"What Should I Write?"

The number of the Intensive Care Unit flashed on my caller ID as I picked up the phone. "Sue, it's 'Nancy,'" the social worker said, "I have a patient for you. Her name is 'Marilyn,' and she's in ICU bed six. She came to the ED in acute respiratory failure, and they found an infection, and pneumonia, and she's been in ICU ever since. She has a tracheostomy and is on a ventilator, and she'll be going home today. She's pretty obese, too. The doctor is right here with me. He can explain more, and you can tell him what you need."

Nancy handed the phone to the intensive care physician managing Marilyn's case while my curiosity mounted. Few patients are discharged from the ICU directly to home, so as home healthcare liaison I don't see critical care folks very often and am an anomaly when I appear in the unit. "We're getting ready to send her out," the doctor said, "She will need a nurse to see her at home. But what would a nurse do for a patient like this? I'm writing the discharge orders now, but, about the nurse, what should I write?"

It's a good and fair question, although I smiled at the realization that the doctor knew the patient needed a nurse, but he couldn't say why or what that nurse would do. It was perhaps the most honest and refreshing question I've been asked in a long time, but the fact is that none of us really know exactly what our colleagues in other professions know and do, at least not well enough to write orders or treatment plans for them.

From time to time I send patients to the doctor, or to the Emergency Department, or to a Physical Therapist or another provider. But I don't tell the doctor, ED, PT, or anyone else what to do once the patient arrives. I call ahead and explain why I'm sending the person, describe what I have observed and done, note how the patient responded, and sum up with a status report of how the patient is at the moment and any circumstances or special considerations I think the receiving provider should know.

But having done that I don't say, "And Doctor, I expect you to do a complete examination, order these blood tests, that scan, an EKG, and x-rays. Then when you have narrowed the differential diagnosis down to 'x' vs. 'y' vs. 'z' you should . . . " No. I provide my input as the treating nurse, and trust the doctor to practice medicine.

I will tell a Physical Therapist that I'm referring a patient because she or he was very weak when I visited, having difficulty rising from a chair, holding onto furniture for balance while walking, and complaining about back pain that made standing upright difficult. I don't say that I expect the therapist to do a comprehensive evaluation of the patient, assessing strength of all muscle groups, balance, endurance, gait, transfers, and the patient's ability to fling an empty beer bottle at the television when the referee makes a bad call. No. After I have described my observations and detailed my concerns, I trust the Physical Therapist to do his or her job.

I may call a counselor, a dietician, a speech pathologist, a pharmacist, a respiratory therapist, a member of the clergy, a chiropractor, a social worker, and/or any of a plethora of others, but I don't tell them what their jobs are or how to do them.

And that's a darned good thing, because no matter how capable a nurse I am, I'm not qualified to practice any profession other than my own. And neither is anyone else, including physicians.

The work of medicine is diagnosing and treating pathology. That's what doctors do. Along the way most have learned something about preventing some diseases, and so they counsel against smoking and in favor of "flu shots." But their focus is disease, and symptoms are the clues that tell doctors if they're proceeding well, that is, if patients are improving or deteriorating. Treat the disease, manage the symptoms and side effects of treatment along the way, and keep tweaking the plan until the patient is well, or as close to well as possible. Yes, that's what doctors do.

When healthcare is assumed to be synonymous with disease management, symptoms are a secondary focus, markers along the road that are an indication of the extent to which the pathology at hand is being well managed. This may be why doctors sometimes downplay symptoms that are important to patients: The doctors can see that the disease is improving and so the symptoms matter less, because in time, if all continues to go well, the pathology will be banished and the symptoms with it. In this line of thinking, some dizziness, discomfort, constipation, insomnia, nausea, whatever, are but relatively insignificant bumps on the road to health, and while a few pills can be tossed into the mix to lessen these, "really" the patient is "fine" and there's little cause for concern.

However, for patients the experiences that doctors call "signs and symptoms" are primary most of the time. While of course patients want their broken bones to heal, their hearts to recover from "attacks," their cancer to go away and never return, and their other diseases to be cured; in short, while in this way they and their doctors share a common goal, in the day after day dailiness of their lives what most affects patients is not that their ejection fraction is 30% but that just making a sandwich and washing the dishes wears them out. It's not that the x-ray looks "beautiful," but that the fracture site throbs at night and it's next to impossible to get dressed because the cast is in the way, nothing fits over it, and keeping one's balance while attempting the feat has become a gymnastic event. And while there's no better news than that the scan shows the tumors are smaller, what is in the forefront of patients' minds most of the time is the relentless fatigue that has taken over their lives since chemotherapy started, along with the sores in their mouths and and the backsides that have become almost unbearably tender from so many trips to the bathroom.

