The experts

 
November 2011 -- The cover story in this month's issue of Reader's Digest is "50 Secrets Nurses Won't Tell You." But in fact they will tell you . . . in this feature by Michelle Crouch, though many do so anonymously. The sub-head:  "Doctors are clueless about what really happens in the beds, rooms, and halls of our hospitals. That's why we went to the experts." Actually, physicians emerge from the piece as worse than clueless. They are presented as people with a basic lack of regard for other humans, particularly in failing to provide adequate pain relief. But the broader focus of the piece is to give readers helpful tips about what happens in hospitals and how to survive there. Some of the 17 nurses quoted convey the challenges of nursing today, and they make good points about nursing skill, from saving lives to psychosocial care. One nurse points out that ABC's Grey's Anatomy is a laughable fantasy, in part because in real life nurses do most of what surgeon characters do on the show. Another nurse asks not to be told that she is "too smart to be a nurse," noting that she is not a wannabe physician. To a limited extent, we even hear about nursing autonomy and advocacy, with several references to questioning physician care plans. Some comments do suggest the great stress of nursing, and there are references to the practice of stacking long shifts, the danger of under-staffing, and the very high overall level of acuity today. Yet the piece does not quite say that nurses often confront dangerously high patient ratios, and most readers aren't going to put it together. Not all of the quotes are helpful. One nurse warns that nurses will gossip about personal details patients reveal because "we're here for 12 hours with nothing to talk about." And the piece's focus on advice from hospital direct care nurses means it does not convey the scope of nursing education or practice. Advanced practice nurses, scholars, and public health nurses are largely unrepresented. But the piece does provide a lot of valuable information about nursing. We thank Michelle Crouch and Reader's Digest.

The trimmings

The secrets
 

The trimmings

The first striking thing about the feature is its prominent use of images of famous Hollywood nurses:  Showtime's Nurse Jackie leads the pack in a full-page photo at the start of the piece, and she is followed by smaller images of Margaret "Hot Lips" Houlihan from the television series M*A*S*H, Mildred Ratched from the film One Flew Over the Cuckoo's Nest, Carol Hathaway from ER, and Carla Espinosa from Scrubs. That's a defensible selection in terms of cultural influence, though not, of course, if the goal is to identify the best portrayals.

Mixed in with the images are factoids, in what amounts to a long single sentence that spans the length of the piece. It goes like this:

Nurses are . . . sturdy . . . scarce [By 2025, the United States is expected to be short about a quarter-million registered nurses.] . . . irritated [Eighty-five percent of nurses say they work with someone who insults them, yells, or show no respect.] . . . needed [A hospital patient's risk of death rises as much as 2 percent with every shift that's low on nurses] . . . tired [Nurses routinely work 12-hour shifts--sometimes three in three days.]

These statements are not sourced in the piece (the risk of death data is from a recent Mayo Clinic study), but they do provide a few helpful bullet points about where the profession is today. Of course, needless to say, it's not the prettiest picture. The piece might also have included a few more positive aspects of the profession's current state, such as that it is expected to offer many jobs in the coming years and an increasing variety of educational and practice opportunities.

Sidebars interspersed throughout the piece also provide bits of information about the profession. The "hospital lingo" box includes short definitions of terms like "frequent flier," crump," and "GOMER." "Nursing by the numbers" has super-important information from a 2010 Scrubs magazine survey, like what percentage of nurses have "used a scalpel to cut cake" (15%) and how many have had to leave a patient's room quickly because they were about to "laugh uncontrollably" (86%). (The one significant and somewhat unsettling bit of data from that survey is that 34% of nurses admit to having "sneaked off for a nap at work.")

