Code Green: Money-Driven Hospitals and the Dismantling of Nursing (2003)
By Dana Beth Weinberg
Foreward by Suzanne Gordon
ILR Press/Cornell University Press
The title says it all. Sociologist Dana Beth Weinberg's Code Green tells how two Boston hospitals responded to severe market pressures by merging in 1996 to become Beth Israel Deaconess Medical Center, in the process seeming to sacrifice quality nursing care and patient wellbeing on the altar of cost-cutting. The book, though flawed, is a powerful and insightful defense of quality nursing in the managed care era. It presents dedicated professionals who are used to managing their patients' care watching helplessly as short-staffing and restructuring undermine their practice and authority, drive them to burnout, and reduce some to tears.
Weinberg's stance on how to promote excellence in nursing care actually spurred the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) to pressure Brandeis University to cancel Weinberg's appearance at a 2004 conference on the nursing shortage because of hospital complaints about her "perceived bias."
Weinberg suggests that this basic story has become too common across the U.S., though she could have explored the policy implications of what's happened to nursing and what might be done about it in more depth. The book, based on Weinberg's doctoral research, is well written and enlivened by comments drawn from her interviews with hospital personnel. Even so, it remains an academically-oriented work mainly for those interested in health care structures or workplace sociology. Sadly, the book does not acknowledge nursing's unique knowledge base or scope of practice, and it appears to mistake a lower level of power for fundamental subordination, leaving the impression that nurses are skilled physician assistants.
In the 1990's, as Weinberg explains, many U.S. hospitals became increasingly desperate to make ends meet. Rising health care costs had been a major problem for many years. Reimbursement rates began to drop as private insurance entities gained power to bargain in the managed care era, and dropped sharply in the wake of the Balanced Budget Act of 1997, which restricted Medicare reimbursement. As a result, the hospital industry increasingly turned to prevailing private sector business practices to cut costs, including consolidation, internal restructuring, and lean staffing. This often meant that fewer nurses struggled to care for more patients. Many tasks previously done by registered nurses simply did not get done, or were performed by assistive personnel with far less training, even though hospital patients were now sicker and rushed in and out of facilities because of these same reimbursement pressures. Weinberg aptly describes this situation as a "code green," a reference not only to the increasingly "money-driven" nature of care, but also to a term used at some hospitals for an urgent facility failure.
In Boston, two Harvard teaching hospitals responded to this situation by merging. In 1996, Beth Israel Hospital and the neighboring New England Deaconess combined to form Beth Israel Deaconess Medical Center (BIDMC) in an effort to survive in the increasingly competitive Massachusetts health care market. Beth Israel was legendary for the strength and professional quality of its nurses, and for having pioneered, since the 1970's, a "primary nursing" model under chief of nursing Joyce Clifford. Under this globally influential model, each nurse was responsible for planning and coordinating the care of specific patients from admission to discharge. (Suzanne Gordon, who contributes the foreword to Code Green, profiled Beth Israel nurses before the merger in her book Life Support (1997). Gordon serves on the Center's advisory board.) Deaconess nurses, by contrast, generally had less formal education and operated with less discretion under a relatively standardized practice model. They prided themselves on cost-effectiveness.
By Weinberg's account, the mixing of these two cultures was not a success. Though the new BIDMC was ostensibly to adopt the primary nursing model, and Beth Israel nursing executives initially dominated the new nursing service, Weinberg shows how BIDMC nurses across the board came to feel that they were struggling to overcome a lack of institutional support, especially human and other resources. Some of this was inevitable. Many Beth Israel nurses did not respect the Deaconess model, which they felt offered less than what patients needed from nurses. Many Deaconess nurses regarded the Beth Israel approach as a wasteful luxury hospitals could no longer afford, and the Beth Israel nurses themselves as "very Nancy Nurse-y," as one Deaconess nurse memorably put it.
