Saturday, December 27, 2008

The Knitting Must Stop!

A friend of mine had a baby in August. She credits me as her inspiration for studying nursing; now she's working on her PhD, studying hormonal aberrations in elite female athletes. So my baby gift had to be good. To purchase it, instead of patronizing Babies R Us or Target, I took the elevator to the 13th floor of a local hospital. There (not in the hospital's gift shop) I chose a fuzzy, pale yellow, hand-knit angora hat from among pumpkin-colored, flower-embellished, cable-knit, and striped varieties. It was hard to reject the pastel one with sweet little ears on top, but it wasn't gender-neutral. Darn.

The 13th floor is the mother-baby ward. The post-partum nurses sell these lovingly knit hats there for $20 each. The tiny hats are not made by good-hearted retirees, volunteers or hospital auxiliary ladies. They are knit by registered nurses who volunteer their time and money (and yarn can be expensive) and donate all the proceeds to the Lactation Support Program. Without nurse knitters, and limited grant money, there would be no Lacation Support Program for mothers who need help with breastfeeding.

Breastfeeding, to the uninformed, seems "natural", and thus, in the reasoning of the clueless, is assumed to occur effortlessly. As is often the folly of the ignorant, that which they do not understand is assumed to be simple. You may count the administrators of the hospital among the uninformed. In truth, mothers need coaching, support, resources and education to successfully breastfeed their infants. Many mothers who leave the hospital breastfeeding will give it up in a few months for lack of support. Support means time away from other responsibilities, a quiet & comfortable place, and education from an informed, caring individual, among other things. Many lacation consultants are nurses, professionals who have the requisite knowledge of growth and development, a dash of anatomy and physiology, and very strong interpersonal skills.

In addition to nursing skills, post-partum nurses have the dedication it takes to buy yarn and knit tiny hats in support of women, babies and health when their employr refuses to do so.

This is a common story. We nurses are lauded for selfless commitment to improving health when the health care system and our employers fail at the task. Today by e-mail I read of Michelle Battistelli, a nurse at Morris Hospital and Healthcare Centers in suburban Chicago. Michelle makes embroidered pillows that reduce pain for abdominal surgery patients. The American Nurses Association news brief said, "The ICU nurse and [her] colleagues wanted to do something to make it less painful for surgery patients when they cough, and holding the pillow against their stomach helps."

Why are nurses knitting and sewing? With patient safety, patient satisfaction, and other indicators of hospital quality under close scrutiny, why are hospitals not supporting programs that are known to improve patient outcomes?

Part of the reason is that health promotion doesn't "count" - literally - in our disease care system (it's not really a health care system; it runs on disease.) Hospitals are reimbursed on the basis of medical diagnoses, and breastfeeding success is not among them. Neither is pressure ulcer prevention, functional improvement, effective coping with loss, post-operative pneumonia avoidance or a host of other desirable health outcomes. Because there is no line item on the spreadsheets, the accountants miss all the dollars gained by prevention and health enhancement, work often done by nurses. Because there is no billable code for lactation consultants' services, nurses must knit.

If the accountants had access to a larger view, they'd notice that breastfed infants have fewer pediatrician visits as toddlers and do better in school, and the value of these outcomes would show up in support for breastfeeding consultations. If they could see a few steps beyond the immediate, they'd endorse the cost-effectiveness of buying pillows for people after abdominal surgery. But health care accounting systems, like all systems, see what they are built to see. And the nurses go on knitting and sewing.

What are implications of this situation for health care reform? In the current system, Hospital A competes against Hospital B, spending dollars on advertising and fancy machinery that add little or no value in terms of health outcomes. The disciples of Milton Friedman would say that costs are controlled through competition and open markets, but they are not referring to health care; they are referring to purchases of consumer goods where one purchase is not dependent upon another, as followup care depends upon the outcome of a hospitalization. They also are not referring to a system where costs are usually unknown to the consumer, as in health care. Health care as a market is also drastically different from consumer goods in that its availability is necessary for societal productivity: the sick use resources, but cannot work. Getting your hypertension under control is in no way analogous to buying a new Toyota. Thus my contention that multiple competing providers and insurers cannot work in health care, and the present crisis is evidence of that.

