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

Blue Jeans

Blue jeans, soft, worn, and fitting just right do bespeak comfort, relaxation, and absence of pretense, but I never thought my jeans on my body would have that affect on someone else!

It was a cold, gray, late autumn afternoon back in the days when I routinely rose at 4:15 AM in order to be ready to make home visits in "the projects" while the local rabble rousers still were sleeping off the effects of the previous night. Starting that early meant I often was home by early afternoon and never making calls after dark unless I was "on call" and covering an emergency. That day had been rainy, with that penetrating dampness and cold that sets one's bones to shivering, and I was more than glad to go home to a warm house and slip into my favorite jeans and a soft, cozy sweatshirt. But then the phone rang.

"Corazón" needed a visit, that day. I had picked up a second, part-time job not long before, and Corazón, an elderly Mexican woman, was one of my early patients with that new company. I don't remember now what problem had arisen, but it was unlikely that anyone else in that very small and minimally staffed agency was available to see her. Darkness was gathering, meaning that I'd been going non-stop for twelve hours or more, and the prospect of taking the car out of the garage, driving the three or four miles to her home through late afternoon traffic, and then doing whatever it was that Corazón needed only left me feeling all the more tired. But I would go, I said to the caller, even though I cannot bring myself to change into proper work clothes once again, I told myself. Throwing on a coat, grabbing the necessary supplies, and beckoning my German Shepherd into the back seat, I set out.

Corazón lived with her son, "Joe," a big, imposing man with an air about him that suggested he was chronically dubious about everything. Behind eyes that seemed to think and feel much more than he ever said, he always had been receptive and courteous, but reserved, and as I drove I was a bit concerned about appearing too casual and therefore disrespectful in duds more suited for a night on the couch or a trip to the dog park than to a home visit to provide professional healthcare. But on that day at that time that family was lucky not to receive a nurse in a robe and pajamas, as my director said a few days later when I recounted this story to her. I climbed the front stairs and rang the bell.

Joe responded, and I launched into my explanation that I'd just learned Corazón needed me and had opted to respond quickly instead of taking the time to put myself together in a more professional-looking package.

I don't know that the first sentence was out of my mouth before Joe's face softened, all of the tentativeness and skepticism I might have sensed in our earlier encounters evaporated like a drop of water on a hot grill, and with a huge smile he ushered me into the home. Likewise, Corazón's smile when she saw me lit up her cramped little bedroom more than all the lamps in the home ever could have done. It was unsettling, the sensation one has when tempted to turn around to see if people are looking at and talking to someone else.

Understand that my normal dress for home visits is practical and not fancy or pretentious. If I need to climb on a bed or sit on the floor I do it, and any of a number of possible accidents could result in the need for a sudden change of clothes, so nothing requiring a trip to the dry cleaner or other high maintenance fussing is in my work wardrobe. Washable dresses, skirts, and slacks fill the bill and, one would think, hardly are off-putting.

But something about seeing me on the front porch in the cold dusk with jeans poking out below my coat and sweatshirt sleeves edging over its cuffs put Joe at ease more than ever before, and moments later, Corazón, too.

Throughout our remaining days together Joe's polite cautiousness and undertone of skeptical reserve never reappeared. Not once. It was so much easier to work in that home with the barriers dropped and only authentic connection remaining. And then came the moment when everything stood still.

After reviewing her latest test results Corazón's doctor told me her vital organs were failing irreversibly and there was nothing to be done that would save her. It was time for the family to make a decision about hospice care. All these many years later I don't remember for sure, but I hope the doctor had had a similar conversation with Joe. Corazón was bedbound at home, however, so the doctor would not have been able to talk directly with her.

I remember arriving at the home and talking with Joe about his mother's prognosis and the need to consider hospice care, and noting gently that someone needed to tell her and learn her wishes. Without missing a beat Joe responded, "You tell her." I asked him to consider whether this message might best come from a family member, priest, or even the doctor by phone, but Joe was firm: "You tell her." In Spanish, my second language, in which I yet was less than fluent at that time. "Really?" I asked. "Yes," he said firmly.

In over forty years as a nurse I don't believe there's been another time when I was the first and only person to tell someone that his or her body was failing, medicine could not change this, and she or he was going to die. There's the usual "We will keep you comfortable and help you to have as much good time as you possibly can" addendum, and then the "You will have medical and nursing care and the help you need as long as you live; now we need to decide how that is best to be provided" preliminary to the hospice discussion. But the whammy is the "There's nothing more we can do; I'm sorry" message. In Spanish.

