Since it feels timely to do so, I am choosing to republish a previous blog post from 2009 that I feel is still poignant and worthy of discussion. Here is the post in its entirety, originally published under the auspices of the nurse blogger scholarship which I received from Value Care, Value Nurses, the nursing arm of the Service Employees International Union (SEIU).
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I have recently been re-reading From Silence to Voice: What Nurses Know and Must Communicate to the Public, by Bernice Buresh and Suzanne Gordon. What I am most struck by is that nurses still have not necessarily found their collective voice, and despite the media attention given to the global nursing shortage, I still believe that Buresh and Gordon's thesis still holds true: the public still does not fully understand what nurses do, and until that day comes, nurses' real value as clinicians will not be common knowledge.
Buresh and Gordon touch on many themes and areas of interest vis-a-vis nurses and their relation to the public, to doctors, and to one another. While I will not provide a review of the book---nor a comprehensive enumerating of its content---there are certain area which pique my interest, and I encourage curious readers to order a copy of the book and explore some of these issues for themselves.
Doctors Cure, Nurses Care
When I first heard this phrase, I was moderately disturbed by it for several reasons. Doctors, by and large, receive the lion's share of praise and gratitude when a sick patient is cured of an illness. Granted, doctors undergo a great deal of training and education in order to offer curative treatments for a variety of diseases, yet all too often, the work of nurses is grossly overlooked when it comes to successful treatment. While nurses do indeed carry out many orders originated from doctors, nurses use their own brand of critical thinking and autonomous action in order to perform specialized patient care. The public may not be aware of this fact, but many actions taken by nurses are initiated by nurses themselves, and the professional clinical assessments performed by nurses will often lead to changes in treatment and greater overall success.
Sure, nurses care, and nursing is seen by the public as a "caring" profession. However, nurses utilize scientific methods, skilled observation, and keen assessment skills to monitor patients' progress. Nurses are not just "the caring eyes and ears of doctors"---nurses are skilled professionals fully involved in patient care---and patient cures.
The Nurse as Angel, Teddy-Bear, and Child
In their book, Buresh and Gordon make one thing clear: nurses' self-presentation says a great deal to the public, and images of nurses that instill themselves in the societal zeitgeist are difficult to dispel.
Somewhere along the line, the "angels of mercy" moniker became attached to nurses as a group. Granted, in the early days of nursing, nurses' ability to act autonomously was extremely limited, and we were, by and large, the handmaidens of deified doctors. However, as much as that regrettable history has largely changed, the image of the nurse as angel unfortunately persists quite widely in our culture and websites galore promote gifts and baubles that continue to diminish nurses' professionalism. Images such as this one drive home the point: nurses are childlike individuals with starched white hats who love teddy-bears. Adding insult to injury, nurses can actually be depicted as winged angel/teddy-bears, further enforcing the infantilization (and deprofessionalization) of our profession. Would doctors allow themselves to be thus represented to the public?
Rather than being perceived as cherubic angels and childlike creatures, this writer feels that being perceived as the valuable and skilled professionals who we truly are would allow the public to have a much more accurate perception of what we do, and our importance to the care of millions.
The Clothes on Our Back
Nurses' uniforms have certainly changed over the years, and as scrubs have become the norm for nurses in most clinical settings, many companies have capitalized on the popularity of such utilitarian clothing. Now, designer scrubs covered with angels, teddy-bears (there they are again!), and any number of cartoon-like images adorn the hard-working bodies of nurses around the world. If nurses want to be taken seriously by the public---and by doctors and other professionals---how does the wearing of such (in my opinion) unprofessional clothing help our cause?
Picture this: a team meeting occurs midday to discuss a patient on the adult oncology floor. Present at the meeting: a medical resident, a medical student, the attending doctor, the oncologist, two unit nurses, a social worker and a respiratory therapist. Of all of the professionals in the room, who would possibly be wearing pink scrubs covered with teddy-bears and hearts, and a pin on her chest saying "Doctors Cure, Nurses Care"? And what message does this convey about the nurse's self-image and how the other professionals present in the meeting should perceive him or her?
What's in a Name?
In From Silence to Voice, Buresh and Gordon make their case that nurses being addressed by first name only is also a major image problem when it comes to the public's perception of us a collective whole.
When doctors introduce themselves to patients or other professionals, they always do so by using the title "Doctor" before their name. This practice immediately creates an impression that the doctor is a professional, that he or she has a name that should be remembered, and a hierarchy of power and authority is clearly established from the start.
Conversely, we nurses almost ubiquitously introduce ourselves by first name only, ostensibly to break down the barriers between patients and nurses, assisting the patient in overcoming fears and anxieties related to their treatment. While this tactic may have some limited benefit, Buresh and Gordon argue that "if nurses introduce themselves by their first names only, they are asking to be regarded as nonprofessionals because that is the conventional way that nonprofessionals present themselves."
The "first-name only convention", as the authors have named it, makes it significantly more difficult for individual nurses to receive recognition for their work when only their first names are known. It also creates a hierarchical structure in which the doctor stands alone as a figure of authority, towering above the patient and nurse with (patriarchal or matriarchal) power and authority.
Interestingly, many nurses will argue that introducing ourselves as "Nurse Smith" or "Nurse Cadmus" is awkward at best, but also brings to mind the infamous "Nurse Ratched" from "One Flew Over the Cuckoo's Nest". Granted, Nurse Ratched is a mythic and hated figure in the pantheon of film and modern literature, yet do we see doctors eschewing their well-earned title due to historical figures such as Dr. Kevorkian or Dr. Mengele (of Auschwitz fame)? Absolutely not. Doctors use their title so commonly and so frequently that the word "doctor" simply holds too much cultural power to be diminished by one literary (or real-life) character who used that title for ill.
As for "naming practices" between doctors and nurses themselves, further examples of an unequal playing field emerge, with nurses almost continually subjugated to a diminished status by always being addressed by first name by both patients and doctors, whereas doctors maintain their professionalism and authority through the use of their title and last name.
Taking Credit Where Credit is Due
All too often, the work of nurses is diminished by nurses themselves. When thanked for their work, nurses will frequently say, "Oh, I didn't do much. The doctors really did the hard part." Or when a nurse is asked what he or she does, the answer will often be, "I'm just a nurse." This diminution of nurses' worth does little to cement in the public's collective mind the utter importance---the crucial presence---of nurses in the healthcare system. The "just a nurse" phrase---used all too painfully often---hurts nurses' cultural standing and diminishes the profession in the public's eye.
Nurses need to stand up and take credit for the work that they do. Buresh and Gordon urge nurses to say "You're welcome" when they are thanked. "I am so glad that I could assist you in learning so much about your diabetes, Mr. Smith" or "It was my pleasure to provide your post-operative nursing care, Mrs. Jones"---these are statements that take credit for nurses' actions, acknowledge patients' gratitude, and accept responsibility for providing crucial nursing care that directly impacts patients' recovery and health.
Nurses' Agency
Buresh and Gordon recommend that nurses discover their "voice of agency". According the authors, "the voice of agency is the voice that says: 'I helped the patient to walk after surgery so that she wouldn't get blood clots in her legs' or 'I taught the patient how to take his medications so that they would be effective and produce fewer side effects.' The authors further illustrate their point by reminding us that "the voice of agency is the voice that conveys the message, 'I'm here. I am doing something important.' "
For nurses to develop their own agency---their own power---nurses must first claim and recognize the importance of what they do. As Buresh and Gordon elucidate so clearly in their book, patients do not learn self-care skills in a vacuum. Someone must teach them those skills, and it is nurses who bring their knowledge and education directly to patient care. When recovering from surgery, it isn't doctors who monitor patients every fifteen minutes, using a lifetime's worth of learning to perform important expert assessments. Nurses use a wide variety of skills---often on an autonomous basis---to provide patients with the care and attention they need for optimal health.
While nurses are indeed held in very high esteem by the general public in surveys and polls, most members of that adoring public would be hard pressed to actually describe what it is that nurses do. As Bernice Buresh and Suzanne Gordon make so abundantly clear, it is up to nurses to claim their rightful place of importance in the care provided to patients in a variety of settings. Nurses need to proudly speak of their work with a voice of agency and power, and communicate clearly---to the public, the media, their families, their friends, and their colleagues---that nursing is important, that it is meaningful, and that what nurses do contributes to successful patient care and positive outcomes. We must forgo the teddy-bears, the hearts, the flowers, the useless diminutive statements and self-deprecation, and claim our professionalism for our own.
Nursing's voice must be heard, and Buresh and Gordon feel that the time for that voice to be clearly heard is now.
Showing posts with label Value Care-Value Nurses. Show all posts
Showing posts with label Value Care-Value Nurses. Show all posts
Friday, December 16, 2011
Saturday, November 01, 2008
Value Care, Value Nurses Blogger Scholarship Completed
I have now completed my series of posts under the auspices of the Nurse Blogger Scholarship which I was awarded in July of this year from Value Care, Value Nurses. I would like to take this opportunity to thank VCVN and the Service Employees International Union (SEIU) for their generosity and support. VCVN and SEIU exerted no influence on the subject matter, tone, or content of my posts, and I was given absolutely free reign throughout the length of the scholarship period.
As a way to make all of my entries available in one place, I am creating links to each post---in chronological order of their publication---here.
Value Care, Value Nurses Scholarship
The Nursing Shortage: A Global Crisis, Close to Home
Obama, Healthcare and a Trio of Mythic Figures
The Aging World
Hispanics and the U.S. Healthcare System
Religion and Discrimination in Healthcare
Nurses' Voices, Nurses' Image: Nurses' Power
The Office of the National Nurse
Economics and the Elderly
The Irony of Mental Health Parity
Multiple Chemical Sensitivity: A Hidden Disability
The Nursing Shortage, PBS-Style
New Nurses, Primary Care, and the Calculus of a Multifaceted Shortage
Nurses have a great deal to say, and nurse bloggers are frequently outspoken, taking risks and shining a light in some interesting (and sometimes disturbing) corners of the healthcare system. My hope is that the Value Care, Value Nurses Nurse Blogger Scholarship will become an annual award that will continue to bring nurses' voices to the fore at a time when those voices are greatly needed.
Again, my sincerest gratitude to VCVN and SEIU for their support, generosity, and encouragement.
As a way to make all of my entries available in one place, I am creating links to each post---in chronological order of their publication---here.
Value Care, Value Nurses Scholarship
The Nursing Shortage: A Global Crisis, Close to Home
Obama, Healthcare and a Trio of Mythic Figures
The Aging World
Hispanics and the U.S. Healthcare System
Religion and Discrimination in Healthcare
Nurses' Voices, Nurses' Image: Nurses' Power
The Office of the National Nurse
Economics and the Elderly
The Irony of Mental Health Parity
Multiple Chemical Sensitivity: A Hidden Disability
The Nursing Shortage, PBS-Style
New Nurses, Primary Care, and the Calculus of a Multifaceted Shortage
Nurses have a great deal to say, and nurse bloggers are frequently outspoken, taking risks and shining a light in some interesting (and sometimes disturbing) corners of the healthcare system. My hope is that the Value Care, Value Nurses Nurse Blogger Scholarship will become an annual award that will continue to bring nurses' voices to the fore at a time when those voices are greatly needed.
Again, my sincerest gratitude to VCVN and SEIU for their support, generosity, and encouragement.
Tuesday, October 28, 2008
New Nurses, Primary Care, and the Calculus of a Multifaceted Shortage
(Note: This is my twelfth---and final---post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
It seems that everywhere I turn, someone is telling me that, a) they just applied to nursing school, b) someone they know just applied, or c) they or someone they know was just accepted/rejected from nursing school.
New nurses---and those who wish to be nurses---are entering a profession in transition, a profession that is losing its older members more quickly than its educational institutions can churn out novices ready to enter the fray.
Today I was interviewed on a radio program in Gainseville, Florida about a recently published book of non-fiction writing by nurses in which I was a featured contributor. The show's hosts seemed sincerely perplexed when I explained that older nurses are retiring faster than they can be replaced, and that nursing schools simply cannot offer faculty salaries that can compete with what nurses are paid in clinical positions. Thus, thousands of qualified applicants for nursing school programs are turned away each year since there are not enough professors to educate them.
As a consequence, far too many eager and highly qualified applicants are rejected from nursing schools around the country---and in fact, around the world, as well---and where do they turn? Do they re-apply the following year? Do they look for another school to which they might have a chance of acceptance? Or do they give up their quest to join the nursing profession and simply move in another career direction entirely?
At a time when aging Baby Boomers are living longer with chronic illnesses and are increasingly in need of quality nursing and medical care, it's time for our government and other influential entities to step up to the plate. The government itself must realize that the calculus of the nursing shortage must change, and this continuous hemorrhage of nurses from the profession without a consistent transfusion of new nurses must be short-circuited.
I will grant that we are in difficult economic times. I will also admit that the U.S. healthcare system is dysfunctional at best, and broken at worst. It is also plainly apparent to me that a growing lack of sufficient nurses to provide care in numerous facilities across the country is a recipe for a public health disaster of enormous proportions.
Meanwhile, if an Obama administration gains control of the White House, a push for near-universal healthcare coverage for all Americans will most likely be an important agenda item in the first year of such as administration. This is a laudable goal that may or may not be achieved. However, it must be acknowledged that the process of bringing more citizens into the healthcare system must be met by a similar process of encouraging more healthcare providers to take part in delivering that care.
The nursing shortage is real, and it is effecting how healthcare is provided around the country. Similarly, there is a very real shortage of primary care physicians, with more physicians opting for specialties in which the demands and low pay of primary care are eschewed.
Now, it is easy to see that if more citizens are insured (a goal that should absolutely be pursued despite the current economic climate), then we must simultaneously ensure that a sufficient number of physicians and nurses are available to provide the quality care that would consequently be delivered.
We must create incentives to lure physicians back into primary care, perhaps by reaching out to medical students and residents with a campaign to describe the value and rewards of primary care. Financial incentives such as loan repayment programs could also be enacted for new doctors who enter the field of primary care or family medicine, whether they work with vulnerable populations or not.
In terms of the provision of primary care, an expansion of Masters-level Nurse Practitioner programs and Doctoral nursing programs (especially for the new Doctor of Nursing Practice designation), could go a long way toward assuaging the nationwide shortage of primary care physicians, especially if interest-free loan programs and other incentives are created and fully funded.
We also must urgently expand the capacity of nursing schools by subsidizing nursing professors' salaries, expanding programs, and enacting a massive campaign of grants, scholarships and interest-free loans to make nursing school more readily affordable for a broad spectrum of prospective students.
Yes, these programs would indeed be expensive, and a great deal of money would need to be designated for such a sizable undertaking. Yet we must examine the relative costs of our inaction, and the crisis of untreated chronic illness and substandard medical care that will be the result of such a failure to act.
As the population ages and people live longer with more complicated constellations of chronic illness and multiple comorbidities, the provision of medical care will necessitate an enormous number of nurses as well as a solid base of primary care providers for patients across the lifespan. Nursing education must be funded and supported, nursing faculty must be recruited and well-compensated, and primary care providers must be given viable reasons for remaining in an area of medicine that has fallen from favor.