When as a teen I announced my interest in a career in nursing teachers and many others often encouraged me to reconsider and choose medicine instead. I was too smart, too quick, too capable for mere nursing, they said, and really should be a brain surgeon or neurophysiologist instead. Or something else. But certainly not "just a nurse." And somewhere past the halfway point of my first undergraduate year the full crisis hit, and I sat sobbing in my dorm questioning whether I should change my major to pre-med after all and transfer to the "better" university that also had accepted me, in order to be as well positioned as possible for a slot in a top medical school three years later.

I stayed where I was, in one of the best undergraduate nursing programs in the country, but it was years before I could articulate why.

If one is fascinated by the human body as a biological organism and by pathophysiology and all that can be done, down to the sub-cellular level, to confound it, and if one feels a yen to serve by curing diseases and eliminating the suffering they cause, then a career in medicine is the way to go.

But if one is fascinated less by the disease, less by the biological science, less by the body as an organism, and more by persons, the choices they make, and life in all its richness and messiness that unfolds in so many different ways for different people, then the world of medicine is far too confining. Similarly, when patients want to be vibrant and healthy; comfortable, strong, and free; and able to envision the lives they want and to go about making those lives happen, regardless of age or of the specifics of their dreams or heartsongs, then "healthcare" that reduces to "sick care" simply isn't enough.

Nursing is the profession that is about helping people position themselves to live their best lives, whatever that means for them, whatever is possible for any given human being. We start where the patient is and move forward. We don't and can't do it all by any means, but we may be the best at knowing who can help, which referrals are in order, what other expertise to tap, and how to coordinate all the pieces.

Although I couldn't explain it at the time or for years to come, at fifteen, with a year as a "Candystriper" (hospital volunteer) under my belt, I knew better than my teachers and mentors where I belonged. And today I shake my head and try not to roll my eyes every time someone mentions "doctor's orders," because apart from the rather small slice of the healthcare pie that is medicine doctors really don't "order" anything at all, or know what to order in the first place.

"Well," I said to the intensive care doctor on the phone, "I'm hearing about Marilyn for the first time right now. I haven't met her or reviewed her chart. But based on what Nancy just told me I'd say that this patient is at high risk for pulmonary complications, so a nurse visiting her at home will assess and evaluate her respiratory status carefully, looking for any indication of infection, decreased pulmonary function, or other problems. I imagine you have tweaked Marilyn's medication regimen while she's been in the hospital; the nurse seeing her at home will evaluate the use and effectiveness of those drugs. The nurse also will assess the learning needs that Marilyn and her husband have and provide needed education based on those findings. Infection prevention and control are likely to be important, and the nurse will address those and also will address nutrition, both to promote strength and healing and to support the goal of weight reduction. I don't imagine Marilyn is moving around very much, so the nurse will be looking for complications of poor mobility and teaching ways to prevent these. And I'd suggest a Physical Therapy referral for a safety evaluation and to get this patient moving in whatever ways are possible."

"That's awesome!" the doctor exclaimed, with a tone that sounded truly awed, as opposed to the commonly overused, hackneyed invocation of the word to refer to anything positive or good, "That's perfect; thank you . . . " And I heard him muttering as he typed, " . . . evaluate respiratory status . . . nutrition . . . refer to Physical Therapy . . . "

"Really, just give me a jumping off point," I said, "'Evaluate and treat' or 'Home health to consult' almost always is sufficient. From there we'll evaluate the patient, flesh out the treatment plan, and send it to the patient's doctor. I'll be down shortly to start that process for Marilyn, once I meet her and read her chart."

All of us in healthcare professions bring something different to the table. In my state and many others a physician cannot even testify in court about the practice of a nurse or other non-physician; they are different professions, all highly educated, individually licensed, and uniquely experienced. It is a disservice to patients to implicitly or explicitly limit their healthcare to things falling under the umbrella of "doctor's orders," and everyone is best served when complementary disciplines work together. There was a time when physicians circled the wagons and fought to maintain control of healthcare, arguing that this was in patients' best interests, although that it served the financial and political self-interest of doctors was glaringly apparent. In the practice setting that is easing somewhat now, with day-to-day posturing of this sort mostly focused on squabbles about the actual diagnosis and treatment of pathology that has been doctors' forte all along (to what extent should Nurse Practitioners be able to make medical diagnoses and prescribe drugs, for example).

Be this as it may, and while yes, we yet have a ways to go, it is mightily encouraging when, instead of strapping on the traditional blinders of medicine and assuming that a correct diagnosis of pathology and a proper medical treatment plan is the sum total of 21st century healthcare, a doctor treating a patient, even a patient in a critical care setting, calls a nurse about the work of nursing to ask,

"What Should I Write?"