As so often is the case, despite not having been told Corazón already knew, and she comforted me. I didn't see her for much longer after that, as she did enroll in hospice care. But before we parted ways, she made me a bracelet, in the colors of the Mexican flag, which to this day is one of my prized possessions.

I have thought off and on over the years since then that what turned the tide from perfectly adequate and polite encounters to something more profound was my happening to turn up in a sweatshirt and jeans on that one cold, dark late afternoon. Since then, although I have my respectable suits, white coats, and "business casual" garb and do wear them, I've turned up on many a doorstep in jeans . . . and even a bicycle helmet. And I've wondered if sometimes our "professionalism," or at least its symbols are ironic barriers to the authentic connections with those we serve and seek to influence intimately. I'm not advocating widespread dressing down; surely there is reassurance to be had when our doctors look like doctors and other professionals do the same, and how we dress affects how we conduct ourselves in the workplace. But that latter? That's the rub. We need to be mindful, I think, of any tendency to act out the role associated with the clothes we wear, because any acting is a way of being that is less than authentic. And it is compromised authenticity that others sense and from which they pull back.

These days I wear a white coat a good bit of the time, but make a point when I don it to be sure I'm not hiding behind it, and that in my speech, my demeanor, my smile, my being I am as fully present and real as I can be. Because no matter what our business and professional costumes may be - white coat, suit, clerical collar judicial robe, whatever - what most matters and assures the best outcomes is the sort of connection that comes with such things as

Blue Jeans.

My Doctor Needs a Nurse

My doctor needs a nurse.

Several weeks ago while trying to find the ATM at an unfamiliar bank branch I found an unexpected patch of ice instead, and down I went, shattering the end of one of the long bones in one arm, rotating it forty degrees out of place, and bending it backwards. It was not one of my better days. After a stint in the ER I landed in the office of an orthopedic surgeon who took one look at my X-rays and explained that surgery was the only way to put me back together, and not long thereafter I had an opportunity to see the OR from a patient's perspective. Fortunately, the doctors were able to realign my broken parts without nearly the cutting and hardware they had anticipated, and I emerged with what looked like a mummified extremity and was dispatched home to recover.

By the next week I was feeling pretty chipper, if clumsy and less than glamorous wearing the sweatshirts and jacket of a large male friend (the only duds that fit over the surgical dressing on my arm), and set out for my first follow up appointment with the surgeon. I hadn't needed pain medication for a few days, and acute orthopedics not being my field it didn't occur to me to take any that morning.

It's standard practice to ask patients to rate their pain on a ten point scale, with zero being no discomfort at all and ten being the worst possible pain a patient can imagine. When that dressing came off my pain was 23/10, no doubt about it. Any movement or touch was excruciating, and I became lightheaded and nauseated just being examined. The surgeon told me my X-rays looked very good and I was healing well, and having ascertained that nothing was wrong medically proceeded to reposition my hand the way it needed to be for the new cast (pain 52/10). The orthopedic technician then went to work constructing that device (pain holding at 52/10, with me lying down on the table at that point so I wouldn't fall to the floor if I fainted). Once the arm was casted I felt better, although I probably took more pain medication that day than I had the entire previous week.

Fast forward another week and I was feeling like a new woman, swinging my cast around and mastering all manner of one-handed tasks. Preparing for my next appointment with the surgeon I considered taking pain medication, but felt so well that I opted against it. After all, I'd had an entire additional week to heal!

But back in the doctor's office there was a repeat of the previous week's experience, complete with me stretched out on a gurney in the cast room to keep from toppling over.

By the following week I was using the hand of the casted arm more, and had mastered carrying laundry baskets, washing dishes, and vacuuming . . . but, even so, before returning to the surgeon I loaded up on pain medication such as I hadn't taken since my first post-operative day. And the exam, x-rays, and casting process were the proverbial piece of cake, even if the patient was a little "loopy" all the while!

My doctor is on staff at multiple hospitals, chairs the department of orthopedic surgery at a major university, and works in the office of a large and busy orthopedic practice where the air of sophistication and competence is unmistakable. I see many distinguished and renowned surgeons bustling about when I'm there, as well as the technicians who make and fit the various devices that orthopedic patients need, assorted office staff, and a warm, funny, efficient medical assistant who keeps my doctor's practice humming. But I have yet to see a nurse.

And if there were a nurse on hand, I never would have experienced 23/10 or 52/10 or any number much above 4-5/10 again, no matter what the doctor and others were doing.