What will work is cooperation and transparency. We must have a single payer system where better coughing among abdominal surgery patients in the ICU translates into measurable, "countable" efficiencies that are shared across health care venues. Rather than paying for more procedures and more doctor visits after the surgery, let's pay for better coughing to prevent all that. Because of the interrelatedness of human health, because breastfeeding support produces kids who spend less time at the pediatrician's office later, we must have a single system that takes advantage of, rather than fights, this interrelatedness.

Human beings and our individual and collective health are interdependent, like strands of yarn knit into tiny baby hats; our health care system must also be.

Sunday, November 2, 2008

Joe Takes Care of His Own, Perpetually.

Part I

It was June 3, 1976, when my sister Joan and her husband Ted went on their very first outing as a couple after the birth of their son. Aaron had been born nine months earlier, to the great joy of all of his family. He was the first local grandchild for my parents. He was a bit colicky, and, of course, a first child, so Joan had been reluctant to leave him, especially merely for recreation and relaxation.

But finally, she was ready to rebuild their social life. So while Joan and Ted rode roller coasters and ate amusement park food with their friends, my parents and I babysat Aaron. I was 17; with that combination of ignorance and arrogance best brought to life by a teenager. Aaron had one of those baby-walker things which, back then, were built narrowly enough to fit through a doorway.

We religiously kept the door to the stairway shut. Which is why I don't know even now how it could have happened. In seconds, Aaron fell down the 3 stairs to the landing by the garage door, his baby-walker upended. I reached down for him, then my mother grabbed him, and in a moment my parents were in the car, headed to the local hospital.

He was pronounced dead at 4:44 a.m.

Part II

My father went into the Navy after high school to avoid the factory worker life led by his father. He had a bright, scientific mind and a knack for the visual. Because he wore glasses, he had to choose one of the more cerebral military pursuits: he chose aerographer's school.

He was stationed in the Phillippines in 1942. Like the other Navy personnel, he evacuated to the island of Corregidor before the fall of Bataan and the Death March. When Corregidor fell in May, 1942, they were captured by the Japanese, transferred to burning hot, packed, stinking railroad cars, and sent to various prison camps in the Phillippines pending final transfer to Japan.

Upon arrival in their Japanese camp, Dad was chosen camp commander by the men. He did not outrank them; it was a democratic election. Although some officers in their ranks were initially miffed, they, too, grew to appreciate his leadership and heroism.

I don't know most of what happened in those prison camps. I do know, though, that Dad endured beatings and torture on behalf of those men for such infractions as demanding better food. Many of them felt indebted to him for life for his actions. One of them was a short, dark-haired man named Joe Perry.

When I was about 7, without announcement, a beautiful new blue bicycle arrived for me. It wasn't my birthday or Christmas. It was Joe Perry just thinking of Dad and his family. I don't know what Dad did for Joe - I wish I did. But there's no doubting that Joe was deeply grateful to my father and would be for life. Our family received kind greetings from Joe Perry every Christmas, every birthday and every first Communion without fail, including 1976.

Part III

Aaron died early on a Saturday morning. Our stunned and devastated family attended church that Sunday. We were barely able to find our way to the pew; the world was so unfamiliar now.

After we got home, Dad told us something he had seen. As he walked up to the altar for Communion, from the corner of his eye, he saw someone he knew. He turned his head to look and saw Joe Perry, standing in the communion line, tenderly holding Aaron in his arms.

Weeks later, we learned that Joe Perry had died. On June 3, 1976.

Tuesday, October 21, 2008

Joint Commission, are you listening?

I mourn for the demise of nursing care. I miss giving back massages, changing linens merely for comfort, sitting down to talk with people. I especially miss the value formerly placed on nursing measures as critical to quality health care.

