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Led Changes in Nursing

Joyce Clifford 
November 1, 2011 -- Today The New York Times published a very good obituary for Joyce Clifford, who led the nursing staff at Boston's Beth Israel Hospital for 25 years. Clifford pioneered the application of the "primary nursing" care model, in which one nurse is mainly responsible for each patient during the course of the patient's stay, and she advocated what the Times describes as a "partnership of equals" between nurses and physicians. Clifford later founded the Institute for Nursing Healthcare Leadership. Paul Vitello's obituary does a fine job explaining the basic significance of Clifford's work in a limited space. And the piece relies on input from nursing scholars Linda Aiken of Penn and Margaret Grey of Yale, in addition to physician and former Beth Israel CEO Mitchell Rabkin and sociology professor Mary Beth Weinberg, whose 2003 book Code Green: Money-Driven Hospitals and the Dismantling of Nursing described the demise of primary nursing at Beth Israel following its 1999 merger with Deaconess Medical Center. Rabkin, a longtime Clifford supporter, notes that he realized on the first day of his internship that "the nurses knew a hell of a lot more than I did," a statement that is impossible to imagine coming from a physician character on any current Hollywood television show. The obituary makes clear that Clifford had a masters degree in nursing and a doctorate in health planning, referring to her as "Dr. Clifford" throughout. We thank Vitello and the Times for this tribute to an innovative and influential nursing leader.

The online headline of the obituary is "Joyce Clifford, Who Pushed for 'Primary Nursing' Approach, Dies at 76," but we like the headline for the print edition: "Joyce Clifford, 76; Led Changes in Nursing." The piece leads with the "partnership of equals" bit and the statement that Clifford's "ideas were adopted in some of the nation's best hospitals because they reduced medical errors and improved survival rates." The piece provides a brief snapshot of Clifford's career, noting that she was "the nursing administrator and later vice president" at Beth Israel, "a Harvard teaching hospital," from 1974 until 1999, and that she had a PhD in health planning from Brandeis. The piece observes that Clifford "was part of the first generation of registered nurses who sought to make bachelor's degrees a minimum requirement in a field where most held associate degrees," and that the BSN "was a requirement she set for all the nurses she hired at Beth Israel." The piece does not say so directly, but of course a "partnership of equals" is difficult if not impossible where there is a vast difference in levels of formal education between nurses and physicians.

Then it's on to primary nursing, which occupies at least half of the obituary. The piece says that under that care model, which Clifford introduced at Beth Israel in 1975,

nurses were assigned primary responsibility for four or five patients -- caring for each while on duty, being on call when off duty, and acting as an advocate and intermediary with each patient's doctors. The idea was to restore the continuity and accountability that were considered casualties of the nursing system then widely in use, known as team nursing. In the team system each nurse had a specialized task, like dressing wounds or managing medication, but no single nurse had a glimpse of the big picture.

Then the piece offers comment on primary nursing from several experts, two of them nurses. Margaret Grey, the Yale nursing dean, explains that "doctors see a patient for a couple of minutes a day, but nurses are there 24/7," so "Joyce Clifford put together a system that gave the primary nurse the benefit" of that nursing knowledge. The piece quotes more extensively from leading scholar Linda Aiken, "director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, who published research about the work of Dr. Clifford." Aiken says that Clifford did not create the primary nursing model, but she was (in the piece's words) "probably the first to put it into practice in a large teaching hospital."  

Studies showed that the system was good for patients and for hospitals, Professor Aiken added. The increased accountability and higher level of education it demanded were linked to a decline in patient mortality and a lower turnover of nurse staff. "Beth Israel had a waiting list of applicants," Professor Aiken said, "even when there were nurse shortages everywhere else."

Sociologist Dana Beth Weinberg, who teaches at Queens College, says that (again in the piece's words) "Dr. Clifford's achievement was in showing how primary nursing could work." The piece also notes that Weinberg's "Harvard dissertation, published in 2003 as the book 'Code Green: Money-Driven Hospitals and the Dismantling of Nursing,' chronicled the dismantling of primary nursing at Beth Israel after its merger with Deaconess Medical Center in 1999 and Dr. Clifford's departure." (The Joint Commission (formerly JCAHO) invited Weinberg to speak at its 2004 conference on the nursing shortage, but later revoked the invitation because of hospital complaints about Weinberg's "perceived bias." Critics of denursification can be scary!)