There are six parameters that nurses assess and manage, regardless of practice setting or specialty. I summarize them crudely when I teach so students easily can remember, and to this day call to mind the same six words every time I look at a patient and ask myself, "Is there anything else? What have I missed?" Those words are: Eat, sleep, move; pee, poop, pain.

No matter what sort of problem a patient has, what kind of doctor she or he is seeing, or where the encounter takes place, a nurse wants to know if and what a patient is eating, the extent to which this meets nutritional needs, and if there are problems or concerns surrounding intake of nutrients and fluids. If the "eat" cue triggers a nurse's radar there are a million assessment parameters and questions that may follow, but whether briefly or in depth, "eat" is assessed and evaluated.

Likewise "sleep." Is the patient resting and sleeping well or poorly, too much or too little, with or without aids? Are there nightmares or discomfort, does the patient need to be in a special position, does anything disrupt sleep?

And "move." How much or how little, how well or with what difficulty,is the patient moving? Are there pain, breathlessness, inertia, or simple bad habits? Is movement safe? How is posture, gait, and the process of getting up and down? Are there indications of complications of decreased mobility, such as skin breakdown, fluid in the chest, or extremities that no longer straighten out all the way? Is the patient manic, constantly in motion, anxious and agitated, unable to relax? How about balance, endurance, and the ability to execute movements needed to do daily tasks? Movement is a parameter that speaks volumes to the astute clinical nurse.

For all the jokes about elimination, it matters. Too much or too little, abnormal character of output, too many or too few trips to the bathroom, bleeding or pain or other symptoms, indications that waste is being retained instead of eliminated, it all matters. And more.

And pain. Is the patient comfortable, and if not, why? Location, severity, onset, duration, what makes pain better and worse, what the patient does to manage pain and how effective those actions are, how the patient copes, whether pain is acute or chronic; it's all important. Is pain physical, emotional, spiritual, or other? What's the patient's story about this aspect of his or her experience?

Eat, sleep, move; pee, poop, pain: This is what a nurse does.

I smiled more than once coming out of surgery and preparing to go home. Rolling me out of the OR the nurse asked if I needed to use the restroom. My first thought was, "Why? I haven't had anything to eat or drink since yesterday, and it's now afternoon!" But I realized I no doubt had been pumped full of IV fluids in the OR . . . and that the nurse needed to be sure I could urinate before I left. Once I was settled in post-op recovery the nurse offered me a sandwich and some juice. Processed turkey meat stuffed between two slices of white bread was the most delicious meal I'd had in my life, and I noticed the nurse noticing my wolfing it down. I did walk to the restroom, and dressed with the assistance of the friend who would take me home, and of the nurse. "Would you like a wheelchair when you leave, or do you think you can walk?" the nurse asked. "I think I can walk," I responded. "I think so, too, " she replied, with a tone both warm and deliberate such that I realized I had been assessed and deemed safe. A lay person might say, "Oh, the nurse was nice, and brought me something to eat and helped me get dressed," but I know that "eat, eliminate, and move" had been assessed and evaluated carefully. "Sleep" had been well monitored in the OR, and the nurse had instructed me about pain management before I went to surgery, explaining that afterwards I would not be in any condition to remember what she said.

Eat, sleep, move; pee, poop, pain: This is what nurses do.

And when we find problems, the solutions are not necessarily medical. A patient with nutritional issues may need a dietician or simply someone to go to the grocery store, not a doctor. Another with mobility problems may need a Physical Therapist, not a physician. Patients who are eating poorly, falling, and living in a dirty homes because they are alone and without help may need a social worker to set them up with community resources and support services, not more medicine.

Everyone needs to eat, sleep, move, eliminate, and be comfortable; hence everyone who engages in a healthcare encounter should be assessed by a nurse. Exceptions might be the person who needs only to pop into the local pharmacy for a shingles vaccine or a clinic for a TB test required by an employer, but where there are health problems to be solved, health screening and prevention to be done, and long term coping and planning to be managed, patients, all of them, need nurses.