Another box is labeled "best of the bloggers." The piece says nursing blogs tend to be "compulsively readable," with "warts-and-all-portraits." The box includes several quotes from head-nurse.blogspot.com. These are all mocking complaints from an unnamed Texas nurse about the different ways people fail to be good patients:  by not adhering to care plans (no more driving really means no more driving!), by not disclosing allergies, and by asking when they can resume doing illegal drugs. This same nurse has a comment in the main part of the piece about how she'd like to tell the patient who waited a week after his stroke symptoms started to come to the hospital that he's a "moron." We guess complaining about patients is part of nursing, and it does give readers a sense of what nurses have to contend with, but what's presented here did not suggest the adjective "best" to us. 

The secrets

The heart of the piece is the quotes from nurses, the "50 secrets." The introductory paragraph explains that although nurses don't wield scalpels or prescribe drugs (of course, NPs do), nurses "are the ones with patients 24 hours a day, comforting us, helping us with our most basic needs, dealing with our complaints, and yes, saving lives." Yes, "saving lives"; we only wish the magazine had replaced the bland helping descriptions that came before with some specific examples of saving lives. The intro goes on to note that the magazine gave the 17 quoted nurses the chance to "tell it like it really is," and they responded with tips and inside information that "will help you have a better experience if you land in the hospital--and make you think twice before you push that call button to complain." Nurses advise patients to (among many other things) stay well-hydrated when having blood drawn; take a few deep breaths (rather than holding your breath) before a painful procedure; ask your nurse to wet your bandage before removal to reduce pain; understand the importance of physical touch for those who are dying; and beware July syndrome, when the new crop of physician interns starts in U.S. hospitals.

A few of the nurses' comments directly address their life-saving skills and their clinical worth. Perhaps the best is this one:

The doctors don't save you; we do. We're the ones keeping an eye on your electrolytes, your fluids, whether you're running a fever. We're often the ones who decide whether you need a feeding tube or a central line for your IV. And we're the ones who yell and screech when something goes wrong.

Note that the quote does not stop with the life-saving, but goes on to include specific things that nurses do, to illustrate how the life-saving happens. Another helpful skills-related comment, apparently from the head-nurse blogger, notes that a nurse is "the person who knows not only the various ways to save somebody else's life but also how to comfort those left behind," a good summary of the range of nurses' skills. Similarly, another nurse observes, "I know you asked for mashed potatoes, but that sound you hear is my other patient's ventilator going off." This is a good illustration not only of the range of nursing responsibilities but also of one reason why the public has trouble understanding the profession's importance. How could someone responsible for mashed potatoes--and whose services the hospital bills together with the mashed potatoes under "room and board"--also be an expert life-saver? Another nurse advises you to "never talk to a nurse while she's getting your medications ready," because this can increase the risk of error. In fact, this problem is the subject of a controversial recent U.K. initiative in which nurses giving drugs actually wear tabards discouraging others from talking to them. Another nurse has this to say about Grey's Anatomy:

We watch it and laugh. Ninety percent of the things doctors do on the show are things that nurses do in real life. Plus, there's no time to sit in patients' rooms like that.

This points to the physician nursing that continues to dominate most U.S. television portrayals of hospital care. And the nurse who objects to "too smart to be a nurse" comments explains: "I went to nursing school because I wanted to be a nurse, not because I wanted to be a doctor and didn't make it." The nurse might have added that you can't be too smart to be a nurse.

Indeed, some of the comments reveal nurses to be savvy evaluators of patient conditions and conduct, and these at least suggest a measure of nursing autonomy. These nurses do not rely on physicians to do their thinking. One nurse says that when patients tell her how much they smoke, drink, or do drugs, she doubles or triples it. Another notes that if you're "happily texting and laughing with your friends" until the moment the nurse walks in, that nurse is not going believe that your pain is a "ten out of ten."

Other comments also touch on nursing autonomy. One nurse observes that nursing makes an unusual combination of physical, mental, and emotional demands on nurses, then advises those who have a problem with a specific nurse to first speak to "the charge nurse (the one who oversees the shift). If it isn't resolved at that level, ask for the hospital supervisor." The nurse does not advise readers to speak with physicians; that's because nurses do not report to physicians. It would have been helpful to actually say that, but the comment does strongly suggest it.