We cannot afford to ignore the multifaceted issues which are throwing the American healthcare system into crisis, and rest assured that any money invested now in improving the delivery of care will pay astronomical dividends in terms of prevention, improved healthcare maintenance, and increased cost-effectiveness. It is in our best interest to act, and we can only hope that political will and popular support will be enough to set these wheels in motion.
It seems that everywhere I turn, someone is telling me that, a) they just applied to nursing school, b) someone they know just applied, or c) they or someone they know was just accepted/rejected from nursing school.
New nurses---and those who wish to be nurses---are entering a profession in transition, a profession that is losing its older members more quickly than its educational institutions can churn out novices ready to enter the fray.
Today I was interviewed on a radio program in Gainseville, Florida about a recently published book of non-fiction writing by nurses in which I was a featured contributor. The show's hosts seemed sincerely perplexed when I explained that older nurses are retiring faster than they can be replaced, and that nursing schools simply cannot offer faculty salaries that can compete with what nurses are paid in clinical positions. Thus, thousands of qualified applicants for nursing school programs are turned away each year since there are not enough professors to educate them.
As a consequence, far too many eager and highly qualified applicants are rejected from nursing schools around the country---and in fact, around the world, as well---and where do they turn? Do they re-apply the following year? Do they look for another school to which they might have a chance of acceptance? Or do they give up their quest to join the nursing profession and simply move in another career direction entirely?
At a time when aging Baby Boomers are living longer with chronic illnesses and are increasingly in need of quality nursing and medical care, it's time for our government and other influential entities to step up to the plate. The government itself must realize that the calculus of the nursing shortage must change, and this continuous hemorrhage of nurses from the profession without a consistent transfusion of new nurses must be short-circuited.
I will grant that we are in difficult economic times. I will also admit that the U.S. healthcare system is dysfunctional at best, and broken at worst. It is also plainly apparent to me that a growing lack of sufficient nurses to provide care in numerous facilities across the country is a recipe for a public health disaster of enormous proportions.
Meanwhile, if an Obama administration gains control of the White House, a push for near-universal healthcare coverage for all Americans will most likely be an important agenda item in the first year of such as administration. This is a laudable goal that may or may not be achieved. However, it must be acknowledged that the process of bringing more citizens into the healthcare system must be met by a similar process of encouraging more healthcare providers to take part in delivering that care.
The nursing shortage is real, and it is effecting how healthcare is provided around the country. Similarly, there is a very real shortage of primary care physicians, with more physicians opting for specialties in which the demands and low pay of primary care are eschewed.
Now, it is easy to see that if more citizens are insured (a goal that should absolutely be pursued despite the current economic climate), then we must simultaneously ensure that a sufficient number of physicians and nurses are available to provide the quality care that would consequently be delivered.
We must create incentives to lure physicians back into primary care, perhaps by reaching out to medical students and residents with a campaign to describe the value and rewards of primary care. Financial incentives such as loan repayment programs could also be enacted for new doctors who enter the field of primary care or family medicine, whether they work with vulnerable populations or not.
In terms of the provision of primary care, an expansion of Masters-level Nurse Practitioner programs and Doctoral nursing programs (especially for the new Doctor of Nursing Practice designation), could go a long way toward assuaging the nationwide shortage of primary care physicians, especially if interest-free loan programs and other incentives are created and fully funded.
We also must urgently expand the capacity of nursing schools by subsidizing nursing professors' salaries, expanding programs, and enacting a massive campaign of grants, scholarships and interest-free loans to make nursing school more readily affordable for a broad spectrum of prospective students.
Yes, these programs would indeed be expensive, and a great deal of money would need to be designated for such a sizable undertaking. Yet we must examine the relative costs of our inaction, and the crisis of untreated chronic illness and substandard medical care that will be the result of such a failure to act.
As the population ages and people live longer with more complicated constellations of chronic illness and multiple comorbidities, the provision of medical care will necessitate an enormous number of nurses as well as a solid base of primary care providers for patients across the lifespan. Nursing education must be funded and supported, nursing faculty must be recruited and well-compensated, and primary care providers must be given viable reasons for remaining in an area of medicine that has fallen from favor.
We cannot afford to ignore the multifaceted issues which are throwing the American healthcare system into crisis, and rest assured that any money invested now in improving the delivery of care will pay astronomical dividends in terms of prevention, improved healthcare maintenance, and increased cost-effectiveness. It is in our best interest to act, and we can only hope that political will and popular support will be enough to set these wheels in motion.
Saturday, October 25, 2008
The Nursing Shortage, PBS-Style
(Note: This is my eleventh post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
Well, it finally happened. The nursing shortage received some well-deserved coverage that, in many ways, actually did the subject justice. Now with David Brancaccio, a weekly half-hour television show of investigative journalism on PBS (previously hosted and made famous by Bill Moyers), focused its attention on the nursing shortage in America, and I can only hope that the message delivered is heard by the people who most need to hear it.
With a shortage of as many as one million nurses projected by the year 2020, calls to address this crisis within the troubled American healthcare system are becoming louder and louder.
As described in the course of the program which aired this evening on PBS, nurses are the engine that keep the healthcare system humming. While doctors may sometimes receive the lions' share of the praise for life-saving surgical techniques and heroic medical measures, it is round-the-clock nursing care that can often mean the difference between life and death. And as outlined during Mr. Brancaccio's investigative story, a number of studies have demonstrated quite clearly that when the number of patients cared for by nurses increases, mortality also increases. And by most measures, successful outcomes most often directly correspond to the quality of nursing care received.
As the population ages and lives longer with more chronic illness, the need for nurses in hospitals, health centers, nursing homes, and in home care will continue to increase exponentially. (It was pointed out during the broadcast that approximately 75 cents of every healthcare dollar is spent on chronic illness.) And with nurses working harder as salaries remain essentially stagnant in the face of increasing workloads and a sagging economy, attrition from the profession should be of paramount concern.
Speaking of attrition, approximately 25% of new nurses reportedly leave the profession each year, and one can only imagine that falling from the frying pan of nursing school into the fire of full-time nursing may be one of the many factors that push new graduates right out of the profession before they have even had the chance to settle in.
As 25% of new nurses leave the profession, the average age of the American nurse continues to increase, with retirements from active duty occurring on a daily basis. Meanwhile, 70% of nursing schools turn away thousands of qualified applicants due to a shortage of nursing faculty which, if left unchecked, will continue to cripple any efforts to assuage a shortage that only seems to expand with each year that passes.
When it comes to retaining new nurses who have recently entered the field, some facilities (as shown during the broadcast), utilize a year-long residency or internship structure so that new graduates actually receive the guidance and mentorship needed to make it in the real world, post-nursing school. Similar to the medical residency that newly-minted doctors receive, a nursing residency or internship allows a new nurse sufficient time to receive the focused training that he or she will need in order to deliver high quality and safe care. Thus prepared for full-time nursing, the new graduate is thus less likely to burn out, and more likely to succeed in his or her work and be satisfied with a newly chosen profession that desperately needs to retain its newest recruits.
If you would like to watch the Now broadcast in streaming video on your computer, you can click here. To watch a four-minute interview with a University of Pennsylvania School of Nursing professor regarding continuity of care from the hospital to the home, click here. To find what hospitals in your state have received the American Nurses Association "stamp of approval", click here. And to follow a week in the life of a new graduate working on a New York City burn unit, follow this link.
My one criticism of the program is that, like all media covering nursing and the shortage, only hospital-based nursing was addressed. There was no mention of home care, community health, public health, or school nursing, areas which are also struggling mightily with the effects of the shortage. This focus on hospital nursing---however important hospital care certainly is---only serves to underscore the public's (and the media's) misconceptions about nursing. Our society seems to ubiquitously see nurses solely as workers in the hospital, overlooking the fact that nurses provide crucial care to myriad populations of citizens well beyond the walls of the nation's hospitals.
Such media attention on the crisis of the national---and global---nursing shortage is truly needed, and it is only by educating the public (and our elected officials) about the crucial need for nurses that change and growth might occur. While Barack Obama and John McCain both have, to some extent, made gestures vis-a-vis the shortage of nurses in America today, a new administration in Washington will have many pressing issues to address as power is assumed in January of 2009, and fixes to the healthcare system will certainly take time.
No matter how the enonomic climate evolves, people will still get sick and need nursing care and medical care. No matter how many banks fail, hospital doors will still be open, visiting nurse agencies will visit patients at home, and surgeries and emergencies will continue to occur. Even as the global economy reels from the latest financial implosion, qualified applicants will be turned away from nursing schools and shortages of nursing faculty (due to relatively low salaries and other factors) will plague the halls of academia.
A new administration will need to have the political will to take some bold strides vis-a-vis the American healthcare system. The delivery of care as it pertains to chronic illness will need to be addressed. Nursing faculty---the key to educating new nurses in preparation for the workforce---will need to receive improved compensation for their important work as educators of future nurses. Nursing students from a broad socioeconomic spectrum will need scholarships and grants to offset the costs of a community college or university education. And healthcare facilities will need funds to give new graduates the time and attention they need for mentorship and preparation for autonmous practice.
The list above is by no means exhaustive, and the program aired on PBS is also by no means the final word on a shortage that currently is without a forseeable end. Creativity, forethought, vision, and a savvy understanding of both the economy and the vicissitudes of the healthcare industry are all necessary in order for current healthcare problems to be sufficiently addressed and remedied. Many of us are cynical that any meaningful change is close at hand, but we can only hope that our pleading, explanations and supplications do not, in the end, fall on the deaf ears of bureaucrats who just cannot see the healthcare forest for the trees.
Well, it finally happened. The nursing shortage received some well-deserved coverage that, in many ways, actually did the subject justice. Now with David Brancaccio, a weekly half-hour television show of investigative journalism on PBS (previously hosted and made famous by Bill Moyers), focused its attention on the nursing shortage in America, and I can only hope that the message delivered is heard by the people who most need to hear it.
With a shortage of as many as one million nurses projected by the year 2020, calls to address this crisis within the troubled American healthcare system are becoming louder and louder.
As described in the course of the program which aired this evening on PBS, nurses are the engine that keep the healthcare system humming. While doctors may sometimes receive the lions' share of the praise for life-saving surgical techniques and heroic medical measures, it is round-the-clock nursing care that can often mean the difference between life and death. And as outlined during Mr. Brancaccio's investigative story, a number of studies have demonstrated quite clearly that when the number of patients cared for by nurses increases, mortality also increases. And by most measures, successful outcomes most often directly correspond to the quality of nursing care received.
As the population ages and lives longer with more chronic illness, the need for nurses in hospitals, health centers, nursing homes, and in home care will continue to increase exponentially. (It was pointed out during the broadcast that approximately 75 cents of every healthcare dollar is spent on chronic illness.) And with nurses working harder as salaries remain essentially stagnant in the face of increasing workloads and a sagging economy, attrition from the profession should be of paramount concern.
Speaking of attrition, approximately 25% of new nurses reportedly leave the profession each year, and one can only imagine that falling from the frying pan of nursing school into the fire of full-time nursing may be one of the many factors that push new graduates right out of the profession before they have even had the chance to settle in.
As 25% of new nurses leave the profession, the average age of the American nurse continues to increase, with retirements from active duty occurring on a daily basis. Meanwhile, 70% of nursing schools turn away thousands of qualified applicants due to a shortage of nursing faculty which, if left unchecked, will continue to cripple any efforts to assuage a shortage that only seems to expand with each year that passes.
When it comes to retaining new nurses who have recently entered the field, some facilities (as shown during the broadcast), utilize a year-long residency or internship structure so that new graduates actually receive the guidance and mentorship needed to make it in the real world, post-nursing school. Similar to the medical residency that newly-minted doctors receive, a nursing residency or internship allows a new nurse sufficient time to receive the focused training that he or she will need in order to deliver high quality and safe care. Thus prepared for full-time nursing, the new graduate is thus less likely to burn out, and more likely to succeed in his or her work and be satisfied with a newly chosen profession that desperately needs to retain its newest recruits.
If you would like to watch the Now broadcast in streaming video on your computer, you can click here. To watch a four-minute interview with a University of Pennsylvania School of Nursing professor regarding continuity of care from the hospital to the home, click here. To find what hospitals in your state have received the American Nurses Association "stamp of approval", click here. And to follow a week in the life of a new graduate working on a New York City burn unit, follow this link.
My one criticism of the program is that, like all media covering nursing and the shortage, only hospital-based nursing was addressed. There was no mention of home care, community health, public health, or school nursing, areas which are also struggling mightily with the effects of the shortage. This focus on hospital nursing---however important hospital care certainly is---only serves to underscore the public's (and the media's) misconceptions about nursing. Our society seems to ubiquitously see nurses solely as workers in the hospital, overlooking the fact that nurses provide crucial care to myriad populations of citizens well beyond the walls of the nation's hospitals.
Such media attention on the crisis of the national---and global---nursing shortage is truly needed, and it is only by educating the public (and our elected officials) about the crucial need for nurses that change and growth might occur. While Barack Obama and John McCain both have, to some extent, made gestures vis-a-vis the shortage of nurses in America today, a new administration in Washington will have many pressing issues to address as power is assumed in January of 2009, and fixes to the healthcare system will certainly take time.
No matter how the enonomic climate evolves, people will still get sick and need nursing care and medical care. No matter how many banks fail, hospital doors will still be open, visiting nurse agencies will visit patients at home, and surgeries and emergencies will continue to occur. Even as the global economy reels from the latest financial implosion, qualified applicants will be turned away from nursing schools and shortages of nursing faculty (due to relatively low salaries and other factors) will plague the halls of academia.
A new administration will need to have the political will to take some bold strides vis-a-vis the American healthcare system. The delivery of care as it pertains to chronic illness will need to be addressed. Nursing faculty---the key to educating new nurses in preparation for the workforce---will need to receive improved compensation for their important work as educators of future nurses. Nursing students from a broad socioeconomic spectrum will need scholarships and grants to offset the costs of a community college or university education. And healthcare facilities will need funds to give new graduates the time and attention they need for mentorship and preparation for autonmous practice.
The list above is by no means exhaustive, and the program aired on PBS is also by no means the final word on a shortage that currently is without a forseeable end. Creativity, forethought, vision, and a savvy understanding of both the economy and the vicissitudes of the healthcare industry are all necessary in order for current healthcare problems to be sufficiently addressed and remedied. Many of us are cynical that any meaningful change is close at hand, but we can only hope that our pleading, explanations and supplications do not, in the end, fall on the deaf ears of bureaucrats who just cannot see the healthcare forest for the trees.
Sunday, October 12, 2008
The Irony of Mental Health Parity
(Note: This is my ninth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
In June of this year, I reported on Nurse LinkUp that Congress was poised to once again begin a concerted push to pass legislation bringing parity for insurance coverage for mental health, including addiction, eating disorders, and any illness classified in the DSM-IV. That effort basically failed, and it is only now, just prior to the end of this Congress, that mental health parity legislation has actually become law.
We are all by now (nauseatingly) familiar with the $700 billion financial bailout recently passed by Congress and signed into law by President Bush in the waning days of his presidency (more on that in future). As a part of that package, most health plans are now required to cover mental illness and addiction with the same level of access and cost as any physical illness. After years of struggle, editorials abound, almost ubiquitously praising the legislation which was added to the latest---and ultimately successful---version of the bailout plan.
