As I Lay Dying
October 23-26, 2005 -- This week the Boston Globe ran Scott Allen's major four-part special report, "Critical Care: The Making of an ICU Nurse." We understand that the report was the result of persistent efforts by Massachusetts General Hospital to persuade the paper to help increase public understanding of the expertise of its nurses. Allen's report does that. It provides an in-depth chronicle of the intense eight-month ICU training of new nurse Julia Zelixon by 20-year veteran nurse M.J. Pender. Michele McDonald's photographs give a sense of the focus required of the nurses, and the staggering amount of technology they manage. The piece actually shows the primacy of nursing care for ICU patients, and reveals the extent to which resident physicians rely on the nurses' expertise. Despite some focus on patient advocacy, at some points the report does not reflect a full grasp of nursing autonomy. The piece incorrectly suggests that nursing is essentially a subset of medicine, and that physicians have the final say on all aspects of care. But readers who make it through all four parts get an unusually vivid sense of the complexity and importance of highly skilled nursing in a major hospital, with a few hints of the stress that the nursing crisis has put on such critical health systems. We commend Mr. Allen, Ms. McDonald, the Globe, and Mass. General for their impressive work.
The piece explains that Zelixon is a confident 35-year-old mother who recently graduated with excellent grades from the nursing program at the University of Massachusetts at Lowell. She was born in Russia, where she was a "voracious" student who loved translations of William Faulkner novels, and where she began training to be a physician. However, three years into her training, she moved with her husband to Israel, where she could not continue her medical studies. She got a business degree, and a management position at an electronics plant. In the late 1990's, she emigrated to the U.S. Soon, her young son developed a genetic disorder, and he ultimately died. After this tragedy, she decided not to continue in business. Instead, she completed the four-year program at Lowell in three years, while taking English classes--and reading "her beloved Faulkner in the original."
The journalists reportedly spent time on a surgical intensive care unit at Mass. General periodically for eight months, the period of Zelixon's post-BSN training to be an ICU nurse. This amounts to a kind of nurse residency, though no one says so. The piece makes the important point that the very fact that Zelixon was permitted to enroll in the challenging ICU program right out of nursing school is an effect of the nursing shortage. Until a few years ago, potential ICU nurses at Mass. General were required to have years of experience first, as Pender did. The piece gives a few details about the shortage, including the 6.7% current vacancy rate in Massachusetts that has led to "once unthinkable" measures like large signing bonuses.
Allen's text, McDonald's photos, and a slideshow and lengthy audio commentary on the Globe web site present readers with a detailed picture of nurse training at the cutting-edge. Such a close look at high-stakes, high-tech on-the-job training is an especially effective way to highlight the work of key professionals in modern society. That's why recent television hospital dramas like "ER," "House," and "Grey's Anatomy" have used it to such powerful effect--for physicians.
But contrary to what many in Hollywood believe, the drama we see here could easily support a television series. (See our FAQ Nurses are just wonderful, but you really can't expect Hollywood to focus on them, can you? After all, popular media products have to be dramatic and exciting. Why don't you just focus on getting a nursing documentary on PBS or basic cable?). In the midst of the impressive technical jargon, the Globe piece shows that Zelixon and Pender experience the same interpersonal tensions and challenges that the public knows--because of TV's relentless focus--characterize the training of new physicians. Pender tries to support Zelixon, but the consequences for mistakes could scarcely be higher. Pender never stops thinking of new things that have to be done, new problems that have to be addressed, new threats to the patient that must be foreseen and avoided. It's enough to drive Zelixon a little crazy--and we see that it does. The piece suggests that in some ways the two may have "too much in common," since both are "smart, opinionated and strong-willed." The report also explains that the ICU training is so intense that four of the 17 nurses in Zelixon's program will not make it, "a higher dropout rate than basic training for the Marines." The "prize" for "those who survive" is a "job with lots of autonomy at a world-famous teaching hospital, where senior nurses make more than $100,000 a year."
The piece does an excellent job of illustrating the stress, complexity and importance of ICU nursing at Mass. General. Each patient reportedly needs 20 hours of nursing care daily, a number that has increased with advances in care that can keep patients alive who would have died 30 years ago, according to Jeannette Ives Erickson, the hospital's "nursing chief." Pender's analysis of the patients' condition and needs is relentless, as the nurses work to manage seemingly countless different medications, tubes, and monitors. It becomes clear that, just as in medicine, there are many grey areas, and it is not always clear what the best course of action is.
