Nurse and Patient
Lesley Alderman's "Patient Money" column, "Aftercare Tips for Patients Checking Out of the Hospital," consults only physicians about an important aspect of hospital care in which nurses have taken the lead for decades. A nurse does appear in an accompanying photo (right), which shows a patient with two caregivers. The caption: "Preparing to leave Piedmont Hospital in Atlanta, Wendell Tooks, center, gets discharge information from his nurse, Betsy Anderson, and Dr. Tim McDonald." But that's it for nursing. The column has some good practical advice, but it wrongly portrays the discharge process and hospital care generally as endeavors in which nurses play no important role.
Alderman explains that earlier in the year, her 85-year-old father had a cancerous tumor removed from his thigh at a "prominent New York City hospital." All went well, and "soon he was sent home," but three days later he was back because he was "unable to cope with a complicated wound care regimen." Alderman attributes this to poor discharge planning. She explains that discharge is critical, but "it often is rushed and poorly coordinated, resulting in complications that send patients back to the emergency room." Indeed--it is often rushed because nurses are desperately under-staffed, but this article says nothing about that, because when you don't consult nurses, you and your readers are less likely to learn that. Alderman does cite a study in the New England Journal of Medicine showing that readmissions are a serious and expensive problem for Medicare patients. One reason is that hospital stays are shorter now, but according to Alderman, "experts say" it's not just about "compressed care." Actually, though Alderman has no apparent interest in how "compressed care" itself might affect patients, people do often return to the hospital because they have been discharged before they have received enough nursing care; decision-makers do not understand the importance of skilled nursing and early discharge looks like a good way to cut costs. In fact, nurses are the experts in "complicated wound care," and in many cases they--not patients or families--should be providing it. Of course, when you don't consult any nurses…
The first "expert" the piece does quote is one of the NEJM study authors, "Dr. Mark V. Williams," who notes that hospitals focus more on admissions because that's when patients are sickest. That's not always true; many patients can manage better before admission than immediately after surgery. Leaving that aside, the next expert--"Dr. Eric A. Coleman, a geriatrician and professor of medicine" at the University of Colorado-Denver--observes that "at discharge, the assumption is that the patient is better and all will be fine." That may be a correct statement of what many physicians assume, but it's certainly not what nurses assume. Of course, when you don't consult…
The column rightly notes that patients often leave the hospital with many difficult issues to manage, including new medications, symptoms, and follow-up appointments, at the same time as their capacity to function is diminished. Williams, who is "chief of hospital medicine" at Northwestern, observes that hospitals currently have no financial incentive to manage discharges well, and may even benefit from not doing so, since they will also be paid to provide the care patients get after readmission. Coleman says discharge planning "falls into the space between billable events," which is true if you consider only physician care to be billable. Of course, hospital nursing is billed, but within "room and board," as if it were jello, which makes it easier to forget that it exists at all.
The piece goes on to discuss initiatives to improve this state of affairs. It says there is a "movement to improve care after discharge and to reduce readmissions." Apparently this "movement" is entirely the idea of physicians, because they are the only professionals presented as playing a role in it. The column explains that Coleman has "developed a hospital-based program called Care Transitions Intervention, with the support of the John A. Hartford Foundation, which helps reduce the number of re-hospitalizations for older adults by coaching them to take a more active role in their care." Actually, it seems that Coleman worked with leaders in nursing, public health, social work and other fields to develop the program, which makes sense since implementing a program like this would involve all of those professions, but we guess it's easier to just credit physicians for everything, as Hollywood usually does. The column also mentions a Medicare program to "improve hospital hand-offs for high-risk patients," and another program being developed "to reward hospitals for lowering readmission rates." And it describes Project Boost, a promising program "developed by the Society of Hospital Medicine" to give hospitals information and procedures on improving discharge and reduce readmissions. The piece notes that Piedmont Hospital has used the program to significantly reduce readmissions for younger and older patients.
The last part of the column offers practical advice to consider if "you or a relative is hospitalized in an institution that has not recently revamped its discharge process," because in that case "you may need to take an active role in managing the discharge."
