tag:blogger.com,1999:blog-44198676986060185712024-02-08T03:19:08.274-08:00Florid NightingaleThoughts on the nursing profession, health care, feminism and whatever else pops into my mind.florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.comBlogger17125tag:blogger.com,1999:blog-4419867698606018571.post-55405251490930869042012-11-27T14:27:00.000-08:002012-11-27T14:27:49.977-08:00<span style="color: #93c47d;"><b><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">Look!! Nurses blogging! </span></b></span><br />
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Take a look <a href="http://ajnoffthecharts.com/nursing-blogs/" target="_blank">here</a> for a list of nurse-authored blogs compiled by the editors of the American Journal of Nursing, an evidence-based, peer-reviewed journal that has been published since the year <span style="color: #93c47d;"><b>1900</b>.</span> AJN calls itself the "oldest and most honored broad-based nursing journal in the world," and believe it.<br />
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Happy reading!<br />
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- Florid florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-20439545489625439592012-09-06T11:15:00.001-07:002012-09-10T14:08:21.650-07:00Nursing's Long, Rough Road to (Some) RecognitionI slept 12 hours last night, groggily emerging from my rest at 11:30 a.m. I never do this and I don't know why. Maybe simple fatigue from rushing for 12 1/2 hours yesterday in the Trauma ICU, coupled with my advancing age suffices, but something about this fatigue feels more than physical. I process when I sleep, often awakening with new insight into an old problem, or at least a clear awareness that the problem exists. That's what happened during those 12 hours last night.<br />
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I awakened thinking it's time for a new career, frustrated by the many defeats of our profession, and the numerous insults and slights I've suffered as a nurse. A smattering: in the 1980s, when I started nursing, our profession was just beginning to emerge from subservience and acknowledge our specialized knowledge and unique contributions to health care. On my first nursing job, the head nurse, Sue, proved to a skeptical cardiologist that she could, indeed, define hysteresis with regard to pacemakers. She was a beacon. Others, not so much. Like Diana who informed new orientees that Dr. Baker preferred a glass of orange juice in the morning. It made him less likely to yell at you. And there was the outright lechery. The urologist who called me a ripe cherry ready for picking, with a leer. The senior resident who ogled me on the day he left, saying, "Oh, I sure hope I'll see YOU again," with a creepy smile. The hematologist who DEMANDED my phone number upon meeting me. (Great pickup line, jerk.) Even after I got my PhD, the surgeon who paid no attention to my credentials or experience, (or even my name), as he delivered a diatribe against nurses who manage feeding tubes incorrectly, never thinking that a nurse who had done research in this area might be the subject of his invective. The pulmonologist who complained that the nurses in my hospital "won't do anything for you," right to my face. The assumption that nurses are not persons that is embedded in every one of these incidents gave me reason to feel discouraged, and ready to leave my profession of 30 years. Still groggy, I continued to muse on the rough road taken by the nursing profession over the course of my career. <br />
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The 1990s were important. In 1989, the American Journal of Nursing <a href="http://www.jstor.org/discover/10.2307/3426283?uid=2&uid=4&sid=21101155636107" target="_blank">published a questionnaire</a>, asking nurses to report the physician-billed services that they actually perform. This was the first of several studies on the theme of<a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1547-5069.1993.tb00778.x/abstract" target="_blank"> </a><a href="http://www.blogger.com/blogger.g?blogID=4419867698606018571" target="_blank">nurses doing work that physicians bill, and get paid, for</a>. These articles, and other movements of the time such <a href="http://www.pacificu.edu/magazine_archives/2008/fall/echoes/feminism.cfm" target="_blank">second-wave feminism</a>, questioned medical supremacy and risked breaking down the scaffolding upon which health care had so long rested. ("Doctors know everything, nurses know nothing. Doctors give orders, nurses follow orders...and so on.") The larger problem with the practice of physician billing for services rendered by nurses is that nurses and physicians are paid under different systems: the physician bills insurers directly, and is paid directly. Nursing care was (and is) paid by insurers to employers as part of "room rate", so if physicians billed for things actually done by nurses they did not employ, they were being paid for work done by employees whose costs they did not absorb. (This has since been remedied by Medicare, which requires attestation by the physician of his/her presence during the "critical" aspects of the procedure now.) <a href="http://books.google.com/books?id=ojdhsVqdmawC&pg=PA122&lpg=PA122&dq=ajn+nurses+billing+physicians&source=bl&ots=CWO6Et2tdI&sig=DbYZoeG7USXQG5m5ecg3lZqtlSY&hl=en&sa=X&ei=Jj0xUPuHCcfhiwL0z4HoBA&ved=0CGMQ6AEwBw#v=onepage&q=ajn%20nurses%20billing%20physicians&f=false" target="_blank">Further research</a> in the 90s showed that nursing taxonomies were far superior to CPT codes (a system owned by the AMA) for describing, and potentially billing for, nursing services. Sadly, capturing nursing care for billing purposes never caught on, and the CPT system remains supreme. Nursing care is still not valued by the health care system, which puts nursing in the "cost" column and medical care in the "revenue" column, for reasons that probably have to do with medical hegemony, misunderstandings on the part of health care administrators, and good old fashioned sexism.(See above.) <br />
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It was in the late '90s that nurses tried to gain reimbursement parity for identical services rendered by physicians and were shot down in the <a href="http://www.kff.org/medicaid/upload/8167.pdf" target="_blank">Balanced Budget Act of 1997</a> (see page 2 in linked pdf). The rationale for the lack of parity was that, because physicians practices and education cost more to run, they should be paid more. This was called "resource-based relative value," and it made nurses lower-cost providers for services which advanced practice registered nurses (APRNs) had the right to bill Medicare. It also codified the current policy of 100% reimbursement for services rendered by non-physician providers while working under the direct supervision of a physician, but only 85% reimbursement for independently-provided services, again on the rationale that physicians cost more, so they should make more money. (I can't name another profession that gets to decide how much they should make based on the cost of their overhead, but that is another topic.) There was hope, however, that the failure to gain parity could work in favor of nurses
and patients by increasing public access to more cost-effective nurse-provided services. This might have happened <u>if</u> the laws of economics held. <br />
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So, where was the outcry for more nurse practitioners, certified registered nurse anesthetists, clinical nurse specialists, and nurse midwives? APRN practice could save money, because we took fewer "resources" to render identical services, but nursing organizations continued to fight for small amounts of funding for nurse education, research and quality improvement. I, and doubtless many other nurses, wrote to my legislators imploring them: support the education of APRNs, and save our health care system money! No-brainer! But it fell on deaf ears, even in the time of Clinton-era health care reform. Even though the president's mother was a CRNA. Perhaps the status of the American Hospital Association and the AMA as<a href="http://www.opensecrets.org/lobby/top.php?showYear=2012&indexType=s" target="_blank"> the country's 2nd and 7th biggest-spending lobbyists</a> in 1999 played a role.<br />
