Two business columns offer very different visions of nursing
September 26, 2014 -- Two pieces by business-oriented columnists that appeared within the last few days present a striking contrast in perspectives about what nurses offer the public. Three days ago Forbes contributor Robert J. Szczerba (left), whose focus is "the intersection of healthcare, technology, and business," published "Looking to Transform Healthcare? - Ask a Nurse." That piece argues that despite nurses' traditional "back seat" role in health care, in recent years it has become clear that nurses can and should assume a leadership role in improving care and reducing costs through innovation. Szczerba cites a national initiative by the American Association of Critical-Care Nurses to empower nurses as clinical leaders that has prevented pressure ulcers and falls and increased patient mobility, with dramatically better outcomes and lower costs. We thank Szczerba for conveying the merits of nurses' clinical leadership to an influential audience. On the other hand, today the StarPhoenix (Saskatchewan) ran an attack by John Gormley on a nursing union's efforts to persuade the public not to allow tasks traditionally done by registered nurses (RNs) to be performed by licensed practical nurses (LPNs). Gormley, a radio host and lawyer, argues that the "wealthy union" was simply trying to protect its turf. He takes care to note that the nurses he has met have been "highly skilled," but he also observes that "on a vertical axis, physicians, medical residents, nurse practitioners (and one day, physician assistants) are all above the skill sets of a registered nurse," and "for goodness' sake, they're not winning the Nobel Prize in Medicine. They're nurses." The Nobel bit is factually correct, but only because of the kind of uninformed contempt we see in Gormley's piece. In fact, nurses should win Nobel prizes, as we have long argued, and although their skill set overlaps with others, it is unique and second to none. In addition, without commenting on this particular dispute, assigning tasks that RNs should be doing to less qualified colleagues in order to cut costs has been a recent trend, even though higher proportions of RNs mean better patient outcomes and can save money in the end. These two columns both have a business focus, but they reflect very different levels of understanding of nursing.
Clinical Scene Investigator
Robert J. Szczerba's Forbes piece begins by noting that nurses have traditionally been the "face of healthcare." He cites the broad, holistic scope of the profession, which encompasses health promotion and advocacy, as reflected in a definition from the American Nurses Association. However, because of what Szczerba terms the "culture of the healthcare industry," nurses have taken a "back seat" to physicians and administrators in improving care practices. But "there is a wealth of evidence that points to the vital and increasing leadership role nurses are taking in healthcare practices." An example is an initiative of the American Association of Critical-Care Nurses (AACN) called the Clinical Scene Investigator (CSI) Academy, "a 16-month, hospital-based nurse leadership and innovation training program with teams of staff nurses from 42 hospitals in six regions" designed to "empower bedside nurses as clinician leaders and change agents whose initiatives quantifiably improve the quality of patient care and hospital bottom lines." Teams from several states have completed the program, with anticipated savings of $21 million. AACN president Teri Lynn Kiss says "studies confirm that empowered nurses provide the best patient care." She summarizes the program results, noting that on average the
nurse-driven initiatives decreased patient length of stay in ICUs and progressive care units by up to a full day. They decreased by one day the time patients needed support from a mechanical ventilator. And they cut in half ICU complications and infections.
The CSI teams did that by focusing on "reducing skin pressure ulcers, preventing falls, and helping patients become mobile sooner." The piece gives an example of each. The team at Boston's Brigham and Women's Hospital reduced pressure ulcers at the lower back by 63% with a program that included a "two-person, head-to-toe skin assessment when a patient is admitted." At St. Francis Health in Indianapolis, the team decreased patient falls by 35% with a "No Fall Zone" initiative featuring better staff education and a "patient-family fall prevention contract." And of the teams focusing on early mobility, Szczerba notes that the team at Duke Raleigh Hospital developed a multidisciplinary protocol that cut a day from the average length of stay for postoperative ICU patients and those needing mechanical ventilation, saving the hospital more than $1.2 million a year. He also explains that all the project materials are available online, and non-participating hospitals are already using them, as Virginia's Inova Fairfax Medical Campus did to reduce central line-associated bloodstream infections in ICUs by 80% and save $962,000. Szczerba says that hospital administrators "looking to improve the quality of care and reduce costs [should] try talking to the people working on the front lines every day -- talk to a nurse."
This short piece includes a great deal of helpful material about nurses' potential for health care innovation and leadership. By singling out specific teams, Szczerba encourages others to participate in the CSI program. But perhaps the best part is that he emphasizes specific data, the percentage reductions in adverse outcomes and the precise dollar savings. That is vital to persuading people, particularly those who are focused on financial issues, that nurses have tangible value in the health care system--that they are not just nice (but expendable) helpers. You can send Dr. Szczerba a message of thanks at email@example.com.
John Gormley's piece in the StarPhoenix takes a very different view of nurses' value. The columnist's "Nurses overreaching in fight with LPNs" aims to persuade readers that the Saskatchewan Union of Nurses (SUN) is "powerful" and "wealthy," and that having gotten nurses a generous raise six years earlier, some ads the union recently ran about nurses' life-saving skills were just a "branding" exercise in the lead-up to a new round of contract negotiations. In particular, he says, SUN's objections to proposals by the Saskatchewan Association of Licensed Practical Nurses (SALPN) to assign RN tasks to LPNs are just an economic "turf war" with SALPN. Gormley quotes SUN president Tracy Zambory as saying that under the proposed standards, it "appears to us that the LPN scope would encompass close to 99 per cent of what a registered nurse does today." Gormley offers no specific contradiction of that statement, but he does say: "Precisely what a trade union has to do with nursing standards is not clear." Right--what would some union know about nursing standards? Unless, of course, the union is composed of, uh, nurses. Gormley is confident that this will all be sorted out by the Saskatchewan Registered Nurses Association and ultimately the provincial government.
