Alexandra Robbins examines the state of U.S. nursing
“That’s why her hair is so big. It’s full of secrets.”
– Mean Girls (2004)
May 2015 – Journalist Alexandra Robbins placed many generally strong pieces about U.S. nursing in major publications to promote her 2015 book The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital. Her long May 12 piece in Politico was “Nurse Confessions: Don’t Get Sick in July.” It was a collection of insider information about subjects ranging from slow codes to how much more nurses do in hospitals than is shown on television or understood by most of society. These “confessions” didn’t always tell readers about nurses directly, but they did present nurses as sentient health care team members and keen observers, not as the clueless helpers who are often seen on, well, television. A shorter April 29 piece in Slate, “Doctors Throwing Fits,” described physician bullying of nurses with anecdotes, studies, and historical analysis. This one explained how such disruptive conduct threatens patient care. And for the long May feature in Marie Claire, the title said it all: “Mean Girls of the ER: The Alarming Nurse Culture of Bullying and Hazing.” This was not a happy story, but it gave a good sense of how and why many nurses feel bullied and undermined by senior colleagues and peers alike. All of the items told the public about the challenges nurses face in the clinical setting and why that matters, while avoiding many damaging stereotypes. Some elements of the pieces did reinforce those stereotypes. The focus on “secrets” and “confessions” may be enticing to readers, and we assume the almost universal anonymity of Robbins’s sources was at the nurses’ own insistence. But these elements can make nurses seem like cowering gossipers. In addition, none of the pieces really conveyed that nurses are autonomous professionals with their own scope of practice (not just people who picked up some knowledge through long experience). And there was little sense that at least some nurses are clinical leaders, advocates, and scholars who are empowered enough to speak for attribution, using their real names and credentials, with the notable exception of the Marie Claire piece, which relied significantly on nursing scholars. In any case, the pieces reached a large general audience with compelling information that should improve public understanding of nursing and, therefore, help nursing itself. We thank Alexandra Robbins and these publications.
The Politico piece “Nurse Confessions: Don’t Get Sick in July” is a large compendium of “confessions” that provide a “secret look inside how America’s health care system actually works.” The introductory section explains the lengthy research Robbins did and how it changed her view of U.S. health care, clearly showing the strong and less strong elements of her work: we hear that nurses are the “best-informed, hardest-working and savviest professionals in health care,” but also that “many” nurses supposedly call their profession “a secret club.” Nurses sound like heroically oppressed yester-women: dedicated, alert, and savvy, but not necessarily well-educated, highly skilled, or courageous.
Still, there is a lot here that would benefit nursing greatly if widely known. A common theme is that it is actually nurses rather than physicians who spend a lot of time with patients, who know them, who help them at the hardest times; physicians just “breeze in and out,” as one nurse says. Nurses also spend a lot of time trying to cope with physicians. We learn that nurses counter the “July Effect,” the deadly time when new physician residents arrive at U.S. teaching hospitals. Nurses often correct major errors, especially necessary for residents who are “too enamored of their M.D.” to ask nurses for help. Also, “nurses manage many of the duties that viewers see doctors performing on TV, such as inserting an IV or catheter.” One Arizona nurse confides: “I laugh when I see shows like House or Grey’s Anatomy where doctors are pining at the bedside of patients, giving them medications or administering treatments. Doctors do nothing of the sort.”
“The doctor is at your bedside for all of three minutes unless you’re getting intubated or coding. The nurse is the one rapidly assessing you at the door, immediately determining what interventions need to be made so that when the doctor does come into the room he has something more intelligent to say than, ‘Well, we’re going to get some labs and an X-ray,’” a North Carolina ER nurse said. “I get you undressed, on the monitor, cleaned up if needed. I will wash the blood and vomit out of your hair, and not gag or make you feel embarrassed that you’re sick. I’m the one who will go to the doctor and tell them you are having nausea, pain or a neuro status change because suddenly you think it’s 1988. That will be the reason that you get a head CT, and we find a brain bleed and contact the neurosurgeon. And then I will be at your bedside for the next three hours while we wait, reassuring your mother.”
Plus, nurses “know secrets about your doctors”! They know which physician’s patients have more complications, despite their good reputation. Nurses may “lie” to you, although this seems to happen mainly to hide their opinions about health options, presumably so as not to threaten physician authority or profits. Another “secret” is that you may not need the surgery a physician says you do, and that it might actually make you worse off. One nurse observes that the U.S. health care financing system “incentivizes doctors and hospitals to advise aggressive, high-cost treatments and procedures.” But nowhere does the piece directly question whether physicians should have so much power and nurses so little. The piece does identify a problem that is rarely mentioned in the mainstream media, that some health workers “impersonate nurses.” A medical assistant may pretend to be a nurse and give advice. One nurse says that is “illegal and dangerous,” noting that unlicensed medical assistants may have taken a one- or two-year certificate training program, whereas RNs have two- or four-year college degrees and a license. (Actually, RNs generally have at least three years of college; many people fail to count the year of pre-requisites to get into a two-year associates degree nursing program.)
