Changing how the world thinks about nursing

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"These days there's far too much emphasis on academia and an overwhelming desire to achieve an equal status with doctors."

July 25, 2006 -- In two recent broadsides in major U.K. papers, anonymous physicians essentially argue that nursing must be saved from itself. They are "Are nurses angels? I don't think so," a piece by an unnamed male physician in the July 18 Daily Mail, and "Why nurses are no angels," a June 20 piece by "Lucy Chapman," a pseudonym, that appeared in the Independent and the Belfast Telegraph. These paternalistic pieces urge the National Health Service (NHS) to stop assigning nurses new management and clinical roles, a practice that has supposedly helped produce a generation of nurses who are stupid, uncaring, lazy, and too eager to dump everything on physicians, while wrongly seeking the same high status. Instead, the pieces argue, nurses should focus on the basic caring and hygiene tasks the physicians think define nursing. To its credit, the Daily Mail today ran responses from nurses, who argue that they are hardworking and committed but overworked. The two physician op-eds purport to be by authors of different genders. But their similarities suggest that they were written by the same person or group. Toward the end of each piece, the op-eds reach what we believe is their main goal: to discourage the U.K. government from allowing nurses to move into clinical roles that have traditionally been the exclusive province of physicians. But the existing research shows that the care of advanced practice nurses is at least as good as that of physicians. So one strategy to prevent the expansion of nursing roles is to paint current bedside nurses as dense, uncaring slackers, and argue that a key cause is misguided efforts to encourage them to assume new roles. Needless to say, then, those little nurses must be kept far away from the powerful physician domain.

The two long physician op-eds follow the same basic path: (1) an anecdote about a lazy, incompetent nurse paging the author about a serious patient issue she should have handled herself or notified the physician about far sooner; (2) general assertions that most U.K. nurses now are similarly uncaring, inept, and a major drag on the functioning of committed young physicians like the author; (3) assurances that there are some good nurses who focus on "care," "dignity," and "cleanliness," but they are a minority because the profession has been simultaneously dumbed down and encouraged by the NHS to aspire to high-level functions well beyond its proper scope, such as drug prescription; (4) touching statements that society has undervalued the "caring" function of nursing, and so we must give nurses higher pay and increase the number of "competent" "senior" nurses who can train a new generation; and (5) strong concluding arguments that we must resist government efforts to encourage nurses to "pretend" to be physicians with expanded clinical roles, since nurses who wish to be physicians must "go to medical school."

On the "pretending to be physicians" point, both pieces offer scary comparisons to having persons in other high-stakes work settings do difficult things they were not trained to do. The Daily Mail piece suggests that advanced practice nursing is like a teenager fighting a fire after watching a few TV shows about firefighting. The Independent one suggests it's like having an ""air-hostess" fly a plane in dangerous conditions, an argument that is a particular favorite of some U.K. physicians, as other press pieces have shown. Of course, we're not aware of a wealth of research showing that flight attendants fly planes as well as pilots do. And in contrast to teenage TV fans, advanced practice nurses have a wealth of university health care training to do exactly what they do.

The longer Daily Mail piece includes some additional features worth noting. It paints a detailed picture of lazy, inept nurses who constantly page physicians for no apparent reason, or for reasons they can't begin to articulate (they're just "worried"). These nurses leave patients "for hours when they have soiled themselves," whether because of short-staffing, not-my-job-ism, or the fact that the nurses "simply don't care." In an interesting twist, the piece pauses to note that bachelor's-prepared nurses "such as my girlfriend" have actually chosen nursing over other careers "because they really want to care." Physicians can learn a lot from such nurses, the author assures us, but they are becoming less common. The reasons are that the NHS has created a system that encourages a "who cares?" attitude, and that nursing has been "dumbed down" from its former status as an "intellectual and well-respected career" because bright women can now become physicians. This has led to a perception that nursing is a "second-rate profession," and a reality that "those who are academically successful rarely choose to go into it." Sure nurse training is "much more academic," but apparently that just makes nurses think that "hands-on stuff no longer matters as much." The end result is that nurses no longer have a "vocation" for "ministering to patients," and indeed, that they lack the "common sense" and thinking ability to do so. Instead, "it's all about becoming a manager." The author singles out the many U.K. nurses from Africa; he says they struggle greatly with the new practice setting, and for the most part are "indifferent in the extreme."

There are certainly some real issues mixed in among the anecdotal aspersions and logical inconsistencies. The stress nursing has experienced as a result of expanded career options for women, the continuing lack of real public respect for the profession, the serious practice issues associated with the flight of homegrown nurses from the bedside and resulting increase in nurse immigration, and the need of many nurses for higher pay. Not everything the author says is inaccurate or imaginary, and we share some of his concerns. Obviously, all professionals should get adequate training and resources for their duties, and if a given scheme fails to provide that, it should be changed. In particular, we don't doubt that the abysmal working conditions nurses face today have demoralized or driven away many excellent nurses, and resulted in low standards of care in some settings.

