But Pham’s colleagues said that was not the case. National Nurses United, the country’s largest nurses’ union, spoke to the nurses and issued a statement asserting that the hospital neither trained the nurses nor established protocols to begin with. Supervisors told nurses that certain protective masks were unnecessary, hospital authorities resisted a nurse supervisor who demanded that the patient be moved from a non-quarantined zone to an isolation unit, and the nurses’ protective gear left their necks exposed, according to the NNU.
While, amid an uproar from nursing communities, Frieden later said his remarks were misconstrued. “There’s a lot of outrage about Frieden’s comments,” American Academy of Nursing president Diana Mason told NPR. “It’s blame the nurses again.”
Some health organizations place nurses on the front lines, and then fail to protect them, let alone treat them like the heroes they truly are. On a lesser scale, many hospitals develop policies that blatantly set nurses apart from other staff members. WSMV-TV Nashville reported that at Vanderbilt Medical Center in 2013, administrators cut costs and risked cross-contamination by forcing nurses to perform housekeeping duties, including emptying garbage cans, changing linens, sweeping, and mopping patient rooms and bathrooms. At other hospitals, nurses were the only employees who were charged for parking. A lighter but still legitimately irritating example occurred at a northern California hospital, where administrators announced that they would no longer provide half-and-half for nurses and other staff, but would continue to have it available for doctors and administrators. The staff responded by planting a “Will Work for Half-and-Half” jar in a break room, in which coworkers deposited donations of half-and-half containers.
These administrators’ message is clear: They value doctors more than they value nurses and treat them accordingly. They might also prioritize some doctors over others. In one study, nearly 40 percent of doctors said that administrators are more lenient with the physicians who generate large amounts of money for their organization. Hierarchies like these do not promote patient care; rather, they enmesh doctors and nurses in territorial fights that can make them lose sight of what matters.
The controversy over the doctorate of nursing practice degree (DNP) is emblematic of the professions’ crossed signals. As of 2015, nurses wishing to become nurse practitioners—who are able to diagnose and treat patients in ways similar to a general practitioner—must go beyond master’s level training to earn a doctorate, and can therefore add “doctor” to their title. Nurse leaders say the additional education is important to expand nurses’ expertise, enhance their qualifications for hospital administrative jobs, and gain more respect in the medical field.
But physicians have turned the debate into a turf battle over the “doctor” title that some NPs, as they are known, would use, claiming that the degree threatens the medical doctors’ position as healthcare leaders. They argued that nurses calling themselves “doctor” will confuse patients and is an attempt to equate their status with physicians, who have thousands more hours of medical training. The American Medical Association loudly protested the Doctor of Nursing Practice designation, calling it “title encroachment,” and proposed a resolution to restrict the “doctor” title in medical settings to physicians, dentists, and podiatrists. Eventually, the AMA instead adopted a resolution to “advocate that professionals in a clinical healthcare setting clearly and accurately identify to patients their qualifications and degrees attain(ed)” and to “support state legislation that would make it a felony to misrepresent one’s self as a physician.”
Nurse practitioners say they are looking to develop their knowledge, not to take over the field. In general, they have more time than physicians to spend with patients and charge less for their services. A major study found that nurse practitioners’ patients have “essentially the same” health as physicians’ patients. At the time of this writing, nineteen states and the District of Columbia allow nurse practitioners to practice independently. Nurse-owned practices are a growing component of healthcare; in 2011 (the most recent year for which data is available), 100,585 advanced practice registered nurses billed $2.4 billion in services to 10.4 million Medicare patients—32 percent of the Medicare fee-for-service population. Those numbers are expected to grow. With a looming physician shortage in the United States by 2020, nurses with advanced degrees offer an additional option to patients, particularly in rural areas where access to doctors is scarce.
Effective 2009, The Joint Commission required hospitals to have a “code of conduct that defines acceptable and disruptive and inappropriate behaviors” and a process for managing those behaviors. Since then, studies have shown “moderate improvement” in doctor bullying and nurse reporting of this behavior. In 2005, only about 10 percent of critical care and OR nurses spoke up if they were bullied by a doctor or if they felt patient care was compromised; by 2010, this number had increased to about one-quarter of these nurses. TJC continues to receive reports of intimidation, and medical researchers say “there are still large, disconcerting gaps between what we have been able to achieve and where we need to go.”
Some healthcare providers have devised helpful strategies to handle intimidation. In one surgical department, when any staff member in the room feels that tensions are rising, he or she can call out, “Tempo!” as a reminder for everyone to calm down. (That safe-word strategy would not work in all hospitals.) A Southern hospital keeps red phones at each nurses station; if a physician is berating a nurse, she picks up the phone and an administrator quickly arrives to assist her. Similarly, nurses in a New Brunswick, Canada, hospital began a practice known as “Code Pink” when they got fed up with a particular doctor bully. When the doctor lambasts a nurse, other nurses spread the “Code Pink” alarm and stand beside her in support. The practice has expanded; at another hospital, a mistreated nurse can page a “Code White” to the same effect.
Still, these codes go more toward treating a symptom rather than preventing problems in the first place—perhaps fitting in an American healthcare model. Rather than collaborating with each other, too many groups of healthcare providers view their roles as practically adversarial. Some doctors equate “nurse-friendly” hospitals with “doctor-unfriendly,” as if what’s good for the nurse can’t possibly also be good for the doctor.
Nurses have earned their place at the table. Is it possible to have a chain of command without implied levels of superiority? To view the various scopes of practice as complementary rather than hierarchical? One strategy is to rework administrators’ perspectives and doctor–nurse relationships so that all staff members view each other as part of a team. Obviously, this won’t work for every pairing. As one ER pediatrician told me, “If I have a shitty nurse, it affects my entire day.” But it is imperative that the professions acknowledge that every member of the team deserves a voice.
In his 2011 commencement address at Harvard Medical School, surgeon Atul Gawande said, “We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.” He explained to the graduates that the hospitals that achieve the best medical performance results are not the most expensive, but rather, the places where “diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews.”
To get there, healthcare organizations are going to have to force stakeholders to agree on the most effective role for a twenty-first-century nurse. As a Canadian ER nurse posted on KevinMD.com, “The issue boils down to whether the healthcare industry can tolerate highly educated, vocal, critically thinking, engaged nurse-collaborators who, in the interest of their patients, will constructively work with—and challenge, if necessary— physicians and established treatment plans. Or does the industry just want robots with limited analytical skills, who blindly and unthinkingly collect vital signs and carry out physician orders? More importantly, which model presents the best opportunity for excellent patient care?”