Quality has been redefined to suit the criterion of measurability over any other. Now the ability to track standardized processes of care (not the outcomes necessarily) is the primary purpose of the medical record, and fluff like which position the person prefers for sleeping because of rib fractures and chronic back pain is devalued, and even discouraged. There is little room these days for individualization of care, which is where nursing has always excelled.

Because of the poor quality of its documentation of standardized processes, the hospital where I work is threatened with revocation of its Joint Commission approval - which means if our quality does not improve, we can't get Medicare reimbursement, and Medicare constitutes the major source of payment for any hospital. This could shut our doors.

Our Joint Commission status is "provisional," meaning if they show up and look around and find us wanting, we are history. To say our administrators are concerned would be like saying the KKK is concerned about the qualities of persons with enhanced dermal melanin content. Just doesn't quite capture the true spirit of the thing.

Pain management is one criterion on which our hospital was cited by Joint Commission. Certainly a worthy goal. The Joint Commission take on quality pain management requires that pain be quantified, treated, and re-assessed after treatment, and it follows that these elements must be documented such that they can be easily audited. Management has repeatedly stressed that nurses document these elements (not that nurses do these things.) Documentation is the only proof of adequate pain management that "The Joint" requires or desires. Indeed, our chief nurse executive informed us that one of the benefits of having computerized charting is that now she can tell who is documenting correctly and who is not - and disciplinary action can thus be taken. (Way to improve quality - threats!)

There is no evidence, unfortunately, that good documentation = good nursing care. There is nowhere to chart that, despite my giving the 71-year-old Cantonese-speaking lady more narcotic than was ordered, her pain was still a 7 out of 10. Nowhere to chart that her snoring respirations caused me enough concern that I was reluctant to increase her dose of narcotic further in spite of the pain she complained of whenever she was asked. Nowhere to chart that the non-verbal pain indicator scale did not concur with what she said when her son was there to translate. Nor is there anywhere to document that I spoke with the physician, who concurred with my plan. This is what quality nursing care looks like: letting her family remain at her bedside for comfort, judging cautiously how much narcotic to give and when, covering her with warm blankets when she was cold, believing what she said over the mandatory pain scale, wiping her forehead with a cool cloth when she vomited, speaking softly to her. But none of these actions is documented. None of them count.

The Joint doesn't know that these are quality nursing measures because they didn't even begin to ask nurses until 2003, when their first nurse advisory group was convened. The American Hospital Association and the American Medical Association have long been integral to the Joint Commission, but historically the American Nurses Association had been shut out.

There is hope: in 2008, one of the 13 Joint Commission officers is a nurse. In 2002, they released a white paper on the nursing shortage with recommendations for improving the supply of nurses. Some of the white paper covers what we already know: the shortage is unprecedented, people are aging, and nurses are crucial health care providers. Other parts of the report are insightful and action-oriented. The need for fiscal incentives to enhance nurse retention, ongoing education and federal funds for nursing enhancements in educational and health-care settings are plainly pointed out.

I am happy to conclude that "The Joint" is starting to get it, and I hope that one day they will stop to read all of what I put in my patient's chart and see how the individuality of each person informs my caring much more profoundly than a Joint Commission mandate ever could.

I will continue wiping foreheads and applying warm blankets. Perhaps there will be a time when such caring measures are also considered meaningful indicators of quality nursing care.

Sunday, October 5, 2008

College students are SO CUTE!

Salon magazine has a great article about Sarah Palin and the dumbing-down of the GOP (and America) here.

If this doesn't frighten you in preparation for Halloween, I don't know what will.

America has a long tradition of anti-intellectualism, borne, perhaps innocently, of trust in democracy, in the wisdom of the commoner, and the importance of hearing all voices in a country that strives for freedom. Or perhaps not. Maybe disdain for elitist smart people comes from a tragic belief that smart people are not like "us" (which means....hmmm...who? Dumb people?) Or maybe there's suspicion that well-groomed, college-educated, high achievers do not belong in positions of leadership in society. (Danger! Capable person in decision-making position! Danger!)