A lot of this is very helpful. It shows that nurses play a far more important role in health care than many people realize. And it gives specific examples, not just the range of skilled care evident in the block quote above but also advice that readers can apply in their own situations. Unfortunately, none of these “secrets” is the fact that nurses have their own scope of practice and report to senior nurses, as opposed to physicians. Some of the anecdotes could certainly support the incorrect view that physicians’ greater power is actually formal supervisory authority over nurses. Thus, despite its length, the piece fails to convey nursing autonomy. And no named nurse expert appears, although the piece does quote a named PhD ethics expert in a discussion of how “Do Not Resuscitate” prescriptions are often ignored or overridden. Readers get little sense that nurses, like physicians, have expertise by virtue of their advanced educations—indeed, that nurses are “experts” at all, as opposed to savvy, veteran observers of the expertise of others. Indeed, while determining which physicians are skilled seems to be an issue of concern, determining which nurses are skilled does not.
Monkeys still available to address nursing shortage! Just sayin’
The Slate article tells how a “doctor-bully epidemic is jeopardizing both nurses and patients.” Robbins recounts stories of physicians verbally abusing nurses, assaulting them, and throwing things. A 2013 Institute for Safe Medication Practices survey found that in the past year, most nurses had experienced physicians being abusive and “26 percent of nurses had objects thrown at them by doctors.” The Joint Commission has linked abusive physician conduct with higher costs and rates of health care errors, including those resulting in death. That’s because physicians may not listen to nurses, and nurses may be too afraid to raise concerns. The Journal of the American College of Surgeons relayed a nurse’s note that a cardiologist had told her
“it was not her job to think, just to follow orders. Rx [prescription] delayed. MI [heart attack] extended.”
Researchers at a Pacific Coast Obstetrical and Gynecological Society meeting heard about a nurse who told a physician that a post-tubal ligation sponge count was wrong. The physician “said that an expensive x-ray would be ordered because the nurse obviously suffered from obsessive compulsive disorder. A sponge was found in the patient.” An anesthesiologist reportedly told an Arkansas nurse anesthetist: “I could teach a monkey to do your job.” Robbins says nurses may fear reporting abuse because “administrators” will support powerful physicians, who generate revenue, and even retaliate against the nurses, whose jobs are more vulnerable. “But when nurses don’t speak up, there’s a risk that people will suffer or die.” Robbins describes efforts to limit the abuse, including “code pinks” in which nurses gather to support a colleague suffering abuse.
Ultimately, these issues can be attributed to a fundamental lack of respect for nurses, who deserve much more appreciation than they get. The physician and nurse professions, which should be considered complementary and equal, are instead too often treated as master and servant. The term nurses often use to describe the role some doctors seem to assign them is “handmaiden.”
Robbins says that the “doctor-nurse hierarchy is rooted in the past,” describing the era when (mainly female) nurses had to stand when (mainly male) physicians entered rooms, in their expected role of assistants to the godlike physicians. Robbins cites psychiatrist Leonard Stein’s 1967 description of the “doctor-nurse game” in which nurses feel they have to trick physicians into thinking the nurses’ care ideas actually came from the physician. Robbins argues that “skilled and educated” nurses deserve respect and “a voice in health care decisions.” She asks: “Is it possible to have a chain of command without implied levels of superiority?” She suggests that “the various scopes of practice” could be seen as “complementary rather than hierarchical,” and that a team approach would improve patient care and eliminate most of the “bully doctors.”
Well, yes. Robbins has the right basic inclinations and goals, particularly that the two professions “should be considered complementary and equal.” And she presents a strong account of the abuse nurses endure and the threat it presents to patients. But she does not seem to understand that the professions already are complementary and that the “chain of command” she describes does not actually exist. Sadly, it’s easy to believe that none of the nurses she talked to emphasized that to her. Although physicians have more power, nurses do not report to them, but to nurse managers, as part of a separate “chain of command” extending up to the hospital leadership. Of course, nurse managers have not solved the problems Robbins discusses here. But even though those managers are themselves underpowered, the first step in addressing that would be letting people know nurse managers exist, that there is a structural base on which to build nursing autonomy, beyond discretionary physician or administrator goodwill. Also, despite all the research cited and discussed here, only physicians appear as identified experts, even though nursing scholars have conducted this kind of research, and they would have been happy to offer their views. Again, nurses seem to be health care troopers, but not leaders or experts.