Beginning, I believe, in 2009, all group insurance plans and companies with more than 50 employees must offer health insurance coverage that provides equal benefits for mental health treatment, potentially benefiting 113 million insured Americans, as well as approximately 82 million self-insured Americans who are not protected by state-mandated mental health parity legislation. Interestingly, 38 states currently have some form of parity laws on the books, a fact of which I was previously ignorant.
Paul Wellstone (D-MN), the late Senator from Minnesota, was one of the great champions of the mental health parity cause, along with his colleague Pete Domenici (R-NM). The bill, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, was named for the two senators and honors the posthumous legacy of Wellstone's tireless fight for the rights of Americans living with mental illness and addiction. And it was Senator Edward Kennedy (D-MA) and his son Representative Patrick Kennedy (D-RI), who used their political muscle and clout to ease the bill through the Senate and the House.
As someone who has struggled with depression since childhood, I can attest that obtaining coverage for mental health can be a challenge, especially if one needs ongoing treatment rather than the "episodic care" often covered by many health plans. I can also confirm that many health insurance plans charge much higher co-payments for mental health visits, and impose nonsensical and arbitrary limits on the number of outpatient visits per year.
In terms of inpatient care, insurance regulations regarding mental health are notorious for prematurely cutting short crucial inpatient treatment for mental illness, addiction, and eating disorders. It is plainly obvious that inpatient treatment teams know best vis-a-vis the length of stay which would be most efficacious for a particular patient. Naturally, some oversight should be involved so that billing abuses do not occur, but bureaucrats and statisticians should not be making decisions that only clinically trained professionals should make. The imposition of arbitrary limits on the length of stay for the treatment of such chronic conditions belies the fact that insurance companies are generally more concerned with profitability than the effectiveness and quality of care. In fact, I would hazard a guess that forcing a patient out of detox or an inpatient psychiatric unit before they are clinically ready for discharge more than likely leads to worse outcomes, more frequent relapse, and higher costs over the long term.
Global Ironies: Mind the Gap
Ironically, on October 10th, World Mental Health Day (one week after mental health parity became a legal reality in the United States), the World Health Organization announced that as many as 75% of people living with mental disorders in developing countries receive no care or treatment of any kind. The irony is that while we in the United States pine for lower co-payments and equal access to care, those living in war-torn nations, developing nations, and non-industrialized countries suffer immeasurable harm without even the merest hope of treatment.
The WHO study points out that nine out of ten people in Africa who live with epilepsy are entirely untreated. It also starkly points out that while most countries spend approximately 2% of their health dollars on mental health, one-third of people with schizophrenia, half of those living with depression, and seventy-five percent of those struggling with addiction go untreated worldwide. And tragically, one person dies from a completed suicide every forty seconds of every day, somewhere in the world, mostly due to untreated mental illness.
These numbers tell a story, and even as the United States prepares to tackle the issues of mental illness and substance abuse more fairly, the WHO is calling for governments, foundations, donors and mental health activists to increase funding for treatment worldwide. The program, entitled Mental Health Gap Action Program (mhGAP): Scaling Up Care for Mental Health and Substance Use Disorders, asserts, according to the WHO press release, that "with proper care, psychosocial assistance and medication, tens of millions could be treated for diseases such as depression, schizophrenia, and epilepsy and begin to lead healthy lives, even where resources are scarce."
To bolster their case, the WHO's recent studies demonstrate that "in low-income countries, scaling up a package of essential interventions for three mental disorders – schizophrenia, bipolar disorder and depression – and for one risk factor – hazardous alcohol use – requires an additional investment as low as $US 0.20 per person per year." Claiming that treatment of mental illness, addiction and neurological disorders such as epilepsy should not only be "evidence-based" but "value-based", the WHO plan includes "assessing countries' needs and resources; developing sound mental health policy and legislation; and increasing human and financial resources" in order that "people with these disorders are not denied opportunities to contribute to social and economic life and that their human rights are protected."
Global Parity: A Laudable Goal
So, as mental health parity becomes law in the United States and we continue to wrestle with the needs of the uninsured and the under-insured, the rest of the world---especially the developing world---needs our assistance to offer even the most basic of mental health care to millions and millions of deserving citizens. Mental health is not a luxury, and many in the fields of mind-body medicine (and also mainstream medicine, for that matter) strongly believe that good physical health is simply not possible without solid mental health. In fact, recent research demonstrates quite clearly that untreated depression can absolutely lead to physical symptoms including chronic pain.
I would assert that those who have so valiantly and tirelessly fought for the rights of the mentally ill here in the United States should now challenge themselves to broaden their visual field, take in the big picture of global mental health, and direct some of their energies in supporting the timely efforts of the World Health Organization.
As the global financial system continues its apparent implosion, we can naturally expect the incidence of anxiety, depression and substance abuse to rise as people attempt to manage lives thrown into chaos by economic hardship. We in the United States recently won a long twelve-year battle, happily enough. But now is not the time to rest on our laurels. Now is the time for action on a global scale. It is in humanity's best interest to see that all people have access to treatment for improved mental health, and it is our moral and ethical duty to further that cause.
In June of this year, I reported on Nurse LinkUp that Congress was poised to once again begin a concerted push to pass legislation bringing parity for insurance coverage for mental health, including addiction, eating disorders, and any illness classified in the DSM-IV. That effort basically failed, and it is only now, just prior to the end of this Congress, that mental health parity legislation has actually become law.
We are all by now (nauseatingly) familiar with the $700 billion financial bailout recently passed by Congress and signed into law by President Bush in the waning days of his presidency (more on that in future). As a part of that package, most health plans are now required to cover mental illness and addiction with the same level of access and cost as any physical illness. After years of struggle, editorials abound, almost ubiquitously praising the legislation which was added to the latest---and ultimately successful---version of the bailout plan.
Beginning, I believe, in 2009, all group insurance plans and companies with more than 50 employees must offer health insurance coverage that provides equal benefits for mental health treatment, potentially benefiting 113 million insured Americans, as well as approximately 82 million self-insured Americans who are not protected by state-mandated mental health parity legislation. Interestingly, 38 states currently have some form of parity laws on the books, a fact of which I was previously ignorant.
Paul Wellstone (D-MN), the late Senator from Minnesota, was one of the great champions of the mental health parity cause, along with his colleague Pete Domenici (R-NM). The bill, the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008, was named for the two senators and honors the posthumous legacy of Wellstone's tireless fight for the rights of Americans living with mental illness and addiction. And it was Senator Edward Kennedy (D-MA) and his son Representative Patrick Kennedy (D-RI), who used their political muscle and clout to ease the bill through the Senate and the House.
As someone who has struggled with depression since childhood, I can attest that obtaining coverage for mental health can be a challenge, especially if one needs ongoing treatment rather than the "episodic care" often covered by many health plans. I can also confirm that many health insurance plans charge much higher co-payments for mental health visits, and impose nonsensical and arbitrary limits on the number of outpatient visits per year.
In terms of inpatient care, insurance regulations regarding mental health are notorious for prematurely cutting short crucial inpatient treatment for mental illness, addiction, and eating disorders. It is plainly obvious that inpatient treatment teams know best vis-a-vis the length of stay which would be most efficacious for a particular patient. Naturally, some oversight should be involved so that billing abuses do not occur, but bureaucrats and statisticians should not be making decisions that only clinically trained professionals should make. The imposition of arbitrary limits on the length of stay for the treatment of such chronic conditions belies the fact that insurance companies are generally more concerned with profitability than the effectiveness and quality of care. In fact, I would hazard a guess that forcing a patient out of detox or an inpatient psychiatric unit before they are clinically ready for discharge more than likely leads to worse outcomes, more frequent relapse, and higher costs over the long term.
Global Ironies: Mind the Gap
Ironically, on October 10th, World Mental Health Day (one week after mental health parity became a legal reality in the United States), the World Health Organization announced that as many as 75% of people living with mental disorders in developing countries receive no care or treatment of any kind. The irony is that while we in the United States pine for lower co-payments and equal access to care, those living in war-torn nations, developing nations, and non-industrialized countries suffer immeasurable harm without even the merest hope of treatment.
The WHO study points out that nine out of ten people in Africa who live with epilepsy are entirely untreated. It also starkly points out that while most countries spend approximately 2% of their health dollars on mental health, one-third of people with schizophrenia, half of those living with depression, and seventy-five percent of those struggling with addiction go untreated worldwide. And tragically, one person dies from a completed suicide every forty seconds of every day, somewhere in the world, mostly due to untreated mental illness.
These numbers tell a story, and even as the United States prepares to tackle the issues of mental illness and substance abuse more fairly, the WHO is calling for governments, foundations, donors and mental health activists to increase funding for treatment worldwide. The program, entitled Mental Health Gap Action Program (mhGAP): Scaling Up Care for Mental Health and Substance Use Disorders, asserts, according to the WHO press release, that "with proper care, psychosocial assistance and medication, tens of millions could be treated for diseases such as depression, schizophrenia, and epilepsy and begin to lead healthy lives, even where resources are scarce."
To bolster their case, the WHO's recent studies demonstrate that "in low-income countries, scaling up a package of essential interventions for three mental disorders – schizophrenia, bipolar disorder and depression – and for one risk factor – hazardous alcohol use – requires an additional investment as low as $US 0.20 per person per year." Claiming that treatment of mental illness, addiction and neurological disorders such as epilepsy should not only be "evidence-based" but "value-based", the WHO plan includes "assessing countries' needs and resources; developing sound mental health policy and legislation; and increasing human and financial resources" in order that "people with these disorders are not denied opportunities to contribute to social and economic life and that their human rights are protected."
Global Parity: A Laudable Goal
So, as mental health parity becomes law in the United States and we continue to wrestle with the needs of the uninsured and the under-insured, the rest of the world---especially the developing world---needs our assistance to offer even the most basic of mental health care to millions and millions of deserving citizens. Mental health is not a luxury, and many in the fields of mind-body medicine (and also mainstream medicine, for that matter) strongly believe that good physical health is simply not possible without solid mental health. In fact, recent research demonstrates quite clearly that untreated depression can absolutely lead to physical symptoms including chronic pain.
I would assert that those who have so valiantly and tirelessly fought for the rights of the mentally ill here in the United States should now challenge themselves to broaden their visual field, take in the big picture of global mental health, and direct some of their energies in supporting the timely efforts of the World Health Organization.
As the global financial system continues its apparent implosion, we can naturally expect the incidence of anxiety, depression and substance abuse to rise as people attempt to manage lives thrown into chaos by economic hardship. We in the United States recently won a long twelve-year battle, happily enough. But now is not the time to rest on our laurels. Now is the time for action on a global scale. It is in humanity's best interest to see that all people have access to treatment for improved mental health, and it is our moral and ethical duty to further that cause.
Sunday, September 28, 2008
Economics and the Elderly
(Note: This is my eighth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
So, as the bad news splashes across the headlines and the denizens of Wall Street throw up their hands to ward off the falling sky (that they themselves created), the elderly here in the United States are facing some tough economic times of their own as we turn the corner to 2009.
Reports now tell us that premiums for drug coverage under Medicare Part D will rise an average of 31% in the coming year. For some seniors, most of whom are on fixed incomes, a monthly increase of $50 to $100 could spell economic disaster, especially when one considers the simultaneous (and often astronomical) rise in the cost of food, gas, general healthcare costs, home heating, and other necessities.
As I recently reported in an article on Nurse Linkup, Bloomberg, The Associated Press, medical websites, and other independent news outlets are all reporting the inevitability of these increases, the writing already being on the proverbial wall.
To add insult to injury, changing Medicare rules may make some seniors' lives a living hell as they attempt to navigate the shifting sands of Medicare Part D.
And just as the economic climate intensifies with bad news and dire forecasts, American seniors also face the daunting task of negotiating the spending caps created under the Medicare Part D regulations. These rules limit annual reimbursements for medications to $2,510. When this magic number is reached, Medicare recipients must then be on their own purchasing medications until they have spent a total of $5,726, whereby Medicare will begin paying for medications once again. Confused? You should be. If some fortunate seniors are able to purchase expensive "gap coverage" for this period of time, they may break even or come out slightly ahead. For those unable (or too confused or intimidated) to do so, their economic peril may await.
So, what does this say about our country? Who are we? What are we doing to our seniors and disabled citizens? When pharmaceutical lobbyists have more influence than seniors (and their advocates) in the writing of the Medicare Part D regulations, we all know who loses.
Senior citizens are vulnerable members of our society, many of whom have worked all their lives, diligently paid their taxes, and now must struggle to make ends meet in the Autumn and Winter of their lives. Sure, the global economic crisis has indeed cast its pall on almost everyone, but even as the U.S. Congress holds midnight meetings to rescue Wall Street from its excesses and errant ways, no one is talking about how to rescue vulnerable and sick seniors as they fall down their own financial rabbit hole.
No doubt, even as the "rescue" ensues, some CEOs and others in power will somehow come out ahead, making off with money that is not rightfully theirs at a time when that money should be trickling down rather than up.
When I think of the cold months of winter ahead, I think of middle class and working class senior citizens who honestly don't know how they'll make ends meet. Meanwhile, in the halls of Power, there's money to be traded----and made.
So, as the bad news splashes across the headlines and the denizens of Wall Street throw up their hands to ward off the falling sky (that they themselves created), the elderly here in the United States are facing some tough economic times of their own as we turn the corner to 2009.
Reports now tell us that premiums for drug coverage under Medicare Part D will rise an average of 31% in the coming year. For some seniors, most of whom are on fixed incomes, a monthly increase of $50 to $100 could spell economic disaster, especially when one considers the simultaneous (and often astronomical) rise in the cost of food, gas, general healthcare costs, home heating, and other necessities.
As I recently reported in an article on Nurse Linkup, Bloomberg, The Associated Press, medical websites, and other independent news outlets are all reporting the inevitability of these increases, the writing already being on the proverbial wall.
To add insult to injury, changing Medicare rules may make some seniors' lives a living hell as they attempt to navigate the shifting sands of Medicare Part D.
And just as the economic climate intensifies with bad news and dire forecasts, American seniors also face the daunting task of negotiating the spending caps created under the Medicare Part D regulations. These rules limit annual reimbursements for medications to $2,510. When this magic number is reached, Medicare recipients must then be on their own purchasing medications until they have spent a total of $5,726, whereby Medicare will begin paying for medications once again. Confused? You should be. If some fortunate seniors are able to purchase expensive "gap coverage" for this period of time, they may break even or come out slightly ahead. For those unable (or too confused or intimidated) to do so, their economic peril may await.
So, what does this say about our country? Who are we? What are we doing to our seniors and disabled citizens? When pharmaceutical lobbyists have more influence than seniors (and their advocates) in the writing of the Medicare Part D regulations, we all know who loses.
Senior citizens are vulnerable members of our society, many of whom have worked all their lives, diligently paid their taxes, and now must struggle to make ends meet in the Autumn and Winter of their lives. Sure, the global economic crisis has indeed cast its pall on almost everyone, but even as the U.S. Congress holds midnight meetings to rescue Wall Street from its excesses and errant ways, no one is talking about how to rescue vulnerable and sick seniors as they fall down their own financial rabbit hole.