Chasing Two Rabbits

It's said that when one attempts to chase two rabbits at the same time the only sure outcome is that both will escape. And for all our talk about busy-ness, multi-tasking, and juggling, to the point that these come to seem normal if not praiseworthy, the fact remains, with an increasing body of supporting data, that one cannot do two things at one time and do them justly and well. Even Jesus of Nazareth said no one can serve two masters, yet in healthcare we're expected to do it every day.

"Lucille" is 93 years old and in August went to the Emergency Department with back pain that turned out to be due to a compression fracture of one of her vertebrae. This means that one of the bones in her back had collapsed, a problem that occurs fairly often in advanced elderly patients who have thinning bones. She was admitted to the hospital to undergo a procedure that restores the height of the collapsed bone and then cements it in place so it doesn't collapse again.

The next day the manager of the orthopedics department called me. Lucille wants to go home, he said, but she lives alone in a second floor walk-up apartment and has homemaker services only fifteen hours per week. While her granddaughter and grandson-in-law live downstairs, they both work outside the home and so aren't available to help except in the evenings and on weekends. Lucille was doing well after her procedure the previous day, but the manager was concerned. "Will you go talk with her and see what you think?" he asked.

On a personal note, August was a bear for me. Property taxes for half the year were due, a painful bite in excess of five thousand dollars. At the same time, the car developed a two thousand dollar problem, and two of the dogs ran up a nearly thousand dollar tab for the vet. The mortgage, utilities (including summer air conditioning expense), and routine expenses ranging from groceries to gas all had to be paid as well. Some months just are like that, but darn! they're tough when they happen.

One of the professional hats I wear is that of home healthcare liaison to an area hospital, where I help to transition patients from hospital to home, being sure that they have the supplies, equipment, and services they will need once discharged. I meet with patients and their families or other helpers before they leave to answer their questions, assess their needs, and evaluate whether there may be safety or caregiving issues at home while the patients recover or as they cope with chronic illness. I review the medical record and discuss each case with the hospital providers, and then send pertinent information to the home health agency so services can be initiated. Roles of this nature have been around for a long time, but too often these days their focus has shifted.

Originally liaisons were service providers whose job was as described above. However, with the rise of for-profit healthcare there has been increasing pressure to turn liaisons into sales people whose job is to secure new business (read: "patients") for the home health company. When I took this part-time gig I said very clearly that I would be there to serve and not to sell, except to the extent that good service and outcomes themselves generate business. Nonetheless, there is a provision for bonuses attached to my employment agreement, whereby I receive a four-figure bonus any month in which I generate a specified number of referrals, a designated percentage of which have Medicare as the primary payer. (Medicare is the best payer for home healthcare.)

So there was Lucille, 93 years old, home alone most of the time, stairs to her apartment and probably dated fixtures and accommodations within it, with a broken back and a wish to go home. And Sue, with eight thousand dollars in new and due bills superimposed on the usual monthly expenses, and happening to be within striking distance of earning a bonus for the month of August.

Rabbit #1: Lucille's health and safety
Rabbit #2: Sue's sorry finances that month
Rabbit #3: A for-profit hospital and for-profit home health agency with stockholders who expect a good return on their invested dollars

No clinician ever should be in a position where his or her personal financial interests come up against the health interests of his or her patients, while a corporate entity looms over them all with an eye to maximizing investors' returns.

But it happens every day, many, many times a day, in ways great and small.

Lucille turned out to be a very alert, spunky senior with a sparkle in her eyes, a smile that would melt a stone, and determination that would move the rock of Gibraltar. She had walked to the bathroom by herself that morning, she told me, and then dressed herself. And she was eager to go home, having told the ortho manager very clearly that she wanted no part of any inpatient rehabilitation setting. I explained what home healthcare is and what we do, assured her that whenever she went home we would be there to provide those services, and said that she and her doctors would be the ones to determine when that happened and if any intermediate steps were needed. And I told the manager that I had done just that.

Lucille went to inpatient rehab, I never saw her again, and I earned no bonus that month. In fact, I'm proud to say that in the two years I've been doing this job I never have earned that bonus. To do so would require meeting an absurdly high quota, which in turn would require aggressive selling, promising services I know wouldn't be delivered, and pushing patients like Lucille towards home and home healthcare despite it being clear that they would be best served in another setting.

When I walk into a patient's room, in my white coat with my name tag bearing not only my credentials but also a large, easy-to-see attachment that says "NURSE," that patient must be able to know that I am there to advocate for his or her best interests. The day that doesn't happen is the day I've sold my soul to the devil.