Had there been a nurse in my surgeon's office, she or he would have insisted that my pain be managed. My doctor had examined me and looked at my x-rays; he knew that there was no medical issue of concern. The business of diagnosis and treatment, which is what doctors do, had been done, and while sympathetic, he was not overly concerned about my discomfort given that he understood there was nothing medically wrong. But a nurse would have said, "We need to manage this," and not let up until that was done. A nurse would have instructed me to pre-medicate in the future, and explained why (although my arm is healing, I still have a fracture. When the cast is removed there is no support for that broken part, and the weight of my hand is supported only by the wrist that is broken. That hurts!). An orthopedic nurse would have understood the movement and positioning that the doctor wanted, and would have guided and taught me to do this properly, as opposed to the doctor's saying, "Do it!" and scowling when I didn't quite do it right. A nurse would have asked how I was managing at home, and would have known if I was eating properly, including the nutrients I need for healing, if I was resting well, if the medications I was taking had caused constipation or diarrhea, and if I was moving about and functioning reasonably well and safely.

And a nurse in the office would have saved the practice time and money. Having me dizzy, nauseated, and unable to move or cooperate took more of the doctor's and technician's time, and that translates into dollars lost. Is this enough to offset the expense of a nurse's salary? Multiplied by the number of patients going to that office and the number of needs and problems they have that a nurse can anticipate, prevent, solve, and/or minimize, the answer is a resounding "Yes!"

Better care, better clinical outcomes, greater efficiency and cost effectiveness, there's no doubt about it:

My Doctor Needs a Nurse.

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.

Isolation Toasts Sadness

Joan is smart, funny, warm, and engaging, and I liked her from the start. Hospitalized after her homemaker found her unconscious on the floor and subsequently diagnosed with a small stroke, Joan was doing better and eager to go home when I met her in my role as hospital-to-home liaison. Ultimately, though, she was persuaded to postpone her discharge and accept a ten day stay on the inpatient rehabilitation service to gain strength and work on the balance deficiencies that seemed to contribute to her history of multiple falls. That she had abused alcohol in the past also was noted, but waking up in the Emergency Department and learning she had suffered a stroke had startled and scared her, so Joan had been receptive to abstinence counseling and remarked many times that she didn't miss drinking and wasn't about to resume her old ways.

I followed her as she progressed through rehab, and accepted her as my own patient when she finally did go home. For weeks she stayed sober, and I discovered that she was well informed about issues of the day, highly articulate, and strongly committed to work with the homeless, once having been homeless herself. Indeed, one of her pressing objectives was to regain strength sufficient to resume work at a local shelter, either as an employee or volunteer, depending on the shelter's need and budget at the time. Her "no nonsense" attitude coupled with her ready smile and quick wit struck me as a uniquely winning and effective combination, and we talked about her ability to offer both academic insight and the wisdom of personal experience in her work on the problem of homelessness. And every time I saw her she smiled and affirmed that she was "done with the booze." As time went on I saw no hint of alcohol in her home, and her air of practicality and bottom-line realism led me to believe that while not out of the woods, her prognosis was good.

Until today.

I knocked and knocked on her door, but heard only a television or radio inside. Confident that Joan wasn't yet able to go out, I knocked longer and more loudly, until a muffled voice seemed to answer from within. I waited. And waited. And then knocked some more, and called out, "Joan, it's Sue. Are you in there?"

"I'm in here. Where else would I be?" came the slow, familiarly sarcastic, . . . and unfamiliarly slurred response. "Let me drag myself up."

"Take your time and be safe," I answered. And I waited.

All grew quiet, and I debated leaving ("Has she fallen back to sleep," I wondered) or calling for help ("Is she on the floor?"). But then came shuffling, silence, stumbling, more shuffling, fumbling with the lock, and, after the handle had spun helplessly while the door didn't open, finally, a slurred command, "Open it and come in."

I did, and there she was, dressed only in an oversized t-shirt, balancing precariously on legs she did not seem to recognize as hers, and breathing alcohol fumes in my face. She staggered against the adjacent bathroom door frame and tried to look casual as she leaned on it for support. "I went to the store for the first time yesterday, all by myself. . . . All. by. my. . . . self!" she said with a forced, crooked smile.

"And what did you buy?" I asked, knowing the answer.

"Tons of food," she said, "Tons and tons and tons and tons of food." She stumbled to the refrigerator, opened it, and repeated, "Tons and tons of food." Collapsing onto a chair she looked up at me as though expecting a response to a profound pronouncement.

"Did you also buy some booze?"

"A little," she slurred, attempting with small success to make a pinching gesture with one thumb and forefinger.

"Let's have a look at you, Joan," I said, beginning a cursory exam, because there's truly nothing to be said to a drunken drunk. "Do you have any of that booze left, or did you drink it all?"

"A . . . LOT. I have a LOT left!" she announced with a sloppy smile.

"You did well for quite a few weeks, Joan, and tomorrow's another day. You can start again. One day at a time."

"Yeah. One day at a time."