No doubt, even as the "rescue" ensues, some CEOs and others in power will somehow come out ahead, making off with money that is not rightfully theirs at a time when that money should be trickling down rather than up.
When I think of the cold months of winter ahead, I think of middle class and working class senior citizens who honestly don't know how they'll make ends meet. Meanwhile, in the halls of Power, there's money to be traded----and made.
Saturday, September 20, 2008
The Office of the National Nurse
(Note: This is my seventh post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
Unbeknownst to many Americans, a grassroots campaign to create an Office of the National Nurse has been underway for several years. While many in the nursing community recognize that the Surgeon General plays an important role in managing and overseeing the health and health education of the nation, it is also recognized that nurses are woefully underrepresented when it comes to our national priorities vis-a-vis healthcare and prevention.
With a global nursing shortage in full swing at this pivotal historical time, we still see that neither presidential candidate in the current race fully acknowledges (or plans to adequately address) the shortage and its potentially devastating effects on the health and healthcare of the country. Many involved in the campaign to create an Office of the National Nurse feel that the office "would strengthen efforts by nurses in every community to assist in initiating a nationwide shift to prevention to yield improved health outcomes" nationwide.
Since 1871, the Surgeon General of the United States---the nation's "chief health educator"---has overseen and guided the health of Americans. Charged with overseeing the U.S. Public Health Service, the Surgeon General is appointed by the President and approved by Congress for a four-year term. According to the official website of the Surgeon General, this individual's duties include, but are not limited, to:
The goal of the organizations and individuals behind the drive for an Office of the National Nurse is "to elevate and enhance the Office of the PHS Chief Nurse to bring more visibility to the critical role nursing occupies in promoting, protecting, and advancing the nation's health."
The proposed role of the National Nurse would be to:
It is the opinion of many involved in the call for the establishment of the Office of the National Nurse that it is time for nursing to have a seat at the nation's healthcare table. While some might argue that the aforementioned Chief Nurse Officer of the U.S. Department of Public Health already adequately fulfills that role, most still see that role as one of subservience to the Surgeon General rather than one of professional equality. Just as nurses are rarely consulted by the media for their expert opinions vis-a-vis the various challenges faced by the nation and its beleaguered healthcare system, the government also fails to fully utilize nursing's unique and crucial input to the fullest extent possible, in the interest of the health and well-being of the American people.
The establishment of the Office of the National Nurse would set a new standard for a more accurate and realistic recognition of nursing's importance to health and healthcare in the United States. If the federal government enthusiastically and publicly embraced nursing, making its crucial contributions crystal clear, perhaps the public, the media and the private sector would all then have a greater understanding of, and appreciation for, the multitudinous ways in which nursing impacts the health of millions of Americans.
Most importantly, however, the establishment of this office would certainly bring an important voice even more strongly to the ongoing conversation about health and health care in America. A National Nurse could, in effect, deliver a unified message of preventive health at a time when millions of Americans---including millions of children---live without health insurance or access to regular primary care. At a time of crisis and uncertainty vis-a-vis the health of the country, the Office of the National Nurse could very well be a welcome, stabilizing and empowering voice of reason and prevention.
I fully support the drive to establish such an office, and hold out hope that a new administration will recognize nursing's contributions to the health of the nation, and give thoughtful consideration to an idea whose time has come.
Unbeknownst to many Americans, a grassroots campaign to create an Office of the National Nurse has been underway for several years. While many in the nursing community recognize that the Surgeon General plays an important role in managing and overseeing the health and health education of the nation, it is also recognized that nurses are woefully underrepresented when it comes to our national priorities vis-a-vis healthcare and prevention.
With a global nursing shortage in full swing at this pivotal historical time, we still see that neither presidential candidate in the current race fully acknowledges (or plans to adequately address) the shortage and its potentially devastating effects on the health and healthcare of the country. Many involved in the campaign to create an Office of the National Nurse feel that the office "would strengthen efforts by nurses in every community to assist in initiating a nationwide shift to prevention to yield improved health outcomes" nationwide.
Since 1871, the Surgeon General of the United States---the nation's "chief health educator"---has overseen and guided the health of Americans. Charged with overseeing the U.S. Public Health Service, the Surgeon General is appointed by the President and approved by Congress for a four-year term. According to the official website of the Surgeon General, this individual's duties include, but are not limited, to:
- Protect and advance the health of the Nation through educating the public, advocating for effective disease prevention and health promotion programs and activities, and, providing a highly recognized symbol of national commitment to protecting and improving the public's health
- Articulate scientifically based health policy analysis and advice to the President and the Secretary of Health and Human Services (HHS) on the full range of critical public health, medical, and health system issues facing the nation
- Provide leadership in promoting special Departmental health initiatives, e.g., tobacco and HIV prevention efforts, with other governmental and non-governmental entities, both domestically and internationally
- Administer the U.S. Public Health Service (PHS) Commissioned Corps, which is a uniquely expert, diverse, flexible, and committed career force of public health professionals who can respond to both current and long-term health needs of the Nation
- Provide leadership and management oversight for PHS Commissioned Corps involvement in Departmental emergency preparedness and response activities
- Elevate the quality of public health practice in the professional disciplines through the advancement of appropriate standards and research priorities, and
- Fulfill statutory and customary departmental representational functions on a wide variety of federal boards and governing bodies of non-Federal health organizations, including the Board of Regents of the Uniformed Services University of the Health Sciences, the National Library of Medicine, the Armed Forces Institute of Pathology, the Association of Military Surgeons of the United States, and the American Medical Association.
The goal of the organizations and individuals behind the drive for an Office of the National Nurse is "to elevate and enhance the Office of the PHS Chief Nurse to bring more visibility to the critical role nursing occupies in promoting, protecting, and advancing the nation's health."
The proposed role of the National Nurse would be to:
- Assist in the initiation of a nationwide cultural shift to prevention.
- Bolster efforts to focus the public on healthy living.
- Intensify roles for nurses, including students and retirees, in community health promotion.
- Provide greater support to the Surgeon General in calling for improvements in health literacy and reduction in health disparities.
- Encourage all nurses to spread prevention messages in their communities.
- Encourage participation of nurses in Medical Reserve Corps (MRC) units.
- Provide leadership to network with existing volunteer health promotion efforts.
- Strengthen linkages with providers, nursing programs, and public health leadership.
- Serve as a visible national spokesperson for professional nursing.
- Increase public awareness of nursing roles and contributions.
- Enhance nursing recruitment and education throughout all communities.
- Support and justify additional funding for nursing education, research and service.
It is the opinion of many involved in the call for the establishment of the Office of the National Nurse that it is time for nursing to have a seat at the nation's healthcare table. While some might argue that the aforementioned Chief Nurse Officer of the U.S. Department of Public Health already adequately fulfills that role, most still see that role as one of subservience to the Surgeon General rather than one of professional equality. Just as nurses are rarely consulted by the media for their expert opinions vis-a-vis the various challenges faced by the nation and its beleaguered healthcare system, the government also fails to fully utilize nursing's unique and crucial input to the fullest extent possible, in the interest of the health and well-being of the American people.
The establishment of the Office of the National Nurse would set a new standard for a more accurate and realistic recognition of nursing's importance to health and healthcare in the United States. If the federal government enthusiastically and publicly embraced nursing, making its crucial contributions crystal clear, perhaps the public, the media and the private sector would all then have a greater understanding of, and appreciation for, the multitudinous ways in which nursing impacts the health of millions of Americans.
Most importantly, however, the establishment of this office would certainly bring an important voice even more strongly to the ongoing conversation about health and health care in America. A National Nurse could, in effect, deliver a unified message of preventive health at a time when millions of Americans---including millions of children---live without health insurance or access to regular primary care. At a time of crisis and uncertainty vis-a-vis the health of the country, the Office of the National Nurse could very well be a welcome, stabilizing and empowering voice of reason and prevention.
I fully support the drive to establish such an office, and hold out hope that a new administration will recognize nursing's contributions to the health of the nation, and give thoughtful consideration to an idea whose time has come.
Friday, September 12, 2008
Nurses' Voices, Nurses' Image: Nurses' Power
(Note: This is my sixth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
I have recently been re-reading From Silence to Voice: What Nurses Know and Must Communicate to the Public, by Bernice Buresh and Suzanne Gordon. What I am most struck by is that nurses still have not necessarily found their collective voice, and despite the media attention given to the global nursing shortage, I still believe that Buresh and Gordon's thesis still holds true: the public still does not fully understand what nurses do, and until that day comes, nurses' real value as clinicians will not be common knowledge.
Buresh and Gordon touch on many themes and areas of interest vis-a-vis nurses and their relation to the public, to doctors, and to one another. While I will not provide a review of the book---nor a comprehensive enumerating of its content---there are certain area which pique my interest, and I encourage curious readers to order a copy of the book and explore some of these issues for themselves.
Doctors Cure, Nurses Care
When I first heard this phrase, I was moderately disturbed by it for several reasons. Doctors, by and large, receive the lion's share of praise and gratitude when a sick patient is cured of an illness. Granted, doctors undergo a great deal of training and education in order to offer curative treatments for a variety of diseases, yet all too often, the work of nurses is grossly overlooked when it comes to successful treatment. While nurses do indeed carry out many orders originated from doctors, nurses use their own brand of critical thinking and autonomous action in order to perform specialized patient care. The public may not be aware of this fact, but many actions taken by nurses are initiated by nurses themselves, and the professional clinical assessments performed by nurses will often lead to changes in treatment and greater overall success.
Sure, nurses care, and nursing is seen by the public as a "caring" profession. However, nurses utilize scientific methods, skilled observation, and keen assessment skills to monitor patients' progress. Nurses are not just "the caring eyes and ears of doctors"---nurses are skilled professionals fully involved in patient care---and patient cures.
The Nurse as Angel, Teddy-Bear, and Child
In their book, Buresh and Gordon make one thing clear: nurses' self-presentation says a great deal to the public, and images of nurses that instill themselves in the societal zeitgeist are difficult to dispel.
Somewhere along the line, the "angels of mercy" moniker became attached to nurses as a group. Granted, in the early days of nursing, nurses' ability to act autonomously was extremely limited, and we were, by and large, the handmaidens of deified doctors. However, as much as that regrettable history has largely changed, the image of the nurse as angel unfortunately persists quite widely in our culture and websites galore promote gifts and baubles that continue to diminish nurses' professionalism. Images such as this one drive home the point: nurses are childlike individuals with starched white hats who love teddy-bears. Adding insult to injury, nurses can actually be depicted as winged angel/teddy-bears, further enforcing the infantilization (and deprofessionalization) of our profession. Would doctors allow themselves to be thus represented to the public?
Rather than being perceived as cherubic angels and childlike creatures, this writer feels that being perceived as the valuable and skilled professionals who we truly are would allow the public to have a much more accurate perception of what we do, and our importance to the care of millions.
The Clothes on Our BackNurses' uniforms have certainly changed over the years, and as scrubs have become the norm for nurses in most clinical settings, many companies have capitalized on the popularity of such utilitarian clothing. Now, designer scrubs covered with angels, teddy-bears (there they are again!), and any number of cartoon-like images adorn the hard-working bodies of nurses around the world. If nurses want to be taken seriously by the public---and by doctors and other professionals---how does the wearing of such (in my opinion) unprofessional clothing help our cause?
Picture this: a team meeting occurs midday to discuss a patient on the adult oncology floor. Present at the meeting: a medical resident, a medical student, the attending doctor, the oncologist, two unit nurses, a social worker and a respiratory therapist. Of all of the professionals in the room, who would possibly be wearing pink scrubs covered with teddy-bears and hearts, and a pin on her chest saying "Doctors Cure, Nurses Care"? And what message does this convey about the nurse's self-image and how the other professionals present in the meeting should perceive him or her?
What's in a Name?
In From Silence to Voice, Buresh and Gordon make their case that nurses being addressed by first name only is also a major image problem when it comes to the public's perception of us a collective whole.
When doctors introduce themselves to patients or other professionals, they always do so by using the title "Doctor" before their name. This practice immediately creates an impression that the doctor is a professional, that he or she has a name that should be remembered, and a hierarchy of power and authority is clearly established from the start.
Conversely, we nurses almost ubiquitously introduce ourselves by first name only, ostensibly to break down the barriers between patients and nurses, assisting the patient in overcoming fears and anxieties related to their treatment. While this tactic may have some limited benefit, Buresh and Gordon argue that "if nurses introduce themselves by their first names only, they are asking to be regarded as nonprofessionals because that is the conventional way that nonprofessionals present themselves."
The "first-name only convention", as the authors have named it, makes it significantly more difficult for individual nurses to receive recognition for their work when only their first names are known. It also creates a hierarchical structure in which the doctor stands alone as a figure of authority, towering above the patient and nurse with (patriarchal or matriarchal) power and authority.
Interestingly, many nurses will argue that introducing ourselves as "Nurse Smith" or "Nurse Cadmus" is awkward at best, but also brings to mind the infamous "Nurse Ratched" from "One Flew Over the Cuckoo's Nest". Granted, Nurse Ratched is a mythic and hated figure in the pantheon of film and modern literature, yet do we see doctors eschewing their well-earned title due to historical figures such as Dr. Kevorkian or Dr. Mengele (of Auschwitz fame)? Absolutely not. Doctors use their title so commonly and so frequently that the word "doctor" simply holds too much cultural power to be diminished by one literary (or real-life) character who used that title for ill.
As for "naming practices" between doctors and nurses themselves, further examples of an unequal playing field emerge, with nurses almost continually subjugated to a diminished status by always being addressed by first name by both patients and doctors, whereas doctors maintain their professionalism and authority through the use of their title and last name.
Taking Credit Where Credit is Due
All too often, the work of nurses is diminished by nurses themselves. When thanked for their work, nurses will frequently say, "Oh, I didn't do much. The doctors really did the hard part." Or when a nurse is asked what he or she does, the answer will often be, "I'm just a nurse." This diminution of nurses' worth does little to cement in the public's collective mind the utter importance---the crucial presence---of nurses in the healthcare system. The "just a nurse" phrase---used all too painfully often---hurts nurses' cultural standing and diminishes the profession in the public's eye.
Nurses need to stand up and take credit for the work that they do. Buresh and Gordon urge nurses to say "You're welcome" when they are thanked. "I am so glad that I could assist you in learning so much about your diabetes, Mr. Smith" or "It was my pleasure to provide your post-operative nursing care, Mrs. Jones"---these are statements that take credit for nurses' actions, acknowledge patients' gratitude, and accept responsibility for providing crucial nursing care that directly impacts patients' recovery and health.
Nurses' Agency
Buresh and Gordon recommend that nurses discover their "voice of agency". According the authors, "the voice of agency is the voice that says: 'I helped the patient to walk after surgery so that she wouldn't get blood clots in her legs' or 'I taught the patient how to take his medications so that they would be effective and produce fewer side effects.' The authors further illustrate their point by reminding us that "the voice of agency is the voice that conveys the message, 'I'm here. I am doing something important.' "
For nurses to develop their own agency---their own power---nurses must first claim and recognize the importance of what they do. As Buresh and Gordon elucidate so clearly in their book, patients do not learn self-care skills in a vacuum. Someone must teach them those skills, and it is nurses who bring their knowledge and education directly to patient care. When recovering from surgery, it isn't doctors who monitor patients every fifteen minutes, using a lifetime's worth of learning to perform important expert assessments. Nurses use a wide variety of skills---often on an autonomous basis---to provide patients with the care and attention they need for optimal health.