Today, every day, in innumerable ways, every provider faces these situations. Some are blatant and glaring, others so subtle that they could be overlooked.

There are managers who receive bonuses for keeping costs down. By far, the biggest line item in a hospital budget is nursing services, so by cutting nurse staffing to a bare bones minimum significant dollars can be saved, and bonuses paid to managers and dividends to stockholders. Someone recently wrote that the appearance of nurses marching on the Capitol in Washington is the canary in the coal mine for healthcare. In May of this year nurses indeed marched, for safe staffing standards, and I'll tell you that the canary indeed is on its back and kicking very feebly. Nurses aren't agitating for better staffing because they want cushy jobs; most of us are terrible at sitting around and truly want to work and to serve. But a nurse cannot rightly attend to one critically ill patient while another who is just as ill waits, others whose needs are less urgent don't see a nurse for hours, and none receive instructions they can understand or the support they need to be able to care for themselves safely when they go home.

Last week a newly diagnosed diabetic patient with little command of English went home with insulin but no needles to inject it and no meter to measure his blood glucose. The doctor had written a prescription for insulin but not for needles, and the nurse was too busy to check to confirm that the orders written were complete. In two days the patient was back in the Emergency Department with a sky-high sugar level. Had he delayed any longer, he would have died.

Another day, at 3 PM doctors determined that a patient with a serious bone infection in his leg could go home with intravenous antibiotics. The infection was particularly difficult to treat, requiring two different and very strong drugs, and if treatment failed the patient would lose his leg and possibly die. Processing an order for home infusion takes some time, as a special infusion pharmacy must be contacted and someone must gather and send supporting clinical data for the pharmacist there to review and in turn complete and submit a request for insurance payment for the infusions. Once insurance coverage is confirmed any copayments that are required must be discussed with the patient and arrangements made to collect those. Then the drug must be prepared, all the supplies for maintaining the intravenous line gathered and packed, everything loaded onto a truck, and the order dispatched to the patient's home, which usually is many miles away and where someone must be available to receive it. Knowing this, I stood in front of the nurse and said, "Don't let this patient go until I tell you that arrangements for his home infusions are in place. He will need his last antibiotic dose for today here at the hospital before he leaves, as this late in the day there is no way to make a delivery to his home tonight." But the patient was discharged before he received the drug and without the blood test needed to assure that the dosage was correct, which meant the infusion pharmacy could not proceed with the home order at all because the dosage to be dispensed was unknown. There had been a discharge order, someone had arranged transportation earlier in the day, and when the van arrived the patient left, while the nurse was busy with another patient and didn't see him go. Mercifully, he was contacted and agreed to return to the hospital the next morning.

Physician colleagues regularly tell me that for-profit corporations are decimating their practice, adding layers and layers of paperwork and authorization requirements while cutting payment and denying services. Recently a paralyzed patient with bedsores was discharged from the hospital; since being home she has been unable to see a doctor because none will accept her "Medicare Advantage" insurance plan. The reason? That plan isn't paying even its own contracted physicians. Another of my patients is able to eat only small amounts of fruit and occasionally oatmeal because he is so sick from cancer spreading through his body and from the chemotherapy being used to treat it. He is skin-and-bones, and no longer able to climb the stairs to the only bathroom in his home. His "Medicare Advantage" plan refused to approve a request for a bedside commode. Excuse my language, but the insurance company that has taken his Medicare dollars for years will not give this man a pot to piss in. Literally.

A few years ago a senior physician with whom I worked for years at one of the university medical centers here shared his concern about young doctors graduating "with a mortgage but no house." Suffocating in debt for their medical education they cannot afford to practice in primary care and many other specialties, and often cannot afford to do the work they love, that which initially drew them to medicine. Instead they are casting about for any opportunity that promises to help pay the bills and keep their heads above water. Just this week another mid-career physician spoke of the reduction in payment and billing issues that soon will make it impossible for doctors in private practice to make a living at all, effectively forcing them into corporate or very "nontraditional" positions.

So the rooster is going to have to go to work for the fox guarding the hen house.

If car repair bills, veterinary expense, and property taxes could set someone like me in opposition to the best interests of patients like Lucille, what are these far more dire and ongoing circumstances likely to do to the lives and judgment of our doctors?

There are those among us who "tsk-tsk" and "cluck-cluck" about all of this, but think themselves somehow exempt. However, under their Armani suits or ragged jeans they are as vulnerable as anyone else when they land in an Emergency Department and find themselves looking up at name tags that say "NURSE" or "PHYSICIAN." And if the HMO didn't pay the doctor that month or the nurse had to come up with tuition dollars for a child and there is a dollar bonus attached to swaying patients' care one way or another, a burnout and fatigue factor operating from chronic understaffing, a pharmaceutical company ready to "take care of" a doctor who orders its drugs, and/or a ruthless insurance company out to serve its own interests, even the tsk-tsker and cluck-clucker are likely to experience first hand the consequences of pitting the best interests of patients and the best practices of clinical science against the greed of insurers, big pharma, and other corporate interests. And ultimately all will experience the fallout of simultaneously

Chasing Two Rabbits

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.