Even my adult, post-graduate university students, (whose admission GPA, by the way, hovers around 3.8) live under the delusion that utter equality is both achievable and desirable. Taken to the extreme, they think being equal (a noble ideal, to be sure) means being identical. It does not; it means celebrating the differences among us and not considering them signs of inferiority. It means providing for identical opportunities, not identical rewards.

Assigning grades is a notoriusly contentious example of the fine distinction between equality and identicality. Grading, some students believe, is akin to judging them on their score in a rigged game of dice. All who play, they say, deserve an A!

Forgive my ignorance, but who ever told you that college grades were a measure of how hard you worked?

The mistaking of semi-objective measures of achievement for global judgments of suitability, acceptability, (or just about any kind of ability) turns otherwise well-intentioned students into little monsters clawing at my office door, pleading for me to turn back time and to even out all the messy, random, unfair, individual disparities that forced them to mark choice C instead of choice A, as their best friend did.

"You didn't return all my papers on time, so I should get an A." "Other students had better clinical schedules; it is hard, you know, working and going to school. (So I should get an A.)" "None of the other professors gave me a B. (So I should get an A.)" "I was raised speaking another language. (So I should get an A.)" "Well, you know that I was sick during midterm. (So I should get an A.)"

One student actually asked me how she is expected to get the material if it's not written on the slides and she does not listen in class!

WHAAAAAAATTTTT??? Help, Lord!!! I am abandoned in the cruel and savage land of hostile non sequiturs!!!

---- several deep breaths later ----

Peppered with such nonsense from packs of hungry 20-somethings, foaming from mouths full of perfect teeth, what is a professor to do?

For one thing, we should admit it: tests stink as measures of mastery. In nursing practice, or any other profession/job/trade, your effectiveness has zero to do with your ability to sit in an uncomfortable seat and make the right marks on a worksheet surrounded by 40 other people doing precisely the same thing. Professors know this, but students don't, and (in another ugly fact) grades do count for things such as getting into the right graduate school.

There is no elegant solution to this dilemma, so I hope you haven't read this far hoping for one. This insuperable state is the sorry source of grade inflation, and no one's come up with a solution to that yet.

Not even the college-educated elitists.

Wednesday, June 18, 2008

The dangers of exclusionary science, or: Can you trust your doctor?

If you're female, perhaps you can't. People tend to think of their own doctors and medicine as a whole as objective, scientific and above all, ethical. Perhaps this is a coping tactic in the face of the unappealing truth that medicine is far from free of sociocultural bias. As an element of our society, the medical profession is subject to influence by modern social values. This influence becomes a problem, however, when it urges doctors to disregard science in favor of whim, driven by exclusionary doctrines that treat sections of the population as inferior.

Case in point: the "special" category of women's health (which, of course, applies to about half the people in the world) is but a few decades old. Nearly all of the research that informs current medical practice was done solely on white males. How did we get to this point? Here's a short history lesson:

Language "urging" (but not requiring) the inclusion of women in federally-funded health research was first published in the National Institutes of Health's (NIH) Guide to Grants and Contracts in 1987. In 1994, NIH finally enacted a Congressional mandate to include women and minorities in research. Prior to 1994, it was considered a good idea, but not mandatory, and the flimsiest of excuses (such as cost) would suffice for excluding half of the population to which the findings would be applied.

"Interference" by women's hormonal vicissitudes and the risk of pregnancy were cited as reasons for excluding women from research before 1994, although this was obviously many years after the development of oral contraceptives. Researchers apparently felt safe concluding that the factors that justified exclusion of women did not preclude generalizing the results of research done on white males to women of all races.

The media's love affair with breast cancer, when heart disease is the top killer of women, is emblematic of the sociocultural influence on women's health. Although public polls show that women think breast cancer is the top killer, breast cancer is not even the most common cancer killer of women. What is? Lung cancer. According to SEER, from 2001-2005, the "median age at diagnosis for cancer of the breast was 61 years of age." From a very large study of lung cancer published in Annals of Oncology (2002), "women developed the disease at an earlier age than men (60.02 versus 62.18 years; P <0.001)." In other words, both lung and breast cancer are usually found around age 60, so the "popularity" of breast cancer cannot be attributed to younger age at diagnosis.