As Weinberg's book makes clear, Clifford's Beth Israel model encouraged professionalism and critical thinking, in contrast to some nursing approaches which emphasized following predetermined protocols. The struggle between nursing models continues. Indeed, as the obituary explains, primary nursing "has never become the norm," and today only about 10 percent U.S. hospitals use it "in one form or other." The piece notes that "corporate mergers and cost-cutting" have led some hospitals to modify or eliminate the system. Still, 10 percent is a lot of hospitals, many patients and nurses were helped by primary nursing, and there is always hope that a care model proven to actually work well may be embraced in the future (along with many other tactics to create truly great health care).

The obituary also includes comment from Clifford's great ally at Beth Israel, Mitchell Rabkin, the physician and longtime hospital CEO who hired Clifford. The piece attributes to Rabkin the "insight," arrived at on the first day of his internship, that "nurses knew a hell of a lot more than I did."

Dr. Rabkin gave Dr. Clifford carte blanche to put together a nursing staff that would work collaboratively with doctors. There was some resistance at first. Medical doctors complained that instead of talking to one nurse about the patients in a section of a ward, say, they had to contact each patient's primary nurse, which meant making a number of separate contacts. "The resistance did not last long," Dr. Rabkin said. "Because the doctors soon realized that they were getting far better information, and the patients were getting better care."

We love how this is presented as a matter of simple logic:  because patients were getting better care, physician resistance quickly disappeared! That must explain the ease with which advanced practice nurses have been able to work to the full scope of their abilities.

The obituary also includes a little additional information about Clifford's background and career. It says that she "received a nursing diploma from St. Raphael Hospital in New Haven and a bachelor of science degree in 1959 from St. Anselm College in New Hampshire." In the 1960's, she joined the Air Force and "received a master's degree in nursing administration in 1968 from the University of Alabama in Birmingham, where she was stationed." And the piece notes that, after Clifford's time at Beth Israel, she "went on to found and lead the Institute for Nursing Healthcare Leadership, which promotes research and advanced education in nursing and the primary nurse system."

There are many good elements in this obituary. Just presenting readers with the story of an influential nursing leader has great value. The piece also spends time explaining primary nursing, which of course is not well-known outside of the nursing profession, showing how the model can improve care, and by implication, that nurses are capable of revamping care systems and that nursing in general is critical to providing good patient care. The piece's mention of the "partnership of equals" is good, as is the related part about Rabkin; we could probably have used a bit more on that. And the brief reference to Clifford's work with the Institute for Nursing Healthcare Leadership--great name--is also helpful.

Vitello's choice of expert sources is excellent. He consulted two prominent nursing scholars who are well-placed to comment on Clifford's primary nursing work, plus the sociologist who wrote what is probably the best-known work for lay readers about that model and the challenges it faces in the cost-cutting managed care era. Finally, consulting physician Rabkin was entirely appropriate, given his long professional relationship with Clifford and the relevance of the perspectives of physicians on Clifford's work.

The obituary's emphasis on nursing education and credentials is significant, because nurses cannot count on public understanding of their advanced training. Thus, the article's mention of Clifford's focus on promoting a higher level of nursing education at the bedside is helpful, and the piece might have benefited from more detail on that. In addition, the piece's references to her as "Dr. Clifford" (while making clear that she was a nurse) are helpful, as are its descriptions of some of the credentials of nursing scholars Aiken and Grey, though they have doctorates too, and if the piece was going to use the honorific for Clifford and Rabkin, it should have done so for everyone. Of course, references to "Professor Aiken" are not bad. And although Clifford's doctorate was not in nursing, the piece makes clear that her master's degree was.

We thank the Times for a very good short portrait of Joyce Clifford.

See the obituary by Paul Vitello, "Joyce Clifford, Who Pushed for 'Primary Nursing' Approach, Dies at 76," published on November 1, 2011, in the New York Times; the print version appeared on page B17 of the New York edition with the headline "Joyce Clifford, 76; Led Changes in Nursing."

Write to the author Paul Vitello at his NY Times page. Once you get there, click on "send an e-mail to Paul Vitello."





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