Changing how the world thinks about nursing

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Breast implant surgeonJuly 14, 2009 -- Two recent press articles reflect some of the complex issues nursing faces in Europe during the current shortage, though the specific subjects of the stories could hardly be more different. Today, the Denver Post ran an Associated Press story by Daniel Woolls reporting that the infant son of the first person to die of H1N1 flu in Spain had himself died because of what appeared to be a tragic nursing error. The piece says that a nurse working her first shift in the NICU had apparently fed the baby formula intravenously, rather than through a naso-gastric tube. The main Spanish nursing union urged caution pending an investigation, stressing that the nation's hospitals do not have enough nurses, and those who are working may not have the specialized experience needed on their units. On May 24, the New York Times published a piece by Dan Bilefsky focusing on the inducements desperate employers are offering to lure nurses to jobs in Prague, the capital of the Czech Republic. These include free plastic surgery. Reactions to this not only underline the severity of the shortage in a nation that has lost many of its nurses to better-paying jobs abroad, but also reveal public attitudes toward the underpowered profession, which is still associated with female subservience and sexual attractiveness. Taken together, these generally good pieces suggest (though neither actually says) that nurses remain caught in a dangerous disconnect between their image as disposable female helpers and their actual life-and-death responsibilities to patients.

The error

"Where attractiveness is often as highly prized as clinical skills"

 
The error

The AP story was "Nurse in Spain baby death new to neo-natal care." It reports that the apparent error occurred at Madrid's Gregorio Maranon Hospital--the same one that had sent the infant's mother, Dalila Mimouni, home twice in June before ultimately diagnosing her with H1N1 "swine" flu. Her son Rayan was delivered in late June by Cesarian section at 28 weeks, and his mother died the next day. The baby apparently did not have H1N1 flu.

Unfortunately, according to "hospital managing director Antonio Barba," the child died because of the unnamed nurse's "horrific error" in feeding him the formula. According to Juan Jose Guemes, the regional health minister, the nurse had previously worked in pediatrics and critical care, but never in the NICU. The nurse has reportedly been "suspended pending an investigation." Other press accounts have suggested that a criminal prosecution is possible, though as in other recent cases involving alleged nursing errors, prosecuting a health care professional for an error (rather than some intentional wrongdoing) would appear to be dangerously bad policy. The AP story does note that the widower, identified as Mohamed, is considering suing the hospital for failing to diagnose his wife's H1N1 flu. The piece does not give details about how that happened or who was involved in her care.

The article does briefly describe a statement by Spain's Nursing Union cautioning against reaching "hasty conclusions" before an investigation is complete. The union also noted that Spanish hospitals do not have enough nurses, and that "some of those they do have lack specialized training for assignments like neonatal care."

The details here are sketchy, but nursing errors are more likely in situations where nurses are short-staffed, and where they are working in specialty areas in which they lack experience--both of which are common features of the current nursing shortage. And it is also important to recognize that short-staffing may occur even at the staffing levels hospitals intend, because of budget constraints and the undervaluation of nursing care. Sadly, patients as sick as an infant delivered two weeks earlier at 28 weeks are especially vulnerable to even a minor error. But this error wasn't minor.

It was also a systems error, since the tubings for IVs and tube feeding have interchangeable connectors which makes it physically possible for a feeding tube to be connected to an IV. This is not the first lethal tubing mixup error, and such errors will continue until the health care industry implements a system of different gauge tubings for different uses. We encourage nurses and others to advocate for this change.

We hope that any action taken against the nurse in this tragic case is consistent with what he or she actually did, based on all the circumstances, including the extent to which the error was the result of systemic problems beyond the nurse's control, such as short-staffing, forced overtime, or pressure to work in an area for which the nurse may have had inadequate experience. However, one thing that is not wrong with the article's coverage, and the apparent focus of the authorities, is that they indicate that nursing is a responsible job whose practitioners hold lives in their hands. Nurses have independent legal and ethical duties to patients, and for the profession to get the respect it needs, nursing must accept responsibility for the profession's errors as well as their saves. Here, at least no one is suggesting that some physician is really responsible for the baby's death because this person is "just a nurse."

 
"Where attractiveness is often as highly prized as clinical skills"

The Times piece is "If Plastic Surgery Won't Convince You, What Will?" Its focus is 31-year-old surgical nurse Petra Kalivodova, who recently renewed her contract at Iscare, a private health clinic in Prague, partly because the clinic offered her free plastic surgery she could not otherwise afford as one of its standard inducements. She had cosmetic breast surgery and liposuction on her thighs and stomach. Kalivodova explained:

I feel better when I look in the mirror. We were always taught that if a nurse is nice, intelligent, loves her work and looks attractive, then patients will recover faster.

The piece reports that "nurses insist they are under enormous pressure to look good in a society where attractiveness is often as highly prized as clinical skills." Kalivodova said that a male interviewer for a nursing job had recently "asked her to walk in a straight line, as if modeling on a catwalk." She "insisted" that the choice to get the plastic surgery had been hers. But she also reportedly said that the workplace "empowerment" women had experienced in the two decades since communism fell in the Czech Republic had been "accompanied by added social pressures -- fanned by women's fashion magazines and television -- to be thin and attractive." Apparently the plastic surgery inducement is not common elsewhere in Europe, but the report says that the Czech Republic "has an obsession for female beauty pageants" and lacks "the political correctness that has prevailed in the west." So the article reports that many Czechs of both genders have no problem with the inducement.

