When Care Givers Became Cost Centers: The Genesis Of The Crisis In Nursing

The moment that the crisis in American nursing went from being worrisome to dire was when hospital administrators stopped considering nurses to be care givers and they became "cost centers."

It's not possible to pinpoint exactly when that metamorphosis occurred. Ten or 12 years ago is close enough, but the consequences have been all too apparent: More nurses are leaving the profession than entering it because of mandatory overtime, patient overload and burnout, the workforce is getting older and grayer, pay raises are fewer and farther between, and only a relatively small percentage of nurses have health insurance, let alone other benefits.

All that although nurses are what make hospitals tick, especially went it comes to direct, around-the-clock care of the most seriously ill patients.

* * * * *

The history of modern nursing, which can be traced to Florence Nightingale in the 1850s, goes a long way to explaining why nurses have been so marginalized despite their vital role.

Nursing was the first profession for respectable women who wanted to work outside the home, but from the outset nurses were viewed as a source of cheap, disposable labor by most hospitals and mere servants by most doctors.

Not even the emergence of women's liberation in the late 1960s and the steady if uneven integration of women into important jobs in professions once off limits to them has altered the historic view of nurses as being always dependent and ever subordinate, but at least they weren't viewed as little cogs in big financial wheels until profit-making, restructuring and downsizing began subsuming patient care.

To a great extent, nurses have only themselves to blame for getting so little respect.

It is drilled into them from the time they are nursing school rookies that although they are the most important link in the continuity of care, altruism and self sacrifice always come first and the doctor is always right even when he is ignorant or abusive.

No matter the circumstances, the doctor is not to be contradicted even when the nurse has a much better understanding of a patient's needs. This results in a nurse, if she is savvy and experienced enough, having to resort to speaking in a kind of code to a doctor when she believes that he has to be nudged into prescribing the appropriate drug or course of treatment.

Doctors, meanwhile, are seldom taught how to interact with nurses, but it is repeatedly reinforced through medical school, internships and residencies that nurses are always inferiors. This has not changed even with the growing number of woman doctors.

Long story short, while doctors have the theoretical knowledge it is nurses that have the practical knowledge, but seldom does the twain meet in this dysfunctional relationship.

I know that from firsthand experience.

When I spent several days in the stroke unit of a major hospital after suffering a kind of stroke known as a cardio-vascular accident, doctors ranging from my neurologist to residents to interns regularly gathered around my bed to review my case. But although it was nurses who provided virtually all of my care -- and first-rate care at that -- they were made to stand outside the bedside circle and their input never was solicited.

Meanwhile, few nurses are represented by unions and workplace gains frequently come only after the rare strike, if then. Nursing associations are notoriously weak and one result of this is that while doctors have occupational autonomy and considerable clout in state legislatures and Congress, nurses have none. Witness the utter absence of nurses as a voice in the ongoing debate over health-care reform.

Then there is the way that nurses are portrayed in popular literature and the media.

No nurse is better known than Mildred Ratched in Ken Kesey's One Flew Over the Cuckoo's Nest, a bestselling novel and award-winning movie, while doctors are gods and nurses field hands on popular television shows like ER. In fact, the wildly popular NBC show goes so far as to always dress nurses in pastel scrubs to make sure no one confuses the RNs with the MDs.

I can recall only two exceptions to the TV rule that nurses are always handmaidens: The role of Major Margaret Houlihan (Loretta Switt) as it evolved in the later seasons of M*A*S*H and Lieutenant Colleen McMurphy (Dana Delaney) on China Beach. It probably is not coincidental that the settings for both of these shows were war zones where nurses played outsized, real-life roles.

As bit players, nurses seldom make the news and only then when a patient is killed or they go out on strike. When there is good news -- say the miraculous recovery of a famous person or a child who falls into an icy pond and is presumed dead -- doctors always get the credit even nurses played lifesaving roles.

* * * * *

Today by some estimates there are vacancies in 15 percent of the registered nurse positions in the U.S. and a similar shortfall in the faculty needed to train the next generation of nurses.

This crisis is occurring in plain view but away from the media spotlight at a time when aging baby boomers are being hospitalized in record numbers.

A result is that many nurses have staggeringly high patient loads -- sometimes as many as 10 or 12 patients per nurse per shift -- at a time when hospitals are discharging patients after a day or two when they once were hospitalized for longer stretches. Meanwhile, many procedures are being done on an outpatient basis that sometimes result in emergency room visits and hospital admissions because the patient wasn't ready or able to take care of themselves.

To end where we began, underlying this sea change is that hospital administrators, as well as profit-hungry insurance and pharmaceutical companies, consider doctors to be revenue generators while nurses are . . . well, merely cost centers.

Paying more would seem to be a way to solve the crisis in nursing, but that isn't necessarily the case because better pay won't make up for lousy working conditions.

If there is a solution it is taxpayer-supported universal health care akin to the systems in other industrialized countries that would provide more money for nursing education, staffing and interdisciplinary collaboration while getting wasteful spending under control and giving every American access to decent care.

But no one expects what emerges from the congressional sausage factory after the bruising debate over health-care reform to come close to universal care, least of all nurses.

This essay is based on part on Nursing Against the Odds: How Health Care Cost cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care (2005) by Suzanne Gordon.