And at least one comment reveals a nurse acting in an area that many readers probably assume is the sole province of physicians. A cardiac nurse says the nurse would never directly advise a patient to choose DNR status (better referred to as "Allow a Natural Death"), even though the nurse may cringe at the thought of breaking the patient's ribs during CPR. But with "certain patients" the nurse "may talk to family members to clarify their goals for the patient's care. This sometimes leads to an elderly person being placed on comfort care rather than being continually tortured by us with procedures that aren't going to help." This nurse clearly recognizes that physicians do not own the care environment, and that patients benefit from nursing advocacy.

Unfortunately, not all the nurses quoted seem to have this strength and belief in their own responsibilities to the patient. One nurse observes that "doctors don't always tell you everything," noting that in the hallway they may say that a patient has a "very poor prognosis" and there is really nothing to be done, but then say nothing to the patient. This nurse concludes:  "Sometimes I try to persuade them to be more up front with the patient, but I don't always succeed." It's great that the nurse advocates to the extent she does, but it's not clear that she knows she has the right to speak with the patient and family directly. Another nurse, in trying to convey the nurse's own calm under pressure, seems to pass the buck to physicians completely, saying that no matter what calamity a patient may be experiencing, "I'll say calmly, 'Hmmm, let me give the doctor a call and let him come look at that.'" This approach suggests that nurses are just physician helpers, without independent responsibilities to the patient. And still another nurse admits that the nurse might falsely say that biopsy results are not back, "because the doctor is really the best person to tell you. He can answer all your questions." The physician may be the best person to tell you about some things, but he--or she--can't necessarily "answer all your questions"; nurses are more expert about a number of aspects of patient care.

In fact, a surprisingly large minority of the comments are about nurses' relations with physicians, and many of these do illustrate nurses' role as patient advocates, in effect trying to protect patients from physician incompetence and neglect. One nurse notes that nurses will not "tell you your doctor is incompetent," but "if I say, 'You have the right to a second opinion,' that can be code for 'I don't like your doctor' or 'I don't trust your doctor.'" The gall! One notable theme is physicians' failure to prescribe adequate pain medication. One nurse supervisor flatly says:

Many doctors seem to have a lack of concern about [others'] pain. I've seen physicians perform very painful treatments without giving sedatives or pain medicine in advance, so the patient wakes up in agony. When they do order pain medicine, they're so concerned about overdosing that they often end up underdosing.

Another nurse notes that when a patient is terminally ill, "sometimes the doctor won't order enough pain medication." In that case, the nurse says, "sometimes we'll give more than what the doctor said and ask him later to change the order." The nurse suggests that people will "probably howl" when they hear that, but "you have to take care of your patient." Nurse Jackie couldn't have said it better! Oh wait--Jackie's an unethical rogue and no real nurse would ever dare to break the rules to protect a patient from physician incompetence, right? Another nurse advises patients to speak up if they don't understand what a physician is saying:

I once heard a doctor telling his patient that his tumor was benign, and the patient thought that benign meant that he had cancer. That patient was my dad. It was one of the things that inspired me to become a nurse.

This nurse doesn't say so directly, but the clear implication is that it is part of nurses' job to make sure patients understand physician communications, which often seem to reflect little or no concern about patient comprehension. And still another nurse says that there are "a few doctors at every hospital who just don't think that they need to wash their hands between seeing patients," so she advises patients to always ask those who enter their rooms if they have washed their hands. Another nurse offers a catalogue of physician errors she has caught:

Your life is in our hands--literally. We question physicians' orders more often than you might think. Some of the mistakes I've headed off: a physician who forgot to order a medication that a patient was taking at home, a doctor who ordered the incorrect diet for a diabetic, and one who tried to perform a treatment on the wrong patient.

We're not in love with the relentless use of the word "orders," by this nurse and many others in the piece. We urge nurses to reconsider this word, which in the context of physicians' excessive power suggests the force of military orders, and to begin using "prescriptions," "care plans" or some alternative. Nurses cannot ultimately do their work if they are subject to "orders" from some other workers.