The first tip is very revealing: it is "take charge." According to Dr. Schreiber, the "biggest problem in the discharge process is that no one person takes ownership of the patient." The column notes that many people in the hospital "may have been involved in supervising a patient's care: a surgeon, a nurse, an attending fellow and a discharge planner." So it's important to ensure that discharge plans are sound:
Schreiber observes that "sometimes you have to be a jerk." Alderman says that when her father was readmitted, she "went over the discharge planner's head and dealt only with her supervisor. Guess what? The second discharge went much better than the first."
It's not clear if Alderman knows that most "discharge planners" are nurses or social workers, and it's pretty obvious she does not know that discharge planning has been a core nursing function for many decades, long before programs like Project Boost or Care Transitions were developed. Of the professionals Alderman lists as being involved in a hospital patient's care, it is only nurses who are there with the patient consistently in the patient's final hours in the hospital. And nursing, like social work, is holistic by design, so nurses are at least as well-qualified as anyone else to perform this work.
It's easy to see the new programs Alderman discusses at least in part as a result of the denursification of hospitals in the last decade. As cost-cutting prevents nurses from doing what they have traditionally done, including discharge planning and providing adequate pre-discharge care generally, those who notice the effects come up with "new" ideas, and in the case of the "discharge planner," a new job. In fact, it's not hard to see the growth of hospitalists--the physicians who are often involved in these matters--as driven in part by denursification. People do eventually notice that there is a problem when hospital nurses are prevented from doing their jobs. But they do not necessarily understand that the root of the problem is too little nursing nor that the answer may be more resources for nursing (how could that be so important?), and as a result they may rework or reinvent care processes that nurses have traditionally done. The media, reporting on these bold new initiatives, often seems oblivious that nurses are even involved. Physicians did it!
The column also advises patients to "check the drug list," because Schreiber says medication errors are a frequent cause of readmission. The piece suggests getting an up-to-date list, checking with the hospital pharmacist, and making sure the patient understands the regimen. That all makes sense, but there is no indication that nurses are the ones who bring all this together. Nurses are the double-check on medication errors by physicians and pharmacists, and in this way they save countless lives. Nurses are the ones who help patients understand their new drug regimens at discharge (if there is time).
The next tip is to "make a discharge plan." The column notes that it may be hard to decipher the hospital's discharge plan, so consider creating your own, which "can be a guide for the patient, the caregiver and other doctors." The piece suggests places to look for models, including the Boost program's web site. It also notes that patients may not be ready to go home, though evidently it's not because they need to stay in the hospital.
The last tip is "contact the primary doctor." The column advises readers to
Apparently, care is all about handoff between hospital physicians and primary care physicians, though "discharge planners" and "hospital staff" are also involved. At no time does the column suggest that readers even talk to the nurses who provide most of the skilled care patients receive in hospitals. The piece's persistent avoidance of even mentioning nurses by profession, to say nothing of the apparent failure to consult even one, masks this central role. And even though one of the physician experts commendably uses the acronym for "primary care provider"--an inclusive term that acknowledges the existence of advanced practice nurses--the column sticks with "primary care doctors."
We have no reason to think that Alderman was consciously try to erase nursing from her account of hospital care. But if she were, the column would have looked about the same.
Pauline Chen's "Doctor and Patient" pieces sometimes transcend the insular column title and acknowledge that nurses matter in modern hospital care. Not her column of October 21. In "Losing Touch with the Patient," Chen manages to discuss the practical effects of the contact precautions that protect vulnerable patients from infection without ever mentioning nurses.
Chen (right) describes a patient with a severe infection of the abdominal wall. His "primary doctors" "quickly isolated him," "directing visitors to put on gloves, mask and gown before entering." Chen tells us how constricting this arrangement was, making it hard to "examine or even visit him," so that "most of us were loath to go through the process of gearing up more than we had to; and even his wife of more than 20 years occasionally groaned as she dutifully swathed herself in the protective coverings each day." Over time, Chen says, "we clinicians found ourselves minimizing our interactions, designating one team member to suit up and complete the work needed or shouting out updates and questions to the patient from the sterile safety of the doorway." The patient began to withdraw, his organs failed, and he died more than two months later. As all this happened, the "small space in which he was confined eventually became a space-age pastiche of beeping machines, plastic tubes and wires, and shrouded, faceless, hovering yellow figures."