The piece also highlights nursing expertise relative to that of at least some physicians. It notes that Pender has "vastly more bedside experience than the young residents who pass through," and that residents rely on her during rounds, often saying things like: "Isn't that right, M.J.?" And speaking of things you won't see on TV, the piece clearly conveys the primacy of nursing care in such critical care settings. It notes that nurses provide the vast majority of such care on their own, and even quotes an anesthesiologist who points to the much higher patient loads of physicians and notes that he often feels that "we're here more as consultants to the nurses." This is indeed one way to view the work of many physicians--as highly trained specialists who collaborate with the nurses who play the central role in inpatient care (See our FAQ: Do physicians help nurses improve health?). At another point, the piece actually suggests that Pender is "calling the shots" relative to a resident physician; she tells the resident that a patient will need a nasogastric tube and sends the resident to get it. Pender stops a physician from speeding a transfusion to an especially critical patient, fearing that it will dilute the medication dripping through the same IV. The report does not directly suggest that the nurses are teaching the physicians, though that's what it is.
For all its commendable focus on the technical prowess ICU nursing requires, the piece does not ignore the psychosocial aspects. At one point, it becomes clear that a young accident victim with an array of serious ailments will soon die. Pender decides that the patient's husband should come in. The piece conveys her considerable expertise at this delicate task, as she shakes the husband's hand, introduces herself, encourages him to take his wife's hand, and clears the room of non-essential medical staff. Later, the piece notes that Zelixon--herself adept at reassuring patients and families--is not sure she could have managed the situation so well under so much pressure, and in the midst of such chaos. Pender stays more than two hours after her shift ends to lend additional psychosocial support to the dying woman's family--another mark of a true professional.
The piece also includes a few telling points about the nursing image. The piece itself seems to be a result of Mass. General's efforts to improve the image of its nurses and nursing generally, as the audio commentary and other information indicates that the hospital had to persuade the Globe to do the story. The piece also mentions the lack of social and media respect that is a key factor in the current "upheaval" in nursing, which has led to the presence of a new grad like Zelixon in the SICU. It states that nursing is
one of the most demanding but least glamorized professions in medicine. Although television shows such as "ER" make it seem as if doctors do just about everything in hospitals, nurses actually provide nearly 90% of intensive care, usually with no doctors in sight. Nurses sometimes feel like second-class citizens, but they are the backbone of the ICU, and hospitals struggle to recruit and train enough of them. ... [Pender] and other ICU nurses know that the public views them as less important than doctors, and they chafed when Abby, the only nurse among the main characters on "ER," went off to medical school a few years ago.
We appreciate the focus on the importance of the media in shaping public opinion and in nurses' own morale, though we're not huge fans of the common "backbone" compliment, which may suggest that nurses are reliable but not big thinkers. Indeed, the piece quotes another ICU nurse as saying: "Doctors say, 'Oh, you're so smart; why aren't you a doctor?' I say, 'I don't want to sleep on a cot.'" Obviously lifestyle is important in career choices, and it has been reported that many new physicians themselves are starting to opt for specialties that require fewer sacrifices of this type. However, we do wish that we would at least occasionally see an account of a nurse taking on such "smart enough to be a doctor" remarks--which praise an individual nurse by insulting her profession--by saying something like "nursing requires my intelligence as much as medicine does," or "because I can improve health more as a nurse." (See our FAQ "You could be a doctor!) Pender notes that she did not want to become a physician because it seemed to entail a lot of time with the "bookwork of medicine" and not a lot of time with patients. That does not directly suggest that medicine was too demanding, and the patient contact point is a good one, though her comments may still strike some as undervaluing the thinking and knowledge that nursing requires--qualities that Pender herself displays in abundance.
Most of the piece is likely to leave open-minded readers marveling at the ICU nurses' expertise and autonomy. But there are also statements indicating that physicians are ultimately in charge of all aspects of patient care, and that nurses must defer to them even if they feel strongly that it is not in the patients' best interests. The story does mention a few nursing managers, but it does not really discuss ultimate power structures, and readers will not necessarily get that nurses do not ultimately report to physicians in patient care. In fact, nursing is a distinct profession that encompasses significant clinical areas in which most physicians have little expertise, such as wound care. Physicians generally have greater expertise in what is commonly called "diagnosis and treatment," but patient care requires far more than that. Much of what nurses do is not part of physician care plans, but the result of independent nursing judgments and actions. Moreover, nurses often play key roles in "diagnosis and treatment," and as autonomous patient advocates, they have legal and ethical responsibilities to resist care plans they believe are not in a patient's best interest, taking it as far up the line as needed. Of course, these duties are often hard to fulfill, given physicians' greater power, but they do exist.