The Iscare managing director, Jiri Schweitzer, said that there is "nothing sexist about helping women look beautiful." He also noted that the offer of plastic surgery in exchange for a commitment to spend three years at the clinic "was less expensive than raising overall salaries," and it had helped increase job applications. So far, he said, 10 of the clinic's 50 nurses had had the plastic surgery. He also noted that the program "helps to improve the morale of both our employees and our patients." Schweitzer said that it was even harder for him to recruit enough nurses now because the financial crisis had actually increased demand for cosmetic surgery by women who "hoped to improve their job prospects," a trend that apparently has not occurred in the U.S. The clinic's head of plastic surgery, Patrick Paulis, also defended the perk, stressing that he warned all patients of the risks, and nurses were more aware of them than most.

If you want to have good employees, you have to have good incentives, and we are offering free breasts. Others could offer free Mercedes.

Some nurses apparently hesitate because of those risks. Nurse Linda Havranova noted that "[w]e all want to be sexy and to look good," but "[s]urgery is cutting into the body, and there are risks. So for now, I would rather get a Peugeot car."

The Times piece explains how the plastic surgery perk fits into the nursing shortage in the Czech Republic and elsewhere. Some argue that the inducements are the "most drastic" sign of the shortage, which health officials say is "undermining the Czech health-care system." Analysts reportedly say that the nation's public sector is short 5,000 nurses, with 1,200 leaving in the previous year for higher paying jobs in nations like Germany and Britain. The piece notes that the lack of nurses recently caused a hospital in Brno, the largest Czech city after Prague, to close its intensive care unit--a signal that hospital bed capacity depends on nursing, not just on the presence of spaces and physical resources, as the media sometimes implies. The article also notes that the average Czech nurse's wage is less than that of a bus driver. In this environment, many institutions offer incentives to attract nurses; the web site of the largest state-funded hospital in Prague apparently lists "lunch vouchers, child day care and 'aesthetic operations at reduced prices.'"

The Times report shows that such inducements attract critics. Jirina Siklova, "a gender studies expert and sociologist," says the breast implant perks essentially turn the nurses into "prostitutes," noting that she "would expect such behavior from an erotic salon -- not from an institution devoted to health care." Dana Juraskova, the Czech minister of health and "a former nurse," prefers other ways to motivate nurses. As an example, she cites "cost savings" that are being "passed on to nurses" as a result of a controversial new Czech policy to charge a small fee for "visiting a doctor." It's not clear exactly how this "savings" gets to the nurses.

On the other hand, Irena Pejznochova of the Czech Nurses Association reportedly had no problem with the free plastic surgery, suggesting that it was a natural result when "nurses worked 12-hour shifts, were underpaid and could not even prescribe an aspirin without a doctor's permission." She noted:

The problem is that the public still perceives nurses as they were represented in communist-era television shows: as low-level workers who emptied bed pans and cleaned hospital rooms.

That sounds likely, and it's an excellent point:   an enduring public image of nurses as unskilled helpers does undermine the profession. But the prevalence of that image does not mean that the sexual image the free breasts program reinforces is not also a problem. It sounds like the naughty nurse stereotype is a strong one in the Czech Republic, with some nurses and physicians themselves appearing to embrace it. Consider the nurse's comment that she had been taught that "look[ing] attractive" will help patients recover, and that she had been asked to "walk in a straight line" in a job interview, and the physician's assertion that plastic surgery for the nurses improves the "morale" of patients. Just like the unskilled imagery that the nurses association representative rightly protests, the naughty nurse undermines nurses' claims to adequate clinical and educational resources. No skilled health profession can prosper when its members are evaluated as much for physical attractiveness as they are for clinical skills.

Unfortunately, it is not unusual for nursing advocates to claim that the only problem with the nursing image, or nursing generally, is the one that bothers them the most; everything else is irrelevant, and no one should complain about it. In reality, however, it is possible that nursing can be harmed by more than one thing. Some problems actually have more than one cause, as evidenced by the popular concept of the "perfect storm."

The Times article generally does a good job drawing out different views about the plastic surgery and setting them in the larger context, with no snickering. One key element of context that is missing is to place the "prostitute" angle within the history of the nursing image. Unlike most professions, nursing has been relentlessly linked to female workplace sexuality for decades, so it is far more likely to be undermined by this kind of sexual association. The report also notes that minister of health Dana Juraskova is a "former nurse," as if nursing was not a professional qualification, but a job performed only at the bedside that could not encompass high-level public health and policymaking positions. It's hard to image the Times referring to a minister of health as a "former physician."

Looking for a positive sign for nursing and its image in Europe, some hint of progress in the midst of the desperation and suffering of the ongoing shortage?

The Czech minister of health is a nurse.

 

 

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