There are alternative explanations for our culture's breast cancer fascination. Among them is the idea that lung cancer, and some other cancers, are self-induced whereas breast cancer is blameless. A second is that our culture loves breasts so much that damaged or missing breasts are seen as horrible, even if the woman survives. No one mourns a lost lung this way.

Most of the women answering those public polls do not know that heart disease is actually the greatest threat to their health. Heart disease is the greatest killer of both women and men, yet the image of the older man clutching his chest is what comes to mind when Americans think "heart attack." The so-called classic heart attack symptoms do not happen in women, who are more likely to experience jaw pain, back pain, fatigue, and nausea. Something's very, very wrong with this picture: although women die of heart attacks more than anything else, why do they still think the signs of a heart attack in a man are what they ought to be looking for? It's a different syndrome in women, but few women know that because of the emphasis placed on male symptoms of heart attack. Indeed, the science behind heart attack symptoms in women is relatively new - no one thought to do research on women and heart disease until after the 1994 NIH mandate.

This brings us to the terrifying tale of hormone treatment. Hormone replacement therapy was perpetuated by physicians who simply assumed that restoring a woman's youthful hormone balance would yield cardiovascular benefits. The temporal relationship between hormonal changes at menopause and increased incidence of heart disease later in life was never shown to be causal. Hormones were prescribed to millions of women for decades with barely a shred of evidence that hormone treatment decreased cardiovascular risk, or at least did not elevate it. In 1990, the FDA declined to add heart disease prevention to the list of indications for hormone therapy because of the lack of evidence. When the proper studies were finally done, it became clear that estrogen/progestin combinations actually increased women's risk of heart attack and stroke.

An early form of hormone treatment was diethylstilbestrol, or DES. The Food and Drug Administration approved DES for use in pregnant women to prevent miscarriage in 1947. The drug had not undergone safety testing, and as a consequence, many women who took DES suffered consequences that included breast cancer in the mothers and a higher rate of cancers and birth defects in their children. Nonetheless, the FDA did not remove DES from the market until 1971.

Estrogen has been used since the 1930s to treat hot flashes and other physical changes that women experience at menopause. But starting in the 1960s, the list of reasons for women to take hormones began to grow. In 1966, the book Feminine Forever became a best seller with its claim that "menopause is completely preventable." The book's author, Dr. Robert A. Wilson, asserted that postmenopausal women who didn't accept hormone replacement were no longer truly female. Wilson traveled the country, lecturing on this topic and promising that with the help of estrogen therapy, "Every woman alive today has the option to remain feminine forever." He was later revealed to be a paid spokesman for a firm that sold estrogen replacement. Nice guy.

Dr. Wilson's tactic, reframing the natural as pathological in order to sell a treatment, is well-known in medicine. Consider the promotion of the medical diagnosis "micromastia" by plastic surgeons. Micromastia means small breasts. It does not mean inadequate mammary tissue to lactate and breastfeed a child, which would be a physiologic problem. It refers to a cosmetic problem that plastic surgeons can "cure."

So are you still confident that medicine's not sexist? I consider hormone treatment and the breast cancer fascination sufficient evidence of bias in medicine, but if you need more, just look up the derivation of the word "hysteria."

Saturday, February 16, 2008

An interesting arrangement

A few years back, I diminished my employment by 30%, from full-time to 70%.  Instead of crying out, "What will we do without you?", my boss thanked me. More cutbacks in nursing education were occurring at Big Fat University (BFU) up on the hill; and she needed to find ways to save dollars. Yes, the nursing shortage is global and growing. Yes, the nursing faculty shortage is even worse.  Yes, the population is "graying" and the demand for nurses will only increase. Yes, the research shows that better-educated nurses save lives. But health care financing is tight and the schools are supported by hospital revenue to a good extent. Done deal. 