Although it's not clear if Weinberg is aware of it, these two models to some extent represent competing views of nursing generally. It would be easy to oversimplify, but such disputes could be seen to implicate a fundamental issue: are nurses professionals or skilled technicians? Are they critical thinkers and autonomous actors who use their unique knowledge base to advocate for patients under a holistic care model, even if that means taking extra time and assertively challenging the positions of physicians or others on the health care team? Or are they less concerned with solving broader problems and advocating for patients based on a unique practice focus, and more with using pre-determined procedures to operate in a highly efficient way?
However nurses with these differing perspectives might have integrated in an ideal merger, what Weinberg found in her focus groups, interviews, and other data shows that the BIDMC merger was not ideal. The restructuring and the new "flex staffing" policy effectively increased the patient loads of individual nurses, and made them responsible for more tasks in the hospital as support positions and resources were cut back. At the same time, the formerly powerful Beth Israel Nursing Department was splintered, greatly reducing the profession's institutional status. Increasingly frantic bedside nurses became alienated from nursing administrators, who reacted defensively to concerns for patient safety, which they characterized as a self-serving resistance to change. Weinberg also shows how nursing practice was disrupted by particular problems flowing from the restructuring in specific units, such as coordination problems in the new combined Emergency Department, and turf battles between surgeons from the two original hospitals in the new cardiothoracic unit that led to a decline in nurse-physician collaboration.
Weinberg does an excellent job of describing the effects of the nurse short-staffing at ground level. Her account is dispassionate but at times heartbreaking, as nurses desperately tried to provide basic survival care, often at the expense of the patients' long-term interests and psycho-social needs, not to mention the nurses' own mental and physical wellbeing. The nurses felt powerless to fight the changes in any meaningful way, instead turning inwards, sacrificing and blaming themselves for the poor care many felt they were providing. The book certainly presents the hospital administrators' contrary views, but Weinberg effectively suggests that the quality of patient care was affected, relying on anecdotes, survey data, and broader research by Penn nursing scholar Linda Aiken and others as to the role of nursing status and resources in patient outcomes. Weinberg notes the increase in complaints to the BIDMC central nursing office. She might also have noted that because much key nursing care takes place in nurses' heads and is not well understood by non-nurses, its absence might not be easily recognized by patients and families, to say nothing of administrators and their financial consultants.
Weinberg indicates that the evidently declining care quality seen at BIDMC may be becoming "accepted industry practice," but that such cost-cutting strategies may not even achieve their most basic goal--restoring financial viability--in view of likely side effects including nurse turnover and adverse patient events. She also suggests that these practices have been a major factor in the critical nursing shortage, and she issues a timely warning that short-term nurse recruiting fixes will not solve the underlying care problem.
The author might have explored in more depth why this has happened to nursing, what it may mean about modern U.S. society, and what might be done about it. Weinberg shows the pernicious effects of the merger on the BIDMC nurses and their patients. But she is vague on what the hospital might have done differently, and more fundamentally, what society might do differently in crafting its health policies. Is it simply a matter of strengthening our commitment to paying for the health care we need in what journalist Laurie Garrett has persuasively called an "anti-government" era for public health? Should we work to increase public and private sector reimbursement? Should there be new regulatory structures, such as the nurse staffing ratios that California enacted in 1999? And what of nursing itself--was it arguably the biggest sacrifice of the managed care era (other than patients) because it remains underpowered, underfunded, and underappreciated? Are lessons to be drawn from other professions under comparable stresses, if there are any? And perhaps most importantly, how might nursing fight back?
