Nurses: The Unsung Heroes 5/95
This issue emphasizes the practice of nursing as it inte-relates with the practice of medicine. The functions served by nursing are summarized in a statement from the Code of Ethics of the International Council of Nurses:
Nurses minister to the sick, assume responsibility for creating a physical, social and spiritual environment which will be conducive to recovery, and stress the prevention of illness and promotion of health by teaching and example. They render health service to the individual, the family, and the community, and coordinate their services with members of other health professions. Service to mankind is the primary function of nurses and the reason for the existence of the nursing profession. Need for nursing service is universal. Professional nursing service is therefore unrestricted by considerations of nationality, race, color, political or social status.
According to Lucile P. Leone, contributor to the Britannica Macropedia, "Men and women engaged in nursing throughout the world comprise the largest single group of health workers. The availability of effective nursing care in a country is a principal measure of its potential advancement in health. Modern nursing is essential not only to hasten the recovery of sick people but also to provide people with knowledge that will improve their health and productivity. Since health possesses humanitarian and economic values, nursing is an instrument of social progress."
In the USA there are nearly a million registered nurses and over a million practical nurses. During this century with the evolution of the modern hospital, doctors and nurses have largely worked side-by-side in the same institutional environment. As the physicians role has greatly expanded with the technological explosion of the past several decades, so also has the nurses role expanded. Doctors and nurses, the two clinicians on the health care team, work together in complementary roles in caring for the sick and dying.
When I was a medical student working as a summer extern, I observed a cardiologist as he disciplined an RN for listening to the heart and lungs. At that time the duties of a nurse had been expanded to include the use of a stethoscope to take a blood pressure -- something that was still in the physicians diagnostic domain. For a nurse to use that new instrument to listen to the chest was not considered the practice of nursing and was threatening to some physicians. Now we expect nurses not only to listen to the chest and give us the physical findings on the phone, we even discuss the changing working diagnosis and treatments as we manage the patients between daily hospital rounds. Then we use the nurse's findings to write new phone orders until the next time we make rounds.
This has led to an increasingly expanded nursing role. In addition to the nurse midwives since the 1930's, the last three decades have seen over 100,000 RNs obtain additional skills as nurse practitioners and nurse clinical specialists.
As a pulmonary fellow in the late 1960's, we made the rounds with nursing groups and spoke about the collaborative role of doctors and nurses -- how the patient gets the best care in such an environment. I once received a standing ovation from a CNA assembly of over 700 RNs after speaking about the complementary role of doctors and nurses. It was only later that I found that some of organized medicine was perceived as adversarial to the expanded role of nursing. In fact, some elements of organized medicine were so adversarial, that we facilitated the introduction of another type of allied health specialist, the physician assistant, adding to the over twenty allied specialties already present. We licensed them under our own state medical board. There are now over 23,000 PAs.
Nurses don't want to be doctors any more than we want to be nurses. However, PA's do want to be doctors, perform physicians' duties, and will increasingly practice medicine as soon as they have the votes, the power, or the ability to become totally independent. A limited license, such as podiatrists, optometrist, and psychologists have, will lower the level of primary care even though the public may not see it that way.
Although NPs and PAs have nearly identical training, the NPs are in graduate school and the PAs are undergraduate. Even at UCD, NPs, a graduate program, and PAs, an undergraduate program, are the same program. To fully standardize the training, we should make an RN degree the entry requirement for the PA program and thus amalgamate the two fields under the nurse practice act.
The desperation of nurses with increasing patient loads, who are being held responsible for lesser trained practical nurses and nurses aides delivering inferior care, was recently seen when 5,000 RNs marched on Washington, D.C. "We are the ones who mop your brow, who hold your hands...who suction your tracheotomy," said Joan Swirsky, Editor-In-Chief of Revolution -- The Journal of Nurse Empowerment, which organized the protest, "We are the last patient advocates in America."
This group of RNs no longer see physicians as patient advocates because they see us contract with just about everyone but the patient. The same institutions that are hiring doctors on salaries, will soon be hiring lesser trained "doctors" to actually do the hospital admissions, do the endoscopic procedures and minor surgery under our direction, and deliver increasingly inferior care. If each doctor supervised as many "PA type doctors" as RNs supervise "practical type nurses" it would only take a couple of dozen doctors to run a 200 bed hospital.
There actually was a paper delivered at a national meeting some years ago by a physician who proposed that a family physician could extend his practice by hiring a number of PAs, each with a different specialty interest. By extending this concept, a few hundred physicians and surgeons with about 2500 PAs could care for all of Sacramento and El Dorado counties. Could the 2500 physicians they displaced find something more "useful" to do?
Marching in Washington, D.C. is anathema to most of us. Having a Journal on "Physician Empowerment" may be equally repulsive. But physicians are marching in many different directions. We are being divided as we are being conquered. The same institutions, whether healthcare, fiscal intermediaries, or the government, which have disempowered nurses, are now disempowering physicians. These institutions are on a mission, will listen to us politely, and continue in their quest for ultimate power.
Our obligation is primarily to the public, our patients, the 250 million Americans that depend on us for their life and death struggles. Only they can re-empower us. We must incessantly point out that when technicians working on one organ system, rather than nurses who know the entire patient, turn off the wrong ventilator; when technicians turn up the oxygen on a patient in CO2 narcosis, and eliminate the remaining hypoxic drive for life; it's the patient, the public, that dies. Otherwise, we may become a dying institution -- a dispensable profession. We can then join the nurses in their march as unsung heroes. We will then be supportive of each other as colleagues... Something we should have been all along.