The long “Mean Girls of the ER: The Alarming Nurse Culture of Bullying and Hazing” piece in Marie Claire focuses on horizontal aggression within nursing. Robbins says that given the “compassion and selflessness” of the nurses she spoke with, she was surprised to find “the profession’s silent secret”: “rampant hazing, bullying, and sabotage so destructive that patients can suffer and, in a few cases, have died.” Robbins notes that in 1986 “nursing professor Judith Meissner coined the phrase ‘Nurses eat their young’ as a call to action for nurses to stop ripping apart inexperienced coworkers.” Three decades later, the extent of the problem remains “staggering,” as overworked and oppressed nurses seem to continue taking out their frustrations on their peers. Some nurses defend harsh treatment as a way to be sure newer nurses are tough enough, or to protect patients from deadly errors, which are more likely in understaffed settings where new nurses may have more responsibility than they should. Still, Robbins presents stories of bullying, clique-ishness, public humiliation, failing to help new nurses with urgent patients, putting a bloody syringe in a nurse’s locker, and tolerance of such misconduct by the “manager” (curiously never described as the “nurse manager”). The piece also relies on a good deal of research and expert commentary. Some of that is credited to “studies,” “researchers,” “experts,” a non-nursing institution, or no one specific. For example: “[N]urses are verbally abused more frequently by each other than by patients, patients’ families, and physicians, all of whom commonly abuse nurses.” Or: “Scholars contend that nurses are a beleaguered population because of a history of powerlessness and submissiveness to mostly male physicians and administrators. Browbeaten, they grew to accept bullying as an inevitable occupational hazard.”
But some of the expert input is linked to nurses, or at least nursing. Robbins notes that “[w]orldwide, experts estimate that one in three nurses quits her job because of bullying and that bullying—not wages—is the major cause of a global nursing shortage.” On this point she also relies on “New England Institute of Technology professor Martha Griffin, Ph.D., a leading researcher of nurse lateral violence (intimidating colleagues at the same level).” Griffin is cited for statistics and comments, including that it’s “very rare” for nurse bullies to get in trouble because of the dysfunctional nursing culture, which includes a sense of impunity. And Robbins relies on Griffin for specific findings on the most common forms of lateral violence, which include undermining, withholding information, and sabotage. This matters especially in nursing, where communication and teamwork are matters of life and death. “UMass Lowell nursing professor Shellie Simons, Ph.D., reported in a 2010 study that a nurse told her, ‘During my first pregnancy, because the charge nurse didn’t like me, I was assigned the most infectious patients—HIV, tuberculosis, and hepatitis.’” Robbins says that “when nurses have better working conditions, they’re less likely to be aggressive towards one another, according to a 2010 Journal of Advanced Nursing study.” The American Nurses Association (ANA) is another source, for its opposition to bullying. Griffin is also quoted in support of the idea that horizontal aggression is “a safety concern,” for example in leaving bullied nurses without help in lift a large patient. The anonymous-nurse anecdotes are stronger, with one nurse flatly stating that patients die because of nurse bullying, such as when newer nurses ask for help with serious care issues but are ignored or met with guessing games: “People die because older cliques torment the newbies.”
Although this piece is not a pleasant one for nursing, it is generally fair and does the profession a service by exploring critical problems. The piece makes clear that these issues do not exist because nurses are bad people, but because of the profession’s history of oppression and marginalization. And here, Robbins relies to a large extent on nursing scholars. Simons and Meissner are identified as “nursing professors”; Simons and Griffin have their PhDs listed. It would have better to make clear that Griffin actually is a nurse. We can’t assume the public knows that those who teach or study nursing are nurses, given the frequent messaging that nurses are vacuous physician helpers. The references to the Journal of Advanced Nursing and the ANA are probably sufficient in that respect. Unfortunately, even this piece fails to convey that hospital nurses have formal management authority over other nurses, beyond whatever “charge nurse” will mean to lay readers. And then there is the main photo that accompanies at least the online version of the piece: a large, old-timey image of what seems like early 20th Century nurses, all female, all in white, with white caps. This kind of retro image unhelpfully associates nurses with a long-gone era, suggested that they too are yesterday’s girls, gendered and backwards.
On balance, Robbins’s pieces convey a lot of helpful information about the nature and importance of nursing to diverse groups of mainstream readers. We thank all those responsible.
See “Nurse Confessions: Don’t Get Sick in July: A secret look inside how America’s health care system actually works,” by Alexandra Robbins, published May 12, 2015 in Politico.
Also see “Doctors Throwing Fits: One of the hardest parts of being a nurse is dealing with bullying doctors,” by Alexandra Robbins, published April 29, 2015 on the Slate website.
And see the article “Mean Girls of the ER: The Alarming Nurse Culture of Bullying and Hazing: It’s not only threatening the profession, it’s putting patients’ lives at risk,” by Alexandra Robbins, published in the May 2015 issue of Marie Claire.