Some nurses describe physician aggression. One says that "every nurse has had a patient blame her in front of a patient for something that is not her fault." Another says that "it can be intimidating when you see a physician who is known for being a real ogre make a mistake," admitting that while "you want to protect your patient," you also fear "a verbal slap in the face." Of course, one of these same nurses describes aggression from other nurses, which in her case came in the form of a lack of support for her as a new nurse and obnoxious correction of her mistakes. She observes that nurses take the stress of their work out on each other.

The piece could be faulted for an overly negative view of physicians. Yet it can also be seen as taking a corrective approach, balancing the overwhelmingly and unrealistically positive vision of physicians presented by virtually all of the mainstream media, such as, to take just one example, the roughly 150 hours of Grey's Anatomy seen by millions around the world to date.

Some nurses seem to undervalue their own contributions. One nurse practitioner describes a pediatric patient who had been in a coma for more than a week. The child's chances of waking up did not look good, but the nurse had read that the sense of smell is the last one to go, so she instructed the child's mother to put her perfume on a diaper (!) and hold it near the child's nose, in the hope that it would "trigger something." This NP ends her anecdote: "The child woke up three hours later. It was probably a coincidence, but it was one of my best moments as a nurse." But if the nurse really thought it was just a coincidence, would it be one of her "best moments as a nurse"? Why would she be telling the story here at all? Nurses have long been socialized to minimize their own contributions, and we might suggest that this nurse's downplaying of what she did is part of that sad tradition. But it's probably just a coincidence.

However, it's nothing compared to the nurse who reveals this vital patient care secret:

Feel free to tell us about your personal life, but know that we're here for 12 hours with nothing to talk about. So the stuff you tell us will probably get repeated.

At least the nurse does not seem to be talking about patients' health information (revealing that might be unethical or even illegal). And it's not so much that this presents nurses as gossips--people talk in almost every work place--but saying nurses have "nothing to talk about" suggests that nursing is a set of unskilled physical tasks carried out by people with blank minds. Don't nurses have to talk to colleagues about patient care? Don't they have to educate patients and families? And even if they have time for gossip, isn't anything going on in the nurses' own lives?

Of course, this nurse is among the roughly half of the quoted nurses who comment with partial or complete anonymity. We understand why many nurses decided to do so in conveying "secrets." And physicians have occasionally done the same when saying something that could get them in some trouble, as did the mysterious "Dr. X" in advising readers of the November 2005 issue of Good Housekeeping to lie to triage nurses in order to be seen faster. But the fact that so many nurses felt compelled to conceal their identities suggests that many nurses remain frightened to stand up and be seen as real professionals. We know many nurses feel that they have little power, but when they keep their heads down, others get both the blame and the credit. To some extent this may reflect the overall approach of the piece, which arguably suggests that nurses are insider-assistants who closely observe the charismatic experts with real power (physicians), and who can be persuaded to reveal juicy "secrets" about these medical masters only with protection.

The Reader's Digest feature is also somewhat limited in scope, and as a result it does not give readers a full sense of nurses or their "secrets." Perhaps the most notable issue, for a piece focused on direct care, is the lack of any real recognition of the work of advanced practice nurses, even though there are now hundreds of thousands of them. Nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives would have had plenty to offer. But apart from the perfumed diaper anecdote above from an NP (which may not have taken place while the nurse was practicing as an NP) we see no sign of advanced practice nursing. It's all about the "doctor" and "his" "orders"--not a very accurate vision of modern health practice. We guess it's more understandable that a feature with the focus this one has would not mention nursing scholars, public health nurses, forensic nurses, or a number of other specialties. But it would not have been out of place to include a few tidbits (perhaps in the "More Things We Want You to Know" section) that would convey something of the profession's full depth and breadth.

Still, the piece presents a lot of information about nursing that the public needs to know. And the collection of quotes provides a compelling and mostly accurate, if limited, vision of the profession. We thank Michelle Crouch and Reader's Digest.

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