While nurses are indeed held in very high esteem by the general public in surveys and polls, most members of that adoring public would be hard pressed to actually describe what it is that nurses do. As Bernice Buresh and Suzanne Gordon make so abundantly clear, it is up to nurses to claim their rightful place of importance in the care provided to patients in a variety of settings. Nurses need to proudly speak of their work with a voice of agency and power, and communicate clearly---to the public, the media, their families, their friends, and their colleagues---that nursing is important, that it is meaningful, and that what nurses do contributes to successful patient care and positive outcomes. We must forgo the teddy-bears, the hearts, the flowers, the useless diminutive statements and self-deprecation, and claim our professionalism for our own.
Nursing's voice must be heard, and Buresh and Gordon feel that the time for that voice to be clearly heard is now.
I have recently been re-reading From Silence to Voice: What Nurses Know and Must Communicate to the Public, by Bernice Buresh and Suzanne Gordon. What I am most struck by is that nurses still have not necessarily found their collective voice, and despite the media attention given to the global nursing shortage, I still believe that Buresh and Gordon's thesis still holds true: the public still does not fully understand what nurses do, and until that day comes, nurses' real value as clinicians will not be common knowledge.
Buresh and Gordon touch on many themes and areas of interest vis-a-vis nurses and their relation to the public, to doctors, and to one another. While I will not provide a review of the book---nor a comprehensive enumerating of its content---there are certain area which pique my interest, and I encourage curious readers to order a copy of the book and explore some of these issues for themselves.
Doctors Cure, Nurses Care
When I first heard this phrase, I was moderately disturbed by it for several reasons. Doctors, by and large, receive the lion's share of praise and gratitude when a sick patient is cured of an illness. Granted, doctors undergo a great deal of training and education in order to offer curative treatments for a variety of diseases, yet all too often, the work of nurses is grossly overlooked when it comes to successful treatment. While nurses do indeed carry out many orders originated from doctors, nurses use their own brand of critical thinking and autonomous action in order to perform specialized patient care. The public may not be aware of this fact, but many actions taken by nurses are initiated by nurses themselves, and the professional clinical assessments performed by nurses will often lead to changes in treatment and greater overall success.
Sure, nurses care, and nursing is seen by the public as a "caring" profession. However, nurses utilize scientific methods, skilled observation, and keen assessment skills to monitor patients' progress. Nurses are not just "the caring eyes and ears of doctors"---nurses are skilled professionals fully involved in patient care---and patient cures.
The Nurse as Angel, Teddy-Bear, and Child
In their book, Buresh and Gordon make one thing clear: nurses' self-presentation says a great deal to the public, and images of nurses that instill themselves in the societal zeitgeist are difficult to dispel.
Somewhere along the line, the "angels of mercy" moniker became attached to nurses as a group. Granted, in the early days of nursing, nurses' ability to act autonomously was extremely limited, and we were, by and large, the handmaidens of deified doctors. However, as much as that regrettable history has largely changed, the image of the nurse as angel unfortunately persists quite widely in our culture and websites galore promote gifts and baubles that continue to diminish nurses' professionalism. Images such as this one drive home the point: nurses are childlike individuals with starched white hats who love teddy-bears. Adding insult to injury, nurses can actually be depicted as winged angel/teddy-bears, further enforcing the infantilization (and deprofessionalization) of our profession. Would doctors allow themselves to be thus represented to the public?
Rather than being perceived as cherubic angels and childlike creatures, this writer feels that being perceived as the valuable and skilled professionals who we truly are would allow the public to have a much more accurate perception of what we do, and our importance to the care of millions.
The Clothes on Our BackNurses' uniforms have certainly changed over the years, and as scrubs have become the norm for nurses in most clinical settings, many companies have capitalized on the popularity of such utilitarian clothing. Now, designer scrubs covered with angels, teddy-bears (there they are again!), and any number of cartoon-like images adorn the hard-working bodies of nurses around the world. If nurses want to be taken seriously by the public---and by doctors and other professionals---how does the wearing of such (in my opinion) unprofessional clothing help our cause?
Picture this: a team meeting occurs midday to discuss a patient on the adult oncology floor. Present at the meeting: a medical resident, a medical student, the attending doctor, the oncologist, two unit nurses, a social worker and a respiratory therapist. Of all of the professionals in the room, who would possibly be wearing pink scrubs covered with teddy-bears and hearts, and a pin on her chest saying "Doctors Cure, Nurses Care"? And what message does this convey about the nurse's self-image and how the other professionals present in the meeting should perceive him or her?
What's in a Name?
In From Silence to Voice, Buresh and Gordon make their case that nurses being addressed by first name only is also a major image problem when it comes to the public's perception of us a collective whole.
When doctors introduce themselves to patients or other professionals, they always do so by using the title "Doctor" before their name. This practice immediately creates an impression that the doctor is a professional, that he or she has a name that should be remembered, and a hierarchy of power and authority is clearly established from the start.
Conversely, we nurses almost ubiquitously introduce ourselves by first name only, ostensibly to break down the barriers between patients and nurses, assisting the patient in overcoming fears and anxieties related to their treatment. While this tactic may have some limited benefit, Buresh and Gordon argue that "if nurses introduce themselves by their first names only, they are asking to be regarded as nonprofessionals because that is the conventional way that nonprofessionals present themselves."
The "first-name only convention", as the authors have named it, makes it significantly more difficult for individual nurses to receive recognition for their work when only their first names are known. It also creates a hierarchical structure in which the doctor stands alone as a figure of authority, towering above the patient and nurse with (patriarchal or matriarchal) power and authority.
Interestingly, many nurses will argue that introducing ourselves as "Nurse Smith" or "Nurse Cadmus" is awkward at best, but also brings to mind the infamous "Nurse Ratched" from "One Flew Over the Cuckoo's Nest". Granted, Nurse Ratched is a mythic and hated figure in the pantheon of film and modern literature, yet do we see doctors eschewing their well-earned title due to historical figures such as Dr. Kevorkian or Dr. Mengele (of Auschwitz fame)? Absolutely not. Doctors use their title so commonly and so frequently that the word "doctor" simply holds too much cultural power to be diminished by one literary (or real-life) character who used that title for ill.
As for "naming practices" between doctors and nurses themselves, further examples of an unequal playing field emerge, with nurses almost continually subjugated to a diminished status by always being addressed by first name by both patients and doctors, whereas doctors maintain their professionalism and authority through the use of their title and last name.
Taking Credit Where Credit is Due
All too often, the work of nurses is diminished by nurses themselves. When thanked for their work, nurses will frequently say, "Oh, I didn't do much. The doctors really did the hard part." Or when a nurse is asked what he or she does, the answer will often be, "I'm just a nurse." This diminution of nurses' worth does little to cement in the public's collective mind the utter importance---the crucial presence---of nurses in the healthcare system. The "just a nurse" phrase---used all too painfully often---hurts nurses' cultural standing and diminishes the profession in the public's eye.
Nurses need to stand up and take credit for the work that they do. Buresh and Gordon urge nurses to say "You're welcome" when they are thanked. "I am so glad that I could assist you in learning so much about your diabetes, Mr. Smith" or "It was my pleasure to provide your post-operative nursing care, Mrs. Jones"---these are statements that take credit for nurses' actions, acknowledge patients' gratitude, and accept responsibility for providing crucial nursing care that directly impacts patients' recovery and health.
Nurses' Agency
Buresh and Gordon recommend that nurses discover their "voice of agency". According the authors, "the voice of agency is the voice that says: 'I helped the patient to walk after surgery so that she wouldn't get blood clots in her legs' or 'I taught the patient how to take his medications so that they would be effective and produce fewer side effects.' The authors further illustrate their point by reminding us that "the voice of agency is the voice that conveys the message, 'I'm here. I am doing something important.' "
For nurses to develop their own agency---their own power---nurses must first claim and recognize the importance of what they do. As Buresh and Gordon elucidate so clearly in their book, patients do not learn self-care skills in a vacuum. Someone must teach them those skills, and it is nurses who bring their knowledge and education directly to patient care. When recovering from surgery, it isn't doctors who monitor patients every fifteen minutes, using a lifetime's worth of learning to perform important expert assessments. Nurses use a wide variety of skills---often on an autonomous basis---to provide patients with the care and attention they need for optimal health.
While nurses are indeed held in very high esteem by the general public in surveys and polls, most members of that adoring public would be hard pressed to actually describe what it is that nurses do. As Bernice Buresh and Suzanne Gordon make so abundantly clear, it is up to nurses to claim their rightful place of importance in the care provided to patients in a variety of settings. Nurses need to proudly speak of their work with a voice of agency and power, and communicate clearly---to the public, the media, their families, their friends, and their colleagues---that nursing is important, that it is meaningful, and that what nurses do contributes to successful patient care and positive outcomes. We must forgo the teddy-bears, the hearts, the flowers, the useless diminutive statements and self-deprecation, and claim our professionalism for our own.
Nursing's voice must be heard, and Buresh and Gordon feel that the time for that voice to be clearly heard is now.
Monday, August 25, 2008
Religion and Discrimination in Healthcare
(Note: This is my fifth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
A San Diego fertility clinic that refused to provide artificial insemination to a lesbian woman based on her sexual orientation has tasted defeat at the hands of the California Supreme Court.
Guadalupe Benitez was denied insemination by two doctors at the North Coast Women's Care in Vista, California, after being told by the doctors in question that their Christian values would not allow them to artificially inseminate a lesbian. In later testimony, the doctors stated that they simply would not perform the procedure for any woman who was unmarried, despite her sexual orientation.
While a state appeals court did indeed rule in favor of the doctors' rights to refuse to treat based on sexual orientation or marital status, the California Supreme Court overturned that ruling by citing The Unruh Civil Rights Act, which prohibits discrimination by any business---including medical facilities---based on gender, sexual orientation, religion, and many other protected categories.
An editorial in the Los Angeles Times praises the decision, while also citing disturbing statistics that many states actually have legislation in place protecting doctors' rights to deny patients treatments or services that they find "religiously objectionable". The LA Times also shares the results of recent studies revealing that 14% of doctors polled stated that they would deny certain treatments to certain individuals while refusing to provide viable alternatives or referrals for such care, if confronted with a situation at odds with their religious convictions.
In reaction to the ruling, the Los Angeles Times editorial states:
"The tradition of religious freedom in the United States is one of the founding ideals of this country. But as our framers envisioned it, religious freedom referred to a right to practice one's own religion free of interference from others. It did not refer to religiously based interference with the rights of others, who may have their own and different religious traditions. Even in the relatively religiously homogeneous era of the framers, such interference was not acceptable. It is even less so in 21st century America. With religious heterogeneity growing, the devotional demands of one group may be increasingly at odds with those of others.
"Yet too often, our deference to religion in contemporary American society has allowed us to subordinate all other values. It has allowed us to routinely accept religiously motivated behaviors that we otherwise would have no reluctance to sanction and that, indeed, would be impermissible with any other justification.
"So it's time to say 'enough.' In the United States, we all are free to practice our religion as we see fit, as long as we do not interfere with the well-being of others by imposing our religious views on them. If physicians or other healthcare providers who have religious objections to legal medical treatments will not at a minimum inform their patients about those treatments and refer them to others who will deliver them, they should act in a way that is consistent with their convictions and the well-being of their patients and find other professions. "Freedom of religion is a cherished value in American society. So is the right to be free of religious domination by others."
I could not agree more with the statements by the LA Times editorial team. While I wholeheartedly respect the beliefs and values that guide any individuals' life, doctors and medical personnel hold an oath to first "do no harm", and I believe that "harm" includes refusal to provide care to another human being based upon discrimination, potentially leaving that individual without recourse or alternative affordable options for such care. Even though in vitro fertilization is indeed an elective procedure which does not have life-and-death implications per se, it is the principal of the matter that lies at this heart of this case.
As the LA Times stated in yet another editorial: "A clothing store may choose not to sell polo shirts. But once it sells polo shirts, it cannot withhold them from customers based on their race, religion, sexual orientation and so forth." Taking into consideration that medicine is also a business, following the letter of the law, a business must abide by anti-discrimination laws when serving consumers of any class, group, or minority, regardless of the feelings or values of the business owner or operator.
Now, doctors can still indeed refuse to perform abortions, in vitro fertilizations, or any other manner of procedure that does not fall within the bounds of their personal moral compass (just as the aforementioned clothing store can choose to not sell polo shirts). However, following non-discrimination laws, if they choose to offer a procedure to their patients, then it must be offered equally to all, not solely to select groups who meet the doctors' criteria for moral righteousness.
While some may argue that the refusing doctors did, after all, refer the plaintiff to another provider who eventually performed the procedure (and apparently incurred the costs that the patient would have paid in higher fees to the other provider), it is easy to imagine other less fortunate patients being sent on a wild goose chase, seeking medical care that was consistently denied to them based on some aspect of their beliefs or lifestyle.
The California Supreme Court obviously felt that this case had much broader implications beyond fertility and in vitro insemination. With this decision, the court decided to send a clear message that protection against discrimination based on sexual orientation and marital status is just as crucial as protection against discrimination based upon race or gender. If this case had been decided differently, perhaps we would then begin to see further erosions of the rights of gays and lesbians in all manner of areas of legal, medical and commercial transactions.
I am certain that this issue is not going away, and that proposals and ballot initiatives striving to ban gay marriage entirely will surely gain moral steam in reaction to this decision. However, the California Supreme Court has taken a stand, and I personally feel that their choice to rule in the plaintiff's favor, however controversial, will stand the test of time and further appeal.
A San Diego fertility clinic that refused to provide artificial insemination to a lesbian woman based on her sexual orientation has tasted defeat at the hands of the California Supreme Court.
Guadalupe Benitez was denied insemination by two doctors at the North Coast Women's Care in Vista, California, after being told by the doctors in question that their Christian values would not allow them to artificially inseminate a lesbian. In later testimony, the doctors stated that they simply would not perform the procedure for any woman who was unmarried, despite her sexual orientation.
While a state appeals court did indeed rule in favor of the doctors' rights to refuse to treat based on sexual orientation or marital status, the California Supreme Court overturned that ruling by citing The Unruh Civil Rights Act, which prohibits discrimination by any business---including medical facilities---based on gender, sexual orientation, religion, and many other protected categories.
An editorial in the Los Angeles Times praises the decision, while also citing disturbing statistics that many states actually have legislation in place protecting doctors' rights to deny patients treatments or services that they find "religiously objectionable". The LA Times also shares the results of recent studies revealing that 14% of doctors polled stated that they would deny certain treatments to certain individuals while refusing to provide viable alternatives or referrals for such care, if confronted with a situation at odds with their religious convictions.
In reaction to the ruling, the Los Angeles Times editorial states:
"The tradition of religious freedom in the United States is one of the founding ideals of this country. But as our framers envisioned it, religious freedom referred to a right to practice one's own religion free of interference from others. It did not refer to religiously based interference with the rights of others, who may have their own and different religious traditions. Even in the relatively religiously homogeneous era of the framers, such interference was not acceptable. It is even less so in 21st century America. With religious heterogeneity growing, the devotional demands of one group may be increasingly at odds with those of others.
