Nursing and Health CareNursing and Health Care

Suzanne Gordon, an award-winning journalist and frequent contributor to the Boston Globe, New York Times, and Washington Post, has written a wide-ranging and sometimes exasperating but ultimately worthwhile book about the current state of nursing and health care.

The first section, “Nurses and Doctors at Work,” portrays with great empathy—and more than an occasional lapse of reportorial objectivity—the frustrations of today’s registered nurses in an environment in which hospitals are financially strapped, physicians overworked and stressed, patients incredibly sick, and nurses’ work under-appreciated and frequently invisible. Physicians are often portrayed as callous, deliberately and sometimes offensively dismissive of nurses’ contributions to patient well-being. The nurses Gordon describes in multiple anecdotes are almost always clinically astute and are frequently the first, occasionally the only, professionals to observe, interpret, and respond appropriately to signs and symptoms that foretell disaster for the patient. Despite the horror stories of disasters and averted disasters, Gordon fortunately places the issues of nurses and doctors at work in a larger historical and sociological context. In the last chapter in this section, “Making Matters Worse,” she discusses the social construction of nursing and how its roots in the church—“the fusion of nursing and moral virtues” (p 128)—continue to affect nursing (and the often conflict-fraught relationships between nurses and physicians). This chapter alone is worth the price of the book.

In the second part, “The Media and Nursing,” Gordon discusses media portrayal of nurses— frequently as sex objects, objects of derision, or villains (think of Nurse Ratched in Ken Kesey’s One Flew Over the Cuckoo’s Nest), or as “kind, but dumb” (p 163). Rarely are nurses called upon by the mainstream media to comment on current health stories of interest to the public, contributing to the invisibility of nursing work. Again, Gordon recognizes the larger context, suggesting that nurses are socialized “into the old religious notion that they are part of a mass, and should not, therefore, highlight their individual contributions to either the patient or the health care team” (p 215).

The final section, “Hospitals and Nursing,” takes on the variety of ways in which managed care has influenced nurses and the work they do. The chapter “Mangling Care” is excoriatingly sarcastic in its criticisms of several leaders in nursing for their individual failures to predict the eventual influence of managed care on nursing and health care. Given that no one accurately foresaw where managed care would take the system, the criticisms seem unjust and unfair. In “No Nurse Left Behind,” Gordon outlines problems facing nurses in home and community care settings, management and administrative practice, academics, and other countries. The similarities of the problems faced across the spectrum are illuminating.

Finally, Gordon asks, “How can the odds be changed?” She offers a variety of potential solutions but, disappointingly, does not consistently apply the same depth and lucidity of her earlier discussions of the complex political, sociological, and historical roots of some of the problems. However, Gordon acknowledges that nurses themselves must be responsible for making their work visible and understandable to patients, physicians, administrators, and the public. With lengths of stay so short, and nurses’ work schedules so unpredictable, nurses have failed to communicate clearly what their role is in today’s chaotic system. Gordon persuasively argues that nurses have abandoned a rightful claim to both their diagnostic capability (because it is physicians who “diagnose”) and their expertise in the technological aspects of patient care. Simultaneously, they have adopted a paradigm of “caring” that, while serving to remove them from direct conflict with physicians over control of the patient, only renders even less visible nurses’ critical role in health care. To illustrate a positive approach, Gordon cites a British Columbia Nurses Union public relations campaign (p 444):

A nurse is standing smiling at the patient’s bedside, as he is about to begin eating his hospital meal. The ad copy reads: “He thinks he’s having a conversation about the hospital Jell-O. She’s actually midway through about 100 assessments . . . any one of which could mean the difference between recovery and tragedy.”

Nursing here is portrayed as dynamic, involving cognitive activity and decision making critical to patient well-being, rather than as (only) caring, being available, or being “nice.”

Other suggestions for changing the odds include a call for more collective action through unions (a theme throughout the book); legislation of minimum nurse staffing ratios (although Gordon does not mention that no research has yet demonstrated what optimal staffing ratios are); more reasonable work schedules; better pay (but, while improving nurses’ pay is important, there is a contradiction between the recommendation for better hourly wages and the fact that professionals are not hourly workers); and interprofessional education.

A troubling aspect is the book’s failure to clearly identify its audience. After reading the first part, anyone considering a career in nursing is likely to make a different career choice, since its depiction of nursing—in the words of nurses themselves, as well as those of physicians and administrators—is so dismal. If practicing nurses read the book, they will nod their heads in agreement at the all-too-familiar stories. The ultimate dilemma in writing a book like this, and its ultimate success, is how to have it read by the groups who have the skill, power, and political will to even the odds for nurses and thus improve quality of care for us all.