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Now, after 30 years in watching my profession struggle, my heart is all aflutter with the glimmer of hope demonstrated in the publication, in 2010, of the Institute of Medicine (IOM) report <a href="http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx" target="_blank">The Future of Nursing: Leading Change, Advancing Health</a>. The report includes in its major recommendations furthering nurse education, removing barriers to practice for APRNs, and <i>listening to nurses</i> when health policy is made.<br />
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When it was published in 2010, it was tempting to view the IOM report cynically. For decades, nurses have decried our powerlessness in advancing our education (which, believe it or not, <a href="http://www.npr.org/templates/story/story.php?storyId=100921215" target="_blank">some other health care providers still oppose</a>) and changing health policy. Countless white papers, position statements and studies have confirmed that disempowering nurses is not good for the health of our nation. But nurses have been figuratively patted on the head and told to go fluff a pillow so many times one really can't blame a nurse for demonstrating skepticism toward yet another official report. <br />
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The reason I decided, in that blurry waking moment, to go on hoping is that in the 2 years since the publication of the IOM report, a sliver of light has begun shining through the locked doors of policymaking halls. The IOM report brought about the creation of <a href="http://thefutureofnursing.org/news/detail/robert-wood-johnson-foundation-launches-national-campaign-advance-health-through-nursing" target="_blank">Regional Action Coalitions</a>, thanks to the Robert Wood Johnson Foundation, intended "to move key nursing-related issues forward at the local, state and national levels." Now, nearly two years into the RWJF initiative, 15 states have formed RACs and put forth innovative projects with lofty goals, such as doubling the number of nurses with doctoral preparation by 2020. Jumping on the nursing bandwagon with its <a href="http://championnursing.org/" target="_blank">Center to Champion Nursing in America</a> is AARP, with its powerful lobbying engine and huge membership. This year, The Centers for Medicare and Medicaid devoted <a href="http://innovations.cms.gov/initiatives/gne/index.html" target="_blank">$200 million to training APRNs</a>, as policymakers recognize the impact that the "silver tsunami" will have on the future healthcare needs of Americans. <br />
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Make no mistake: nurses don't have much chance of matching the political clout of the AMA or AHA anytime soon. There is only one nurse in Modern Healthcare's 2012<a href="http://www.modernhealthcare.com/article/20120825/INFO/120829998/2012-100-most-influential-people-in-healthcare-text-list?utm_source=home&utm_medium=web&utm_campaign=most-popular-box&mkt_tok=3RkMMJWWfF9wsRoku6%2FMZKXonjHpfsX66e4lXKOg38431UFwdcjKPmjr1YECTsp0dvycMRAVFZl5nQ9KG%2Bmb#" target="_blank"> "100 Most Influential People in Healthcare." </a>(Although I may have missed them, because only physicians are indicated by their titles.) There are <a href="http://www.jointcommission.org/assets/1/18/Facts_about_Board_of_Commissioners.pdf" target="_blank">finally three nurses</a> on the board of commissioners of <a href="http://www.jointcommission.org/" target="_blank">The Joint Commission</a>, the accrediting agency that is the de facto controller of much of nursing practice. (Founded in 1910 by the American College of Surgeons, The Joint Commission did not have a nurse member on its board until 1992.) <br />
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Nurses don't have the money or political gravitas required to be the AMA, ACS or AHA, but the reason I haven't followed my drowsy urge to leave the profession is this: I am proud that nursing has slowly gained some recognition and a certain degree of power by doing the right thing: educating cost-effective, excellent health care providers, carrying out the <a href="http://www.healthleadersmedia.com/page-1/PHY-269597/APRNs-Provide-Care-Equal-to-Doctors-Review-Concludes" target="_blank">rigorous research to prove it</a>, and staying true to our primary mission to do the right thing for people who need health care. So I'll hang around a few more years, at least until retirement. <br />
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<br />florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com1tag:blogger.com,1999:blog-4419867698606018571.post-84655970765844385722012-03-31T18:05:00.003-07:002012-03-31T18:10:26.381-07:00Naive, Childlike, and Wholly UnrealisticLet's take a trip together to a hypothetical United States of the future where the health care industry's* prime interest lies in prevention versus treatment of illness.<br />
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In this election year, with my irrational hope of meaningful health care reform under the Affordable Care Act, I've been thinking a lot about what health care would look like if health promotion (a skill not usually emphasized by the leaders of our medical-industrial complex) were as highly valued as illness treatment.<br />
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I realize my fictional health promotion system will never come to pass. I know that heroic fire-quenching action with its swift, tangible gratification is usually chosen by human beings over the weak satisfaction of making something <span style="font-style: italic;">not</span> happen. But, then again, fantasies help us set goals. So here's my dreamy, wacky, silly, naive, childlike, unrealistic list of what would happen in a reformed U.S. health promotion system, in no particular order, all drawn from what I have myself observed in my 30 years in health care:<br />
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<ul>
<li>No one would wait until <span style="font-style: italic;">after</span> their coronary artery bypass graft operation or their heart attack to get a referral to cardiac rehabilitation. Ditto for pulmonary and post-cancer rehabilitation. And how about we start a rehabilitation program for everyone, not just those with certain diseases? These programs work for people who benefit from social interaction paired with healthy lifestyle education and exercise. These programs also relieve the fears of people with certain diseases about exercise (in other words, people with heart and lung disease learn that exercise <i>is</i> safe for them.) </li>
<li>People undergoing chemotherapy would not be surprised to find that hair loss is the least of the side effects they will experience. Disabling fatigue is the most common and troublesome cancer symptom, but people do not know this before they start chemo. Other side effects are infertility, depression and instant menopause for even young women. Everyone, in my fantasy health care system, would understand the benefits and risks of their own treatment regimen before one molecule of chemo enters their body. This would mean skilled educators explaining, demonstrating and showing patients what to expect as many times as it takes, for as long as it takes, using many different methods. </li>
<li>Ditto for surgery. Relying on surgeons to do the explanation of risks and side effects is the fox guarding the henhouse. </li>
<li>Just as my mail-in pharmacy phones me to remind me when it's refill time, people would be reminded by phone and email when their children need vaccinations, when they need that regular screening physical or colonoscopy, when to visit the dentist, when to get an eye exam, and so forth. We are overcome by information and demands on our time - the health care system must help people put priority on health maintenance, or it is easily forgotten.</li>
<li>Vitamin deficiencies are entirely preventable. A once-daily multivitamin for every citizen should be covered by the health care system. Calcium for women, too. Both of these are cheap. </li>
<li>Not-for-profit public exercise clubs with group classes would be available to every citizen for a small fee per visit. For personal trainers we would pay out-of-pocket. </li>