Peddling away on my bicycle a short time later I felt a profound sadness that permeated my being from head to heart to toes. And I realized that after forty years of practice there's been nothing sadder in my repertoire of experiences than the people doing themselves in with alcohol. And there's not a thing I can do for them until they hit that proverbial bottom and make the decision to help themselves.

If a patient is dying of cancer I can act to control pain, prevent tissue breakdown, maintain hydration, and more. In the face of fear and fever, of multiple trauma in the middle of a street somewhere, of a disease with no cure, of a body whose vital organs are failing irreversibly, of confusion and dementia, of ignorance and inability to learn, and more, I can offer some means of aid. At the very least, or perhaps the very most, I can be present to stand, sit, or walk with another who treads a dark road that perhaps none understand. But the inebriated alcoholic may not even know I'm there; indeed, tomorrow Joan may tell her Physical Therapist that she wonders why she didn't see me this week, never knowing that it was what she put in her mouth that blinded her eyes and her memory to my presence.

I'm glad I was the one who found Joan today, because I know the intelligence, sensitivity, passion, warmth, and hardship of the human being behind the booze. And I'm a seasoned warhorse who knows what I saw and what can and cannot be done at this point in Joan's journey. A younger, greener nurse might have set herself up for unnecessary failure; I could peddle away with sadness, yes, but also with understanding.

Joan needs to meet some friends of a fellow named Bill W., and she probably knows that. I will see her once more, hope she is sober, and if so will suggest an introduction and tell her where in her neighborhood that introduction can happen. And then it's up to her. I told her booze-smitten self today that I'd see her only once more, because there's nothing more I can do for her . . . although there is a great deal she can do for herself, and much support to be had once she makes that commitment.

The world needs Joan and people like her, desperately. She understands the problem of homelessness from every perspective and has the smarts and the skills to communicate with everybody from the badly beaten single mom with no place to go to the policy makers. Few can do that. We need her. But today she drinks.

I write this from a corner lounge overlooking the driveway to the Emergency Department of the hospital where Joan goes, where EMS would bring her if she called 911 or someone else made that call on her behalf. I see ambulances coming and going, and wonder if one of them carries a smart, funny, warm, engaging woman who was found on the floor today with a fractured [fill in the blank]. Or I wonder if she is alone in her tiny apartment finishing off "a LOT" of booze tonight.

And I feel the most profound sadness possible, because there is nothing to be done . . . until Joan takes action herself. Bill W.'s friends reach a point of making amends to those they have harmed whenever possible, except when doing so would cause further harm. Sadness isn't the worst thing in the world, and mentally healthy people know how to handle it and gently let it go. But when people like Joan become acquainted with people like Bill's friends I wonder if they ever truly know not just the overt and subtle harm they may have caused themselves and others, but also just how very sad those who care have been, and how the practice thought to bring pleasure actually is perhaps the most isolating one possible. For in a drunken haze not even the connection of another quiet presence is possible, and no matter how lively the bar or how many people at the party, the alcoholic always drinks alone.

Now in this festive season, as I watch ambulances come and go, I wonder how many times in the guise of fun and celebration

Isolation Toasts Sadness.

You Had a Chance to Be Kind Today

You had a chance to be kind today. I wish you'd taken it.

I didn't mean to usurp your parking space. My new patient's husband, "Charlie," called while I was en route to their home to let me know there was a lot behind the building where I could park. Parking is particularly challenging in your neighborhood, as you well know, so this was good news. However, when I arrived I was concerned to note that although there were many vacant parking spaces, all of them were numbered, and I shared this concern with Charlie, who was sitting in his motorized scooter waiting for me. "Nurse? Are you the nurse?" he'd called out, and I'd addressed him by name and affirmed my identity. When I mentioned my concern about the numbered, and therefore possibly reserved, spaces he told me, "You can park "back there," so I chose a spot where he pointed, pulled in, gathered my computer and supplies, and followed him to the elevator.

It was a long visit, as initial visits usually are. But there also were unusual problems in this case. Charlie's wife, Delphine, was diagnosed with cancer "about a month ago," and just two days ago returned home from a second hospitalization where the cancer had been found to be particularly aggressive, already spreading to other parts of her body. Yesterday I hadn't been able to reach her to schedule a visit; as it turned out, she was back in the emergency room because of severe, unrelieved pain. When I arrived today Delphine still was in pain, didn't have her medicine, and the hospital bed and wheelchair that had been ordered for her had not arrived. It takes some time to sort out such issues as these, with calls first to identify exactly what the problems are, and then more calls to solve them. And my physical exam and everything I do happens in slow motion, because the patient is hurting and moves gingerly, and her ability to hear and understand instructions is compromised. So my car sat in your parking space for quite awhile.