So we've heard about "doctors," "visitors," "us," "clinicians," "team members," and "yellow figures." But guess who provided the vast majority of the care this patient received, which professionals spent the most time coping with the contact precautions, and who would likely have the most insight into the pros and cons of those measures. Chen's account certainly does seem to be that of someone who had only limited contact with this patient, often at a distance--would that approach have been possible for the skilled nurses who met all the critically ill patient's needs, 24 hours a day, every day?
Chen wonders if "we" "lost sight of the person" in trying so hard to manage the infection, and she describes the development of contact precautions, which have become a standard part of hospital care. Although they are now "expected by doctors and patients alike," less attention has been paid to "the unintended consequences of such strict limitations." Chen says an article by "Dr. Leif Hass" in the current Annals of Family Medicine tells how the author, after recovering from MRSA-caused infections, is torn between his desire to "reach out" to patients and his fear of pathogens. Chen continues:
We wonder what the "clinicians" who have by far the most contact with these patients--the nurses who work to prevent adverse events like falls and pressure ulcers--think of all this. Who knows, but let's consult more physicians instead! Chen quotes University of Maryland physician Daniel J. Morgan, lead author of a recent review of the studies, who decries the misperception that infections are the worst thing that could happen in a hospital, which can lead to a failure to see the big picture. And speaking of not looking at the whole picture, it seems to us that because nursing care might be even more impaired by contact precautions, patients might suffer disproportionately from the lack of that care.
Chen describes efforts to develop "less restrictive but equally efficacious precautions," citing studies at the Medical College of Virginia which found that infection rates were the same when "health care workers" wore only gloves with all patients as they were when the workers wore gloves and gowns with patients in isolation. She quotes lead author "Dr. Gonzalo Bearman," who suggests that gloves with all patients may become the clinical standard. Chen admits that "some type of contact barrier is in our future as doctors and patients," quoting Dr. Hass, who notes that sometimes "an I.C.U. looks like an assembly plant in Silicon Valley." Hass also gets the closing quotes, as he implores us not to let modern technology supplant "some of our best tools for healing -- simple things like touching people and telling them you care and making them feel you are there for them."
Chen's own conclusion, near the end, is as follows:
We realize Chen is writing from her own perspective, and we're not suggesting that physicians never touch patients or help relieve suffering through personal contact. But to present a physicians-only picture of this type of clinical care to an audience that has been raised with fantasy images like those of Grey's Anatomy and other Hollywood shows--in which physicians really do provide virtually all hands-on care and all emotional support to hospital patients--is to reinforce a damaging misconception about who does what in hospitals. In fact, physicians typically spend a few minutes a day with each patient, while nurses spend hours with them performing expert assessments and providing skilled hands-on care, including the emotional support that Chen seems to suggest is a big element of physician care. Nurses are the ones who struggle the most with contact precautions and the ones who know the most about how they affect patient care. Conveying nurses' role in this kind of care can be tricky; suggesting that nurses are all about "touching" can reinforce the idea that their work is mostly unskilled hand-holding, an idea that of course would not even occur to people reading about physicians healing through "touch." But it's hardly better to pretend that someone else is providing this important care.
Chen should have consulted nurses and told her readers what they think about these issues. And we're not sure how Chen managed to use so many different words and phrases for those who care for patients in isolation without ever using the word "nurse." At a minimum, she should have acknowledged that managing and coping with contact precautions is more an issue for nurses than it is for any other hospital professionals.
Gardiner Harris's long report on the dangers posed by mistakes involving hospital tubing does acknowledge the key role nurses play in providing the relevant care and gives them some voice in discussing the problem. The report is unusually aggressive in placing the blame for dangerous tube mix-ups squarely on systemic problems--that tubes for different purposes are compatible--rather than on the nurses who actually hook them up incorrectly. The piece could have sought more nursing input, and one of the two nurses who is quoted, a health care executive who argues for systemic changes in the tubing, is not identified as a nurse. In fairness, her nursing status is not evident in her title or very prominent in her online biography either. On the whole, the piece provides a pretty clear sense that nursing matters, and it makes a strong case for changes that will help nurses.
