Inventing nursing

 
March 8, 2010 -- Today The New York Times ran an excerpt from Claudia Dreifus's interview with Johns Hopkins physician Peter Pronovost, who has been acclaimed for his promotion of checklists, hand washing, and other ways to improve hospital safety. Pronovost deserves credit for these efforts and for his calls to empower nurses, since they can play a key role in reducing errors. Unfortunately, in this interview he observes that physicians undervalue the "experiential" perspective that nurses and families have--as if nurses were like lay people we should listen to just because they spend more time with patients, rather than health professionals who use advanced skills and education to catch deadly errors. And Pronovost gets sole credit here, as he often does, for an advocacy focus that nurses have been pursuing for many decades, an apparent reflection of the media's tendency not to notice nursing perspectives until a more respected professional embraces them. Then the ideas are presented as the brilliant health innovations of the embracer, and nurses as merely the workers who implement the ideas. This bias appears in media ranging from news coverage of the Nurse Family Partnership, in which the idea of nurses making home health visits is often credited to a psychologist who founded one admirable program for at-risk mothers, to a recent episode of ABC's Grey's Anatomy that portrayed physician characters as the ones who initiated and even provided skin-to-skin care for a sick newborn. Ironically, by reinforcing the sense that nurses are low-skilled physician subordinates, such media often undermines nurses' claims to the resources they need to do the very work that is being celebrated. Of course, nurses themselves are not blameless. Pronovost reports that some nurses initially reacted to his ideas by telling him that it wasn't their job to monitor what physicians were doing to patients. And the Times interview underlines something very sad:  Why has a physician become the leader of a movement to make changes that are so central to nursing's own care model? Don't nurses have what it takes? Or is it that no one would listen to them?

The Times interview title is "Doctor Leads Quest for Safer Ways to Care for Patients." The paragraph introducing the interview explains that Pronovost is "medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, which means he leads that institution's quest for safer ways to care for its patients," and that he "also travels the country, advising hospitals on innovative safety measures." Does being "medical director" automatically mean he is the "leader"? In fact, the diverse 11-member health team listed on the Group's web site includes three nurses along with Pronovost and two other physicians. To its credit, the Group's site is careful not to award all credit for the Group's work to Pronovost. On the other hand, Pronovost's new book (written with Eric Vohr) is entitled Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

In response to the Times' first question, Pronovost suggests that he became interested in hospital safety as a medical student, after he learned that his father had been misdiagnosed with leukemia instead of the lymphoma he really had, and apparently died as a result. Later, as a physician with "an additional Ph.D. on hospital safety," Pronovost met Sorrel King, whose daughter had "died at Hopkins from infection and dehydration after a catheter insertion." Pronovost notes:

The mother and the nurses had recognized that the little girl was in trouble. But some of the doctors charged with her care wouldn't listen. So you had a child die of dehydration, a third world disease, at one of the best hospitals in the world. Many people here were quite anguished about it. And the soul-searching that followed made it possible for me to do new safety research and push for changes.

In fact, the King case became very well-known, particularly since Sorrel King herself played a key role in the changes that followed, and there was a good deal of press coverage. One very long 2003 series about the case and its aftermath in the Baltimore Sun was notable for its failure to take full account of the role nurses played, clearly suggesting that nurses were basically physician subordinates and that physicians were the only ones really responsible. That series failed to quote a single nurse. In any case, Pronovost explains the problem this way:

As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture. When confrontations occurred, the problem was rarely framed in terms of what was best for the patient. It was: "I'm right. I'm more senior than you. Don't tell me what to do." With the thing that Josie King died from -- an infection after a catheter insertion, our rates were sky high: about 11 per 1,000, which, at the time, put us in the worst 10 percent in the country. ... The C.D.C. estimates that 31,000 people a year die from bloodstream infections contracted at hospitals this way. So I thought, "This can be stopped. Hospital infections aren't like a disease there's no cure for." I thought, "Let's try a checklist that standardizes what clinicians do before catheterization." It seemed to me that if you looked for the most important safety measures and found some way to make them routine, it could change the picture. The checklist we developed was simple: wash your hands, clean your skin with chlorhexidine, try to avoid placing catheters in the groin, if you can, cover the patient and yourself while inserting the catheter, keep a sterile field, and ask yourself every day if the benefits of catheterization exceed the risks.

Pronovost's points about the "hierarchal" structure are excellent in the sense that they accurately describe how many physicians have been trained to operate, with regard to both more junior physicians and nurses. Of course, despite the power imbalance, nurses do not actually report to physicians, and readers might have benefited from hearing that.

In response to all this, the interviewer asks, "Wash your hands? Don't doctors automatically do that?"--a question that frames the issue solely in terms of physicians, as if they are the only ones who provide hands-on care. Nurses spend far more time with patients, and Pronovost himself has just mentioned nurses; yet the journalist fails to mention them. Pronovost explains that estimates are that hand-washing rates are actually very low.