Again settling into his scooter, Charlie escorted me back to the parking lot when I was ready to leave, and there we met you. Oh, my, but you were irate! My car was in your parking space, you shouted, and, "We called the towing and it is coming now." Well, I'd say I arrived just in time, I thought, although clearly that wasn't what you wanted to hear, so I held my tongue. In fact, it didn't take long for it to be obvious that you didn't want to hear anything. And it didn't take much longer than that for anyone around to realize that there was nothing that could be said or done to help you feel better. You were puffed up with righteous indignation, and letting it rip.

I apologized, identified myself and my reason for being there, explained that I had been told I could park there while visiting my patient, emphasized that I now understood I had been misinformed and that I would not do it again, and assured you that I would remove my car at once. "You should have called ME!" one of you said, although I had no idea who you were or how to call you. If you are the janitor or a staff member who can authorize parking I surely would like to know it and would be happy to call you next time, but you weren't about to disclose anything like that. No matter that until moments before I'd had no idea you even were on the planet and that I still didn't know who you were except the wronged probable leaseholder of the parking space in question, I should have called you, you told me, and at a high decibel level. "I came back from SHOPPING," the other one of you announced indignantly, "and couldn't park my car!" While I feel quite sure my car was where it should not have been and that you were inconvenienced as a result, I couldn't help but be struck by your ability to draw yourself up and spew forth righteous entitlement befitting a setting far more well-heeled and exclusive than the asphalt lot behind the modest building where many residents, probably yourselves included, live on public aid. I don't know your life story, but you have the Rodeo Drive air down pat. Well done.

I apologized again, but you told me, "Sorry is no good!" Ah. Having established that my car was in the wrong place and feeling confident that it was not in my power to rewind the clock and make a different decision about where to park it, and quickly coming to a clear understanding that you didn't care that I had made every effort to park properly and truly regretted my error, it took no genius to realize that there was no point in continuing the conversation and every advantage to be gained by my removing my vehicle and being on my way. The tow truck you called arrived and left; my sense was that you were most angry about having been denied the satisfaction of watching my face as my car was towed away. I'm afraid I'm not sorry to have deprived you of that!

Interestingly, before I could leave the parking lot I needed to wait while you pulled your car in front of mine and carefully blocked my way as you adjusted your seat belts and did whatever else you were doing before driving off. I followed you down the road until we turned in opposite directions. It seems you had no intention of using your parking space. Evidently you arrived home from shopping, found your parking space occupied, and simply took another of the many that were vacant. Perhaps you unloaded your purchases and called the tow truck in the process. You may or may not have noticed the sign in my window identifying my car as belonging to a visiting nurse who was on site providing healthcare; if you did, it didn't matter.

My heart is sad for you. I wonder if you know that your 51 year-old neighbor would love nothing more than to be able to go shopping, but she doesn't even have medicine, much less other purchases, and can't so much as roll over because of severe cancer pain and because the hospital bed that would make movement easier has not arrived. I wonder if you noticed your other neighbor who must travel by motorized scooter because he can't walk and doesn't have a car, much less a place to park one. I believe on the basis of your presentation, your particular accented English, and the location of your modest apartment that you may have come to this country as a religious and/or political refugee and may be here at the expense of a charitable sponsor and of the US taxpayers, and that you may have come from a country where the only way to have your basic needs met was to get in someone's face and loudly demand satisfaction. I wonder if you took time to relish being able to peaceably acquire what you bought today, as well as having the money in your pocket to buy it. And I wonder if you enjoyed your ride to wherever you went as you drove off in front of me, if you amused one another with stories and jokes, or sang along with the radio . . . or if you spent a precious evening, of which your 51 year old neighbor probably has few remaining, complaining bitterly about the errant ways of a misguided nurse who borrowed your parking space without permission.

I will see you again. Or someone like me will. I will see you in the ER when you arrive with your chest pain, your stroke, your hemorrhaging gut, your fierce headache, your uncontrolled pain . . . from the effects of the stress hormones that all too often course through your body. You may arrive with stab or gunshot wounds if the next person who meets your rage responds in kind and your mutual anger escalates. I will see you through your hospital stay, and I will be on your doorstep (albeit with my car parked elsewhere) when you arrive home to begin your arduous rehab, after which, I fear, you will be left with significant permanent deficits. You see, rage is deadly, and far more so for the perpetrator than the recipient.

