Uncle

I collect mugs. I never intended or planed to collect mugs; it just sorta happened. When my kitchen was redone a number of years ago the designer popped a small section of floor-to-ceiling shelving in what otherwise would have been unused space, and a display area for mugs was born. I still didn't get it, and only after randomly unpacking, trying to put the new kitchen in order, did I realize that the mugs I'd absently set on those shelves belonged there. Looking at them later I realized that most of them have a story. This is one:

Many years ago I visited a quadriplegic patient. Injured in an accident the details of which I long since have forgotten, he was a talking head. He couldn't move his arms or legs at all, and I'm not sure now that he even could turn his head. Japanese, he lived with family who respectfully called him "Uncle," and they couldn't have been more courteous or deferent if he'd been able to rear up and threaten them with every sort of violence imaginable or to dole out wads of cash. As are many Japanese homes, the apartment was minimally appointed and spanking clean, always. That it was a third floor walk-up didn't stop the men from carrying Uncle down the stairs and strapping him first into the car and then into a wheelchair so they could take him fishing. Uncle loved to fish, and a little thing like quadriplegia wasn't about to stop him from going!

All I did was visit once a month to change his urinary catheter. Never did I find a mark on his skin, a drop of water in his lungs, a hint of infection, or any other complication of such profound immobility. Uncle always smiled and always asked after me, while at least one family member hovered in the background ready to assist and eager to hear any suggestion I might have to make Uncle's life the least bit better. I don't recall ever having even one; this family had it down perfectly. Nonetheless, Uncle and family alike never failed to extend heartfelt thanks at the end of each of my visits.

One Christmas they gave me this mug. It probably was part of a Starbucks gift package; I don't remember. Of course any coffee or hot chocolate that might have come with it was devoured with relish long ago.

I use my mugs on a rotating basis so I can enjoy each one and none become too dusty on a shelf. Every time this one comes up in the rotation I remember Uncle, his smile, his appreciation, his spirit in the face of circumstances that would have broken most people, and also his dedicated family. It now has been some fifteen years since he died.

Funny the impact that the smallest gesture can have. A simple, mass-produced coffee mug keeps Uncle and all that he and his family stood for alive in my heart every single time I see it.

For many this is a season of giving, and also for many there comes a certain angst about what to buy, what to do, what another wants or needs. I suspect the perfect gift is simply seeing and honoring that other, as Uncle's family saw and honored him, and that any item chosen to represent this will be just right as long as it is selected with love and good will. Indeed, one need only pop by the likes of a Starbucks and pick a package off a shelf as long as that package contains within it the joy of giving along with a mug and anything else. I can attest that when this happens both gift and giver will remain with the recipient always, much as in my heart I carry to this day the memory and spirit of

Uncle.

Listen.

Any who have stayed with this page from the outset may remember that its grammatically incorrect name, "Tell It Good," came from an encounter with a patient and her daughter many years ago. Longtime residents of Chicago's Cabrini-Green public housing development, they had watched its rise and (eventual literal) fall, and ultimately had been relocated to a newly constructed apartment adjacent to the site of the old "projects." Albeit clean, bright, and critter-free, with an absence of drunks in the hallways and drug dealers outside the front door, the new place came with its own set of problems, ranging from tenant-paid heat that they couldn't afford to rules against congregating in common areas, which left them isolated and without both their former community and their usual ways of meeting people and making friends. Reminiscing, they told me that for all the problems in the Cabrini of old, were it possible they'd give up the new apartment and go back in a heartbeat. Listening to their poignant, witty accounts I told them they should write a book, that their story should not be lost, and when I pressed they told me, first one speaking and then the other, "You write it." "You tell it." "Yeah, because you tell it real good." Ever since then I have striven to tell the stories that have played out in my work as a nurse, because stories teach as nothing else can. Stories touch hearts and build bridges, and remind us of our common ground. And sometimes telling a story itself births good; from a new understanding or realization of shared humanity goodness grows such that "telling good" is less bad grammar than an actual movement of energy from words to being in the world. But we must not be so busy telling our own stories, often over and over to those whose stories are similar, that we fail to heed the stories of others, to listen.