This case is evident in the blunt headline title, "U.S. Inaction Lets Look-Alike Tubes Kill Patients." That headline conveys the sense of outrage that runs throughout, and it also signals that the report will focus on efforts to address the problem through the U.S. Food and Drug Administration. The piece begins with an example of how tubing problems affect patients. A 24-year-old Kansas woman named Robin Rodgers, who was thirty-five weeks pregnant, was vomiting and losing weight, so "her doctor hospitalized her and ordered that she be fed through a tube until the birth of her daughter." (We don't love the terminology of command in this description; physicians are not in charge of nursing care.) Unfortunately, Ms. Rodgers and her baby "died after a bag of tube feeding formula was mistakenly connected to an existing intravenous line." The piece explains that
The report notes that hundreds of deaths and serious injuries have been caused by "tube mix-ups," though the exact numbers are unclear because there is little reporting. This leads to the piece's central point:
Before getting into the specifics of the regulatory battles, the piece explains the complex array of plastic tubing that hospital patients may have, to "deliver or extract medicine, nutrition, fluids, gases or blood to veins, arteries, stomachs, skin, lungs or bladders." Much of this tubing is "interchangeable," so "with nurses connecting and disconnecting dozens each day, mix-ups happen -- sometimes with deadly consequences."
This is great, and the article also includes a photo of Pratt. Sadly, the piece never says that Pratt is a nurse, and few non-nurses are likely to guess. So although her comments could have shown Times readers that nurses are authoritative experts who can be health care leaders, the benefit of the comments will be limited to how they help draw attention to the tubing problem. In fairness to the reporter, Pratt's own online biography buries her nursing background near the bottom--she has over 20 years as a critical care nurse and a master's degree in nursing. Some health care leaders do not exactly go out of their way to tell people they are nurses, perhaps because they believe, reasonably, that they will be less respected. Pratt's actual title is "senior vice president of clinical effectiveness," a somewhat comical example of the euphemistic titles often bestowed upon nursing leaders who hide the fact that they are nurses managing what is to a large extent, if not primarily, nursing care. We're trying to imagine the range of similar ideas that might have surfaced in the process of coming up with the "clinical effectiveness" title. How about "Senior Vice President of Providing Good Care," or "Senior Vice President of Doing High Quality Work"? Is there also a "Senior Vice President of Clinical Ineffectiveness"?
Fortunately, the piece includes one more strong nurse expert.
This is another great quote, and here the report makes clear that Simmons is a nurse. The somewhat bland description of her ("a registered nurse…who studies medical errors") does understate her qualifications and her work. In fact, she is a Clinical Nurse Specialist with a masters degree in nursing, and she now serves as "Associate Director of the Patient Safety Education Project (PSEP) and a research scientist at Texas A and M University Health Science Center Rural and Community Health Institute."
The piece gives several additional examples of how tube mix-ups can cause harm, and one of them is the well-known situation of Wisconsin nurse Julie Thao.
Once again, the piece is making clear that nurses play the central role in the care that involves these tubes, but placing amazingly little responsibility for tube-related errors on the nurses themselves. Of course, nurses do have a professional responsibility to do their best not to make such errors, but particularly given everything arrayed against nurses now--including under-staffing and mandatory overtime--the piece and its experts are plainly correct that nurses should not be placed in a position where such a mistake is even possible, as the experts make clear is the best practice in other fields.
The piece turns to the status of regulatory and manufacturing reform efforts, focusing especially on the FDA's consideration of "whether feeding tubes that could mistakenly be connected to intravenous tubes should be declared fundamentally unsafe," and specifically whether the FDA should deny approval for new products that are susceptible to such connection errors. It appears that the agency's rules arguably require it to approve new products that are basically the same as previously approved ones, even if the agency has concerns about the previous products and even if they have been recalled. Manufacturers have reportedly resisted legislative efforts to mandate incompatibility of such tubes, including a California bill passed in 2008. The piece highlights disagreements between FDA device reviewers (some of whom are physicians) who seem particularly concerned about the problem and FDA managers who have at times reportedly overruled them.