Gormley takes pains to assure us that individual nurses are decent, valuable health workers, noting carefully that they are "skilled and important participants among many in a complex array of health care professions," and that "except for a couple of notable instances of an officious nurse waddling around barking orders on a hospital ward - to a person, I've never a met a nurse who wasn't highly skilled, helpful, empathetic and engaged." (Gormley does choose words that are normally applied to animal behavior ("waddling," "barking") to describe nurses with apparent authority, implying that they are pathetic battle-axes; we wonder if he would describe physician managers that way.) Trying to put all this pro-nurse hysteria in perspective, Gormley observes that "for goodness' sake, they're not winning the Nobel Prize in Medicine. They're nurses." Then he adds:
Great nurses don't need TV ads to tell the world how well they do their jobs. In fact, sometimes it seems the more a person repeatedly reminds you how valuable and needed they are, the more it raises doubt.
Exactly--because people just know intuitively, or based on their own expert evaluation of the clinical setting, or based on Grey's Anatomy, what nurses do and what they know. After all, Gormley knows: "On a vertical axis, physicians, medical residents, nurse practitioners (and one day, physician assistants) are all above the skill sets of a registered nurse." Gormley also says that "below [RNs] are LPNs, who do everything from brush a patient's hair and rub their back at bedtime to insert IVs and administer medications."
But Gormley says nothing specific about what RNs do or should do. If he is suggesting that the seemingly straightforward LPN tasks he lists are similar, that they can basically do what RNs do, that's wrong. LPNs play an important role on the health care team, but they are not sufficiently trained for the most critical work that RNs do: skilled 24/7 assessment, high-stakes decision-making and interventions for deteriorating patients, patient education and advocacy. We explain how little many in the media know about nursing skill in Saving Lives: Why the Media's Portrayal of Nursing Puts Us All at Risk, specifically in Chapter 3, "Could Monkeys Be Nurses?"
In fact, it is not clear that an LPN with one year of college-level health education should be starting IVs or administering medications. When RNs start IVs they evaluate the integrity of the IV site, then monitor its status for infiltration, infection, and patency. In administering medications by any route, RNs examine whether the medication is appropriate for the patient's condition; whether it may react badly with the patient's other medications or diet; whether it might cause the patient to bleed out or have blood pressure or heart rate changes leading to stroke, respiratory depression, or other deadly conditions. This evaluation may, on occasion, require discussion and advocacy with powerful colleagues.
Zeroing in on the nurses' union, Gormley proceeds to suggest that SUN fears for its money, its power, and its very existence, because the free market may, in its wisdom, be threatening to drastically reduce the scope of RN care. And that may be particularly true for SUN nurses, he suggests, because SUN's version of RN practice seems to mean "onerous and cumbersome" over-regulation of the care setting, as well as "a salary exceeding $85,000 and a union culture preferring to carve out responsibilities and exclude others." Gormley concludes by proclaiming that "the delivery of world-class health care is not about turf wars, practice areas or trade unions," but about "appropriate skills acquisition and training, demonstrated expertise, best practices, continued improvement and patient safety outcomes." In essence, apparently, RNs just need to wake up to the fact that those without RN training can totally do their jobs, and "all the TV ads in the world won't change this."
Of course, Gormley's piece isn't mainly about nursing or even health care, but part of a larger program to weaken organized labor. Still, it's worth briefly exploring some of the nursing misconceptions. First, nurses have not yet won a Nobel Prize, but they deserve to, and there should be a Nobel Prize in Nursing, as we first argued in a 2006 Baltimore Sun op-ed. Leading nurses have made contributions to health care that are comparable to those who have won the Prize in Medicine. Nurses have changed the course of health care not only with the kind of innovations described in the Forbes piece, but with contributions ranging from those of early nurses like Florence Nightingale, Lillian Wald, and Mary Breckinridge to those of modern-day leaders like Loretta Sweet Jemmott, Jackie Campbell, and Susie Kim. Gormley does not explain his ranking of the "skill sets" of various health professions, but we can guess that to the extent it's not just social bias, he is going on total years of formal education. However, it's important to remember that key factors are how much education professionals have in health care, as well as the care model they follow and their relevant experience. RNs have years of college-level health education, and increasingly they enter clinical practice with bachelors of science, or more advanced degrees, in nursing. The notion that all physicians and physician's assistants are "above" the skill sets of all RNs is laughable.
Gormley's claims about the market-driven reduction of nurses' scope of practice rely on jargony abstractions like "appropriate skills acquisition" and "continued improvement and patient safety outcomes." In fact, no one knows more about what actually contributes to patient outcomes than nurses and their leaders--including their union leaders. So decision-makers should be skeptical, to say the least, about proposals to have non-RNs assume tasks currently done by RNs, presumably as a way to reduce RN staffing and cut costs. Such moves are not an inevitable product of market forces. But as a growing body of research shows, they are a great way to increase patient mortality.
See more on efforts by the the American Association of Critical-Care Nurses to empower nurses as clinical leaders -- online or archived in pdf format.