<li>Every person could call a single toll-free number to get health coaching by a nurse or person with a degree in health education (i.e., the people who are educated to do this well). The program would not be linked to their employer in any way. Because I suspect assurances of confidentiality from employers who dole out discounts for taking part in insurance company-run health improvement programs do not convince everyone. The baccalaureate-prepared registered nurses and healht educators who answer the lines would perform a focused health interview and use evidence-based strategies to help people live healthier lifestyles. No guilt; no shame; no overwhelming demands to fix everything at once. No idiotic "You should lose weight" to someone who has struggled their entire life with obesity. (I kid you not - I hear this all the time from physicians; they do <i>not know how to do health coaching</i>, world.) </li>
</ul>
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So that's my short list. Add your own health care plan improvements in the comments. And thanks. </div>
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* Industry may not be the most apt noun because most of our health care costs are paid in public systems, primarily Medicare and Medicaid. I prefer industry vs. system because there really is no system; we have more of a mish-mash of systems.florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-60560263152007755722012-03-31T09:28:00.001-07:002012-03-31T16:41:36.791-07:00News Flash: "Trickle-Down" Does Not Save Lives<br />
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<span style="color: white;"><span style="background-color: black;">This week the <a href="http://www.nejm.org/" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">New England Journal of Medicine</a> published an<a href="http://www.nejm.org/doi/full/10.1056/NEJMsa1112351" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;"> evaluation of Premier HQID</a>, a Medicare pay-for-performance program that provides monetary incentives to hospitals to improve quality of care. Hospitals that perform well on certain measures get 1-2% bonuses and hospitals that underperform are penalized by the same amount. </span></span></div>
<div style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; margin-bottom: 18px; margin-top: 18px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<span style="background-color: black; color: white;">In the study, a huge number of hospitals, 252 in the Premier program and 3363 not, submitted data to Medicare on 33 quality indicators for common conditions such as heart failure, pneumonia and joint replacement. Data from over 6 million patients went into the analysis. </span></div>
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<span style="background-color: black; color: white;">The <a href="http://www.miamiherald.com/2012/03/28/2719653/study-paying-hospitals-based-on.html" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">headline-making</a> conclusion went like this:</span></div>
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<span style="background-color: black; color: white;">"Tying financial incentives to performance, often referred to as pay for performance, has gained broad acceptance as an approach to improving the quality of health care....We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest."</span></h5>
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<span style="background-color: black; color: white;">To me, and I imagine others who were not consulted when this program was planned, this finding comes as little surprise. Let me explain why:</span></div>
<ul style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; list-style-image: initial; list-style-position: outside; margin-bottom: 18px; margin-left: 0px; margin-right: 0px; margin-top: 18px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 1em; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<li style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span style="background-color: black; color: white;"> Financial incentives in the program did not necessarily go to<a href="http://www.ncbi.nlm.nih.gov/pubmed/20797363" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;"> the people who prevent hospital deaths</a>. They went to hospital administrators who had the freedom to use the dollars as they wished. So our tax dollars - make no mistake - might have paid for nurse education or better staffing, and they might have bought a fancy new office suite for the CEO, the benefits of which would presumably trickle down to the little people.</span></li>
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<ul style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; list-style-image: initial; list-style-position: outside; margin-bottom: 18px; margin-left: 0px; margin-right: 0px; margin-top: 18px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 1em; padding-right: 0px; padding-top: 0px; vertical-align: baseline;">
<li style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline;"><span style="background-color: black; color: white;">Almost all of<a href="http://www.hospitalcompare.hhs.gov/staticpages/for-professionals/poc/Technical-Appendix.aspx#POC3" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;"> the Medicare quality indicators</a><a href="https://www.cms.gov/HospitalQualityInits/16_InpatientMeasures.asp#TopOfPage" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;"> </a>concern processes of care, not patient outcomes. Processes (like which drugs are given and when) are only thinly linked to patient outcomes because of the complexity of human beings (whether patient or health care provider) and big organizations like hospitals. If the right antibiotic is given at the right interval before surgery, is there certainty that the patient will not have an infection post-operatively? Of course not. It helps, but the maddening and wonderful complexity of humans and organizations means the process can only boost the odds in the patient's favor, not ensure the desired outcome. In short, there are no guarantees.</span></li>
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<span style="background-color: black; color: white;">All the hospitals in the study <a href="http://www.hospitalcompare.hhs.gov/" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">report their data on Medicare's Hospital Compare website</a>; this characteristic was equalized because public reporting is widely understood as a way to improve hospital quality. However, this understanding is based upon assumption, not fact, and some emerging <a href="http://healthaffairs.org/blog/2012/03/06/medicare-hospital-quality-reporting-brings-little-or-no-mortality-improvement/" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">data suggest otherwise.</a></span></div>
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<span style="background-color: black; color: white;">This new study's findings about pay-for-performance are<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699910/" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;"> not unique. </a> I did find some evidence of success of the Premier program on <strong>(surprise!) </strong><a href="https://premierinc.com/p4p/hqi/" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">Premier's</a> website, where one also finds the list of Premier and other health care executives as well as the cadre of physicians who comprise the Premier <a href="https://premierinc.com/about/mission/practices/KPPD/structure-and-governance/board-of-directors.jsp" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">board of directors</a>. Again excluding <a href="http://www.gao.gov/new.items/d01912t.pdf" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">the largest group of health care providers</a>in the country.</span></div>
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<span style="background-color: black; color: white;">Lest this post appear as a rant from a burned-out nurse, I will add that nearly<a href="http://www.ajmc.com/publications/issue/2012/2012-2-vol18-n2/Hospital-Readmission-Rates-in-Medicare-Advantage-Plans/1" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;"> 1 in 5 older adults discharged from a hospital</a> is re-admitted within 30 days. About half of these patients saw a physician in the interim, so it appears doctor visits did not prevent readmission. Moreover, <a href="http://www.medicalnewstoday.com/releases/11856.php" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">errors in health care</a> are deadly - to nearly 200,000 people a year. And studies from <a href="http://www.ncbi.nlm.nih.gov/pubmed/22457240" style="border-bottom-width: 0px; border-color: initial; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-style: initial; border-top-width: 0px; font-family: inherit; font-style: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none; vertical-align: baseline;">across the globe</a> show that nursing care saves lives. We understand the scope o the problem, and we know at least part of the solution. When will we stop making up voodoo quality strategies and start implementing what works?</span></div>
