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Family presence and nursing presence

October 12, 2004 -- Today the Wall Street Journal published a lengthy unsigned article on family presence during major hospital procedures that recognized that nurses had been most active on the issue and that featured good quotes from several nursing experts. Unfortunately, even this otherwise commendable piece was undermined by powerful elements that clearly told readers that physicians provided all of the meaningful underlying care, suggesting that the nurses were merely knowledgeable about how observing the care affected family members.

The piece is "Hospitals Let Families Witness Procedures: Staying with Patient in ER or ICU Can Have Benefits, but Some Doctors Object." Its basic thrust is that U.S. hospitals are increasingly confronting whether and when family members should be permitted to be present for major procedures, such as in the operating room or emergency department. There appears to be a minor trend toward allowing this presence, at least in certain situations, because of potential benefits to family members who may be able to comfort patients, gain a sense of control, or at least achieve closure. However, evidently family presence is still not allowed in most hospitals, with perceived drawbacks including the possibility that family members can become overwhelmed and that the practice could disrupt the procedures themselves.

The article makes clear that the shift towards allowing family presence has been "largely championed by nurses, who say they see the benefits of family involvement first hand;" it notes that nurses have "helped" to create new hospital policies on the issue. The piece makes clear that physicians are far more reluctant to support family presence. One surgeon is quoted expressing the fear that some procedures may seem "hectic and disjointed" to those who don't know what's going on, noting that he "asks nurses to judge" if particular family members can handle it. The piece does not explore the extent to which such concerns may relate to potential liability issues, but it does note elsewhere that in some hospitals nurses or social workers explain to family members what is going on, which would presumably alleviate any potential confusion. The piece cites a major nurse-conducted study published in the American Journal of Nursing which found that family members at a Texas hospital were "uniformly pleased" with their experience staying with patients for invasive procedures. It also includes quotes from that study's author as well as two other nurse experts, compared to only one physician (one of the two family members quoted also happens to be a nurse). The article on the whole is a fairly balanced look at this important subject. Moreover, it is very unusual for a nurse-driven issue to receive such extensive coverage in an elite U.S. newspaper, and for nurses to dominate the expert discussion within such an article. The Wall Street Journal and its anonymous staff writer(s) deserve credit for the piece to this extent.

Sadly, even this article repeatedly suggests that physicians are the ones who actually perform the major procedures that family members may be permitted to witness, and that the nurses are largely observers who presumably have time to worry about how the scene may affect nearby family members. The piece creates this damaging misimpression right from the start: the very first sentence refers to steps to alleviate "one of medicine's most trying ordeals: That wait in the hall while doctors are working on a loved one." Obviously, this suggests that only physicians are performing the life-saving procedures, or at least that only their work matters. That implication is outrageously false: nurses save lives every day in trauma settings, and they are a critical part of OR and ED teams in every hospital. The third paragraph suggests that the author(s) are not completely unaware of this, noting that proponents argue that family members are not a "hindrance to doctors and nurses, even in major medical emergencies." But in the fifth paragraph, it's back to the physician-centric fantasy world, as we hear that a Boston hospital has begun allowing family members to stay during codes when "doctors may need to shock the patient or open up the chest to massage the heart." Of course, contrary to the image presented by popular televisions shows like "ER" for the last decade, it is ED nurses who typically defibrillate patients. Later, when we learn about the benefits nurses see from family presence, the first one listed is this: "Families can give on-the-spot medical information to trauma doctors." Contrary to the implication here, nurses collect a great deal of important information in their own patient interviews, which are critical to nurses' ability to save lives in trauma settings.

More subtle elements also contribute to the marginalization of nurses even in this nurse-intensive setting. While the piece commendably cites the 2001 AJN study noted above, it does not actually make clear that the study was performed by nurses, nor when quoting the author does it note that she is a nurse. Instead, she is described as "director of emergency and critical-care services" at a Colorado hospital. The public needs to know that a nurse can hold that job. Even the language used to describe the role of nurses in changing hospital policies on family presence sends a subtle message. On both occasions that the piece quotes nurses who have done this, it notes that they have "helped" set up the new policies. This may well be an accurate description of what happened, but we can't help but wonder if the same word would have been used to describe the roles of two physicians in making separate critical changes in care practice, or if it would have been something more like a statement that they "drove the change," or "were a key force," or even the softer, "were instrumental." Likewise, nurses may have "championed" these changes, but can we say that they are actually changing the way health care works in this respect? Or at least changing the way people think? Are those things that nurses do? Or do they just "help?"

Please write to the Wall Street Journal's editors at newseditors@wsj.com2