"Roshell" was a single mom caring for her young children and for her own disabled mother, "Myrtle," who had suffered a stroke some time before I met them and had several other health concerns as well. They lived on a high floor of a Cabrini-Green high-rise; did I climb six flights of stairs to see them, or was it nine? I don't remember, but it was a considerable vertical trek with a heavy backpack, casebook, assorted supplies, flashlight, and police escort. There were drug dealers outside and often more "working" in the stairwells; we'd ask which stairs we should use so as not to disrupt their "business." It was dark and smelly; often there was human waste or vomitus on the stairs, and always there was trash to be skirted. Occasionally we'd come upon rodents that had met their demise; more frequently live ones scurried out of our way.

Things weren't much better in Roshell's apartment. Cockroaches prowled about in broad daylight, and our shoes stuck to the floor as we walked from room to room. The first time I saw Myrtle she was lying on a sagging double bed in urine-soaked linens and clothing, unable to turn without help, much less stand or walk. "She's wet, Roshell. If you'll bring some clean clothes and linens I'll help you clean her up," I said.

Roshell sighed. "I just did that yesterday. Maybe I can do it again tomorrow or the next day, but I'll help you push her over where it's not so wet."

"How often do you bathe and change your mother?" I asked.

"A couple times a week usually," came the response.

A licensed professional nurse, I am a mandated reporter of any abuse of children or vulnerable elders I encounter. It's the law. And here was an old woman, unable to move about or care for herself, living in filth and left lying in her own waste for days on end. It would be time for me to pick up the phone. Once I made that call an investigator from the state Department of Aging would follow up, and finding what I found no doubt would pursue legal recourse to remove Myrtle from the home and send her to a nursing home where she would be cleaned and changed promptly and also assured the food, medications, and other basic care she needed. Of course what that would do to her spirit and to her family is another matter. So I asked Roshell to tell me about taking care of her mother.

Most of us pee several times a day, and Myrtle was no exception. But Roshell had a limited supply of linens and clothing, and doing laundry entailed taking two buses to the nearest laundromat, after carrying the soiled items down the same dark, dirty, gang-infested stairs up which I just had come. This could happen only when someone turned up to be with Myrtle and any of Roshell's children who were home at the time. Frequent trips to the laundromat were expensive, between bus fare and the cost of the washers and dryers, so laundry days had to be limited for financial reasons as well. And because the old mattress was wet and never had time to dry before being wet yet again, clean linens became wet and dirty as soon as they were placed on the bed. The best Roshell could do was try to push her mother from one side or corner of the bed to another so she lay on the cleanest, driest possible spot.

On hearing this my judgment shifted from Roshell-as-abusive-daughter to Roshell-who-made-heroic-efforts-to-do-the-best-she-could-with-what-she-had, and who was as loving and devoted as she could be given the resources available.

Within a day I had a hospital bed, disposable underpads, adult diapers, and Physical Therapy in that home. Next came a bedside commode, and before long the therapist had taught Roshell to transfer Myrtle from the bed to the commode. Later Myrtle learned to do this by herself. Wet linens became largely a thing of the past, and trips to the laundromat decreased to once weekly, with less expense because there were fewer items to be washed. Somewhere along the way the sticky floor was cleaned, perhaps because Roshell had more time for that part of housekeeping, and gradually as we addressed Myrtle's other health issues the home overall became brighter, cleaner, and calmer. A year or two later Roshell and her family were moved from Cabrini-Green to a nearby new apartment and their old building was demolished. Myrtle died a year or two after that, in her clean home surrounded by her family.

Had I knee-jerked and done my legally mandated duty when I first found Myrtle unable to move, lying in urine-soaked clothing and linens, and in the care of a daughter who didn't seem to think this was a problem and who appeared to clean her mother and do laundry only when the stars aligned to allow it, the outcome would have been very different. I wish I could say that I just was savvy and wise and so knew to elicit and respond to Roshell's story, but the blunt truth is that my early days in "the projects" had brought me up short so many times, so often leaving me feeling helpless and at a loss for how to proceed, that all I knew to do was go back, show up, and see what happened, see what avenues for some, any, kind of progress might begin to open. And so, having shown up and encountered what was there, I had asked Roshell to tell me her story.