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<br />florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-91313846339875850812010-03-06T13:42:00.000-08:002012-03-31T09:45:39.288-07:00<div class="pbody" id="pbody">
Waitresses, sex workers, mothers, child care workers....all are included in the welcoming arms of a feminist ethos that values the work of women in society. Women in historically male occupations such as lawyers, physicians, business managers, and such are allowed entry, too.<br />
But not nurses. Why?<br />
Misogynistic stereotypes of dumb nurse-sexpots abound in <a href="http://www.amazon.com/gp/product/B001HKU7GY/ref=cm_cr_mts_prod_img">Halloween costumes</a> , <a href="http://www.truthaboutnursing.org/press/awards/2009/awd.html">television</a> , and even in <a href="http://www.youtube.com/watch?v=NJx_7bJgj6Q">public service announcements for lung cancer</a> . It's pretty plain that the profession takes its hits for being female-dominated (93% of nurses are women), intimate, and, in many ways, <a href="http://allnurses.com/general-nursing-discussion/body-fluids-vomit-200944.html">downright unpleasant</a> . The work of nurses is the traditional work of women: personal, caring, and intellectual simultaneously, without a great deal of prestige or recognition. Nursing embodies precisely the sort of roles that should fire up feminists' advocacy engines.<br />
Yet feminist media do not feature articles about support and empowerment of nurses, the largest group of health care providers. A search of feministing.com, for one, revealed a smattering of articles, mostly about lay midwives (who are not nurses) and breastfeeding. My subscriptions to <a href="http://bitchmagazine.org/">Bitch</a> and <a href="http://www.msmagazine.com/">Ms.</a> do nothing to make me feel included in feminism as a professional. As an artist, a woman, a wife, a sexual being, and a daughter - yes. But nothing about life as a nurse. <br />
Nurses' workplace horrors rival those of the most mistreated workers anywhere. We face high rates of work-related injury, suboptimal staffing and mandatory overtime (in addition to the less-avoidable weekend, night and holiday shifts and exposure to hazardous body fluids and chemicals). If feminists supported the 3 million registered nurses in the United States, would it remain a dirty secret that 69 - 85% of nurses report having experienced <a href="http://www.nysna.org/practice/positions/position35.htm">sexual harassment</a> (mostly by physicians) on the job? (see Valente, 2004).<br />
Nurses are, in many ways, the solution to health care reform. Why aren't feminist organizations telling the public that, for example, better <a href="http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/HealthSystemReform/Agenda/Outcomes/Workforce.aspx">funding for educating advanced practice nurses </a> (APRN) to provide primary care would save health care dollars? APRN students in Seattle undertook a media campaign when the <a href="http://seattletimes.nwsource.com/html/education/2009307255_nursing06m.html">University of Washington increased their tuition</a> to equal that of medical students, but feminist magazines and websites missed the story entirely. No matter that nurses pay our own way through graduate school because of lack of federal funding. No matter that medical residencies receive <a href="http://www.truthaboutnursing.org/news/2009/feb/15_ap.html">375 federal dollars for every 1 dollar</a> spent on nursing residencies (despite the much greater numbers of nurses needed in health care and the 27% rate of one-year turnover among new nursing graduates.)<br />
Even the willingly ignorant cannot help but hearing of the critical <a href="http://www.pbs.org/now/shows/442/index.html">nursing shortage</a> . Much of the shortage is attributed to nursing faculty shortages caused by persistently low faculty salaries. A graduate education in nursing does not bring with it proportional increases in compensation. Most nurses remain educated in 2-year community college programs because there is a lack of drive for better-educated professional nurses, even though research shows better <a href="http://www.nursingadvocacy.org/news/2003sep26_ap.html">patient and organizational outcomes</a> when nurses have more education. Nursing' recent emphasis on doctoral education for advanced practice nurses was <a href="http://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3723">met with opposition</a> from the medical community, who apparently consider highly educated nurses a threat. <br />
So, in nursing we have an underfunded, under-appreciated caring profession that gets little recognition and encounters active opposition to efforts to advance our status. Ninety-three percent of us are women. We place ourselves in both <a href="http://findarticles.com/p/articles/mi_m0MJT/is_5_14/ai_110807499/">physical</a> and <a href="http://www.citeulike.org/user/eddyhyde/article/2873219">psychological</a> danger to nurse. We swim upstream to advance our educations. We work strange hours, skipping meals and breaks because employers do not staff adequately. We are customarily called by our first names, but we call our physician colleagues "doctor." Resistance in the hierarchical systems that exist in health care settings is met by firings, harrassment, and <a href="http://www.nytimes.com/2010/02/12/us/12nurses.html">legal action</a> for nurses.<br />
What about this makes the nursing profession worth ignoring to feminists? Are feminists, too, buying into the stereotype of nurse as feckless doctor-servant? Is the whole nursing mess so hard to manage intellectually and emotionally that even the brave and smart are afraid to enter? Or are nurses viewed as so complicit in our own oppression that feminism can hardly be bothered?<br />
Whichever, it's time feminism started paying attention. <br />
Valente, S. M., Bullough, V. (2004). Sexual harassment of nurses in the workplace, Journal of Nursing Care Quality, 19(3), 234-241. </div>florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com2tag:blogger.com,1999:blog-4419867698606018571.post-24256200058235117612009-06-24T07:33:00.000-07:002009-06-24T07:49:36.726-07:00Nurse Jackie RULES!<p>Undoubtedly you've seen the <a href="http://www.youtube.com/watch?v=FGyWMdCWUrc&feature=PlayList&p=NO-L7C38qEU"><em>Nurse Jackie</em></a> ads occupying every sidebar and banner ad on the Internet. Perhaps you've read <a href="http://www.blogger.com/blog/nurse_phd/2009/04/04/why_scrubs_is_the_best_hospital_drama_on_tv">my previous posts </a>about the inadequacies of the popular media in representing nurses. All of those less-than-completely-truthful rearrangements of electrons notwithstanding, I'm here to say this: </p> <h2 align="center">Showtime GETS it! </h2> <p>Showtime may have exhausted their advertising budget promoting Edie Falco in <em>Nurse Jackie</em>, but I'm not ashamed to report that it worked on me. I watched the pilot the first time I could find it (<a href="http://www.youtube.com/watch?v=FGyWMdCWUrc&feature=PlayList&p=NO-L7C38qEU">here,</a> by the way), and I was more than pleased, despite the <a href="http://www.salon.com/ent/tv/iltw/2009/06/07/nurse_jackie/index.html">dissapointment of others</a>. </p> <p>Edie Falco's burned-out, capable, smart, deeply flawed Nurse Jackie is enough to make my community college nursing instructors turn in their graves (or shake a wrinkled finger, at least those who are still alive). She's screwing a pharmacist and talking back to snotty doctors, and then there's that little pain pill addiction thing. Fittingly, the meticulous Jackie opens a capsule of God-knows-what, counts out precisely 16 granules ("no more, no less"), and snorts them to get her through the day in spite of back pain (A.K.A. the nurse's curse) and as-yet-untold psychic pain. </p> <p>Nurse Jackie's hospital is old, dark, religiously-affiliated and a little scary. Gigantic, vaguely Biblical figures painted on walls loom over Jackie and her nurse friend on breaks, threatening to swallow them up in the bureaucracy and powerlessness nurses fight daily in health care. This point is driven home when an administrator rebukes Jackie for working over 12 hours at a stretch, then asks her to work a double on Monday. I would have laughed, except it's the truth. </p> <p>Plenty of nursing groups are up in arms about this show, including the <a href="http://www.nursingworld.org/HomepageCategory/Announcements/Negative-Portrayal.aspx">American Nurses Association.