Pronovost goes on to describe how Hopkins tested a checklist in the surgical intensive care unit, noting that one obstacle was that basic supplies like disinfectant were not readily available, so people would skip steps. In discussing the team's efforts to correct that, Pronovost speaks in terms of what "we" did, though he does not say who "we" were. The measures he's discussing are squarely within nurses' traditional scope of care, pragmatic changes to the care environment that can make a huge difference. In any case, nurses appear soon enough in his account:

We said: "Doctors, we know you're busy and sometimes forget to wash your hands. So nurses, you are to make sure the doctors do it. And if they don't, you are empowered to stop takeoff on a procedure." ... You would have thought I started World War III! The nurses said it wasn't their job to monitor doctors; the doctors said no nurse was going to stop takeoff. I said: "Doctors, we know we're not perfect, and we can forget important safety measures. And nurses, how could you permit a doctor to start if they haven't washed their hands?" I told the nurses they could page me day or night, and I'd support them. Well, in four years' time, we've gotten infection rates down to almost zero in the I.C.U.

This is both encouraging and distressing. We commend Pronovost for recognizing the importance of patient advocacy, and for trying to provide nurses with the support they need to do it. Indeed, from this account it sounds like Pronovost may understand patient advocacy better than some nurses, assuming it's correct that some nurses actually suggested it was not their job to monitor whether physicians were about to infect their patients (in the ICU, no less). And the nurses did not even want more power to help them do the patient advocacy that was their job in the first place? Of course, Pronovost's account, like the interviewer's earlier question, seems to assume that only physician hand-washing matters, as if nurses do nothing invasive (i.e., nothing important) in patient care. Who is making sure nurses wash their hands? Does that matter?

But now nurses have caught the interviewer's attention. She asks:  "In your book, you maintain that hospitals can reduce their error rates by empowering their nurses. Why?" Presumably she knows why if she read the book, so this is for the benefit of Times readers. Pronovost responds:

Because in every hospital in America, patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant. Yet, a nurse or a family member may be with a patient for 12 hours in a day, while a doctor might only pop in for five minutes. When I began working on this, I looked at the liability claims of events that could have killed a patient or that did, at several hospitals -- including Hopkins. I asked, "In how many of these sentinel events did someone know something was wrong and didn't speak up, or spoke up and wasn't heard?" Even I, a doctor, I've experienced this. Once, during a surgery, I was administering anesthesia and I could see the patient was developing the classic signs of a life threatening allergic reaction. I said to the surgeon, "I think this is a latex allergy, please go change your gloves." "It's not!" he insisted, refusing. So I said, "Help me understand how you're seeing this. If I'm wrong, all I am is wrong. But if you're wrong, you'll kill the patient." All communication broke down. I couldn't let the patient die because the surgeon and I weren't connecting. So I asked the scrub nurse to phone the dean of the medical school, who I knew would back me up. As she was about to call, the surgeon cursed me and finally pulled off the latex gloves.

In fact, nurses are the ones whose job it is to monitor patients 24/7 looking for "sentinel events." And maybe it would be too much to expect the nurses in the OR scenario to get the surgeon to stop if even a fellow physician could not without using a threat, but it is also the nurses' job to protect patients from such allergic reactions, and the nurses should not have needed Pronovost to tell them to do it. In addition, contrary to the impression left here, this is not something that he or any other physician just came up with. Of course, it would be fair to say that nurses have not traditionally been empowered to really do their jobs, but that's really not what we're hearing--we're hearing that Pronovost had the insight that nurses would be handy patient advocates.

Pronovost's checklist story reminded us of a March 2009 episode of NBC's ER in which surgeon Peter Benton is observing an operation in which an old friend is the patient. Benton manages with great effort to persuade the powerful lead surgeon to allow Benton to run through a safety checklist. When Benton asks, a nurse says that they are short on reperfusion solution, which eventually ends up being critical and perhaps saves the friend's life--but only because Benton is there to ask and to push it. Presumably, this plotline was based on the work of Pronovost, or the writings of Atul Gawande, a surgeon who has written about Pronovost's work.

And of course, there's Pronovost's "experiential" comment, which will probably sound supportive to many readers, but actually diminishes nurses. Of course nurses have a lot of information about patients because they spend more time with them, but nurses are also worth listening to because they have years of college-level health education and a great deal of expertise in detecting subtle changes in patient conditions and in many other areas of health care. Nurses are not just people who hang around and pester physicians to wash their hands.

The Times piece closes with a question about what we can do to protect ourselves from hospital errors. Pronovost advises us to question hospitals closely about their infection rates and their use of checklists, and once you are in in-patient, about hand-washing and specific things that are being done to you, such as whether you really need a catheter. He concludes:

It sounds silly. But you have to be your own advocate.

Indeed you do, especially when your nurses have been so undervalued that they lack the power to be your advocate, in part because most of the media continues to ignore their skills and contributions. In particular, much of the media promoting Pronovost and his good work gives no sense that nurses already have the professional duty to do much of what he advocates.

In other words, contrary to popular belief, Dr. Pronovost did not invent nursing.

See the interview by Claudia Dreifus "A Conversation with Dr. Peter J. Pronovost: Doctor Leads Quest for Safer Ways to Care for Patients" posted on the New York Times site on March 8, 2010. You can contact the author from her webpage by clicking on "Send an E-Mail to Claudia Dreifus."