No matter how overwhelming the situation, every. single. time. I simply showed up, often without a clue what I'd do once there, an opportunity presented itself. It may or may not have had anything to do with a patient's "diagnosis" or why I might have supposed I was going there in the first place, but a way to begin to make an inroad appeared. I learned to show up, to be as authentically present as I could be, and to listen.


Today approximately half of our country is reeling from the outcome of yesterday's presidential election. The other half is celebrating and hoping that urgently needed change is on the way. In about an hour from now there will be a massive protest downtown in my city, with similar ones taking place across the country. Had the election gone the other way we're told the other side would be plotting a revolt. I have heard many wonder if women, people of color, non-Christians, and those born in other countries would be safe in the new administration. All over social media I see people on both sides declaring that they'll have nothing to do with supporters of the other candidate. Physical, psychological, and financial violence all have been threatened.

But the scariest thing of all is that no one is saying that it's time, indeed, way past time, to show up, be as authentically present as possible, . . . and to listen to the other side.

Writing about problems with healthcare financing some weeks ago I told of a mid-career physician colleague struggling to make a living in private practice and resisting joining the ranks of corporate medicine, to the point that he now works for the government in remote outposts of the western USA, two weeks on, two weeks off, leaving his home, wife, and children behind when he goes. We spoke last week. In the heart of a rural "red state" he just had finished a grueling night shift. There had been a serious accident on a nearby highway, with one fatality and others badly hurt. He had been up all night and was ready to collapse into bed, except that the post-crisis adrenaline rush persisted and he was wired. Exhausted, but still running in overdrive, he wanted to talk. "It's crazy here, Sue, crazy. These are Trump people. There are Trump signs everywhere. It's scary. I have two daughters . . . But the farmers are having a terrible time. It's really bad. The farmers come to the hospital here and talk; I'm telling you, the farmers are screwed. And the government's done it to them."

Between home visits of my own, standing at the side of a busy road next to my bicycle and knowing my next patient was waiting, I tried to cut the conversation short. "When will you be back home?" I asked.

"Tomorrow morning," he replied.

"Good. Let's talk then."

"Done. I'll call you. But these farmers are screwed. I don't know what they can do, and they're mad. And all for Trump. They think he's going to save them. Crazy, man!" Eventually I managed to nudge him off the phone and towards some much-needed sleep. But I wondered. The farmers are screwed? What has happened to our farmers? They're that angry? When was the last time I talked with a farmer? . . . When was the last time I talked with a supporter of the now President-elect . . . and really listened?

Once over the course of ten years I lived in two small towns. But that was almost 35 years ago, and I've been an urban dweller ever since. The farmers are screwed? Now, I'm not totally ignorant of the plight of agricultural 21st century America, but the farmers are that "screwed" and that invested in a Trump presidency?

As election returns came in last night political analysts I respect were stunned, and as I flipped between channels I heard many say, "We were wrong. Our polls were all wrong. We missed this entirely. How did this happen? We need to rethink completely how we poll and report." One who long has struck me as being never at a loss for words, a skillful and determined but courteous and thorough interviewer, sat mutely staring into the camera.

I suspect he and his colleagues haven't been talking with the farmers either. Or with the non-urban natives of the deep South.

Our new President-elect ran on the theme, "Make America great again." If one is a "screwed" farmer, which I imagine means one can't make a decent living off the land any more, to the point that one's entire way of being is threatened with no feasible alternative in sight, the prospect of making America great again might sound awfully appealing. And hearing the other candidate affirm, "America is already great!" might sound like a promise of more of the same policies that have destroyed the lifeways of farming. If one has watched factories close and move to Mexico or overseas, shrinking the population and tax base of one's community and leaving economic rubble in their wake, the appeal of making America great again is understandable. If a candidate says, "I understand, because my father was a small businessman," but that father's business thrived and his daughter received an Ivy League education, the struggling shopkeeper in a dying town might find that candidate lacking in empathy.