</a> "It's unprofessional!" "It's just another distorted image of nurses!" "We have a shortage, you idiots!" they cry. The professor in me would just like to tell the ANA this: </p> <em>Dear ANA, perhaps you are unaware that we do <u>not</u> have a shortage of people who want to be nurses; we <u>do</u> have a shortage of educators and its cause is a shortage of money. Almost 40,000 qualified aspiring nursing students are turned away yearly. In light of these facts, please explain your argument that the image of nurses in the media is harming recruitment into our profession. I expect a double-spaced APA- formatted 5-page paper by Monday. Include suitable references. </em> <p>Frankly, I think some people will never be satisfied. Characters MUST be flawed to be interesting; an icon of professional perfection cannot carry the burden of being a major comic-dramatic character week after week. Perfection is too simple; perfection is downright BORING. So Nurse Jackie saves lives, screws a coworker, snorts pain pills, tells off stupid interns, acts with great compassion and tenderness and flagrantly violates the ANA Code of Ethics in the course of a typical day. And that's why she rocks. </p> <p>I haven't seen TNT's <a href="http://www.tnt.tv/series/hawthorne/about/">HawthoRNe</a> yet, but I hear Jada Pinkett's another tough, smart, imperfect, unconventional nurse. And, no, I didn't hear that from the <a href="http://www.nursingworld.org/HomepageCategory/Announcements/Protesting-HawthoRNe.aspx">American Nurses Association</a>. </p> <p> </p> <p> </p> <p> </p> <p> </p>florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-69499546931489372322008-12-27T11:17:00.000-08:002008-12-27T11:19:07.904-08:00The Knitting Must Stop!<p>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. </p> <p>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 <a href="http://cgi.ebay.com/ws/eBayISAPI.dll?ViewItem&item=200055307278&ssPageName=MERC_VI_RSCC_Pr8_PcY_BIN_Stores_IT&refitem=350111272632&itemcount=8&refwidgetloc=active_view_item&usedrule1=StoreCatToStoreCat&refwidgettype=cross_promot_widget&_trksid=p284.m184&_trkparms=algo%3DDR%26its%3DS%252BI%252BSS%26itu%3DISS%252BUCI%252BSI%26otn%3D8"> expensive</a>) 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. </p> <p>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 <a href="http://www.cdc.gov/nccdphp/dnpa/hwi/toolkits/lactation/index.htm">other things</a>. 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. </p> <p>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. </p> <p>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." </p> <p>Why are nurses knitting and sewing? With patient safety, patient satisfaction, and other indicators of <a href="http://www.hospitalcompare.hhs.gov/Hospital/Search/Welcome.asp?version=default&browser=Firefox%7C3%7CWinXP&language=English&defaultstatus=0&pagelist=Home">hospital quality</a> under close scrutiny, why are hospitals not supporting programs that are known to improve patient outcomes? </p> <p>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. </p> <p>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. </p> <p>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 <a href="http://www.ohsu.edu/ohsuedu/newspub/releases/042406MRI.cfm">fancy machinery</a> that add little or no value in terms of health outcomes. The disciples of <a href="http://www.econlib.org/library/Enc/bios/Friedman.html">Milton Friedman</a> 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. </p> <p> 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. </p> <p>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. </p>florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-35559263606796333162008-11-02T10:32:00.000-08:002008-11-02T10:41:00.861-08:00Joe Takes Care of His Own, Perpetually.<span style="font-style: italic;">Part I</span><br /><br /><span style="font-style: italic;">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. </span><br /><br /><span style="font-style: italic;">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. </span><br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">He was pronounced dead at 4:44 a.m. </span><br /><br /><span style="font-style: italic;"> Part II</span><br /><br /><span style="font-style: italic;">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. </span><br /><br /><span style="font-style: italic;">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. </span><br /><br /><span style="font-style: italic;">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. </span><br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">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. </span><br /><br /><span style="font-style: italic;"> Part III</span><br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">Weeks later, we learned that Joe Perry had died. On June 3, 1976. </span>florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com1tag:blogger.com,1999:blog-4419867698606018571.post-53628401603758934912008-10-21T08:41:00.001-07:002008-10-21T10:17:03.449-07:00Joint Commission, are you listening?I mourn for the demise of nursing <span style="font-weight: bold;">care</span>. I miss giving back massages, changing linens merely for comfort, sitting down to <span style="font-style: italic;">talk</span> with people. I especially miss the value formerly placed on nursing measures as critical to quality health care.<br /><br />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.<br /><br />Because of the poor quality of its documentation of standardized processes, the hospital where I work is threatened with revocation of its <a href="http://www.jointcommission.org/AboutUs/">Joint Commission</a> 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.<br /><br />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.<br /><br />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 <span style="font-style: italic;">do</span> 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!)<br /><br />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 <span style="font-weight: bold;">she</span> 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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-31459707479841153682008-10-06T08:38:00.000-07:002008-11-05T18:31:50.407-08:00Intelligent, reasonable, educated Catholics support ObamaTake a look <a href="http://ncronline3.org/drupal/?q=node/2058">here.</a>florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-16200593234366645702008-10-05T10:13:00.000-07:002012-03-31T16:43:23.281-07:00College students are SO CUTE!Salon magazine has a great article about Sarah Palin and the dumbing-down of the GOP (and America) <a href="http://www.blogger.com/%20http://www.salon.com/opinion/conason/2008/10/04/dumb/%20">here.</a><br />
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If this doesn't frighten you in preparation for Halloween, I don't know what will.<br />
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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!)<br />
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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.<br />
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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!<br />
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<span style="font-size: 130%;">Forgive my ignorance, but who ever told you that college grades were a measure of how hard you worked? </span><br />
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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.<br />
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"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.)"</blockquote>
