Nursing Against the Odds: How Healthcare Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care, by Suzanne Gordon. Ithaca, NY: Cornell University Press; 2005.
Nursing Against the Odds: How Healthcare Cost Cutting, Media Stereotypes, and Medical Hubris Undermine Nurses and Patient Care is a book written for nurses, healthcare professionals, educators, policymakers, and patients. On the basis of interviews, personal experience, news articles, industry publications, books, and popular media, the well-known author Suzanne Gordon investigates the workplace dynamics that drive the current nursing shortage and provides evidence and opinion as to why current industry solutions may serve only to worsen the situation. Future solutions that include organizing for greater "voice," international cooperation, and changes to the healthcare system are suggested. While it could be argued that not all of the dynamics were equally identified nor investigated, the information that Gordon has chosen to include is certain to be revealing, compelling, and inherently logical. It is possible that not all readers will wholly agree with Gordon's analysis or the recommendations, but this journalistic work is certain to inform and challenge the reader on some level-emotionally, intellectually, or politically.
The 14 chapters are divided into 3 topical sections. Part 1 describes the dynamics between nurses and doctors in relation to their care of the patient, and how a subservient role with a limited voice for nurses is perpetuated by the hospital as an institution, the history and academic structure of medicine, the history of nurses and nursing, and the role modeling that occurs for new practitioners. Part 2 examines how the media portrays nurses, with particular regard to shaping of public expectations of what nurses do and what nurses contribute in their caregiving role. Part 3 discusses hospital trends including restructuring, staffing ratios, recruitment of nurses from foreign countries, advanced practice nursing, nosocomial infections, working conditions including stress-related injuries, and use of traveling nurses. Gordon draws on many industry publications, organizations, and spokespersons, including the Institute of Medicine, the American Nurses Association, the American Medical Association, the Joint Commission on Accreditation of Healthcare Organizations, deans and directors, union leaders, and policy analysts. Regarding the views, data, and stakeholder positions of these interested parties and special interest groups, it should be noted that Gordon embraces and criticizes equally among the lot and does not spare any one group regardless of their record of good works or intent.
It is no wonder that nurses are ill-treated by physicians, that nurses are undervalued, and that communication issues proliferate in today's organizations, writes Gordon. Medical schools do not have courses on teams nor communication techniques, residents model their behaviors on what they observe on the job in traditional hierarchical hospital settings, and sadly, many patients' letters of thanks often identify only the physician. Further, nursing behaviors are steeped in the history of religious orders of centuries past, where service to the sick and dying was an act of devotion performed by those who did not question the hierarchy of power, nor was hard work for little pay ever questioned as inequitable. The popular media of today does not do much to modernize the historical image of nurses in the mind of the public, where nurses are often portrayed as angels who minister through holism and caring, undifferentiated from the nurturing role of lay practitioners; the scientific training and what Gordon refers to as "technical wizardry" of today's nurse is too often omitted in film, books, and advertisements.
It also is little wonder that physicians and the general public assume that the purpose of nursing practice is to provide comfort and follow orders. Alas, the assessment, evaluation, and planning, in addition to technical skill, that are essential to nursing practice are minimized in communications, media portrayal, and public expectations. Nurses are portrayed as "virtue workers," says Gordon, much to the detriment of nurses in relationships that require respect for professionalism, power, and credibility. The development of nursing diagnoses and nursing language has not been to the profession's benefit, according to Gordon, in that developing an internal communication system that is viewed as complex and difficult to interpret by other healthcare personnel serves only to set nursing apart rather than build respect for their contributions.
The current nursing shortage differs from that of the 1980s, Gordon observes, in that back then there was a growing optimism that working conditions would improve-and indeed they did, to a point. Increased wages, clinical ladders, and the creation of the clinical nurse specialist role gave nurses hope that the respect and rewards due to them would be forthcoming.
It is the advent of what Gordon terms the "1-800-Mother-may-I" phenomenon of managed care (prior approvals, designated lengths of stay, protocols rather than personalized care) that is a new factor in the current shortage. It is not just the aging of the workforce that is a primary reason that hospitals cannot hire enough nurses to fill the demand today. In Gordon's view, the nurses of today are exhausted. While there are already not enough people to do the work because of a shortage of supply, the managerial acts of cost cutting contribute further by creating what Gordon calls a "shortage of nursing care." In addition to a shortage of nurses, Gordon says, we are also experiencing a shortage of nursing care, given time constraints, workload, and the addition of unlicensed caregivers who are not trained in assessment nor intervention. This new dynamic means that nurses no longer have time to prepare and maintain themselves emotionally nor physically to continue the ongoing stressful and demanding work in hospital settings, as hospitals are places where people suffer and die. The shortage of nursing care leads to a shortage of nurses, as current conditions create job dissatisfaction and a growing inability to recruit new entrants. Gordon notes that to continue to work in a stressful environment and to create the unique caring relationship as needed with each patient, nurses need enough time at the bedside in addition to time for their own personal renewal to be effective and to fulfill their jobs in a meaningful and rewarding manner.
"What about advanced practice nurses?" the reader might ask. "Aren't they a solution to the situation of lack of respect in the workplace?" Gordon addresses advanced practice as a double-edged sword. While advanced education is laudable, Gordon notes that many advanced practice nurses are being prepared for more autonomous clinic and community work, leaving the less prepared nurses to remain at the bedside, which only serves to erode working conditions for the majority of nurses who continue to be employed in hospital settings. Gordon calls this an internal migration within the profession and wonders how this is benefiting the profession as a whole.
Gordon writes of nurses at the bedside in this book. She purposefully and admittedly omits nurse managers, nurse executives, and nurse educators. While the majority of nurses in the profession do work in acute care and also at the bedside, to omit nurses who may be able to influence policy, working conditions, allocation of resources, communications, and the education of the next generation of nurses may be a weakness in the arguments and solutions presented. Gordon mentions that the general public may have erroneous perceptions of what a nurse is and does, and this may be a weakness of the book itself as well, given that nurses who do not work at the bedside are no less nurses for having taken a position of influence for the profession that is located in an office, in a university, or in Congress. Whatever the weaknesses of Gordon's book, it is a compelling and educational read, and is highly recommended for its insights and information.
Dale Mueller, EdD, RN, CNAA, BC
Assistant Professor, College of Health and Human Services, School of Nursing, California State University Dominguez Hills, Carson, CA 90747 (e-mail: [email protected]).