Narrative Matters: The Power of the Personal Essay in Health Policy

CHAPTER 5: TROUBLE IN THE RANKS: PROFESSIONAL PROBLEMS

CHAPTER 5 TROUBLE IN THE RANKS PROFESSIONAL PROBLEMS
Accountable but Powerless Barry Adams Leaving Nursing Ray Bingham Dolores Daniel J. Derksen Attending Death with Dignity Sharon LaDuke
Accountable but Powerless Unable to deliver high-quality care, a nurse calls it quits, but not before blowing the whistle. Barry Adams H aving grown up with both a mother and a cousin who were registered nurses, I was familiar with both the value and the inherent challenges of being a nurse. My own experience of being a patient who was hospitalized twice for open-heart surgery before the age of thirty also taught me the importance of competent nursing care. Yet nothing could have prepared me for my own sojourn in nursing. The profession’s sharpest dilemma crystallized for me during a 3–11 evening shift in 1996, after a nurse supervisor assigned nine patients to my care. One of them was a man with terminal cancer who required frequent increases in pain medication as his disease progressed. Following the institution ’s policy, which required a new prescription order for every increase in narcotic dose (rather than the more flexible range often allowed in care of the terminally ill), I phoned the ordering physician for the third afternoon in a row. He informed me that he was very busy and I was not to call him again. Instead, he demanded that I get the order from his office helper. I attempted to explain that I, too, was very busy, being responsible for eight other very sick patients, and that I was required to follow hospital policy. I reminded him that it would be illegal for me to accept a medication order from an unlicensed assistant. Furious, he asked me to produce the law in writing. Embarrassed that I had never read the law, I agreed. I obtained a copy from the state nursing board; highlighted chapter 112, section 80B, which states that an RN can only receive medication orders from an “authorized” prescriber, and mailed it to him. (Only after I promised to mail the law did he provide the verbal prescription I needed.) Volume 21, Number 1: 218–223. January/February 2002. But after finding the law I needed, I kept reading. One particular line caught my attention: “Each individual licensed to practice nursing in the commonwealth shall be held directly accountable for the safety of nursing care he delivers. . .” Hands Tied At that moment I understood the contradiction that makes nurses flee a noble profession that should be a rewarding career. Although RNs are identi- fied as the last safety net for the patient and are held to high standards of professional accountability, we have no authoritative voice in a health care system that often does not put patients’ needs first. I clearly recall a discussion at the family dinner table thirty years ago after my mother, who was a county public health nurse, was told by her employer not to discharge Medicare patients who, in fact, no longer required nursing care and thus no longer qualified for Medicare reimbursement. The object was to ensure ongoing revenue for the county public health department . Indignant, she protested. But she was immediately reminded by her supervisor of the price of rocking the boat: She might lose her job. Most nurses in this country are “at-will” employees who can be fired without reason unless the firing involves discrimination or other violations of the law. We are expected to take commands from employers, even when the orders may not be in a patient’s best interest, yet it is we who are held directly accountable for patient care and outcomes. When I graduated in 1992 from a university-based nursing program, U.S. health care financing was in the middle of a dramatic upheaval. Viewed by hospitals largely as labor costs rather than as cost-effective, licensed care providers , nursing staffs were cut across the nation for the sake of other budgetary priorities. Predictions for the future of the nursing profession were bleak. I began my career wondering if a nursing education had been a poor investment. I decided that a variety of clinical experiences in different practice settings would be the best way to build my knowledge base and increase my marketability . Per diem employment in nursing was becoming the industry trend, so finding shift work to supplement my first job (which required day, evening, and night rotations...