It's a normal human response to difficult circumstances to become nostalgic for an earlier, happier, more prosperous and secure time. Who among us hasn't daydreamed about previous homes, friends, old loves, past jobs, and good times and thought, "Those were the days!" So if "Make American great again" seemed to portend bringing back industry and shoring up farmers instead of freeloaders, that might sound pretty good. If it seemed to straight, white, Christian men that they had done everything right but all the perks went to people of other colors and/or from other places or to uppity women, the prospect of a return to 1950s America might have strong appeal. If one side is talking about free college, then those who didn't finish high school but went to work, paid their bills, and made lives for themselves might wonder where they fit in the picture, as their expenses rise and incomes fall. College is fine for some people, they might think, but keeping their auto repair shops or hair salons open would be the greater priority. And how they're going to do that and pay a minimum wage of $15/hour eludes them, while refugees from across the globe are lining up for free healthcare while hardworking citizens can't afford insurance, much less copays. When every time there's footage of war on the news or a terrorist attack executed or thwarted at home and the perpetrators seem to be Muslims, it becomes easier to see how the struggling shopkeeper, "screwed" farmer, or laid off factory worker might think it best just to keep "those people" out, and maybe to build that wall on the Mexican border, too.

It appears that half the country is hurting, and those folks haven't been, or felt, heard . . . until last night. Bring back industry, keep out the "foreigners" who are draining our resources, take care of the farmers and other "real" Americans, put God back in the schools, make Christianity the national religion, have women live the life of June Cleaver, and don't mess with our guns or other rights, and life, and America, indeed will be great again.

It won't, of course. As Abraham Lincoln said, revolutions do not go backwards. We are, always have been, and always will be a nation of immigrants. Separate but equal wasn't, and even now the white offender has his hands slapped while the black or brown one goes to prison for the same offense. The cost to the country, much less to their own sanity, of sending women out of board rooms and universities and back to hearth and home for full-time homemaker careers is unfathomable. We are immeasurably enriched by the diversity of cultures, religions, and talent around us; a "white bread" society couldn't begin to compete. The problem of terror is the problem of terror, not of another's religion or heritage. Etc.

But we have failed to listen to one another. If the squeaky wheel gets the grease, then the "screwed" farmers, unemployed workers, and lost non-urban, straight, white men who don't know quite who they're supposed to be anymore and who never seem to catch a break even though they're told they enjoy "white privilege" and see others receiving "handouts," evidently haven't been squeaking loudly enough. Or, they're far enough away geographically and culturally that it's easy to disregard them. Until they rise up, and elect President Trump.

I am so glad I didn't act on my first impression of what Myrtle needed those many years ago, and regret that it was only in the face of defeat ("What on earth could I possibly do here?!") that I learned to show up, shut up, and listen. As our nation transitions to a Trump administration we might do best to protest in the streets and plot resistance a bit less, and to listen more. And as we're urged to volunteer for causes we fear now may be jeopardized, we would do well to heed yet another lesson from the "great" days of old: Keeping "church ladies" in the kitchen, Sunday School, and choir effectively kept them out of the pulpit, off the governing board, and away from the finance committee. Community service is a good thing, but volunteer efforts can be exploited and can deplete energy needed for strategy, coalition building, and leadership.

Remembering Myrtle and Roshell today I am reminded of the power and efficiency that come with understanding, and that understanding never is one-sided. I also am reminded that stories "told good" and heard well build bridges.

Let's make American great in new ways, building both on the historic greatness to which President-elect Trump alluded in his campaign and on the greatness extant in our country today, stirringly cited by Secretary Clinton. And most of all may we show up, be authentically present and open to those around us, and

Listen.

Nurses Know What To Do

Nurses know what to do. I've known it since I was seven years old, maybe before, and bet that deep down you know, too.

After a string of respiratory infections and low-grade fevers kept me out of school for much of my first grade year my pediatrician decided, as was common practice in those days, that my tonsils needed to come out. My parents agreed, so very early one morning I found myself en route to the then Children's Memorial Hospital in Chicago for the big day. My memories of the experience are spotty, but include being most uncomfortable with a little boy as a roommate, as well as receiving the highly coveted Mr. and Mrs. Potato Head toys with which I happily amused my post-operative self, real potatoes and all, in my hospital bed. Indeed, it was only recently that I learned that the Potato Head folks now come with phony spuds, a no doubt neater but otherwise most unfortunate turn of events, as there was nothing quite like jabbing those little plastic parts into honest-to-goodness potatoes. God bless the nurses who apparently never so much as blinked at the spectacle of a seven year-old fresh from the OR with a bed full of potatoes and plastic!