"Yet too often, our deference to religion in contemporary American society has allowed us to subordinate all other values. It has allowed us to routinely accept religiously motivated behaviors that we otherwise would have no reluctance to sanction and that, indeed, would be impermissible with any other justification.
"So it's time to say 'enough.' In the United States, we all are free to practice our religion as we see fit, as long as we do not interfere with the well-being of others by imposing our religious views on them. If physicians or other healthcare providers who have religious objections to legal medical treatments will not at a minimum inform their patients about those treatments and refer them to others who will deliver them, they should act in a way that is consistent with their convictions and the well-being of their patients and find other professions. "Freedom of religion is a cherished value in American society. So is the right to be free of religious domination by others."
I could not agree more with the statements by the LA Times editorial team. While I wholeheartedly respect the beliefs and values that guide any individuals' life, doctors and medical personnel hold an oath to first "do no harm", and I believe that "harm" includes refusal to provide care to another human being based upon discrimination, potentially leaving that individual without recourse or alternative affordable options for such care. Even though in vitro fertilization is indeed an elective procedure which does not have life-and-death implications per se, it is the principal of the matter that lies at this heart of this case.
As the LA Times stated in yet another editorial: "A clothing store may choose not to sell polo shirts. But once it sells polo shirts, it cannot withhold them from customers based on their race, religion, sexual orientation and so forth." Taking into consideration that medicine is also a business, following the letter of the law, a business must abide by anti-discrimination laws when serving consumers of any class, group, or minority, regardless of the feelings or values of the business owner or operator.
Now, doctors can still indeed refuse to perform abortions, in vitro fertilizations, or any other manner of procedure that does not fall within the bounds of their personal moral compass (just as the aforementioned clothing store can choose to not sell polo shirts). However, following non-discrimination laws, if they choose to offer a procedure to their patients, then it must be offered equally to all, not solely to select groups who meet the doctors' criteria for moral righteousness.
While some may argue that the refusing doctors did, after all, refer the plaintiff to another provider who eventually performed the procedure (and apparently incurred the costs that the patient would have paid in higher fees to the other provider), it is easy to imagine other less fortunate patients being sent on a wild goose chase, seeking medical care that was consistently denied to them based on some aspect of their beliefs or lifestyle.
The California Supreme Court obviously felt that this case had much broader implications beyond fertility and in vitro insemination. With this decision, the court decided to send a clear message that protection against discrimination based on sexual orientation and marital status is just as crucial as protection against discrimination based upon race or gender. If this case had been decided differently, perhaps we would then begin to see further erosions of the rights of gays and lesbians in all manner of areas of legal, medical and commercial transactions.
I am certain that this issue is not going away, and that proposals and ballot initiatives striving to ban gay marriage entirely will surely gain moral steam in reaction to this decision. However, the California Supreme Court has taken a stand, and I personally feel that their choice to rule in the plaintiff's favor, however controversial, will stand the test of time and further appeal.
Thursday, August 21, 2008
Hispanics and the U.S. Healthcare System
(Note: This is my fourth post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
The Hispanic population of the United States is growing exponentially, and the Pew Hispanic Center chronicles and tracks the collective successes and challenges of this burgeoning American demographic.
According to the Pew Center, the Hispanic population of the United States---currently the largest minority group in the country---will triple between 2005 and 2050, with non-Hispanic whites poised to themselves become a minority by 2050, certainly the largest projected demographic shift of the 21st century.
Taking these statistics into consideration, it is disturbing to learn that a recent Pew Hispanic Center study reveals that 1 out of 4 Hispanic Americans does not have a regular healthcare provider. Additionally, a similar number of Hispanic respondents reports receiving no medical attention or information from any member of the healthcare system in the previous year.
The Pew study, carried out in partnership with the Robert Wood Johnson Foundation, reveals that "the groups least likely to have a usual health care provider are men, the young, the less educated and those with no health insurance." The study results also clearly show that Hispanics who are less assimilated into American society---including those who are foreign-born, recent immigrants, and/or those who speak only Spanish---are less likely than their more assimilated counterparts to report having a regular medical provider.
Interestingly, when pressed for reasons why they lack regular healthcare providers, 41% of respondents simply said they lacked a provider because they are rarely sick. And a majority of Hispanic study subjects---83%, in fact---report obtaining the majority of their health information from television. Additionally, 79% states that they are acting on the information obtained from television and other media sources, changing diet and exercise practices solely based on reports and advertisements.
In terms of those Hispanics who have indeed received medical care in the last year, 77% reported their care as "good" or "excellent". However, 25% of those respondents who received health care over the last five years reports receiving poor treatment within the mainstream American health care system. The report continues by stating, "those who believe that the quality of their medical care was poor attribute it to their financial limitations (31%), their race or ethnicity (29%) or, the way they speak English or their accent (23%)".
Some other surprising findings also were revealed in the study results:
--45% of Hispanics without a regular health care provider actually have health insurance
--Half of the respondents without a regular provider have at least a high school education
--Many Hispanics without a health care provider were born here in the United States
--60% state that they received health care advice from family and friends in the last year
--A "slight majority" of those without a usual provider are "English-dominant or bilingual"
Following the release of the study, the headlines trumpeted the news: Many Hispanics Shut Out of U.S. Health Care System, Latinos Turn to TV for Health Advice, 25% of Hispanics Don't Visit Doctor Regularly, among other declarative statements meant to inform the public of the results of the study in simplistic and less-than-nuanced terms.
But what do these findings mean? What do we actually take away from the study results? Is there something in American society---or American health care, in particular---that has to change? With Hispanics carrying a disproportionately significant burden of diabetes and other chronic illnesses when compared to other segments of the population, it is in our best interest as a nation to address these disparities in a meaningful way. Whether we want to believe it or not, a lack of preventive health care on the part of such an enormous demographic will eventually have a widespread economic impact on society as a whole, with everyone eventually paying the price in one form or another.
Considering the climate towards immigrants since 9/11/01, it is this writer's fear that xenophobic Americans who rely on a "they should all speak English" anthem will use the results of this and other studies to defend their position that immigrants must conform, assimilate, and master the English language as a means to fuller participation and representation within the larger society. While all immigrants do indeed assimilate to some extent as they enter a new culture, the fact that Hispanics will be a majority of the population of the United States in less than 40 years underscores the notion that a broader view of this situation must be taken in order to fully embrace the coming demographic shift and its implications for health and health care in America. Websites like Optimos Medicos and other sites geared towards the Hispanic community indeed do their part to help bridge these gaps and cultural/linguistic divides.
In my work as a nurse care manager for inner city Latinos over the course of the last decade, I have witnessed first-hand how culturally appropriate health care can be delivered to under-served populations despite barriers of language, education, and socioeconomics. However, the Pew/Robert Wood Johnson data suggests that there is more than simple socioeconomic factors which deter Hispanics from seeking regular preventive health care. When extrapolated, the data demonstrates that a large percentage of Hispanics---whether educated, English-speaking, foreign-born or not---have a relative tendency to eschew regular preventive health care, relying instead on the media, a perceived lack of acute or chronic illness, family and friends, and intermittent urgent care, in order to meet their health care needs.
It is my contention that the Pew findings necessitate a great deal of soul-searching for public health officials, Hispanic and Latino consumer groups and community leaders, government officials, as well as a broad spectrum of insurers, regulatory bodies, medical providers, health care systems, and others. I would venture a guess that Hispanic community leaders, clergy, popular entertainers, and other recognized figures of authority and cultural significance would be most likely to succeed vis-a-vis a public relations campaign urging Hispanics to obtain and utilize regular preventive health care. Additionally, it would behoove state and federal governments to invest in such a campaign with the knowledge that pennies invested in preventive health care now will save many dollars in the care of the chronically ill in the future.
So, what might a public relations campaign look like in order to reach Hispanics? Obviously, since such a large percentage of Hispanics report obtaining (and utilizing) health care information from television and radio, I would suggest a massive bilingual ad campaign targeting all segments of the Hispanic community. Highly esteemed popular entertainers and other prominent figures could be recruited as spokespeople for the campaign, providing a familiar and respected face for the project.
Above and beyond spokespeople and television ads, I picture a nationwide body of trained outreach workers (volunteer and otherwise), fanning out within their communities, educating their fellow community members about the value of preventive health care. These workers would be armed with literature, contact information for culturally sensitive medical providers accepting new patients, and other resources about what types of preventive health care are most highly recommended. Currently existing outreach infrastructures could be utilized in order to reach deeper into neighborhoods and social circles without duplicating efforts, dove-tailing with other outreach teams already actively involved in their communities.
Just as the gay community pulled together in the early days of the AIDS epidemic, educating one another about prevention and treatment options, stemming the tide of the epidemic, the Hispanic community could, with the appropriate resources, reach out within its own population in an attempt to bring more individuals into the fold. Coupled with a sustained, savvy and intelligent media campaign, major inroads could be made vis-a-vis enrolling Hispanics into primary care.
Considering the breadth of the issue and the potential challenges it presents, many arguments could be made that such a campaign is doomed to failure, and that the economic resources do not exist for such a massive outreach effort. And with no mandate for universal health care in this country, uninsured Hispanics would still be left in the dark. However, if one considers the potential impact of of an aging population of Hispanic citizens in 2050, burdening the economy and the society with undetected and untreated chronic illness, there is no question in my mind that millions of dollars in health care costs would be saved over the course of the next generation.
Preventive health care is an investment, and if we are truly a multicultural and tolerant society of immigrants and the descendants of immigrants, we have an opportunity to show our true colors, embracing the health of our Hispanic brothers and sisters as our own, investing in their---and our---collective future.
The Pew/Robert Wood Johnson study demonstrates what may indeed be a crisis of faith on the part of Hispanic Americans vis-a-vis the mainstream health care system in this country. However, the Chinese symbol for "crisis" is also the symbol for "opportunity", and this is one opportunity that we as a society should not miss.
The Hispanic population of the United States is growing exponentially, and the Pew Hispanic Center chronicles and tracks the collective successes and challenges of this burgeoning American demographic.
According to the Pew Center, the Hispanic population of the United States---currently the largest minority group in the country---will triple between 2005 and 2050, with non-Hispanic whites poised to themselves become a minority by 2050, certainly the largest projected demographic shift of the 21st century.
Taking these statistics into consideration, it is disturbing to learn that a recent Pew Hispanic Center study reveals that 1 out of 4 Hispanic Americans does not have a regular healthcare provider. Additionally, a similar number of Hispanic respondents reports receiving no medical attention or information from any member of the healthcare system in the previous year.
The Pew study, carried out in partnership with the Robert Wood Johnson Foundation, reveals that "the groups least likely to have a usual health care provider are men, the young, the less educated and those with no health insurance." The study results also clearly show that Hispanics who are less assimilated into American society---including those who are foreign-born, recent immigrants, and/or those who speak only Spanish---are less likely than their more assimilated counterparts to report having a regular medical provider.
Interestingly, when pressed for reasons why they lack regular healthcare providers, 41% of respondents simply said they lacked a provider because they are rarely sick. And a majority of Hispanic study subjects---83%, in fact---report obtaining the majority of their health information from television. Additionally, 79% states that they are acting on the information obtained from television and other media sources, changing diet and exercise practices solely based on reports and advertisements.
In terms of those Hispanics who have indeed received medical care in the last year, 77% reported their care as "good" or "excellent". However, 25% of those respondents who received health care over the last five years reports receiving poor treatment within the mainstream American health care system. The report continues by stating, "those who believe that the quality of their medical care was poor attribute it to their financial limitations (31%), their race or ethnicity (29%) or, the way they speak English or their accent (23%)".
Some other surprising findings also were revealed in the study results:
--45% of Hispanics without a regular health care provider actually have health insurance
--Half of the respondents without a regular provider have at least a high school education
--Many Hispanics without a health care provider were born here in the United States
--60% state that they received health care advice from family and friends in the last year
--A "slight majority" of those without a usual provider are "English-dominant or bilingual"
Following the release of the study, the headlines trumpeted the news: Many Hispanics Shut Out of U.S. Health Care System, Latinos Turn to TV for Health Advice, 25% of Hispanics Don't Visit Doctor Regularly, among other declarative statements meant to inform the public of the results of the study in simplistic and less-than-nuanced terms.
But what do these findings mean? What do we actually take away from the study results? Is there something in American society---or American health care, in particular---that has to change? With Hispanics carrying a disproportionately significant burden of diabetes and other chronic illnesses when compared to other segments of the population, it is in our best interest as a nation to address these disparities in a meaningful way. Whether we want to believe it or not, a lack of preventive health care on the part of such an enormous demographic will eventually have a widespread economic impact on society as a whole, with everyone eventually paying the price in one form or another.
Considering the climate towards immigrants since 9/11/01, it is this writer's fear that xenophobic Americans who rely on a "they should all speak English" anthem will use the results of this and other studies to defend their position that immigrants must conform, assimilate, and master the English language as a means to fuller participation and representation within the larger society. While all immigrants do indeed assimilate to some extent as they enter a new culture, the fact that Hispanics will be a majority of the population of the United States in less than 40 years underscores the notion that a broader view of this situation must be taken in order to fully embrace the coming demographic shift and its implications for health and health care in America. Websites like Optimos Medicos and other sites geared towards the Hispanic community indeed do their part to help bridge these gaps and cultural/linguistic divides.
In my work as a nurse care manager for inner city Latinos over the course of the last decade, I have witnessed first-hand how culturally appropriate health care can be delivered to under-served populations despite barriers of language, education, and socioeconomics. However, the Pew/Robert Wood Johnson data suggests that there is more than simple socioeconomic factors which deter Hispanics from seeking regular preventive health care. When extrapolated, the data demonstrates that a large percentage of Hispanics---whether educated, English-speaking, foreign-born or not---have a relative tendency to eschew regular preventive health care, relying instead on the media, a perceived lack of acute or chronic illness, family and friends, and intermittent urgent care, in order to meet their health care needs.
It is my contention that the Pew findings necessitate a great deal of soul-searching for public health officials, Hispanic and Latino consumer groups and community leaders, government officials, as well as a broad spectrum of insurers, regulatory bodies, medical providers, health care systems, and others. I would venture a guess that Hispanic community leaders, clergy, popular entertainers, and other recognized figures of authority and cultural significance would be most likely to succeed vis-a-vis a public relations campaign urging Hispanics to obtain and utilize regular preventive health care. Additionally, it would behoove state and federal governments to invest in such a campaign with the knowledge that pennies invested in preventive health care now will save many dollars in the care of the chronically ill in the future.
So, what might a public relations campaign look like in order to reach Hispanics? Obviously, since such a large percentage of Hispanics report obtaining (and utilizing) health care information from television and radio, I would suggest a massive bilingual ad campaign targeting all segments of the Hispanic community. Highly esteemed popular entertainers and other prominent figures could be recruited as spokespeople for the campaign, providing a familiar and respected face for the project.
Above and beyond spokespeople and television ads, I picture a nationwide body of trained outreach workers (volunteer and otherwise), fanning out within their communities, educating their fellow community members about the value of preventive health care. These workers would be armed with literature, contact information for culturally sensitive medical providers accepting new patients, and other resources about what types of preventive health care are most highly recommended. Currently existing outreach infrastructures could be utilized in order to reach deeper into neighborhoods and social circles without duplicating efforts, dove-tailing with other outreach teams already actively involved in their communities.