When Your Care Is Not Their Priority

One would think that patient care is the linchpin on which healthcare turns and the most important consideration of providers, yet these days there are instances, too many of them, when your care is not their priority.

I shy away from this topic. It's painful to consider, risky to acknowledge, and might seem self-serving, you know, the whining nurse looking for sympathy and an easier ride. But the day nurses stop educating and advocating for patients is the day we lose our souls, and patients, together with those who care about them and who might one day themselves become patients, have a right to understand how healthcare works and a duty to join with us to make it better when there are deficiencies that threaten both individuals' health and safety and public health and healthcare overall, now even with its astronomical bottom line not assuring good clinical outcomes or even basic safety.

Just a few days ago popular medical blogger KevinMD sounded the clarion call, writing about the need to reduce nurse burnout (http://www.kevinmd.com/blog/2016/01/reduce-nurse-burnout-treating-nurses-well-treat-patients.html), and noting that "the most overwhelming parts of nursing are the constant system failures" and that "health care organizations . . . function in a way that requires nurses focus more of their limited time and attention diagnosing system needs rather than focusing on patients['] care." That's not about making life cushy for nurses; rather it's the reason your pain medication is late, very late; your call light unanswered for an hour; your questions not heard, much less answered; and the significant decline in your condition unrecognized. Your nurse isn't off sitting in a break room somewhere absently thumbing through a tabloid while chatting on the phone with her boyfriend and waiting for her nails to dry. More likely your nurse hasn't sat down anywhere since arriving at work, her boyfriend long since gave up hope of being able to talk with her at all on days she is working (if he hasn't departed to take up with a more available partner), and she can't remember when her work-worn hands, chapped from being washed so often, last had a manicure.

Writing in The New York Times the very next day, Robert M. Wachter noted the problem of "businesslike efforts to measure and improve quality" having the result that "even superb and motivated professionals . . . come to believe that the boatload of measures, the incentives to 'look good,' had led them to turn away from the essence of their work" (http://www.nytimes.com/2016/01/17/opinion/sunday/how-measurement-fails-doctors-and-teachers.html?src=me&_r=0).

Both writers describe the problem of provider burnout and turnover; beyond this there is an abundance of data demonstrating the correlation between such variables as nurse staffing and clinical outcomes. Today I add my voice, telling you that the problem extends beyond hospital walls and into your own living room, which is to say that the beast of burnout is alive and well in home healthcare, too, with its fire-breathing ways threatening the clinical assessment and care you receive from the one who perhaps is the only healthcare professional you currently see. While hospitalized, patients see many doctors, nurses, technicians of various sorts, and perhaps therapists, dietitians, social workers, and others, and behind the scenes pharmacists are reviewing every drug order, a radiologist reads x-rays before the ordering doctor ever sees them, "case managers" are overseeing care, and more, so if something is missed or an error made, there is some likelihood that someone will notice. But it's a different story at home.

There, it's you, and your nurse and/or therapist(s) who visit intermittently (and never together, as Medicare and others frown on that no matter the benefits of joint practice and collaboration. Indeed, "care coordination" is required, but not permissible face-to-face and in the presence of the patient. Go figure.). If your home healthcare clinician misses something or hurries through instructions so that you don't understand exactly what to do the consequences can be grave before anyone else has occasion to notice.

The Centers for Medicare and Medicaid (CMS) determine what Medicare will reimburse and how the amount is determined. Most other insurers follow the CMS lead. This has resulted in a lengthy and cumbersome assessment tool along with a slew of documentation and "quality" requirements that nurses and therapists must complete. CMS further stipulates exactly which services within each professional discipline are reimbursable, and the requirements beneficiaries must meet to be eligible for any services in the first place. Clinicians must document, repeatedly, precisely which qualifying services have been rendered and that patients who received these services were verified, over and over, to be eligible for them. Individual states toss in additional parameters their surveyors will assess, as do accrediting bodies and organizations that purport to evaluate various forms of quality and bestow distinctions accordingly, or not (the "Magnet" designation for excellence in nursing is an example).