This last issue underlines what may be the book's greatest problem. The book does not seem to reflect understanding of nursing's autonomy, nor its unique practice focus and body of knowledge. It is not clear from Code Green whether the level of professional strength the Beth Israel nurses enjoyed under their "primary nursing" model before the merger is part of a large nursing tradition, or is shared by nurses elsewhere. In fact, despite its low level of practical power, nursing is an autonomous profession with a distinct, holistic practice focus, and a unique body of nursing knowledge. Nursing is an autonomous discipline: nurses are trained by nursing scholars who teach at nursing schools and develop nursing science. But nursing also has many of the hallmarks of autonomous practice, since state laws typically define nursing practice in distinct terms that do not depend on physicians, nurses are licensed by nurse-controlled state boards, nurses have independent malpractice liability and codes of ethics, and nurses typically are hired, fired and managed by other nurses. Though there is clearly a significant overlap with medicine, nursing is not a subset of or dependent on medicine. It is a theoretically and practically distinct scientific profession.
Again and again (see, e.g., pp. 16, 80, 112, 115, 133, 177-78), Weinberg asserts that physicians have the final word on all aspects of patient care, and that nurses are "fundamentally subordinate" to physicians. For this latter idea, she at one point (p. 133) cites seven different authorities, an overwhelming number given her practice elsewhere, and one that suggests she left no stone unturned in a fruitless search for any signs of non-subordination. However, every single one of these sources is a sociologist, and not a single one appears to be a nurse. The work of these sociologists is informed by feminist, critical realist and other social and academic perspectives, and there is no doubt that nursing has traditionally been regarded as "subordinate" to medicine by most of society, including many physicians and--yes--even some nurses. It is also obvious that nurses generally have far less practical power than physicians, that social constructs tend to reflect that, and you can easily argue that all this undermines nurses' autonomy. (See our FAQ on nursing autonomy.)
But it is misleading to present nursing "subordination" to medicine as a simple, uncontroverted fact, without discussing nursing theory or the scope of nursing practice. There is a difference between a relative lack of power and subordination, which suggests that one party reports to another in a formal sense, i.e., a master-servant relationship. Physicians are no more the conceptual "masters" of nurses than the United States is of India. Code Green gives the impression that, while nurses at the peak of their potential power (e.g., pre-merger Beth Israel) may have real influence on patient care decisions, the ultimate authority for everything rests always with physicians. In bad times, it seems, it is simply the nursing role to carry out physician "orders" (granted, a severely under-staffed nurse may well choose to focus on physician-related tasks, for several reasons, but even that does not define her practice). In other words, the book suggests that the physician role varies between ruthless authoritarian and benevolent monarch.
There is little if any indication in Code Green that nursing expertise extends beyond physician expertise, and no mention of nurses' professional obligation to advocate for patients even in the face of physician opposition. Such advocacy may include persistent discussion, obtaining interdisciplinary ethical consults, refusing to participate in care plans or practices nurses deem unsafe, and if necessary going to the appropriate administrative or other authorities to stop such actions. Do nurses find any of that easy to do, given current power structures? No, and it's also no surprise that the BIDMC nurses felt helpless. But that does not make them "fundamentally subordinate."
If nurses' influence on patient care is merely a matter of physicians' grace and is confined to the boundaries of physicians' practice, then nurses' ability to protect themselves and their patients is accordingly limited. Of course, they can organize and bargain collectively, as Weinberg suggests. But if nurses are autonomous professionals with a unique practice model and scope of care--if they are not a class composed only of "physician subordinates"--then they have a far stronger base on which to build and advocate. Indeed, the author of the book's foreword, Suzanne Gordon, co-wrote From Silence to Voice, the thesis of which is that nurses must speak up assertively about their unique practice role and knowledge.
This is not to say that Weinberg does not appreciate what nurses do, including their effects on patient outcomes. Indeed, perhaps the most eloquent statement of Code Green's support for nursing in its embattled state is in the dedication. After her parents, Weinberg dedicates her fine book to "the nurses, for the care they want to give."
Weinberg's analysis of the efforts to strengthen nursing was apparently so scary to hospitals, that the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) cancelled Weinberg's appearance at its 2004 conference on the nursing shortage because of hospital complaints about her "perceived bias."
Review by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Reviewed April 24, 2005
The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.