But as day's end rolled around, and with it the end of visiting hours, a question arose about whether I might be discharged home with my parents, or kept overnight in the hospital. My opinion was clear and strong, and perhaps not what one would expect: "Let me stay right here, thank you!"

It wasn't that I was enamored of the hospital by any means, and it was many more years before the notion of one day working in such a place and feeling a part of its milieu first crossed my mind. Certainly I was eager to escape proximity to that boy separated from me by only a curtain, and of course I wanted to be with Mommy and Daddy.

But that day had been different from any other, and although I had no idea what a "tonsil" was I knew something had been surgically extracted from my body, with a wicked-sore throat left behind as a souvenir. This surgery stuff was something new, as were the uniquely odd post-operative sensations that went with it. While everyone assured me I was doing just fine, children know better than to believe every blanket reassurance adults offer, and I could understand that there remained room for Something to go Wrong. And while Mommy and Daddy were fine parents and handled the ups, downs, and "normal" crises of daily life with aplomb, if Something indeed did happen to go Wrong in my newly post-operative state, I wasn't sure that they would know how to respond. We would be home, by ourselves, miles away from the hospital, and they would have to call someone, I supposed, someone who wouldn't be there and who might offer strange guidance of a sort that mere parents might be unable to carry out. No, thank you; I preferred to stay overnight right there in my hospital bed, even with that boy on just the other side of the curtain, because if anything happened the nurses would be right there, and nurses know what to do.

Today finds us on the heels of another Nurses Week, that annual seven-days-of-awkwardness when employers endeavor to show appreciation of their nurses, spending little or no money in the process, and to make themselves look good for having such talent on the premises and for being aware and grateful bosses. There usually are signs posted around hospitals and in other healthcare settings, and the recruitment rag that attempts to pass itself off as a respectable professional publication is multiple times its usual size, chock full of ads from every employer in the region, all touting their extraordinary nurses and, by extension, themselves. Meanwhile, the nurses suddenly become walking advertisements, sporting lunch bags, coffee mugs, pens, umbrellas, tee shirts, or other similar items, all bearing the employer's name and logo. Sometimes nurses simply receive an email from the boss, a real cost-saver and a gesture that spares them the embarrassment of feeling like something that might adorn the side of a bus. Yep, when Nurses Week rolls around most of us shudder a bit and then wonder what bit of tokenism might come our way in acknowledgment of the previous fifty-one weeks of professional service.

While an extra umbrella to toss in the back of the car, under the dirty dog towels and behind the sports gear, isn't necessarily a bad thing, the realization that when people decided to acknowledge lives immeasurably bettered and often saved, errors averted, and the ship steadied in the rockiest of waters time and time again, what they decided to offer was of the ilk of that umbrella or a cheap pen, this realization does give one pause. In return for the respect and compensation rightly due those who work as nurses every day I suspect we all would be delighted to forego a lifetime of coffee mugs and tee shirts. But we all were raised right and understand that gifts and gratitude are not entitlements, so we smile and say "Thank you," just as our mothers taught us, as we take our new lunch bags and stash them in the back of a closet.

What perhaps is most troubling is the verbiage that accompanies the token gestures, or that stands alone in the email from the boss. Indeed, if I hear one more time that nurses are set apart by their caring and compassion I do believe I'll explode. Most human beings are caring and compassionate; that does not make them nurses, and nurses have not elevated those two qualities to heights unmatched by any others. So to say nurses are caring and compassionate is to say, in effect, nothing in particular about them at all.

The realtor who gently but firmly guides elders in divesting long held possessions in preparation for putting the family home up for sale is profoundly caring and deeply compassionate, and a darned good businessperson. But she or he is not a nurse.

The Little League coach who teaches athleticism and teamwork while correcting errors and safeguarding young egos is caring and compassionate, but not a nurse.

The accountant who smiles warmly while accepting five years of data for unfiled tax returns along with a stack of unopened letters from the IRS and says calmly, "Let's take care of this," with no shaming or fear-mongering, that accountant is caring and compassionate, but not a nurse.

The friend who didn't know what to do twenty-plus years ago when my elderly father walked in one morning, announced that he didn't feel well and fell over, the friend who "tried to hold his head up," instead of initiating CPR, that friend was deeply caring and compassionate, but not a nurse . . . and she did the wrong thing. Dad died on her floor; care and compassion couldn't save him. Whether bystander CPR could have made a difference, and what that might have meant for his quality of life had he survived no one ever will know. I have been grateful that he went quickly and without suffering, and wouldn't have wanted to change that outcome. But care and compassion didn't save him. Indeed care and compassion never do.