The irony is that I would have more free time (not working 6 days a week - what a treat!), make more money, and be more effective in my academic role.

How can this be?

Cutting out the fluff.Concentrating on what matters. Not volunteering. Attending fewer meetings. Leaving the policy-writing to others. Abandoning critical roles on crucial committees that claim to NEED my blessed presence.  I'm putting on my scrubs and athletic shoes. I'm tying back my hair, eschewing most jewelry, getting up at 5:30 and nearly killing myself for 12 1/2 hours on my feet before going home feeling completely satisfied. I'm using my pocket calculator and stethoscope in the intensive care unit and leaving my cell phone at home. I am bringing my best negotiation skills to bear when a glib, self-certain surgical resident tries to gloss over a real issue that he'd prefer to leave to the ICU resident. And I am making more money as a working ICU nurse than as a teacher and researcher while doing what I MUST to bring relevance to teaching. 

Nursing is a practice discipline. One of the implications of this is that we have to practice nursing to maintain skill. In a practice discipline, standing still = falling back. Historically, however, there have been no opportunities for faculty to practice nursing, so faculty have been forced to quit nursing in order to teach nursing. Nursing homes, home care agencies, hospitals and community organizations do not see the value of having an experienced and educated nurse on hand one-half, one or maybe even two days a week. It's full-time or nothing unless you give direct bedside RN care (as I do, although I'm an advanced practice nurse.)  Nursing faculty like me with graduate degrees, years of experience, advanced practice licensure and multiple certifications simply have nowhere to practice nursing.  We have a health care system that thinks there's no place for us. 

Universities do not pay nursing faculty to maintain their clinical practices. After all, they're not in the patient care business. I was an anomaly to negotiate 10% FTE in my first 3 years post-PhD for practice. Most nurse faculty like me simply assume that practice has to be given up.

What went wrong? Well, one thing I know for sure is that those in control have a vested interest in suppressing the power of nurses. Control over health care goes to those who make the big bucks. (I don't harbor fantasies about shadowy, sinister men convening secret meetings in poorly-lit backrooms to plot against female-dominated professions. They actually meet in spacious, tastefully-decorated conference rooms and their names are prominently featured in organizational charts.) This is not the place to explain, so I'll refer you to any of the many books and articles on the topics of paternalism, power, nursing, sexism, and health care.*  And this blog post. 

At BFU the "Executive Leadership Team," (ELT) comprised of MBAs and MDs, once opined that our university may not need a bachelor's of science in nursing program because (paraphrased) "nurses can be trained in community colleges." When one considers that the last word in the organization's name is university, it seems counter-intuitive that any of these people would suggest educating nurses in a university setting makes no difference. Are nurses the one exception to the rule that better education = better performance among professionals? Most organizations encourage their employees to advance their educations. Yet, a certain member of the august ELT at BFU  - that member happened to be the dean of the school of medicine - himself determined, all evidence aside, that nurses could be educated adequately in two years at a community college and a university degree is unnecessary.  This is redolent of my grandmother's being deprived of a desperately-desired high school education because, in rural Ohio, only boys were allowed to attend high school. So much has changed in 90-some years. 

The ELT really can't be blamed for this remark, I guess. The members are ignorant people exerting their right, as the big bosses, to act in their own self-interest. Perhaps if the ELT included at least one representative of the largest single group of employees in the organization (also the largest single group of health care providers in the country), these things would happen less often.

As a part-timer at the  School of Nursing, I would get to hear less of the ELT's antics, and that could only help me stay sane. Perpetual outrage is not good for a person.

* Such as:
Medicine as culture: illness, disease and the body in Western societies
 By Deborah Lupton

Perspectives on power, communication and the medical encounter: implications for nursing theory and practice. 1995. Nursing Inquiry, 2(3), 157--63. by Deborah 

Hospitals, Paternalism and the Role of the Nurse 
by Jo Ann Ashley

  • by Barbara Ehrenreich and Deirdre English