My evening shaped up quite nicely. Since your neighbor had needed more of my time than I'd expected, my plans to meet a friend for dinner were postponed. So I enjoyed nice dinner at home in front of a DVRed episode of Masterpiece Theatre I'd not had a chance to watch, figured out some new computer software and enjoyed a head start on some work, read a bit, and soon will turn out the light and sleep like a baby. I think you may have returned home from wherever you went and relived your anger as soon as you saw your parking space. Unfortunately, your body doesn't know the difference between the memory of anger and stress and a new occurrence of those all over again, so just parking your car probably set off your "fight" response anew. Your poor bodies! I would guess that you may sleep poorly tonight and many nights, or use drugs to ease yourself into a relatively unhealthful slumber; this is another factor that will contribute to your meeting me, or someone like me, again one day.

I am sorry I inconvenienced you by parking in your space. I don't knowingly park in places reserved for others. I'm glad to have avoided a tow, and to know not to park in that lot in the future. But I didn't do anything wrong . . . and neither did you. I asked, I followed the instructions I was given, I double-checked to be sure I had made a correct choice. You pay rent for a parking space, found it occupied by an unauthorized vehicle, called a towing company, and conveyed your displeasure to the offending driver when she appeared.

But you had a chance to notice the sign in my window identifying my car as belonging to a nurse temporarily parked for a home visit. You had a chance to see my cell phone number and call it instead of the towing company. Since you did not need your parking space at the moment anyway, you had a chance to leave a note on my windshield pointing out my error and to take no other action. You had a chance to park elsewhere long enough to unload your purchases and then be on your way, exactly as you did. You had a chance to accept an apology, allow amends, correct a misunderstanding, meet a neighbor, and perhaps even make new friends. You had a chance to forgive, to build bridges, to feel peace, to heal. But you chose rage instead, and that rage seemed to take hold of you and not let go. It is the kind of rage that will harm you one day. It already may have poisoned your relationships with family, neighbors, coworkers, and others. And one day it may kill you. It almost certainly will be a contributing factor to whatever does.

I'm the one who parked in the wrong place today, and all I suffered for it was a bit of unpleasantness from you, which, frankly, doesn't matter to me one way or another. You were the one wronged, however unintended that wrong may have been, and you then wronged yourself all the more by stewing in anger over something that could not be changed and by refusing to accept an olive branch of peace and healing. I will see you in the ER one day, and in the hospital, in rehab, and at home as you struggle to recover from the consequences of your choices, such as the unfortunate one you made when

You Had a Chance to Be Kind Today.

A Good Nurse

Good nurses practice in accordance with the Nurse Practice Act of the state in which they are licensed and working, and in so doing carry out all of the components of the "nursing process," and they do this well. That's all there is to it.

Yet among the thousands and thousands of patients who receive nurses' services every day, and the thousands of organizations that employ nurses, precious few folks seem to know what a "good nurse" truly is or how to spot one.

A nurse can be kind, compassionate, considerate, friendly, thoughtful, smart, funny, and able to change a bandage or administer an injection without causing pain, yet still not be a "good nurse." A nurse can be a conscientious employee who is well-liked, responsible, and loyal, yet not be a "good nurse." And most of all, a nurse can be "nice" (Lord help me if one more person tells me how "nice" a nurse is!), while being a professional disaster at the same time.

The problem is that state laws and professional standards of practice just aren't typical recreational reading for most people, and the essence of good nursing practice often is concealed in mundane activities. So it's all too easy for the public, and for business people who own and/or administer healthcare organizations, to assume that handing out pills and applying cool cloths to fevered brows is professional nursing, and that people who hold RN licenses and do those things well are "good nurses." 'Tain't necessarily so.

Some years ago a recruitment ad running in professional journals showed a nurse standing at the bedside of a patient who was sitting up in bed with a meal tray on the table in front of him. They were smiling at each other and obviously enjoying a pleasant exchange. The caption read something like, "He thinks they're talking about green jello. Actually she's halfway through 146 assessments." That would be true, if she were a good nurse, and the point of the ad, directed to good nurses whom the sponsor hoped to recruit, was that this is the sort of nurse sought and valued by that hospital.