What makes the difference in healthcare is knowing what to do, as captured on a recent billboard for Shriners Children's Hospitals:

And the problem is that when the work of professional nurses and others is seen as only care, compassion, dedication, warmth, and general likability, without concurrent recognition of expertise, the risk is great that patients and their loved ones will confuse a pleasant demeanor and attractive appearance with sound judgment, good skills, and high quality care. Just last week I heard of a well-liked cardiologist allowing a patient to sit in the Emergency Department for hours, until the patient sustained a major heart attack early the next day. The standard of care would be to send such a patient to the cardiac catheterization lab as soon as suspicious test results were known so that action could be taken to restore and maintain circulation to the heart muscle and prevent or minimize a damaging heart attack. This did not happen, but the patient later told the Nurse Practitioner that she will return to that doctor because she likes him, he's nice. And just this week I saw an email from a CEO commending several therapists and nurses for receiving high scores in "patient satisfaction." I know two or three of those clinicians, and wouldn't want them anywhere near my patients or my family, but they're "caring" and "liked," and that's worth points for them and, sadly, ultimately dollars for their employer.

Indeed, given a choice, I'll take the grumpy surgeon with an ego as big as Jupiter if she or he skillfully performs just the right operation in just the right way. I'll take the tight-lipped nurse who never seems to hear or say "Good morning" if he or she catches the medication error that the pharmacy missed or has a remarkable knack for managing an awkwardly placed ostomy and for showing patients how to do it themselves, too. I'll take the Physical Therapist who seems to push patients to physical and/or emotional breaking points, backing off at just the right time, and suddenly they're moving better than ever and are stronger than they thought possible, despite the therapist being "mean."

Of course it's rarely an either/or proposition. Most healthcare providers, like most people, are caring and compassionate, and also skilled in their work. Truly, there's no need to be obnoxious, to be cold and closed off, to be arrogant, judgmental, aggressive, or even fearful. But care and compassion can't stand alone in 21st century healthcare, any more that the deep devotion of Mommy and Daddy over a half century ago could substitute for the hospital nurses who even a seven year-old recognized as knowing what to do, no matter what happened.

In fact, in any healthcare setting, and that includes city streets, private homes, offices and industry, schools, clinics, and more, no matter what happens, if there are nurses on hand it's a sure bet that they'll know what to do. That doesn't mean that we know everything or do everything; it means that we know how to assess a situation, stabilize a person and keep him or her safe, summon the needed resources or assistance, start the ball moving in whatever the right direction happens to be, and convey an air of, "It's cool; I've got this."

There's a point somewhere on the path from novice nurse to expert practitioner where nurses suddenly realize that they no longer go to work with more or less trepidation somewhere in the recesses of their minds, and instead have reached a point of knowing that they'll handle with confidence and grace whatever awaits them. I remember my early days of driving around with virtually my entire professional library in the trunk of my car, worried that something might present itself that I didn't understand and didn't know how to manage. I remember the early terror of answering the phone in the nurses' station, afraid some doctor would start barking orders I couldn't make out or someone in the lab would spew a string of numbers that were test results whose meaning I was supposed to know and on which I should act. At the time I wouldn't have believed that a day would come when I'd remember those moments fondly, and I wonder now if my youthful self could have anticipated the coming years of solo practice in settings with no resources or support met with a curious ease expressed as an easy smile and, "Let's have a look." It's a road we all travel, and if we stay the course we arrive at that destination of confidence and skill.

So while the saccharine air of Nurses Week leaves me wanting to duck and run, the underlying niggling concern remains, that those who tout such qualities as nurses' care and compassion are missing the point, seeing only the good hearts that characterize people of every walk of life, and not fully realizing that the reason that nurses' particular care and compassion feel so good is that underlying them, no matter what transpires, the situation will be managed and movement in a positive direction will begin, because whatever their practice throws at them

Nurses Know What To Do.

