaisson has probably saved the system some money as well as sparing her patient the terrible pain of a pressure ulcer. But while dollars and cents reasoning often comes down on the side of spending money on skilled nursing services, her main point is that nurses put the “care” in health care. Although both doctors and nurses object to the facile formulation that physicians “cure” while nurses “care,” the real-life examples in this book appear to confirm the conventional wisdom that nurses are often the ones to advocate on behalf of the whole person in the hospital bed–especially when it comes to “end of life” issues.
Physician-assisted suicide has garnered most of the headlines in the national debate on medical treatment of the dying, but while nurses have far more experience with death and dying, their opinions rarely make the news. They are among the most vocal advocates for hospice care (indeed, a nurse’s idea in the first place) and for the kind of palliative care–especially pain management and increased nursing services–that eases pain and suffering at the end of life.
In one of Life Support‘s most moving scenes, oncology nurse Nancy Rumplik encourages one of her dying patients to talk about his life. The patient–himself a doctor–rallies and speaks with energy and animation. Rumplik explains, “When I take 15 minutes to talk about his work, it affirms the validity of his life. He is not just a person with cancer, he is a person who has an identity that extends beyond his illness, even beyond his death.”
hen Gordon began research for her book in the late 1980s, nursing appeared to be on the threshold of a professional breakthrough; pay scales and benefits were up, nurses were being brought into the highest ranks of hospital management, nurse practitioners were gaining prominence. “Primary nursing,” a holistic, comprehensive model pioneered at the Beth Israel, had increased work satisfaction to unprecedented levels. Ongoing nursing education became a priority, giving younger nurses the opportunity to learn from the likes of Jeannie Chaisson.
But today, primary nursing is being undermined by staff cuts and the increasing use of aides. Nancy Rumplik reports that her cancer unit is so busy, there aren’t enough chairs for all the chemotherapy patients much less the kind of time that allows for caring relationships with individuals. Chaisson’s job has been redefined so that she instructs younger nurses only one day a week. She says, “There is more and more pressure to push people out of the hospital. Insurers are telling you to discharge a patient at 8:30 at night because they don’t want to pay for another day in the hospital. And nurses, like everyone else, are asked to get involved in that.”
Gordon places the blame for most ills besetting nurses on for-profit health companies and a corporate culture that tolerates cuts in nursing services while health care executives pull down huge salaries and shareholders pocket handsome earnings. Her prescriptions for preserving the “tapestry of care” include a concerted effort by nurses to educate the public about the dangers of understaffing and under-skilled providers. She calls for more media attention to nursing–a tough sell in a nation that still treats doctors like God and views high-tech medicine as the means to immortality.
She also suggests that consumers become more vigilant about health care services. So in addition to checking out our doctor’s track record and credentials, we need to ask questions about hospital nurse-to-patient ratio on medical and surgical floors. (Would you rather be cared for in a unit where there is one registered nurse for every four patients, or one for every twelve?)
The fundamental problem fueling the current crisis in nursing is, as Gordon puts it, “the utterly irrational health care financing system that allows private interest to make billions in profits from the pain and suffering of their fellow citizens.” The wholesale restructuring of health care financing is clearly outside the scope of this book. However, Nancy Rumplik, Ellen Kitchen, and Jeannie Chaisson are, in themselves, the most potent arguments against a profit-based and for a patient-focused health care system. If women like these are disheartened and even discouraged enough to leave the profession they love, we will all suffer the loss. Because if it’s a tough time for nurses, it’s a tough time for patients–a “special interest” group that may eventually include you and me.
Anita Diamant is a Boston-based writer. Her first novel will be published by St. Martin’s Press later this year.