By Sandy Balfour
Jeremy P. Tarcher/Penguin
British journalist Sandy Balfour's Nursing America is a look at the lives and work of skilled nurses coping with the inequities and violence of urban America at a major public hospital. Balfour is a good listener, and the most powerful parts of his book are the stories and commentary of nurses who explain some of what they do, and why they work at Memphis' Regional Medical Center, or "the Med." At a time when understanding of nursing remains dangerously low, this engaging, nurse-centered book has much to offer.
Unlike the physician-centric vision of most media accounts, the book's perspective on health care is largely nurse-focused. It frankly reveals the author's own movement away (though not completely away) from the handmaiden and angel stereotypes of nursing. Indeed, Balfour is astonished at the high skills, autonomy and compensation of the nurses he finds at the Med. He does not overtly suggest that they report to physicians. And he explains some of what nurses actually do, following them in patient interactions in various units and recording some of their real-time comments. At one point, he has a nurse translate her nurses' notes into lay terms. Balfour repeatedly suggests that the most important things to the nurses are autonomy, respect, and adequate staffing. He focuses on clinical nursing leaders, including Advanced Practice Registered Nurses (APRNs). He makes clear that nurses come from both genders and different ethnic backgrounds. The book refers to the financial pressures that lead to short-staffing, and how the Med has dealt with them, though--curiously considering where Balfour's sympathies appear to lie--he appears to accept the management's account of a recent dispute, offering no real counterpoint.
At the heart of the book are the portraits of the nurses. They include Marye Bernard, APRN, a Family Nurse Practitioner who cares for patients in the Med's outpatient AIDS unit. Bernard reveals a powerful combination of technical knowledge, practical wisdom and evangelical toughness. Confronting a patient who is reluctant to drink enough water because her family never did, Bernard tells her: "So break the chain, sister...You got to look into yourself and you break the chain."
Rhonda Nelson, RN, the Med's vice president of patient services, manages the hospital's 500 nurses. By Balfour's account, Nelson manages to cope with the hospital's seemingly permanent budget crisis with a Christian faith-based focus on the impermanence of all things--and by actually praying for the Med, in particular its CEO when he goes to meet with the Governor. As for the challenges of the work itself and her nurses' skills, she notes that "[f]or nurses in America this is as bad as it gets."
Peggy Simpson, RN, manages the 18 nurses in the hospital's elite burn unit, where she is, by her own delicate description, the "Queen Burn Bitch." To his credit, Balfour focuses closely not only on Simpson's intense personality but on her skill and expertise. He is obviously surprised to see that she essentially co-leads the burn care team with the chief physician, and by the level of respect that physician shows her.
Unfortunately, the book reflects only a limited understanding of nursing principles, history, and current issues. Thus, it states but does not clearly explain how nurses save lives. Likewise, it briefly acknowledges problems like the shortage and short-staffing, but does not adequately explain their roots or global significance--despite noting that almost all the complaints Balfour heard from the Med's nurses were about staffing levels. The result is an unduly positive view of the current state of the profession.
Other issues are not adequately pursued. We do not hear about the nursing process, beyond a brief description of an op-ed in which a nursing leader notes that nurses "prevent bad things from happening." At times Balfour marvels at APRN compensation without making clear the additional formal education required to reach that status, or providing a comparison to physician pay for perspective. Rhonda Nelson notes that the Med has not decided whether to pursue magnet status, but we never get even a basic explanation, much less a discussion of how the magnet status measures contribute to patient survival. And in a book full of nursing anecdotes, would even one about the short-staffing that was the source of virtually all the "complaints" have been too much?
Parts of the book reveal the tenacity of the handmaiden stereotype. The physicians are invariably Dr. ____; the nurses are always called by their given names. Dr. Sheldon Korones, whom Balfour clearly reveres, is presented as having "managed" the Med's Newborn Center, an elite NICU, for 35 years. (Nurses manage nursing, physicians manage medicine). Korones is also permitted to deliver a tribute to the excellence of the unit's nurses which unfortunately includes a subtle handmaiden message (they're all a team, though of course "the hierarchy must stand;" teaching hospital "doctors-in-training know less than the nurses in some areas").
The author works hard to maintain a tone of reportage, rather than advocacy. But it is pretty clear that he is dismayed at the United States' reluctance to finance its public sector health care, at the low level of health among this rich nation's poor, and at the potential effects of living in what may be the most violent developed nation in the world. All of this contrasts sharply with the decency, intelligence and good humor of the individuals he finds at the Med. As one of the Med's nurses tells him: "Welcome to America."
Balfour makes a commendable effort to identify what attracts highly skilled nurses to such a difficult work environment. He considers some of the potential factors--money, wanting to help, the Med's local prominence. But he ultimately suggests that it may be a sense of belonging, belonging to a "quintessentially human," dynamic institution confronting the permanent crisis of public sector care. Of course, we all want to feel we belong, but as a complete explanation of nurse motivation, this seems too self-focused.
Isn't it possible that nurses work at the Med at least in part for the same reason nurses have always worked on the harshest frontiers of care, because it is part of the nursing vision to restore to full mental and physical health those who have fallen farthest from it? Couldn't it be that these nurses, through skill and care, promote humanity's sense of belonging, of being part of a whole? Had Balfour done as much research into the theory and practice of nursing as he obviously did into the distressing measures of urban U.S. health, he might have been able to link his striking year at the Med to the work of modern nurses all the way back to his compatriot, Ms. Nightingale.
Review by Harry Jacobs Summers
Nursing Editor: Sandy Summers, MSN, MPH, RN
Advance Copy Reviewed October 18, 2004
The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Center for Nursing Advocacy.