That Which Sets Nursing Apart

Nurses and nursing have been thrust into a worldwide spotlight this week after panelists on ABC's "The View" made snarky, uninformed comments about Registered Nurse Miss Colorado's "talent" segment of the Miss America competition, which was a creative monologue depicting the life-changing story of her work with a particularly memorable patient. The backlash was swift and severe, with hundreds of thousands of nurses and their supporters blowing up social media and blasting conventional media as well. Many sponsors pulled or paused their advertising on The View, and television hosts from Ellen to Dr. Oz have scrambled for a piece of the action. There have been many well informed and thoughtfully articulated tributes to nurses from those who know us best, that is, our physician colleagues and others who serve side by side with us every day, as well as our patients, some of whom were so inspired by the nursing care they received that they later became nurses themselves. It has been a week of many proud and humbling moments after an initial ugly slap in our professional faces.

But for all that has been said about nurses and nursing, there remains a critical omission, a missing nod to that which sets nursing apart.

The questions that most define nursing practice perhaps are something like, "What are the barriers to this patient's enjoying the very best possible health?" and "What are this patient's strengths and the things that are working well, upon which we can help him/her build so as to be and do even better?"

The reason this approach and these questions are so important is that they transcend the purview of any individual healthcare discipline. Nobody other than a nurse builds his or her practice around assessment questions broader than his or her own scope of practice.

This does not mean nurses practice beyond their legal and proper scope; rather it means they know the resources to tap to meet their patients' needs, and how to coordinate those resources for efficient care with optimal outcomes. Only a nurse does this.

Physicians diagnose and treat pathology, and often it indeed is one or more disease processes that are significant barriers to optimal health. In those instances physicians order diagnostic tests and appropriate treatments, and often rely on nurses both to implement these orders and to assess and evaluate their effectiveness, alerting the appropriate doctor if problems arise. While this aspect of nursing practice requires great skill and keen clinical acumen, it is but a small part of what nurses do. Indeed, sometimes patients' healthcare needs do not require a physician's input at all, as there is no pathology present that requires medical diagnosis and treatment.

Consider "Shirley." Shirley is a determined, high-energy, almost-ninety year old woman who was headed to an appointment this week when she had an unfortunate encounter with a hose that careless workers had left stretched across a sidewalk. Down she went, evidently with unusually great force, and she couldn't get up. Passersby summoned help, and EMS soon arrived to take Shirley to a nearby hospital. There she was scanned and xrayed, poked and prodded, bled and monitored, and ultimately told she was badly bruised but nothing seemed to be broken, that she should wear an immobilizer on the knee that took the biggest hit when she fell, and that she should follow up with an orthopod as a precaution and see her primary care doctor as previously planned. She then was dispatched home. Later that night she fell again trying to walk to the kitchen for something to eat.

The next morning she called me.

The doctors had reassured her that all was well medically, but had not addressed the things that were wrong otherwise.

I had seen Shirley just one time, several months before. Then she had just been discharged after a hospital stay for a gut infection, and I determined that she was doing well overall but would benefit from some Physical Therapy to help her regain strength properly and safely. The Physical Therapist took over the case, and I signed off. But Shirley remembered the one visit I made, and she kept my phone number. And so the morning after that trip to the ER, when the sun barely had topped the horizon, my phone rang. "This is 'Shirley Holloway,'" a feeble voice said. "I don't know if you remember me, but I live at 1234 Anystreet and you helped me get Physical Therapy once before. [exhausted pause] I need services again. Different services. I would appreciate if you would call me." I did, and then called Shirley's doctor, because Medicare still requires a "doctor's order" before I darken a patient's doorway if Medicare is to pay the bill. The doctor agreed that I should evaluate Shirley, and then call with my findings.

When I arrived the doorman sent me right up, and said Shirley's door was unlocked and that I should just walk in. I did, and found Shirley settled into a recliner almost completely unable to move about. The leg that had taken the brunt of her fall was deep purple from the thigh to the ankle, and quite swollen as well. There were bruises on one arm and one hip, scraped and torn skin on both hands, and a lump on her head. Every time she tried to walk she felt so weak and dizzy that she thought she would fall. She wasn't hungry and had eaten minimally in the past 48 hours. Her blood pressure was low, and fluid was starting to accumulate in her lungs (two points I ascertained by using my stethoscope, a device the ladies of "The View" had dubbed a "doctor's" tool). And she was hurting, alone, and worried.