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One student actually asked me how she is expected to get the material if it's not written on the slides and <span style="font-style: italic; font-weight: bold;">she does not listen in class</span>!<br />
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<span style="font-size: 130%; font-weight: bold;">WHAAAAAAATTTTT??? Help, Lord!!! I am abandoned in the cruel and savage land of hostile non sequiturs!!! </span><br />
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---- several deep breaths later ----<br />
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Peppered with such nonsense from packs of hungry 20-somethings, foaming from mouths full of perfect teeth, what is a professor to do?<br />
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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 <span style="font-style: italic;">zero</span> 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 <span style="font-style: italic;">do</span> count for things such as getting into the right graduate school.<br />
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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.<br />
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Not even the college-educated elitists.florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-41223102902081736962008-06-18T10:09:00.000-07:002008-11-05T18:36:22.546-08:00The dangers of exclusionary science, or: Can you trust your doctor?<p>I<span style="font-size:130%;">f 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.<br /></span></p><p><span style="font-size:130%;">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 <span style="font-style: italic;">solely </span>on white males. How did we get to this point? Here's a short history lesson:<br /></span></p><p><span style="font-size:130%;">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.<br /></span></p> <p><span style="font-size:130%;">"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.</span></p> <p><span style="font-size:130%;">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 <span style="font-style: italic;">cancer</span> 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.<br /></span></p> <p><span style="font-size:130%;">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.</span></p> <p><span style="font-size:130%;">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 <span style="font-style: italic;">in a man</span> 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.<br /></span></p><p><span style="font-size:130%;">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 <span style="font-style: italic;">never shown to be causal.</span> 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 <span style="font-style: italic;">increased</span> women's risk of heart attack and stroke. </span></p><p><span style="font-size:130%;">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. </span></p><p><span style="font-size:130%;"><a name="estrogen"></a>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 <em>Feminine Forever</em> 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.<br /></span></p><p><span style="font-size:130%;">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 <span style="font-style: italic;">not</span> mean inadequate mammary tissue to lactate and breastfeed a child, which would be a physiologic problem. It refers to <a href="http://www.time.com/time/magazine/article/0,9171,974902,00.html">a cosmetic problem </a>that plastic surgeons can "cure."<br /></span></p> <p><span style="font-size:130%;">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." </span></p>florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com5tag:blogger.com,1999:blog-4419867698606018571.post-39827569225702877232008-02-16T11:44:00.000-08:002012-03-31T20:02:38.766-07:00An interesting arrangement<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;"><br /></span><br />
<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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 <i>faculty</i> 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. </span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">The irony is that I would have more free time (not working 6 days a week - what a treat!), <i>make more money</i>, and be more effective in my academic role.</span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">How can this be?</span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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. </span><span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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 <i>completely satisfied</i>. 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. </span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">Nursing is a practice discipline. One of the implications of this is that we have to <span style="font-style: italic;">practice</span> 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 <i>have nowhere to practice nursing</i>. We have a health care system that thinks there's no place for us. </span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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.</span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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. <a href="http://www.annals.org/content/150/7/485.full" target="_blank">Control over health care goes to those who make the big bucks.</a> (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.* <a href="http://open.salon.com/blog/nurse_phd/2012/03/30/trickle-down_economics_does_not_save_lives" target="_blank">And this blog post.</a> </span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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 <span style="font-style: italic;">university</span>, 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. </span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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.</span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">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.</span><br />
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<span style="font-family: 'Helvetica Neue', Arial, Helvetica, sans-serif;">* Such as:</span><br />
<span style="background-color: white; color: #333333;"><a href="http://www.blogger.com/goog_826930003"><span style="font-family: Arial, Helvetica, sans-serif;">Medicine as culture: illness, disease and the body in Western societies</span></a></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://books.google.com/books?hl=en&lr=&id=OYZTBcOwcGQC&oi=fnd&pg=PA1&ots=b-0g4vFXJw&sig=xaOgr8baMiCMyV_Wh2rQN3mSrKg#v=onepage&q&f=false" target="_blank"><span style="background-color: white; color: #333333;"> </span><span class="addmd" style="background-color: white; color: #333333; left: -5px; margin-left: 2px; position: relative;">By Deborah Lupton</span></a></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://books.google.com/books?hl=en&lr=&id=OYZTBcOwcGQC&oi=fnd&pg=PA1&ots=b-0g4vFXJw&sig=xaOgr8baMiCMyV_Wh2rQN3mSrKg#v=onepage&q&f=false" target="_blank"><span class="addmd" style="background-color: white; color: #333333; left: -5px; margin-left: 2px; position: relative;"><br /></span></a><span style="font-size: small;"><a href="http://usyd.academia.edu/DeborahLupton/Papers/1536092/_Lupton_D._1995_Perspectives_on_power_communication_and_the_medical_encounter_implications_for_nursing_theory_and_practice._Nursing_Inquiry_2_3_157--63" style="background-attachment: initial; background-clip: initial; background-color: transparent; background-image: initial; background-origin: initial; border-bottom-width: 0px; border-color: initial; border-image: initial; border-left-width: 0px; border-right-width: 0px; border-style: initial; border-top-width: 0px; color: #3e3e3e; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; outline-color: initial; outline-style: initial; outline-width: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; vertical-align: baseline; word-wrap: break-word;">Perspectives on power, communication and the medical encounter: implications for nursing theory and practice. 1995. Nursing Inquiry, 2(3), 157--63.