Nurses are mostly absent from this discussion, with a couple exceptions. The piece mentions a tragic 2006 example in which "similarity of feeding and intravenous tubes caused the near death of a premature infant," Chloe Back, when a "nurse mistakenly connected a bag of breast milk to an intravenous tube, leading Chloe to form tiny blood clots throughout her body, bleed profusely and suffer seizures for months."
And near the end, the piece turns again to the formidable senior vice president of clinical effectiveness.
Here again, Pratt's words and deeds seem to be great examples of patient advocacy, nursing leadership, and yes, clinical effectiveness. If only readers knew she was a nurse!
Milt Freudenheim's long article "The New Landscape: Preparing More Care Of Elderly" about geriatrics is not perfect, but it does the best job of these recent pieces in conveying the important role nurses play in key areas of hospital care. The report presents nurses as leading innovators in developing new care models for the elderly and as valuable members of the teams providing clinical care to this important group of patients. Freudenheim's piece is an entry in the Times' "New Landscape" series, which addresses changes brought on by the major 2010 health care reform law.
"Preparing More Care of Elderly" begins by noting that the new health care law and those who administer Medicare are pushing "hospitals, doctors and nurses … to prepare for explosive growth in the numbers of high-risk elderly patients." The piece says that the elderly are a big deal because they "often have multiple chronic illnesses, expensive to treat, and they are apt to require costly hospital readmissions, sometimes as often as 10 times in a single year." But although the Obama Administration is "spending $500 million from last year's stimulus package to support the training of doctors and nurses and other health care providers at all levels," the piece reports that only 11% of National Institutes of Health funding went to aging last year (we might add that less than 0.5% went to nursing research). Note that in these descriptions, nurses are included as team members--not something we can take for granted, as some other Times articles show.
It is true that the early expert quotes are all from physicians. David B. Reuben, chief of geriatrics at UCLA's medical school, says that people do not realize how "dire" the lack of resources for geriatric care is. Judith Salerno, a geriatrician who is executive officer of the Institute of Medicine in Washington, agrees that geriatrics is underfunded given the role of aging in "all the most common causes of death and illness" (presumably she means in the United States, since that's not the case everywhere). The NIH director, physician Francis S. Collins, says its budgets are "tight" after "a $10 billion spike from stimulus funds," and he gets several quotes about the exciting projects NIH could be funding in various relevant areas. J. Fred Ralston Jr., president of the American College of Physicians, says that helping elderly outpatients cope with their "often-complicated" problems takes time and is not adequately compensated by public or private insurance, which "doesn't finance the kind of resources we need to take care of the 20 percent of Medicare patients who use 80 percent of resources." And physician Mark R. Chassin, a former New York State health commissioner who now heads the Joint Commission that accredits hospitals, stresses that the biggest challenge is helping the elderly be independent.
How about that--nurses not only playing an important role in preventing costly readmissions, but actually playing a leading role in conducting the research! Naylor is indeed a leader in gerontology and transitional care, and her work has been highlighted by other receptive journalists, including Joseph Shapiro in a July 2009 National Public Radio report. Although the Times' description of her is not perfect--it does not say she is a nurse with a PhD and a leading geriatric care researcher--most readers probably will at least understand from the Penn association that she is a nurse. And of course she deserves the title "Dr." as much as the physicians, though using it without making clear she is a nurse would imply to many that she was a physician.
The report turns again to Reuben, the UCLA physician, who explains that the elderly do not get most of the care they need in areas like "dementia, falls, bladder incontinence, depression." The piece says that "hospitals are training their staffs to make special assessments of patients who may be at risk of falling, a major threat for the elderly."
Unfortunately, this passage does ignore the role advanced practice nurses play in primary care generally and under the new health care law's reforms in particular.
But nurse practitioners do appear in the ensuing examples of elder care programs. The piece notes that 73-year-old Geraldine Goldsmith, a patient at New York University's Langone Medical Center, said a "team of N.Y.U. geriatric care specialists 'taught [her] how to survive' during her long fight against sickle cell anemia, a genetic blood disorder." The piece explains that Goldsmith "gets continuous support from Marilyn Lopez, a geriatric nurse practitioner." Lopez says that caring for the elderly is ''a profession of the heart,'' which is not helpful in light of the angel stereotype, according to which nursing is mainly about having a kind heart, rather than advanced skills.
