What Does Good Medicine Look Like? Ask a Nurse.
Despite our major role in keeping patients healthy, nursing is undervalued and misunderstood.
Image: Victor Torres/Stocksy
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Last year, the New York Times published an article by Dhruv Khullar, an ER physician. The premise was that thoughtful communication with patients improves care and leads to better outcomes. Khullar writes with compassion, and makes a strong point for "letting patients tell their stories" (the article's title) and viewing patients holistically rather than merely as individuals with diseases. It had the workings of a promising article, but I was left rolling my eyes.
Let me be clear: I am always happy to read about healthcare providers advocating patient-centered approaches. In this age of bionic eyeballs and fecal transplants, reminders of our basic humanity are certainly welcome. But here's the rub: what Khullar is describing isn't a novel technique. What Khullar is describing (and is lauded for in the comments section) is basic nursing practice.
Was Khullar inspired by the nursing model of care? I carefully reread to make sure I didn't miss something. Any stories about a nurse colleague who influenced him? Any mention of how nursing and medicine differ, and how nurses, who are often viewed (incorrectly and patronizingly), as "doctors' little helpers" might actually be onto something? To my dismay (although not my surprise), he omits any meaningful mention of nursing or where the discovery that viewing patients as humans could be important might have come from.
Nursing practice is based in holistic, person-centered care that views patients as people with complex lives, rather than the embodiment of an illness. A "diabetic" isn't reduced to that cold, hard word. Rather we nurses think of our diabetic patients as people—as a person, say, with a family, a job, and three dogs who likes to go orienteering on the weekends and also happens to have diabetes. This is an important distinction because a) generally people don't like being viewed as diseases, and b) if a person cannot fit the treatment that's suggested into their lives, it doesn't matter how impressive the treatment is, they aren't going to benefit from it.
Nurses working in traditional hospital settings are assigned between two and five patients per shift, depending on specialty, and spend significantly more time with patients than other providers at the hospital do. Talking to patients, watching their progress, and hearing their stories are vital parts of a nurse's role. Important subtleties in a patient's condition or details about their lives are almost always picked up by nurses, as they are the ones who get to know the patient best. Nurses who choose to continue their education and become nurse practitioners (NPs) are educated to diagnose and treat conditions and bring this holistic view of individuals to their care. This is one of the attributes that makes NP practice unique and the reason that I decided to pursue it.
Despite its unique perspective, nursing is undervalued and misunderstood. The profession is often sexualized (ask a nurse if they have been sexually harassed on the job; the answer will likely be yes) and our intelligence overlooked. I have been asked if I was forced to choose nursing because I couldn't get into medical school (I didn't apply). Nurse scientists produce extremely important healthcare research (here are just a few examples), yet few people know anything about it, even when it directly improves their health. (To be fair, nursing does not do the best job promoting its research, but I also believe that the failure to view nursing as an academic discipline and a science also contributes to this lack of visibility.)
As with many societal ills, I suspect that we can partly thank misogyny for this. Even as male-identified students are now in the minority in some medical schools, medicine is still viewed as a "male" profession and nursing a "female" one, and I believe that this contributes to nursing's devaluation in relation to medicine. In her book Has Feminism Changed Science?, Londa Schiebinger refers to nursing, a profession that she cites as welcoming for women, as "soft science." Yet the aspects of nursing that are seen as "soft" (person-centered care, patient advocacy, and "letting patients tell their stories"), are now being celebrated by physicians as novel strategies and even being repackaged with a new name: narrative medicine.
In the article Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust, Rita Charon defines narrative medicine as "the ability to acknowledge, absorb, interpret, and act on the stories and plights of others." Charon states that "despite medicine's recent dazzling technological progress in diagnosing and treating illnesses, physicians sometimes lack the capacities to recognize the plights of their patients, to extend empathy toward those who suffer, and to join honestly and courageously with patients in their illnesses." Charon mentions nursing, but she lists it with other professions that have "recently realized the importance of narrative knowledge." A more factually appropriate shout-out would have been to acknowledge that the principles bolstering "narrative medicine" have been nursing's main tenets for quite some time.
Does medicine truly not realize that it is describing nursing's essence or does it not want to admit that it might learn something from nursing? Physicians are obviously a vital part of our healthcare system; I have never met a nurse who would deny that. And yet, the importance of nursing is often ignored at the expense of both nurses and patients.
Recent attempts by hospitals in several European countries to cut costs have resulted in the partial replacement of registered nurses with "nursing associates"; individuals with lower levels of training than RNs. Unfortunately, this might not be the best way to save money. Research conducted by Linda Aiken at University of Pennsylvania found that the replacement of an RN with a lower-skilled worker might put patients' lives in jeopardy. More specifically, the researchers state: "Substituting one nurse associate for a professional nurse for every 25 patients is associated with a 21 percent increase in the odds of dying." This rather horrifying statistic is a warning of what happens to the quality of healthcare when nurses are undervalued. I suggest that we give nursing its due, recognize its strengths and unique perspectives, and stop trying to undercut its worth. We'll all be patients someday and we'll be lucky to have RNs taking care of us.