Shirley already had been worked up by doctors in the Emergency Room, and had been determined to have no pathology in need of medical treatment. So the doctoring was done. But clearly this patient had significant unmet health needs.

I explained why her leg was purple and how to manage the swelling and optimize circulation as well as recognize changes that would signify a problem requiring medical attention, such as blood clots or nerve compression. With Shirley's permission I snapped a photo of the leg and sent it to a Physical Therapist colleague; within minutes we had arranged for him to be there that day to work with her on safe mobility and additional management of the pain and swelling. I explained the hazards of being sedentary in that recliner for days, including the fluid in the bases of her lungs, and the mobility and breathing exercises needed to improve this. We discussed other common complications of decreased mobility, including the potential for everything from skin breakdown to constipation, and the need for attention to hygiene and nutrition. Shirley admitted avoiding drinking in order to minimize trips to the bathroom, fearing the she would fall going or coming. I explained the need for adequate hydration and the relationship between this and her blood pressure; Shirley quickly reached for a glass of water. I referred her to an organization that provides caregiver services, as she had realized she needed someone with her. I showed her how to clean and dress the torn tissue on her hands, and instructed her to "graze" on nutritious snacks throughout the day until her appetite for normal meals returned. We talked about what those snacks might be. I removed loose throw rugs from her hallway and explained the fall risk associated with them, and made sure she was wearing safe footwear with good support.

On reaching my office later I called the physician with an update, and received an, "Oh, ok" in response. There was no medical need, no need for doctoring at that point, nothing for the physician to do.

The next day I returned. Shirley asked if I minded if she iced her leg while we were talking, as the Physical Therapist had given her very specific instructions, and she walked (!) steadily (!) with her cane to and from the kitchen to retrieve the ice. Her bruising was better, she had washed at the sink by herself and changed the bandages on her hands, she was eating and drinking adequately, her blood pressure was normal, and her lungs were clearing. She had called for information about caregiver services, had prices, and was going to follow up. She was on the road to recovery.

Once the Emergency Room doctors had determined that there was no fracture or pathology present, no doctoring or hospitals were needed. But nursing was. And it was the nurse who recognized the need for Physical Therapy and for a caregiver and who made those referrals. It is the nurse who continues to coordinate that care and help Shirley move forward.

Physicians request consultations of other physicians, e.g., the internist requests the opinion of the endocrinologist, the surgeon asks the cardiologist to evaluate a patient before an operation, the hospitalist calls in the nephrologist when a patient's kidney function declines in the course of treatment. But it is the nurse who coordinates all the pieces and knows to add any that have been omitted. It is the nurse's perspective that is broader than pathology and treatment, mobility and function, speech and cognition, mental health and coping, nutrition, wound and skin care, community resource needs, and the functioning of any given body system. It is the nurse whose perspective encompasses all of these, and whose expertise includes knowing whom to consult and how to coordinate the players and assure the patient is progressing. And it is the nurse who is most likely to have occasion to know the patient well as a person and so determine the individual strengths and obstacles likely to be significant to his or her progress, or lack of same.

Physicians look for pathology to diagnose and treat. Physical Therapists look for problems with mobility, strength, and endurance. Occupational Therapists look for needs in functional status and cognition. Speech Language Pathologists look for deficits in communication, swallowing, and mentation. Social workers evaluate social systems and resource needs and provide counseling and referrals. Mental health workers evaluate thought processes and intervene accordingly. Dietitians assess nutrition, recommend meal plans, and teach therapeutic diets and healthy eating. Many specialists are experts in one body system, e.g. Respiratory Therapists in the respiratory system.

But it is the nurse, and only the nurse, who does it all. Not so as to supersede any other healthcare professionals' role or judgment, but rather in order to refer to them and to ensure that not only nursing needs, but also the patient's overall healthcare needs are met.

Nobody else has a perspective so broad and yet so narrowly focused on the particular needs of each unique patient. Consequently while there are many patients who don't need a doctor or don't need a therapist or don't need a counselor or don't need a specialist, there are precious few who, at least briefly, don't need a nurse. And while many of the tasks we do and many of the functions and responsibilities we carry out overlap those of our colleagues in other disciplines, that broad perspective and narrow focus is

That Which Sets Nursing Apart.