Fortunately, there is more. Goldsmith says that the geriatric team ''makes sure that I eat proper food, take my medications, keep my appointments -- as you get older, you forget.'' And she adds that Lopez ''calls and says: 'Geraldine, look at your calendar. I'm going to see you tomorrow.'''
So Lopez is not just about having a good heart, but also using advanced technology and interpersonal skills to keep track of complex treatment regimens and patient conditions, so she can teach patients like Goldsmith "how to survive." Maybe that's why the main photo accompanying this report shows Goldsmith with Lopez and Anessy Uretsky, whom the caption describes as "N.Y.U. nurses in geriatrics."
The piece actually provides another NP-focused example.
It's true that readers may not see the actions the NPs are describing as requiring a great deal of expertise, particularly when this last passage (or Powell herself) falls into the common habit of referring only to "doctors" and "physicians" rather than all health care providers. But at least the NPs are getting credit for managing vulnerable patients. And although we're not fans of using the term "orders" in health care, here the piece at least places nurses in the same category as physicians in describing those clinical interactions.
The report then includes an unusually long passage about the importance of nursing in the future of geriatric care. The piece notes that both of the hospitals it has described follow a geriatric care system called "Niche" (Nurses Improving Care for Healthsystem Elders), and that this system is now used in some 300 U.S. hospitals, with "support from the John A. Hartford Foundation and the Atlantic Philanthropies."
The piece notes that the recession has made it harder for recent U.S. nursing graduates to find jobs in some places, despite the longstanding shortage, but even so the U.S. Labor Department predicts that 600,000 new nurses will be needed within 10 years.
Wait--Fulmer (right) "helped create and develop the Niche approach"? A nurse helped create and develop an influential, effective program now used to improve geriatric care in 300 hospitals? Here again, it would not have been bad to specify that Fulmer has a PhD. And the term "student nurse" is also unhelpful because it subtly suggests that the students actually are nurses, as if studying to be a nurse makes you one; it's generally much less likely for news reports to refer to "student physicians," although in fairness, this report later does so. On the whole, though, this is a helpful passage about nursing leadership and the key role nursing plays in geriatric care.
The report goes on to describe the U.S. government's efforts to help. This year the National Health Service, which is part of the Department of Health & Human Services, has allocated a higher amount, $300 million, to its program "that repays student loans for caregivers who work in rural and underserved urban neighborhoods." The piece explains that those eligible include "family practice doctors, nurse practitioners, dentists and others who care for the elderly." The article adds that the administration is also using funds from the 2009 stimulus and the 2010 health care law to expand "training for geriatric specialists who commit to teaching student physicians and nurses."
The piece focuses again on physicians, noting that geriatricians "are generally not paid extra for the time they spend" listening to elderly patients, and then observing that "not surprisingly, specialists in geriatric care are in short supply." The report says there are now about 7,000, but the American Geriatrics Society says more then 20,000 will be needed, presumably in the next few years. The piece describes a $200 million effort funded mainly by the Donald W. Reynolds Foundation to promote geriatric education. As an example, the report says that "all first-year interns in internal medicine at the Birmingham medical school are spending four weeks with geriatric patients this year." The piece says that Kellie Flood, the physician who directs that University of Alabama program, "discusses newly admitted elderly patients at 10 a.m. daily with [the NP] Ms. Powell and other nurses and doctors, as well as therapists, dietitians and social workers." Flood gives statistics suggesting that "her geriatrics unit" has a shorter average stay and lower rate of return than "comparable general medical units." The piece concludes with a testimonial for "Dr. Flood, Ms. Powell and their team" by patient William Mullins, a retired pharmacist who had a small stroke. Mullins praises the ''great care'' at Birmingham.
These final sections of the piece generally treat nurses, and nurse practitioners in particular, as members of the team that is working to create a better framework for geriatric care in the United States. That may not seem like big deal--just to be included--until you consider all of the influential pieces on this subject, such as an April 2007 New Yorker article by Atul Gawande, that largely ignore nurses and other health professionals, giving the false impression that only what physicians think and do matters.
We thank Times reporter Milt Freudenheim for being part of the solution.
The URL for this page is www.truthaboutnursing.org/news/2010/oct/21_nyt.html