Nurses as Partners for Better Care : We recognize our infatuation with high-tech cures as a costly problem, but are blind to the obvious solution.
We call it “health care,” but in reality our U.S. medical system is about “disease repair,” the more high-tech the better. And therein lies a flaw that, unless corrected, spells failure for attempts at reform.
The flaw is, more specifically, embedded in the dramatic power imbalance between cure-oriented medicine and care-oriented nursing, and the appalling lack of systematic communication between America’s 585,000 physicians and 2.1 million nurses.
In our cure-driven system, the dominant medical model focuses on diseases rather than the people who have them. The medical system contends that given sufficient energy and resources, these diseases can ultimately be defeated and the borders of life continually extended.
The nursing model, while encompassing treatment, also tries to deal with the human experience of loss and dysfunction. Nursing emphasizes both the science and art of short- and long-term care, stresses health education and disease prevention and accepts the inevitability of death.
Real health care, of course, demands a collaboration between these two models. But in our system, the care model has been distinctly subordinate--and even President Clinton’s proposal to make more use of highly trained “advanced practice” nurses fails to really integrate nursing issues into health care. Nursing insights, ideas and innovations are still routinely minimized, devalued or denied. Consider:
* Patients routinely complain that physicians do not really listen to them. To remedy this problem, medical schools are adding courses in “patient communication.” But to learn about good patient communication, doctors need only turn to nurses. For decades, nurses have spent most of their working hours listening to patients and trying to respond to their needs and concerns.
* Expert nurses, because they do listen, have long understood a problem that has only recently garnered public attention--inadequate pain management. In teaching hospitals across the country, experienced nurses often try to persuade anxious, inexperienced interns and residents to give terminally ill or post-surgical patients higher doses of pain medication. And nurses were instrumental in a federal study that found scandalous underuse of pain medication.
* For the two fastest-growing segments of our population, advances in nursing care are critical. These are people 75 and older--most of whom have one or more chronic illness and often some form of dementia--and dependent, usually severely mentally or physically disabled, adults between the ages of 18 and 65. Yet of the total 1992 National Institutes of Health appropriation of $9 billion, only $40 million--that’s four-tenths of 1%--went to the kind of nursing research that guides the care that such people require.
* Nurses are also central in dealing with terminal illness. In their recent study on overtreatment of the terminally ill, “Decisions Near the End of Life,” researchers at the Educational Development Center pointed out that 50% of the physicians they interviewed, but 75% of the nurses, were dissatisfied with the level of patient involvement in treatment decisions. This discrepancy may relate to the training of so many modern physicians as disease warriors, fighting death to the bitter end. Expert nurses, who do not labor under such a weighty and impossible mandate, may thus be the only ones to help patients and families decide to terminate heroic treatment.
In fact, when the decision is made to pull the proverbial plug, nurses generally do the actual pulling. They are the ones who spend time with dying patients, comfort families after a patient’s death and prepare the body. Ironically, in most states only physicians are legally allowed to pronounce death, which raises the question--if nurses cannot be trusted to differentiate between the dead and the living, why do we rely on them for round-the-clock patient care?
The cost- and life-saving value of systematic nurse-physician communication is well-confirmed, but still many conservative physicians, organizations like the American Medical Assn. and hospital administrators believe nurses should “take orders” rather than offer suggestions. And they continue to create and preserve systems that encourage conflict rather than cooperation, and promote the “disease model” rather than comprehensive care.
Fully integrating the care perspective into our disease-driven system would humanize medicine and reduce costs. Imagine how a nursing-oriented approach to dying might help reduce the 30% of health care costs now devoted to largely futile treatment in the last six months of life. This is the only way to turn a disease-repair system into a genuine health-care system.