A nurse indeed could merely banter about food with a patient and then head off to hang the next IV, having noticed and learned little. But more probably the nurse at that bedside noticed whether, what, and how much nutrition the patient was taking. She knew if he was enjoying his meal or if eating was a struggle or a chore. She recognized if he seemed to be in pain or to be having difficulty eating, from trouble swallowing to challenges manipulating utensils to inability to see clearly the things that were on his tray. She noticed his color, his breathing, and his speech. She could estimate his level of literacy, and had a sense of his willingness to engage with her and other providers. She had a sense of his communication style and whether he tended to be blunt, evasive, or something in between. She noticed his position and if he favored or guarded any body part, or if he just seemed more comfortable being "crooked" in the bed. She could tell if he was likely to engage, ask questions, and want to be an active participant in his care, or if he preferred a passive "wake me when it's over and I'm all better" approach. The nurse noticed any hearing deficit, if the patient seemed light-headed or dizzy, or if he was confused, forgetful, hallucinating, or demonstrated impaired cognition. She recognized effects, intended or otherwise, of the medications the patient had taken, and whether he might need something more, less, or different. She had a sense of how eating was affecting his stomach and entire GI tract. She noted sensory impairments he might have, such as not realizing that coffee was hot or that a glass was placed too close to the edge of the table. She saw if he had trouble grasping objects or tended to drop them, and if this involved one hand or both. She noticed if he did not move normally, and if he was tired, or tired quickly. She saw how he coped with whatever health problems he had, and knew the approaches to which he likely would be most receptive. She knew if his IV was running properly, if his bandages were intact, and the significance of displays on the monitor over his bed. And more.

The nurse also knew what to do with all of this information. She used it to formulate diagnoses, plan treatment, evaluate the effectiveness of treatment, prepare to teach the patient, include supportive others and exclude others, plan his discharge, and give other team members heads-ups about the patient's status, needs, and actual and potential problems. She knew what to disregard for the moment, and what warranted prompt action. She knew what questions she still had, and had a plan for pursuing their answers.

But when the phone rang and she excused herself from the bedside as the patient answered it, chances are she overheard him saying, "Hi, Honey. I'm having lunch and just was talking with Jane about the jello. It's green! Yeah, Jane's very nice; she's a good nurse."

More sobering are the administrators and executives of healthcare organizations who don't know what good nursing is, or even what nurses are required to do to be in compliance with the law. Recently I spoke with a Clinical Manager of a home healthcare agency who lamented the unnecessary and time-consuming documentation that many nurses new to home healthcare wrote. "All they need to write is what regulators and payors require," she said, "The rest is superfluous and unnecessary."

Wrong.

Those new-to-homecare nurses indeed may have been including unnecessary information in their notes, but they are required by law and by the standards of their profession, to which they would be held accountable in any court of law, to perform and document the entire nursing process, not just the parts that satisfy the specific requirements of regulators and payors. One would hope that Clinical Manager would help new employees ferret out irrelevant information while fleshing out a complete clinical picture of each patient and of the nursing process as it is carried out in each case. I fear that was not the case in this instance.

Employers can be so focused on their business needs that they fail to be mindful of the larger responsibility of professional healthcare providers. If executives hold business degrees rather than professional licenses they may not even know the standards and requirements for which a nurse, or other licensed professional, is accountable. They may even, unwittingly, I hope!, encourage employees to flout the law: "Just document the patient's homebound status, the skilled services provided, and compliance with the treatment plan that the physician signed and be done with it." But business needs cannot be allowed to trump professional standards or the law.

Because an employer gives a directive does not absolve a nurse from the duty to practice in accordance with the law and with professional standards. If a manager told a nurse, "It's ok, you don't have to file a tax return this year," you can bet the IRS still would go after that nurse and would have no sympathy for what the boss had said. If a director told a nurse to reach a destination as quickly as possible, without regard for speed limits, it's a sure thing that flashing lights in the rearview mirror and a speeding ticket would be in that nurse's future, boss's directive or not. Similarly, when a manager or executive tells nurses how to practice and what to document, it is incumbent on those nurses to be sure that their practice and their documentation both satisfy the needs of the employer and those of the law and of the profession.

It's a wonder more nurses don't seem a little schizophrenic from time to time, given that so many of our patients don't realize even a small portion of what our practice with them truly entails and that so many of our employers are focused on the bottom line to the exclusion of good practices and of compliance with the law. But the next time you encounter a nurse and a dish of green jello, please don't be quick to confuse personality with professionalism. Because before you can down the jello that nurse will have completed 146 assessments, formulated diagnoses and a treatment plan, evaluated what has been done and how you have responded so far, and determined with whom she or he next needs to confer to help you take the next right step towards better health. . . if he or she is

A Good Nurse.