Just as the gay community pulled together in the early days of the AIDS epidemic, educating one another about prevention and treatment options, stemming the tide of the epidemic, the Hispanic community could, with the appropriate resources, reach out within its own population in an attempt to bring more individuals into the fold. Coupled with a sustained, savvy and intelligent media campaign, major inroads could be made vis-a-vis enrolling Hispanics into primary care.
Considering the breadth of the issue and the potential challenges it presents, many arguments could be made that such a campaign is doomed to failure, and that the economic resources do not exist for such a massive outreach effort. And with no mandate for universal health care in this country, uninsured Hispanics would still be left in the dark. However, if one considers the potential impact of of an aging population of Hispanic citizens in 2050, burdening the economy and the society with undetected and untreated chronic illness, there is no question in my mind that millions of dollars in health care costs would be saved over the course of the next generation.
Preventive health care is an investment, and if we are truly a multicultural and tolerant society of immigrants and the descendants of immigrants, we have an opportunity to show our true colors, embracing the health of our Hispanic brothers and sisters as our own, investing in their---and our---collective future.
The Pew/Robert Wood Johnson study demonstrates what may indeed be a crisis of faith on the part of Hispanic Americans vis-a-vis the mainstream health care system in this country. However, the Chinese symbol for "crisis" is also the symbol for "opportunity", and this is one opportunity that we as a society should not miss.
Tuesday, August 05, 2008
The Aging World
(Note: This is my third post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
The predictions are in. The number of Americans over age 65 will double by the year 2050, and this demographic shift is occurring on almost every continent.
Personally, although I am not a member of the Baby Boom generation that accounts for the majority of this projected statistical growth, I will turn 65 in 2029, putting me squarely in the midst of the burgeoning data pool.
So what does this mean? What does such a huge demographic population shift portend? How are we to prepare for such a tilt of the generational scales?
First, it seems apparent that governmental bodies must prepare as massive numbers of older adults begin to retire and collect government benefits (to which they are justifiably entitled). Medicare and Social Security here in the U.S. must be protected from bankruptcy, and there seems to be little actually being done about it from this lay-person's perspective. How will these programs survive the onslaught without further government intervention?
And as these scores of hopeful retirees begin to navigate their "post-career" world, many of them are already discovering that making ends meet at a time of astronomical increases in the cost of living is not merely a challenge, it is a matter of basic survival.
How many seniors are now competing with teenagers for entry-level jobs at checkout counters and convenience stores? How many elderly citizens are having to make painful and difficult choices between food, prescriptions, and home heating oil? Which seniors are choosing to sell their beloved family homes for which they have worked so hard for so long, moving to low-income housing to reduce costs and make ends meet? These are hard times, and for many newly-retired seniors, the times may get even harder.
Back in the day, a nest egg was amassed over time with a combination of diligent saving and the promise of life-long company pensions (now mostly a relic of the past). After World War II, many former soldiers went to college for free, pursued vocational training, or bought homes under the GI Bill, securing economic keys to a bright future promised by a grateful post-war government.
Today, families face a different set of economic circumstances. The cost of college has risen exponentially, and many families go into considerable debt to educate their children (or for middle-aged parents to pursue new careers in the face of a changing workforce). Relatively speaking, housing costs have also risen astronomically, with middle-class families struggling to manage mortgage payments, a substantial number sadly ending up in foreclosure. Add to this the cost of healthcare (with rising insurance premiums and out-of-pocket expenses), the price of oil, and the concurrent rise in food prices, and a recipe for economic suffering is securely in place.
So, within this cultural milieu, the newly retired, the elderly and the very old balance on a financial and societal precipice. With working families less able to assist elderly family members economically, and with elders living longer due to advances in medicine and medical technology, how will we as a society care for our elders who cannot care for themselves? Will we warehouse those who cannot afford tony apartments in bourgeois assisted living facilities, spiriting them away to less-than-adequate nursing homes for the economically challenged? Will the working class elderly have to fend for themselves as the Social Security pie is divided beyond recognition, unable to keep pace with the rising cost of living?
As a society, we truly need to think deeply about how we will make adjustments to care for, house, feed, and provide for a growing geriatric population that is projected to continue to expand for the next forty years. It is apparent to this writer that controlling the rising costs of healthcare, food, and energy are three keys to the potential success of any attempted economic rescue of our---or any other---society. I am no economist or demographer, but I can see the writing on the wall, and elders who are unable to pay for medicine, healthcare, heat, and food are elders who are at great risk on many levels of their lives.
With families around the world struggling to make ends meet, and the economic barometer anything but reassuring, it isn't only the elderly who are in need of succor. Still, like children, the elderly are a vulnerable population requiring stewardship and thoughtful oversight by both the powers that be and the citizenry at large. And how we care for our elders and our children is a good indication of the overall humanity of our collective moral compass.
The predictions are in. The number of Americans over age 65 will double by the year 2050, and this demographic shift is occurring on almost every continent.
Personally, although I am not a member of the Baby Boom generation that accounts for the majority of this projected statistical growth, I will turn 65 in 2029, putting me squarely in the midst of the burgeoning data pool.
So what does this mean? What does such a huge demographic population shift portend? How are we to prepare for such a tilt of the generational scales?
First, it seems apparent that governmental bodies must prepare as massive numbers of older adults begin to retire and collect government benefits (to which they are justifiably entitled). Medicare and Social Security here in the U.S. must be protected from bankruptcy, and there seems to be little actually being done about it from this lay-person's perspective. How will these programs survive the onslaught without further government intervention?
And as these scores of hopeful retirees begin to navigate their "post-career" world, many of them are already discovering that making ends meet at a time of astronomical increases in the cost of living is not merely a challenge, it is a matter of basic survival.
How many seniors are now competing with teenagers for entry-level jobs at checkout counters and convenience stores? How many elderly citizens are having to make painful and difficult choices between food, prescriptions, and home heating oil? Which seniors are choosing to sell their beloved family homes for which they have worked so hard for so long, moving to low-income housing to reduce costs and make ends meet? These are hard times, and for many newly-retired seniors, the times may get even harder.
Back in the day, a nest egg was amassed over time with a combination of diligent saving and the promise of life-long company pensions (now mostly a relic of the past). After World War II, many former soldiers went to college for free, pursued vocational training, or bought homes under the GI Bill, securing economic keys to a bright future promised by a grateful post-war government.
Today, families face a different set of economic circumstances. The cost of college has risen exponentially, and many families go into considerable debt to educate their children (or for middle-aged parents to pursue new careers in the face of a changing workforce). Relatively speaking, housing costs have also risen astronomically, with middle-class families struggling to manage mortgage payments, a substantial number sadly ending up in foreclosure. Add to this the cost of healthcare (with rising insurance premiums and out-of-pocket expenses), the price of oil, and the concurrent rise in food prices, and a recipe for economic suffering is securely in place.
So, within this cultural milieu, the newly retired, the elderly and the very old balance on a financial and societal precipice. With working families less able to assist elderly family members economically, and with elders living longer due to advances in medicine and medical technology, how will we as a society care for our elders who cannot care for themselves? Will we warehouse those who cannot afford tony apartments in bourgeois assisted living facilities, spiriting them away to less-than-adequate nursing homes for the economically challenged? Will the working class elderly have to fend for themselves as the Social Security pie is divided beyond recognition, unable to keep pace with the rising cost of living?
As a society, we truly need to think deeply about how we will make adjustments to care for, house, feed, and provide for a growing geriatric population that is projected to continue to expand for the next forty years. It is apparent to this writer that controlling the rising costs of healthcare, food, and energy are three keys to the potential success of any attempted economic rescue of our---or any other---society. I am no economist or demographer, but I can see the writing on the wall, and elders who are unable to pay for medicine, healthcare, heat, and food are elders who are at great risk on many levels of their lives.
With families around the world struggling to make ends meet, and the economic barometer anything but reassuring, it isn't only the elderly who are in need of succor. Still, like children, the elderly are a vulnerable population requiring stewardship and thoughtful oversight by both the powers that be and the citizenry at large. And how we care for our elders and our children is a good indication of the overall humanity of our collective moral compass.
Friday, July 25, 2008
Obama, Healthcare and A Trio of Mythic Figures
(Note: This is my second post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
Barack Obama, the presumed Democratic nominee for President, faces a tough crowd when talking about healthcare in America. As a nurse, I myself am a tough crowd, and my cynicism towards politicians of any stripe runs relatively deep. In my (potentially naive) hopes for a universal, single-payer health plan for all Americans, I see potential for such a future in some of Senator Obama's positions, but when it comes to his chances (and true motivation) to deliver the goods, my jury is still definitively out.
When perusing the Senator's website, we begin with a quote by Mr. Obama from a speech in Iowa City on May 29, 2007:
“We now face an opportunity — and an obligation — to turn the page on the failed politics of yesterday's health care debates. My plan begins by covering every American. If you already have health insurance, the only thing that will change for you under this plan is the amount of money you will spend on premiums. That will be less. If you are one of the 45 million Americans who don't have health insurance, you will have it after this plan becomes law. No one will be turned away because of a preexisting condition or illness.”
At face value, this sounds like a wonderful idea and I'm interested to know the details. I heard similar rhetoric from the Clinton Administration in the early 90's (and we all know how that panned out). Still, the sentiment---of universal coverage regardless of pre-existing conditions and no change to current premiums---makes some salient points.
Further on, the data is there for all to see: an estimated 47 million uninsured Americans, including 9 million children. Health insurance premiums have risen four times as fast as wages over the last six years, and less than 4 cents of every healthcare dollar is spent on prevention and public health.
Mr. Obama's plan promises many things:
*Coverage for all Americans that is similar to the coverage now provided to members of Congress
*Guaranteed eligibility
*Comprehensive benefits, including mental health, maternity, and preventive care
*Affordable premiums, co-pays and deductibles
*Subsidies for those who do not qualify for Medicaid or SCHIP but cannot afford premiums
*Simplified paper work and decreased costs
*Easy enrollment
*A National Health Insurance Exchange which provides portability from state to state and job to job without loss of coverage
*Employer contributions with exemptions for small businesses
*Mandatory coverage for children
*Expansion of Medicaid and SCHIP
*Flexibility for states already implementing their own plans
I agree that all of the points outlined above are like music to this nurse's ears. With portability, 100% eligibility for all Americans, expansion of Medicaid---it all seems too good to be true. The site continues to describe plans for lowering costs by modernizing the healthcare delivery system, disease management programs, team management of chronic illness, patient safety, independent research on effectiveness, a comprehensive effort to redress health disparities, and stronger anti-trust laws with a goal of decreased malpractice insurance premiums and fewer lawsuits.
Obama's plan also addresses the need for electronic medical records, less reliance on paper charts, and increased competition for drug companies and insurers, not to mention increased biomedical research, an expansion of the global fight against AIDS, support for Americans with disabilities, mental health parity, lead and mercury poisoning prevention, and increased research related to Autism.
Reading my downloaded copy of the plan in further detail, I was disappointed by the omission of several key issues that have been very much on my mind in recent months:
1) The nursing shortage: although Senator Obama's plan states that the number of "primary care providers and public health practitioners" are dwindling, the plan makes no mention of nurses, the (global) nursing shortage, and the need for massive investment in training, increased nursing faculty, loan programs, and other incentives to a) keep nurses in the workforce, b) prevent burnout by decreasing nurse-patient ratios, c) provide financial incentives for those who wish to be nursing faculty, and d) expand enrollment in nursing education. Where does he stand on the nursing shortage, and how can he not consider it a cornerstone of any meaningful national healthcare policy?
2) Schools and student health: although the Senator's plan addresses the need for expanded physical fitness in schools, improved use of lunch programs, and "more healthful environments" in the nation's schools, the plan fails to mention that although the federal government mandates that there be one school nurse for every 750 children, the national average is more than 1,110 children per nurse, with some states far exceeding even that number. Nurses are essential to the health of our school-age children, and Senator Obama seems to have overlooked this very important point. However, we can rest assured that there is a full-time nurse on staff in any private school attended by Mr. Obama's privileged children.
3) Dental coverage: it is widely understood that dental health is one of the most important forms of preventive healthcare, but the Obama health plan fails to mention dental care in the large or the fine print. Millions of Americans who indeed have health coverage through their employers or a private insurance plan still lack dental coverage for even the most routine care. When it comes to the prevention of infection, improved immune function and proper nutrition, dental care is paramount. Unnecessary tooth and bone loss, oral cancers, and preventable complications from dental diseases are truly public health disasters. If the plan for American universal coverage does not include universal coverage for preventive and corrective dentistry, a serious source of chronic health problems will not have been addressed or alleviated.
4) Stem-cell research: one must take note that the Senator's plan makes no mention of advancing and expanding stem-cell research, a controversial issue stymied by the unscientific and "values-based" prognostications of the Bush Administration, although he does call for increased biomedical research (a euphemism, perhaps, in order to not alienate a certain type of moderate voter?)
I am in no way a policy-oriented person, and when it comes to politics, I tend to sit on the sidelines and watch the wheels turn (with the occasional blog post for good measure). Mr. Obama's healthcare plan is impressive in both depth and breadth, and if he can actualize his plan in the real world, we will certainly be considerably more better off as a nation than we are now. As far as the blind eye that the Senator has turned to the nursing shortage (at least as far as his healthcare plan is concerned), he would do well to realize the importance of nursing to the success of any national healthcare agenda and address the very realistic concerns which nurses have raised again and again.
As I said earlier in this article, my jury is still out vis-a-vis Obama's ability to actually manifest his vision when the campaign is over and the ticker-tape has been swept from the streets. History has illustrated again and again that "politics-as-usual" can rear its ugly head quite quickly when the mad dash of the campaign season is over.
Obama's hardest fight will not even begin until he sits in that famous Oval Office and attempts to wrestle with the troubles of the day. Will his ambitious healthcare plan survive the deluge of responsibilities and decisions (and special interests) which will make themselves painfully known after January 20th? Will he see that nurses really matter, and then succeed in bringing their needs to the table? This (somewhat cynical) nurse isn't so sure, but I am willing to give the Senator the benefit of the doubt as long as his efforts remain focused on the needs of ordinary Americans, and not on the desires of lobbyists, insurance company executives, Big Pharma, hospital CEOs, and others who feel that their agenda should supercede that of the American citizenry.
It is the uninsured, the disabled and the working poor (and their children) who truly carry the burden of our dysfunctional and top-heavy healthcare system. With more money spent per capita on healthcare than any other industrialized country in the world, the United States ranks embarrassingly low in terms of poverty, infant mortality, obesity rates, and many other statistical markers of overall public health. This is a travesty.
Transforming American healthcare is at best a Herculean task of enormous proportions, and any president who shoulders the burden could also be compared to yet another long-suffering mythic figure, Atlas. We can only hope that a President Obama would not instead become a figure more akin to Sisyphus, the mythical man doomed for eternity to roll a boulder up a hill every day, only to have it roll to the bottom before he begins the struggle once more. Mythically speaking, I believe that Sisyphus most accurately (and sadly) represents the life history of healthcare reform in America, with Bill and Hillary playing the parts of the last unlucky Sisyphean figures to traverse that cursed hill.