The story at least makes the patient advocacy point. At one point Pender comes down on Zelixon for failing to push the physicians hard enough to give a patient adequate pain medication, a common nursing issue, finally "explod[ing]": "You have a brain, and you are not just supposed to follow orders." Indeed. The piece also describes a time when Zelixon and her other teacher, Jeanne Rufo-Huckins, had "gone over the head of a young doctor" to get a patient adequate sedation, getting a "supervising physician" to agree. The story does not explore what would have happened if the senior physician had not agreed.
But the piece also says that Pender "worried that Julia might be slow to accept a fact of nursing life: Though a nurse can influence doctors' decisions, ultimately she must defer to them in diagnosis and treatment." Pender herself is quoted as saying that Zelixon is a "really smart girl" with "a lot of book knowledge," but that she needs to consult more with the physicians, and that "it's not her job to make a diagnosis." The piece also quotes Pender as noting that it is sometimes hard for Zelixon because "[s]he's used to telling other people what to do." It's fair enough that Pender would want Zelixon to focus on nursing rather than medicine, and to collaborate effectively with the physicians rather than trying to do everything herself. But these passages will suggest to most readers that nurses must ultimately defer to physicians in patient care, and more basically, that physicians "tell nurses what to do."
At one point the piece says that an attending and a fellow "made strategic decisions" about the resuscitation of a very sick patient, but that they often left the room, "leaving" Pender to "direct" the team. At another point the piece refers to a physician as "the resident directing" a patient's care. Yet the piece also suggests that Pender has "more autonomy" than most nurses because the "lines of authority between nurses and doctors" at these ICUs are "sometimes blurry and often crossed." As examples, the piece notes that in an emergency Pender can order X-rays and change drug dosages, seeking physician approval later. (In fact, such arrangements--often called "standing orders"--are not uncommon.) These parts of the story actually reinforce the mistaken view that physicians have the final say on all care, and that nurses have no unique sphere of care, as they suggest that nurses' "autonomy" consists solely of what physicians allow.
In a telling anecdote offered to show that even Pender is not always "right," the piece tells how a physician sided with Zelixon about whether to continue giving a diabetic a blood thinner. The piece does not explore who was actually "right," appearing instead to define "right" as whatever the physician thought. However, physicians do not own patient care. Good nurses question physician plans even in areas where physicians generally have more expertise if the nurses have good reason to do so. Countless lives have been saved in just this way. Considering something to be "right" simply because a given professional thinks so--as opposed to analysis on the merits--is a recipe for disaster.
One issue worth noting briefly is the way the piece names the various players in the story. After the first introduction in each of the four pieces, Pender and Zelixon are always "M.J." and "Julia," and the same is true of the various other nurses who appear. But without exception, the story names the many physicians who appear as "Dr. ____." This is a common, but damaging, affirmation of the widespread assumption that nurses are nice and friendly, while physicians command respect. Would a piece about the training of a physician intern have called the intern, the residents and all the attendings by their given names? Of course, nurses themselves often use only their given names. Even Pender reportedly introduces herself to the husband of the dying patient without her surname, and without saying that she is a nurse, though that may have been evident from other signs. This is not to say that nurses should be distant or overly formal, simply that they should present themselves like other professionals who would never dream of omitting their surnames or failing to make their profession clear to those they help.
The story follows Zelixon through the end of her training period and into her first shifts on her own, as she continues to confront difficult new situations, now without Pender at her side. But all the reports Pender gets from the "rumor mill" are "excellent," and she suggests that Zelixon's new independence may actually have helped her realize that she "has to be a nurse," rather than a physician. Pender's conclusion: "I think she's going to be a great nurse." This forward-looking comment makes a subtle but important statement about nursing: As with other serious professions, it takes years to become a great nurse.
Part Four - "Time comes to perform on her own"
Scott Allen and Michele McDonald discuss their experiences at Mass. General. (7 mins. 20 secs.)
Left click the link above to listen, right click (Mac-option click) to download it.