But overall the piece is full of the destructive attitudes that lie at the heart of nursing's problems. Many nurses have recently left the bedside for advanced practice roles, but a major reason has been the short-staffing that this piece largely ignores--short-staffing that is fueled by regressive attitudes about nursing. It also makes little sense to say that nursing is "intellectual," yet more academic training has ruined hands-on care; is that how it works with medicine? Should we reduce physicians' academic training because it makes them uncaring? Despite the nominal reference to nursing's "intellectual" quality, the assumption here is clearly that nursing is all about basic hands-on care, and not high-level thinking. Modern nurse training has apparently intoxicated nurses with dreams of being real professionals, and distracted them from their real role, making them too posh to wash. The reference to the author's girlfriend is a nice rhetorical touch, but it counts for nothing given the underlying themes of the piece. The piece fails to recognize that nursing is a distinct scientific profession with its own unique health knowledge base and scope of clinical practice. Nor does it offer any evidence to support the idea that academically successful nurses are "rare." There is no evidence here that nurses in advanced practice roles have provided poor care. In fact, the "vocation" and "ministering" language reflects classic paternalistic contempt in the guise of concern: we need to get back to nurses as noble, spiritual beings who would never dream of gaining significant clinical power, questioning the way physicians do things, or, Heaven forbid, suggesting that they could do them at least as well. However, there's nothing magic about medical school that means it is the only way to learn how to do many of the things that physicians have traditionally done, as the 140,000 U.S. advanced practice nurses show every day. On the contrary, many current reforms in U.S. medical training appear to reflect a growing appreciation for elements of nursing training and practice.

The responsive letters that the Daily Mail printed on July 25 make some good points. The heading of the item collecting them is: "Nurses? It's doctors who are the real problem." The brief introduction notes that the physician's July 18 piece "stirred up an overwhelming response from nurses," most of whom "strongly disagreed with his damning criticisms of their profession." One key theme was that nurses in fact work extremely hard ("we work our socks off"), and that the scenario presented in the physician's initial anecdote--a nurse sitting around reading a magazine when there was work to be done--was farfetched. More than one nurse linked the difficult work conditions to short-staffing. Several tried to turn the anecdotal tables, discussing instances in which physicians had made egregious errors, failed to respond to urgent and legitimate nursing requests to help with a patient, shown extreme insensitivity to vulnerable patients, or engaged in disruptive conduct with nurses ("Doctors often talk to nurses as though we are second-rate.").

A thoughtful letter by cardiac rehabilitation nurse Rob Harteveldt points to some important physician problems he has seen, but he notes that he is more interested in defending nursing, so the professions can work better together. He argues that nurses face systemic short-staffing, that nurses taking on new roles are not trying to be "pretend doctors" but will consult with other nurses or physicians if they are unsure, and that nurses are as entitled as physicians to aspire to senior positions. He also rightly notes that the idea that nursing is a "vocation" rather than a career has long been used to keep the profession down. And he assures readers that academic training has not overshadowed the importance of basic care. He closes by suggesting that "one day it will be our nursing expertise that saves the disgruntled house officer in last week's Mail from making a terrible mistake."

One interesting aspect of the published letters is how little focus there is on the question of expanded practice roles, apart from the brief discussion in Harteveldt's letter. No published letter suggests that the physician op-ed is really an elaborate way to justify keeping nurses away from traditional physician tasks in order to preserve physician power and revenue. In this sense, the op-ed author appears to have succeeded in masking what we believe was the author's true intent. While the responding letters focus on whether nurses actually work hard and care about their patients, and whether physicians have problems too, readers hear virtually nothing about whether nurses are clinical experts who are ready to assume additional roles.

The Mail published one dissenting letter from a nurse. In that one, 20-year-veteran nurse Louise essentially argues for what might be called the harsh handmaiden school of nursing:

When I trained, we were taught to treat our patients with respect. These days there's far too much emphasis on academia and an overwhelming desire to achieve an equal status with doctors. In my day, discipline was paramount. Our uniforms were inspected daily and if the observation charts were not filled in correctly, we faced the wrath of the ward sister. We quickly learnt to be diligent and thorough. The nursing profession needs to return to these traditional and rigorous standards of training.

We're guessing the anonymous physician op-ed writer could not have said it better.

See "Are nurses angels? I don't think so," by an unnamed male physician in the July 18 Daily Mail, and "Why nurses are no angels," a June 20 piece by "Lucy Chapman," a pseudonym, that appeared in the Independent and the Belfast Telegraph. See the responses from nurses and others printed in the Daily Mail.