Obama will struggle against many forces united to defeat a movement towards healthcare parity for all Americans, and the interests with the financial wherewithal to thwart such a struggle are more powerful than most of us know. While my cynicism often gets the best of me, I do indeed hold out hope for a healthcare system that can function smoothly and efficiently, keep costs under control, improve public health, advance research, reverse the nursing shortage, and address the myriad concerns mentioned in this and thousands of other diatribes about the current state of healthcare in these United States.
I wish Mr. Obama Godspeed in attempting what has been up until now an impossible task, and I will continually strive to keep my cynicism at bay as we move closer to the day when a new administration assumes its (Sisyphean?) place in the Oval Office.
Barack Obama, the presumed Democratic nominee for President, faces a tough crowd when talking about healthcare in America. As a nurse, I myself am a tough crowd, and my cynicism towards politicians of any stripe runs relatively deep. In my (potentially naive) hopes for a universal, single-payer health plan for all Americans, I see potential for such a future in some of Senator Obama's positions, but when it comes to his chances (and true motivation) to deliver the goods, my jury is still definitively out.
When perusing the Senator's website, we begin with a quote by Mr. Obama from a speech in Iowa City on May 29, 2007:
“We now face an opportunity — and an obligation — to turn the page on the failed politics of yesterday's health care debates. My plan begins by covering every American. If you already have health insurance, the only thing that will change for you under this plan is the amount of money you will spend on premiums. That will be less. If you are one of the 45 million Americans who don't have health insurance, you will have it after this plan becomes law. No one will be turned away because of a preexisting condition or illness.”
At face value, this sounds like a wonderful idea and I'm interested to know the details. I heard similar rhetoric from the Clinton Administration in the early 90's (and we all know how that panned out). Still, the sentiment---of universal coverage regardless of pre-existing conditions and no change to current premiums---makes some salient points.
Further on, the data is there for all to see: an estimated 47 million uninsured Americans, including 9 million children. Health insurance premiums have risen four times as fast as wages over the last six years, and less than 4 cents of every healthcare dollar is spent on prevention and public health.
Mr. Obama's plan promises many things:
*Coverage for all Americans that is similar to the coverage now provided to members of Congress
*Guaranteed eligibility
*Comprehensive benefits, including mental health, maternity, and preventive care
*Affordable premiums, co-pays and deductibles
*Subsidies for those who do not qualify for Medicaid or SCHIP but cannot afford premiums
*Simplified paper work and decreased costs
*Easy enrollment
*A National Health Insurance Exchange which provides portability from state to state and job to job without loss of coverage
*Employer contributions with exemptions for small businesses
*Mandatory coverage for children
*Expansion of Medicaid and SCHIP
*Flexibility for states already implementing their own plans
I agree that all of the points outlined above are like music to this nurse's ears. With portability, 100% eligibility for all Americans, expansion of Medicaid---it all seems too good to be true. The site continues to describe plans for lowering costs by modernizing the healthcare delivery system, disease management programs, team management of chronic illness, patient safety, independent research on effectiveness, a comprehensive effort to redress health disparities, and stronger anti-trust laws with a goal of decreased malpractice insurance premiums and fewer lawsuits.
Obama's plan also addresses the need for electronic medical records, less reliance on paper charts, and increased competition for drug companies and insurers, not to mention increased biomedical research, an expansion of the global fight against AIDS, support for Americans with disabilities, mental health parity, lead and mercury poisoning prevention, and increased research related to Autism.
Reading my downloaded copy of the plan in further detail, I was disappointed by the omission of several key issues that have been very much on my mind in recent months:
1) The nursing shortage: although Senator Obama's plan states that the number of "primary care providers and public health practitioners" are dwindling, the plan makes no mention of nurses, the (global) nursing shortage, and the need for massive investment in training, increased nursing faculty, loan programs, and other incentives to a) keep nurses in the workforce, b) prevent burnout by decreasing nurse-patient ratios, c) provide financial incentives for those who wish to be nursing faculty, and d) expand enrollment in nursing education. Where does he stand on the nursing shortage, and how can he not consider it a cornerstone of any meaningful national healthcare policy?
2) Schools and student health: although the Senator's plan addresses the need for expanded physical fitness in schools, improved use of lunch programs, and "more healthful environments" in the nation's schools, the plan fails to mention that although the federal government mandates that there be one school nurse for every 750 children, the national average is more than 1,110 children per nurse, with some states far exceeding even that number. Nurses are essential to the health of our school-age children, and Senator Obama seems to have overlooked this very important point. However, we can rest assured that there is a full-time nurse on staff in any private school attended by Mr. Obama's privileged children.
3) Dental coverage: it is widely understood that dental health is one of the most important forms of preventive healthcare, but the Obama health plan fails to mention dental care in the large or the fine print. Millions of Americans who indeed have health coverage through their employers or a private insurance plan still lack dental coverage for even the most routine care. When it comes to the prevention of infection, improved immune function and proper nutrition, dental care is paramount. Unnecessary tooth and bone loss, oral cancers, and preventable complications from dental diseases are truly public health disasters. If the plan for American universal coverage does not include universal coverage for preventive and corrective dentistry, a serious source of chronic health problems will not have been addressed or alleviated.
4) Stem-cell research: one must take note that the Senator's plan makes no mention of advancing and expanding stem-cell research, a controversial issue stymied by the unscientific and "values-based" prognostications of the Bush Administration, although he does call for increased biomedical research (a euphemism, perhaps, in order to not alienate a certain type of moderate voter?)
I am in no way a policy-oriented person, and when it comes to politics, I tend to sit on the sidelines and watch the wheels turn (with the occasional blog post for good measure). Mr. Obama's healthcare plan is impressive in both depth and breadth, and if he can actualize his plan in the real world, we will certainly be considerably more better off as a nation than we are now. As far as the blind eye that the Senator has turned to the nursing shortage (at least as far as his healthcare plan is concerned), he would do well to realize the importance of nursing to the success of any national healthcare agenda and address the very realistic concerns which nurses have raised again and again.
As I said earlier in this article, my jury is still out vis-a-vis Obama's ability to actually manifest his vision when the campaign is over and the ticker-tape has been swept from the streets. History has illustrated again and again that "politics-as-usual" can rear its ugly head quite quickly when the mad dash of the campaign season is over.
Obama's hardest fight will not even begin until he sits in that famous Oval Office and attempts to wrestle with the troubles of the day. Will his ambitious healthcare plan survive the deluge of responsibilities and decisions (and special interests) which will make themselves painfully known after January 20th? Will he see that nurses really matter, and then succeed in bringing their needs to the table? This (somewhat cynical) nurse isn't so sure, but I am willing to give the Senator the benefit of the doubt as long as his efforts remain focused on the needs of ordinary Americans, and not on the desires of lobbyists, insurance company executives, Big Pharma, hospital CEOs, and others who feel that their agenda should supercede that of the American citizenry.
It is the uninsured, the disabled and the working poor (and their children) who truly carry the burden of our dysfunctional and top-heavy healthcare system. With more money spent per capita on healthcare than any other industrialized country in the world, the United States ranks embarrassingly low in terms of poverty, infant mortality, obesity rates, and many other statistical markers of overall public health. This is a travesty.
Transforming American healthcare is at best a Herculean task of enormous proportions, and any president who shoulders the burden could also be compared to yet another long-suffering mythic figure, Atlas. We can only hope that a President Obama would not instead become a figure more akin to Sisyphus, the mythical man doomed for eternity to roll a boulder up a hill every day, only to have it roll to the bottom before he begins the struggle once more. Mythically speaking, I believe that Sisyphus most accurately (and sadly) represents the life history of healthcare reform in America, with Bill and Hillary playing the parts of the last unlucky Sisyphean figures to traverse that cursed hill.
Obama will struggle against many forces united to defeat a movement towards healthcare parity for all Americans, and the interests with the financial wherewithal to thwart such a struggle are more powerful than most of us know. While my cynicism often gets the best of me, I do indeed hold out hope for a healthcare system that can function smoothly and efficiently, keep costs under control, improve public health, advance research, reverse the nursing shortage, and address the myriad concerns mentioned in this and thousands of other diatribes about the current state of healthcare in these United States.
I wish Mr. Obama Godspeed in attempting what has been up until now an impossible task, and I will continually strive to keep my cynicism at bay as we move closer to the day when a new administration assumes its (Sisyphean?) place in the Oval Office.
Saturday, July 19, 2008
The Nursing Shortage: A Global Crisis, Close to Home
(Note: This is my inaugural post under the auspices of the nurse blogger scholarship which I recently received from Value Care, Value Nurses.)
The nursing shortage is here to stay. At least that's where the signs all seem to be pointing. From reports of teachers doing the work of school nurses to a profound lack of nursing faculty, the shortage---predicted for years by many in the know---is an inescapable phenomenon with far-reaching repercussions.
For instance, the Joint Commission (which is responsible for accrediting American hospitals and other healthcare facilities) has stated flatly that up to 100,000 preventable hospital deaths per year in the United States can be attributed to the nursing shortage. Additionally, the Department of Health and Human Services' Agency for Healthcare Research and Quality estimates that adding one patient per nurse per shift in U.S. hospitals increases the risk of hospital-based complications by as much as 17%. But how, pray tell, can hospitals decrease nurse-patient ratios in the face of such massive shortages of personnel?
As individual states consider passing legislation to decrease nurse-patient ratios, some state legislatures---like the Massachusetts Senate---seem deaf to the cries of nurses and patient advocates for mandated nurse-patient ratios that will serve to protect both nurses and patients from unnecessary injury. And in the midst of such a shortage, over-working nurses to the point of attrition from the profession is wholly counter-productive.
When it comes to educating new nurses, the American Association of Colleges of Nursing (AACN) predicts a shortage of up to 500,000 nurses by 2025, exacerbated by a severe shortage of nursing faculty across the United States. With 40,000 qualified applicants turned away from nursing schools in 2007, how will the shortage ever truly be addressed as nurses (and nursing faculty) of the Baby Boom generation begin to retire in droves? This AACN fact sheet apparently says it all, and the picture that's painted is anything but pretty.
As the average age of nurses climbs towards 47; as schools of nursing turn away students in record numbers; as Baby Boomers retire and nursing faculty follow suit---how are we to stem the tide? Faculty salaries cannot keep up with inflation, nurses are recruited heavily from region to region, and overworked nurses burn out as they care for too many patients.
From Canada to Prague to South Africa, more nurses are needed than schools can produce as nurses retire faster than they can be replaced. The story appears to be the same around the world, and governments, facilities and organizations seem to be scrambling for a multitude of solutions.
This writer does not purport to know the answers, and as I read the news, talk with nurses, and read what nurses throughout the blogosphere have to say, the nursing shortage is having a far-reaching ripple effect that touches on every aspect of medicine, health, healthcare, and community.
Nurses are essential to the health of myriad communities. Visiting nurses keep patients safe when they come home from the hospital with acute medical and nursing needs. Hospice nurses provide support for patients and their families as they navigate the dying process. Medical-surgical nurses keep hospital units running smoothly, safely, and efficiently. School nurses dispense medications and tend to the (often complex) medical needs of our children. Office-based nurses serve as the backbone of many private and group medical practices, and advanced practice nurses provide specialized medical care in settings where a doctor is neither available nor necessarily essential to good patient outcomes.
In the coming months, it will be interesting to see how the two major political candidates address---or fail to address---the nursing shortage. Barack Obama may have shadowed a nurse for ninety minutes, but a few hours in scrubs does not a policy make. And when it comes to national healthcare for the masses, if there are no nurses to deliver that care, then the plan is moot from the start. As far as this writer is concerned, any national healthcare policy debate that does not take into consideration the very real shortage of nurses in this country is a debate lacking an essential ingredient.
Yes, the nursing shortage is apparently here to stay---at least for the foreseeable future---and the resolution of this crisis is a goal in which every citizen has a serious stake.
The nursing shortage is here to stay. At least that's where the signs all seem to be pointing. From reports of teachers doing the work of school nurses to a profound lack of nursing faculty, the shortage---predicted for years by many in the know---is an inescapable phenomenon with far-reaching repercussions.
For instance, the Joint Commission (which is responsible for accrediting American hospitals and other healthcare facilities) has stated flatly that up to 100,000 preventable hospital deaths per year in the United States can be attributed to the nursing shortage. Additionally, the Department of Health and Human Services' Agency for Healthcare Research and Quality estimates that adding one patient per nurse per shift in U.S. hospitals increases the risk of hospital-based complications by as much as 17%. But how, pray tell, can hospitals decrease nurse-patient ratios in the face of such massive shortages of personnel?
As individual states consider passing legislation to decrease nurse-patient ratios, some state legislatures---like the Massachusetts Senate---seem deaf to the cries of nurses and patient advocates for mandated nurse-patient ratios that will serve to protect both nurses and patients from unnecessary injury. And in the midst of such a shortage, over-working nurses to the point of attrition from the profession is wholly counter-productive.
When it comes to educating new nurses, the American Association of Colleges of Nursing (AACN) predicts a shortage of up to 500,000 nurses by 2025, exacerbated by a severe shortage of nursing faculty across the United States. With 40,000 qualified applicants turned away from nursing schools in 2007, how will the shortage ever truly be addressed as nurses (and nursing faculty) of the Baby Boom generation begin to retire in droves? This AACN fact sheet apparently says it all, and the picture that's painted is anything but pretty.
As the average age of nurses climbs towards 47; as schools of nursing turn away students in record numbers; as Baby Boomers retire and nursing faculty follow suit---how are we to stem the tide? Faculty salaries cannot keep up with inflation, nurses are recruited heavily from region to region, and overworked nurses burn out as they care for too many patients.
From Canada to Prague to South Africa, more nurses are needed than schools can produce as nurses retire faster than they can be replaced. The story appears to be the same around the world, and governments, facilities and organizations seem to be scrambling for a multitude of solutions.
This writer does not purport to know the answers, and as I read the news, talk with nurses, and read what nurses throughout the blogosphere have to say, the nursing shortage is having a far-reaching ripple effect that touches on every aspect of medicine, health, healthcare, and community.
Nurses are essential to the health of myriad communities. Visiting nurses keep patients safe when they come home from the hospital with acute medical and nursing needs. Hospice nurses provide support for patients and their families as they navigate the dying process. Medical-surgical nurses keep hospital units running smoothly, safely, and efficiently. School nurses dispense medications and tend to the (often complex) medical needs of our children. Office-based nurses serve as the backbone of many private and group medical practices, and advanced practice nurses provide specialized medical care in settings where a doctor is neither available nor necessarily essential to good patient outcomes.
In the coming months, it will be interesting to see how the two major political candidates address---or fail to address---the nursing shortage. Barack Obama may have shadowed a nurse for ninety minutes, but a few hours in scrubs does not a policy make. And when it comes to national healthcare for the masses, if there are no nurses to deliver that care, then the plan is moot from the start. As far as this writer is concerned, any national healthcare policy debate that does not take into consideration the very real shortage of nurses in this country is a debate lacking an essential ingredient.
Yes, the nursing shortage is apparently here to stay---at least for the foreseeable future---and the resolution of this crisis is a goal in which every citizen has a serious stake.
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