</a> by Deborah </span></span><span style="font-family: Arial, Helvetica, sans-serif;">Lupton</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: small;"><br /></span>Hospitals, Paternalism and the Role of the Nurse </span><em class="nl" id="yui_3_3_0_2_1333240135885_96" style="display: block; font-style: normal; font-weight: normal; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: Arial, Helvetica, sans-serif;">by <a data-bntrack="Contributor_1" href="http://www.barnesandnoble.com/c/jo-ann-ashley" id="yui_3_3_0_2_1333240135885_102" style="color: #5a7d56; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;" xmlns:func="http://exslt.org/functions">Jo Ann Ashley</a></span></em><em class="nl" id="yui_3_3_0_2_1333240135885_96" style="display: block; font-style: normal; font-weight: normal; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><br /></em><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://www.barnesandnoble.com/w/for-her-own-good-barbara-ehrenreich/1006289984?ean=9781400078004&itm=1&usri=for+her+own+good" target="_blank"><span class="name" id="yui_3_3_0_1_1333240976665_1298" style="border-bottom-style: none; border-bottom-width: 0px; border-color: initial; border-image: initial; border-left-style: none; border-left-width: 0px; border-right-style: none; border-right-width: 0px; border-top-style: none; border-top-width: 0px; font: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;">For Her Own Good: Two Centuries of the Experts' Advice to Women</span> </a><span class="date" style="border-bottom-style: none; border-bottom-width: 0px; border-color: initial; border-image: initial; border-left-style: none; border-left-width: 0px; border-right-style: none; border-right-width: 0px; border-top-style: none; border-top-width: 0px; color: #6b6b6a; font: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; white-space: nowrap;">(2005)</span></span></div>
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<li id="yui_3_3_0_1_1333240976665_1319" style="border-bottom-style: none; border-bottom-width: 0px; border-color: initial; border-image: initial; border-left-style: none; border-left-width: 0px; border-right-style: none; border-right-width: 0px; border-top-style: none; border-top-width: 0px; display: inline; font: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span class="nl" id="yui_3_3_0_2_1333240135885_96" style="display: block; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px;"><span style="font-family: Arial, Helvetica, sans-serif;">by </span><span style="font-family: Arial, Helvetica, sans-serif;">Barbara Ehrenreich </span><span style="font-family: Arial, Helvetica, sans-serif;">and <a class="subtle" data-bntrack="Contributor_1" href="http://www.barnesandnoble.com/c/deirdre-english" id="yui_3_3_0_1_1333240976665_1349" style="border-bottom-style: none; border-bottom-width: 0px; border-color: initial; border-image: initial; border-left-style: none; border-left-width: 0px; border-right-style: none; border-right-width: 0px; border-top-style: none; border-top-width: 0px; color: black; font: inherit; margin-bottom: 0px; margin-left: 0px; margin-right: 0px; margin-top: 0px; padding-bottom: 0px; padding-left: 0px; padding-right: 0px; padding-top: 0px; text-decoration: none;">Deirdre English</a></span></span></li>
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<br /></div>florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com1tag:blogger.com,1999:blog-4419867698606018571.post-67116519205335148072007-05-25T07:50:00.000-07:002007-10-28T20:43:15.511-07:00the logic of medical diagnosisTuberculosis is caused by the tubercle bacillus. In order to get a confirmed diagnosis of tuberculosis, the bacillus must be found in the tissue. Other signs/symptoms, like apical opacities on the chest x-ray and cough, confirm the suspicion of TB, and may serve as "presumptive" critieria if the tubercle bacillus cannot be cultured from tissue, but if you ask any physician or read any general medical text, you will be told that the tubercle bacillus is the cause of TB. So one might ask: "Oh, doctors, why doesn't everybody exposed to the tubercle bacillus get TB?" Reasons like insufficient exposure and a strong immune system are cited in response to that question. Therefore, exposure to the bacillus is necessary, although not sufficient, for the development of tuberculosis. An example of a necessary but not sufficient causative agent.<br /><br />Given that a cause can be necessary although not sufficient, let's look for cases where other combinations of necessary or sufficient agents are deemed causative by medical science. Please consider the case of smoking and lung cancer. An oft-cited statistic is that smoking causes about 90% of lung cancers. This figure includes former smokers, even those who quit decades before diagnosis. We know that smoking is not sufficient to cause lung cancer because 80% (or so) of smokers do NOT get lung cancer. (I am not a paid spokesperson for the tobacco industry; please bear with me here.) We also know that smoking is not necessary to develop lung cancer (of any histological type) because 10-13% of people diagnosed with lung cancer are never-smokers (disregarding the remote smoking question for the time being.) So here is a case of medical science concluding causality from a condition that is neither necessary nor sufficient to develop the disease. <br /><br />I have asked physician colleagues what the criteria for causality are. Why things like gender, age, racial heritage, and so forth are treated as nuisances (confounders) versus causes when they are plainly linked to the disease. I've never gotten a satisfactory answer, or at least one that was logically sound to me. If only men are susceptible to prostate cancer, then having a prostate gland is a necessary, but not sufficient, condition for prostate cancer. If medical diagnosis is driven by logic, and if other medical causes are necessary but not sufficient, then what is the logical basis for excluding male gender from the list of causes of prostate cancer, particularly when we know that male hormone deprivation shrinks prostate tumors? Take away the "cause" and the problem becomes solvable. Maybe it's just too obvious that to have prostate cancer, you must have a prostate gland. Or perhaps demonizing maleness is anathema to medical hegemony, which is based in male power and domination. Perhaps we cannot consider maleness a problem in the way we regard a bacillus. We never have done so, although the medical machine does have a long tradition of treating most female ailments with removal of the uterus. (For more information on this statement, search the etymology of the word "hysteria.") I say this knowing that about 50% of young physicians are women - nothing kept them from joining up with the winning side. That wouldn't change their gender, now would it?florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-16491618924835905842007-05-25T07:49:00.001-07:002017-11-04T17:00:12.536-07:00on suicideIt is, of course, fundamentally selfish. Selfish to think that you, of all people, shouldn't have to put up with all this shit. Yes, you're right - this place is harsh, unjust, and ugly. No one said you'd have to deal with this. But no one said you wouldn't either. And anyone (like your cheery mother) who did say that lied.<br />
Remember that suicide is terribly painful to others. They shouldn't have to deal with grief, guilt, and shame for generations because of your act. Suicide is more shameful, wrong as it is, in our society than murder. <br />
If you do decide to do it, at least have the decency to do it properly. Don't merely shoot your face off, like the young man I met in the trauma ICU. Don't take just enough Xanax to spend the night in the Emergency Department, feeling more and more stupid as you slowly wake up. And don't take just enough Tylenol to damage your liver, so you can walk around yellow-eyed and swollen the rest of your life.<br />
Suicide damages families. I know of a woman who killed herself, and the family tells each other stories about why and how, and some of them make up their own stories, and a lot of the facts don't fit, but no one mentions that. She killed herself in 1934, when my father was 16.<br />
Don't think suicide ends it all. Nowhere near. It's an ugly start to sharing the pain that others didn't even know you were suffering. So start this way instead:<br />
1. Tell someone - doesn't matter who as long as they know you.<br />
2. Consider whether, as you are about to suck air into your lungs one last time, you might regret the choice. What will you do then? Nothing but die.<br />