So when your nurse arrives on your doorstep for the very first time, no matter what problem or diagnosis you have, no matter what you need, how you feel, what your questions are, or what you already know, she or he will "teach" you how to be safe in your own home, even in the absence of any discernible safety risks, dangerous conditions, or lack of understanding on your part. Your nurse is required to determine whether or not you have received influenza and pneumonia vaccines and if not, why; whether or not you are depressed; how long it takes you to rise from a particular type of chair, walk ten feet, return to the chair, and sit down again; your nutritional risk, probably using a tool that doesn't actually measure risk at all; the likelihood that you will develop bedsores, again often using a tool developed for inpatient use whose indicators as operationalized there have little meaning in the home setting, and more. Your nurse is required to have you demonstrate, not just explain, how you step in and out of the bathtub or shower, how you dress yourself, how you walk, and how you get in and out of bed and up and down from a chair. The nurse must assess your pain and ask you to rate it on a ten-point scale; if you have no pain at all you still must give it a number. The nurse must discuss advance directives, your rights and responsibilities as a home healthcare patient, what constitutes an emergency and what to do if an emergency arises, how to contact the home health agency and what to do if you have a complaint, your treatment plan, and if for some reason you are inclined ever again to let this person into your home, when she or he will return and how often. Your nurse may be required to screen you for ebola risk or any other hot button issues of the day, and will have forms to fill out and forms for you to sign. Then your nurse can begin to examine you and assess your particular needs. He or she must look at and make a record of all the medications you have on hand and must reconcile this with the list provided by the hospital or your doctor. If you need to learn how to care for a wound or give yourself an injection or check your blood sugar or anything else, the nurse must teach you that. The nurse must be sure you have at least a basic understanding of your health problems and know when and how to reach your doctor. And the nurse must be "nice," assure that somehow in spite of all of this you are "satisfied," and discreetly keep repeating that she or he is providing "excellent" care so you will remember that word and rate the agency's services as "excellent" when completing your post-discharge survey.

In addition, after leaving you the nurse will need to spend at least one to two hours documenting this visit and filling out the required forms. Yours will be but one of five or six visits your nurse is expected to make that day, perhaps one or two less if some of the patients are new to home healthcare. Your nurse will travel through all kinds of weather, traffic, and road conditions, will deal with the absence of parking spaces and house numbers, and will respond promptly to all calls and email. If you or any of his or her other patients need lab tests, your nurse will draw the blood and/or collect other specimens, drive to some lab, find parking, walk to the appropriate location, do more paperwork, and then go back to the car to resume the day, without an extra penny or allowance for the time and effort this requires. Your nurse will attend endless meetings, complete online courses and in-person training whether or not she or he already has demonstrated mastery of the topic, and jump through a seemingly infinite number of hoops to obtain supplies for you, whether a gauze pad or an oxygen machine or anything else. Your nurse will chase doctors, track down those lab test results and see that they get where they need to go and that appropriate action is taken, and make many, many phone calls from home at night. Your nurse also will have his or her documentation questioned by people who haven't ever seen you and often haven't seen any patient at all for years, if ever, but who want to maximize the dollar amount to be made from your case. And, generally your nurse will be paid a modest, flat fee for making each visit to a patient, period. This means that time spent going to and from labs, making phone calls, sitting in traffic, documenting, and all the rest is uncompensated, with meetings and required training often compensated at a lower, below-market rate because those are not billable activities.

If you believe nurses actually do all of this every time they admit patients to home healthcare please message me: I have a bridge for sale in Brooklyn that you'd just love, and some land in Florida, too!

For one thing, our patients are sick or we wouldn't be there. Often they are elderly and have many problems at once. CMS requires that they be "homebound," which, while not meaning that they need to be absolute shut-ins, does mean that going out is a hardship and is something they do infrequently, usually for essential medical appointments. Suffice it to say they're often weak and frail. And if people just have returned home from the hospital it's a sure bet they're tired, because these days hospitals aren't places where people can rest. Nurses know no one in these circumstances can tolerate hours of "assessment" and "instruction."

Nurses also need to self-protect, the "Don your own oxygen mask first" principle. If nurses work eighteen hour days in order to meet requirements and see enough patients to make the money needed to pay their bills they'll soon hurt someone or have an accident themselves. So something has to give. Similarly, being compensated on a per-visit basis and having a "productivity" quota to meet for their employers, nurses need to be sure to make enough duly billable visits. If patients cancel appointments, are admitted to the hospital, suddenly decide to go stay with family at another location, or miss scheduled visits for any other reason their nurses suffer financially and may be penalized for failing to meet the productivity quota, unless it is possible to add more and more visits to subsequent and already full days. That breeds haste, less than thorough care, and heightened potential for errors.

Whatever the specifics of your situation, this may mean all the drop-down boxes on your medical record aren't checked on the basis on an actual assessment. Your nurse may have determined that it was more important that you be able to manage your IV line than that you be screened for ebola risk or that you demonstrate stepping into the shower, but those parameters still must be documented. So in the best of circumstances the nurse makes an educated guess, and uses the visit time to meet your most pressing needs rather than marching through all the required items at the expense of your and/or his or her own welfare.

But it takes an experienced nurse with keen clinical acumen to know which corners safely can be cut, as well as a certain amount of savvy to avoid detection in doing so. The less experienced and less well initiated do burn out and move on, if they're not first caught in the snare of an unfortunate error of judgment or practice. And even the veterans can guess wrong, or, being human, be swayed by such self interest as the need to compensate for canceled appointments by packing more visits into a single day than can be managed safely and well.

Not long ago I was called to see a patient who told his Physical Therapist that he had developed a sore on his foot in the hospital and although he thought it had healed it was bothering him. I found a massive pressure ulcer that could not have developed in the short time the patient had been home, meaning that the nurse who admitted him to home healthcare and determined that there were no needs for nursing, and that the patient needed only Physical Therapy, never examined that foot, even though the patient's particular problem put him at high risk for just that sort of wound in just that location. Instead, the nurse documented that the patient's skin was intact with no lesions or irregularities present. The untreated wound that the nurse overlooked and the patient couldn't see subsequently had significant adverse consequences for that patient.

Even more recently I read the clinical note of the home health nurse who saw a patient I had followed in the hospital. The patient had a complex medical history, but was hospitalized for a heart attack and had needed open-heart surgery. The home health nurse documented extensive diabetic teaching, and not a word about the patient's cardiac status or care. The patient had been diabetic for years, and control of that condition was not a current concern. A colleague who read the same note remarked that it looked like it had been "cut and pasted" from a standard template, something that certainly would have made the documentation process easier and faster. Although I imagine the nurse who saw this patient was "nice" and the visit may have been very pleasant, the job that needed to be done wasn't, and the patient was left at risk and uninformed. I wonder if she remembered to respond that she had received "excellent" care when her post-discharge survey arrived.

A Physical Therapist colleague has told of discovering that another therapist had been caught pushing an elderly, blind patient to hurry her through the session, while yet another therapist saved time and made money by having patients sign multiple visit forms when only one visit was made. That's fraudulent, and if caught would have cost the therapist his license, a hefty fine, and perhaps jail time, but it happened.

I don't believe people choose careers in healthcare and complete rigorous collegiate and often post-graduate training because they want opportunities to push elderly blind people, ignore wounds, teach irrelevancies, or commit fraud. That these happen is an alarm all need to hear, warning that something is going terribly wrong among good people who once had high ideals, passion for a profession, and a commitment to service. All too often in 2016 paperwork and profit are being prized over patients, supposed measures of quality are valued above quality itself, and looking good is valued more than doing good. The toll on providers is beyond sobering, and when you are a patient the cost to you may be extreme

When Your Care Is Not Their Priority

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.

We'll Talk Later

Unlike just two or three years ago, no one in my personal circle seems to be feeling financially comfortable and confident right now. Payrolls have been "downsized," either by eliminating jobs entirely or cutting pay, companies are struggling, and I am newly aware of an undercurrent that must pervade much of otherwise happy family lives, as breadwinners wonder how much longer they will be able to pay the bills, or what threats may lurk around the next corner. An educator friend is giving me inside looks at the protests ongoing in Wisconsin, as the governor and allied lawmakers attempt to eliminate public employees' right to bargain collectively, a sobering and scary prospect. Many of my elderly clients, who worked and saved responsibly throughout their lives, barely can make ends meet now, and any unforeseen additional expense has the potential to pull them under. And I can't quite imagine how the bright but socioeconomically "at risk" student I tutor will pay for high school (yes, high school!) next year.

So far, my home is warm, my larder full, and my overindulged dogs content. But with clients who pay late and then only partially, or who are not-for-profit entities whose survival by no means is assured, or whose programs are faltering, there can be no assumption that next month's provisions are secure. And I am one of the lucky ones.

The temptation to succumb to fear is real, but the stronger that temptation grows, the more dangerous it grows as well.

Yesterday I lunched with representatives of a large company that would like to hire me . . . for approximately half the salary I made in my previous work. Not addressing the money for the moment, I explained that because I represent more than one client, it is essential that I remain an independent entity and that my role and relationship with each client is clear. There can be no appearance of using a relationship with one client to give a competitive advantage to another, and the ethics of representing an organization as an employee while simultaneously representing another client independently to the same market, are muddy at best. My luncheon companions understood.

I offered the option of their company procuring my services through my own company, Cima Services, in which case my independence and objectivity would be preserved, with my advocacy for and representation of all of my clients clearly defined, and no conflicts of interest apparent or extant.