3. Think: no one else wants this. Only you want this. And maybe the devil. Don't give him the satisfaction.<br />
If you believe in near-death experiences, people who've tried to kill themselves report much less satisfying experiences than others. Neutral, not joyful. I am counting on the joyful part of death myself.<br />
I'm asking you, as someone who has seen too many people who've tried it and as someone who's contemplated it herself, not to do it. The voices that say you should are liars. The promise of ending your suffering is a lie. <br />
So just try to go on - please.florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com1tag:blogger.com,1999:blog-4419867698606018571.post-23901323712277377092007-05-25T07:45:00.000-07:002007-10-28T20:42:37.705-07:00the truth about angels and saintsSo they say to be merely a nurse is to help. Help sick people, poor people, dirty-faced little kids in need of hugs, and of course, to help doctors cure people. We are helping angels. We are saints. We are warmth in a cold, tiled hallway. We wear white dresses with white stockings, white shoes and usually white faces, too. Even after that chemo patient threw up on you and that drinker vomited blood all over the room, you still somehow remained white.<br /><br />Nurses don't talk back. That surgeon who said you were ripe for the picking, like a nice, round, red cherry....he didn't really mean anything by it. They are just that way. When you felt the power drain from your body, and then when you felt powerless for not being able to keep from feeling powerless, it was just your feelings.<br /><br />Everybody knows caring is not as good as curing. Everybody knows that talking with, monitoring, watching out for and teaching can't halt a killing blood clot in its path toward a feckless brain or image an athlete's torn meniscus with micron-sized resolution. Everybody knows nurses do what we are told, and things go just fine.<br /><br />No one ever promised you wouldn't get backaches and heel spurs and bad dreams and reasons to burst out crying driving to the grocery store on Saturday morning. Yes, you may know the anatomy, pharmacology, pathology, psychology, theology and technology - but you are famous for smiling and doing what you're told so use that and nothing else, dear.<br /><br />$33.75 an hour regardless of your graduate degree and 24 years of experience- every other weekend's mandatory: that's the contract language. The least experienced all work the night shift; it's always been that way. You get 15 minutes' break every 4 hours; that's the law. Try not to work overtime; it costs the hospital so much. And....by the way, we're short on Thursday and Friday - could you come in? It's unappealing for saints to negotiate, assert, determine, diagnose, advocate, act up, speak up and even save a few lives. Just don't talk about that part, okay? Clock out and go home, make dinner, put the kids to bed and kiss your husband, and when he is asleep, then think and grieve.florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0tag:blogger.com,1999:blog-4419867698606018571.post-81998798464684289862006-12-13T11:40:00.000-08:002007-10-28T20:41:54.460-07:00U.S. Healthcare is brokenYou've no doubt heard the title statement before. U.S. health care is indeed broken. We spend more of our GDP on health care than any other country in the world, but our outcomes are not superior. Our outcomes are not even as good as those of many other countries. Much internationally- cited medical research takes place on American soil, with American minds and American money. Nobel prize winners are disproportionately American - at least in the sciences. Individuals desiring advanced education travel from all over the world to our universities.<br /><br />Yet we are the only industrialized nation without national health insurance. (South Africa lacks it, but apparently not everyone considers it "industrialized.") Some developing nations, and virtually all "first-world" nations provide better health care than the United States does to its citizens. With 40 million people lacking health insurance, and health care expenses the predominant cause of personal bankruptcy, plainly something is wrong here.<br /><br />Pharmaceutical and medical device companies, insurers and the top-paid physicians (not all of them) are profiting from a system that is partly private, profit-driven and partly publicly-funded. The private interests don't want to give up their stake to an entirely public system in which they would cease to exist or make much less money, but the public system as configured now can't go on not benefitting from the lower-risk, lower-cost pool of insureds who are taking part in the private system. Those in the public system are the high-utilizers: the debilitated, the chronically severely ill. This pool of health care consumer is tremendously costly to care for, and the private system stays ahead by maintaining the prerogative to simply dump these people onto the public sysem when they become too costly to insure. Our system is largely tax-dollar funded, make no mistake: 60% of American health care is paid for in the public system through Medicare and Medicaid. Virtually all residents of long-term care facilities, for example, are cared for in the public system.<br />This intricate power tapestry has to be unraveled. A single, shared system, not a hybrid of public and private interests has to prevail if any semblance of justice is to be achieved.<br /><br />Costly and innovative new therapies are developed and brought into medical usage without accounting for the costs. It is simply assumed that a $40,000/year cancer drug is worth the cost. People receive bone marrow transplants and then are pushed onto a system that lacks the resources to provide sufficient followup care. Insurance pays for three home health nurse visits regardless of the real needs of the older adult who has had a hip replacement. Fabulous new diagnostic imaging systems costing many millions are assumed to be worthwhile in the absence of evidence for them. Invasive procedures do not have to be shown cost-effective, merely safe for human use, before they are adopted into medical practice. In fact, there is no governing body for medical procedures at all, as the FDA governs drug approval. And no one pays attention to costs but the insurers and, of course, the patient who files for bankruptcy because his retirement fund was not large enough to cover a catastropic illness. This situation permits medical values (which are far from sinister, but biased nonetheless) to drive medical expenditures.<br /><br />We need to reconsider our objectives and this will require a hard look at the values that drive health care. Medicine values life. Physicians are socialized to view death as failure, as the enemy. If a chemo drug doesn't stop a patient's cancer in its tracks, they say "the patient failed chemo." They "battle" disease. This "war on disease" mentality lacks perspective. Everyone will die. The discipline of medicine has succeeded (with help from personal hygiene, public sanitation and so forth) in extending lifespan considerably. Thanks to medicine, very few women now die in childbirth, which two centuries ago was a huge cause of premature mortality.<br /><br />Our expanded lifepsan, however, has had consequences. It made senile dementia, cancer and heart disease part of our everyday lives. These are not diseases prevalent in societies where people died before 40 years of age. These are aging-related diseases. So now we need to deal with these diseases, and they are much more complex than the ones medical science solved in past centuries. They cannot be wiped out by a course of antibiotics. It's not by neglect that we haven't discovered "the cure" for cancer. It's because there is no one cure. This pathological process is tremendously complex; as soon as we've cut off one head, it sprouts another. We now have longer lifespans that are still lengthening, and older people who develop diseases that put huge demands on the health care system, leading to ever-increasing costs because we have not had the guts to draw the line somewhere, fearing it will be arbitrary wherever it is drawn.<br /><br />We have to embrace realistic values that value human life but recognize limits, and then we have to draw that uncomortable line.florid nightingalehttp://www.blogger.com/profile/11695630762612540503noreply@blogger.com0