The response? "We don't contract with nurses. We only contract with therapists." And my reply, "We'll talk another time."

There is little doubt that should that company want my services badly enough, they will enter into a business relationship with Cima Services without regard of its being owned by a nurse instead of a therapist; that reality may or may not ever come to pass. But the truth today is that the position of my luncheon companions' company can be taken liberally right now . . . because nurses permit it.

I walked away from that lunch with handshakes and smiles, and we will talk later . . . so that I can drive home my point with focus and clarity apart from the hubbub of the restaurant and the messiness of mutually feeling our way through a new relationship. But I walked away without a contract because too many other nurses do not walk away at all. Even as they complain about a "nursing shortage" and expect nurses to carry workloads dangerous to themselves and to their patients, employers in healthcare by and large continue to operate on the assumption that there always are more nurses to be found who will accept the abuse and its attendant risks. So it is not necessary to pay more, to redefine roles and responsibilities, or to enter into contractual relationships with independent nursing professionals. Nope, there's always another sucker out there who's worried about paying the rent, educating the children, and helping out the grandparents, and so who will drive 200 miles to make home visits to ten patients in one day, or work back-to-back double shifts day after day, or accept a low wage simply because it is offered, and it is a job.

Contrast this with another luncheon meeting last year, with the owners of another large company eager to hire me away from my previous employer. Never mind that the honchos didn't seem to have a job in mind that they wanted me to do, and seemed more eager to undercut my old boss by decimating his team than to build a quality operation of their own, but note their comment in passing that they simply were unable to recruit Physical Therapists. "They all have their own companies," lamented the honchos, "and when we have to contract with them we don't have the control that we would with our own employees. They tell us who they will see and who they won't, and they are considerably more expensive than our own personnel would be."

Hats off to our colleagues in Physical Therapy! They know their own worth, and have assumed control of their own practice. Many are personal friends, and I know they see patients on weekends, do paperwork at night, and drop what they're doing and head off to evaluate a new, high risk patient on a moment's notice . . . hard work, and less-then-ideal circumstances. But done on the therapists' terms, with the therapists having the power to accept or decline referrals, and to set their prices. Certainly if they are not competitive or not readily available their practices will suffer, but the decisions and control are theirs.

And then there is the nurse, often (albeit not always) with a broader scope of responsibility, more education, and more experience, who makes less money and is told, "You're on call because your employer determined you would be, you must accept this assignment, no matter if it's excessive, unsafe, you're tired, or if doing so would put you, us, and the patient at risk." The nurse grumbles, but acquiesces.

My word to my colleagues is, "You must stop." You are compromising your professionalism and integrity, you are placing yourself and those in your charge at risk, and you are enabling healthcare employers to continue to underpay and overwork nurses. You are enabling them to say, "We don't contract with nurses. We contract only with therapists." You are giving away your power. You are modeling passivity and a herd mentality for your children, despite the excellence of your professional skill.

Stop. When you tell that employer that you will drive fifty miles to see five patients, but not 200 to see ten, and stand your ground, that employer can choose between losing the revenue from all ten patients, if you walk away, or losing the revenue from only five, in which case there would be work left over for your nurse colleagues. Is this less lucrative for your employer? You bet! The CEO may have to give up one of his Mercedes or forego one of his luxury vacations . . . and it will be the fault of professional nurses who insisted on reasonable workloads and fair compensation. Reasonable workloads and fair compensation will not destroy the employer, no matter how much the employer wants everyone to believe otherwise. But insisting on these will constitute a much-needed step towards reducing that huge gulf between America's richest and poorest citizens.

Such a deal, my fellow nurses: More money, more power and control over your own practice, better patient care, a sane life, the opportunity to work independently if you wish, and doing your patriotic duty to boot, by taking some of the fat out of the executives and stockholders' wallets and seeing that it is reinvested in workers and in real work.

But it takes some courage: Courage to walk away with smiles and handshakes instead of employment contracts. Our colleagues in Wisconsin are talking, saying an unequivocal "No" to unilateral, top-down determination of their salaries, working conditions, and benefits, and insisting on having a respected place at the table, with a voice, a vote, and self-determination. Our colleagues in Physical Therapy have said "yes" to being their own bosses, and "no" to dictatorial employers. Historically it has been the workers who have prevailed to gain reasonable workweeks, benefits, safe condtions, fair compensation, and a measure of security. Nurses, no matter how scary the prospect and no matter how uncertain the times, whether we bargain collectively, or stand alone, it is time to do the same. It is time to explain what we offer and its price, to insist on a place at the table, rather than on the menu, and to leave with our values and dignity intact, knowing that regardless of the outcome,

We'll Talk Later.