An image from the past when white caps gave nursing its aura. Reproduced from originals in the Center for the Study of the History of Nursing, School of Nursing, University of Pennsylvania.
Earlier this year a University of Pennsylvania research group reported that a noninvasive intervention could prevent the repeated hospitalizations of high-risk elderly patients, improve their overall care, and save taxpayers millions of dollars.
Sound like a candidate for a good health story? The editors of The Journal ofthe American Medical Association thought so. They chose it as the top item for the packet of news releases sent out to reporters about articles in the February 17 issue of JAMA.
But this story didn’t get the kind of play JAMA studies often do. It did not go entirely unnoticed—it went on the Associated Press wire, National Public Radio did a report on it, and a handful of newspapers gave it a paragraph or two. The Philadelphia Inquirer’s Michael Vitez developed the JAMA study into a piece on the care needs of the rapidly expanding number of elders who live with multiple chronic illnesses, and the Inquirer ran the piece on the front page. By and large, though, the media were uninterested.
There may have been several reasons why other journalists ignored the study. Perhaps old people aren’t an appealing subject even though their care has a tremendous impact on health care costs, the allocation of social services and the demands on family caregivers. Maybe there was a lot of competing news that day. But as someone who has watched this happen time and time again, I can’t help but think that the determining factor was that the university researchers were nurses and the intervention they tested was nursing care.
This conclusion stems from many years of writing about nursing and monitoring the coverage of this profession. Nurses are so consistently overlooked in news coverage about health and health care that it is hard not to think that prejudice is at least partly responsible. In a study I led nine years ago, my colleagues and I found nurses and nursing to be all but absent in the health coverage of three of the nation’s top newspapers. Not surprisingly, physicians accounted for almost one-third of 908 sources who were directly quoted in the stories we analyzed. However, sources from government, business, education, nonprofits, even patients and family members as well as nonprofessional hospital workers also were quoted more often than nurses. The voices and views of nurses came through in only 10 of the 908 quotes.
A broader study commissioned in 1997 by the nursing honor society Sigma Theta Tau International found little improvement. Named for the late Nancy Woodhull, a news executive and expert on women and the media, the recent study, like ours, found numerous examples of nurses being passed over in favor of other sources—even when it is clear that nurses would be the most logical sources. For example, a Chicago Tribune article (September 14, 1997) focused on lay midwives and the legal prohibitions which prevent them from practicing in Illinois if they don’t have a nursing degree. The article’s sources included lay midwives and a physician but no practicing certified nurse midwives.
Nurses’ invisibility in the news is noticeable in all aspects of health coverage. My analyses indicate that one-fourth to one-third of health news reports are devoted to coverage of research findings. That’s a conservative estimate if you also count the spinoffs—backgrounders, columns and features—prompted by research studies. It is very difficult, if not impossible, to identify a column, television health program, or health section that regularly includes findings from nursing studies in its reportage.
Lack of attention to nursing research is a serious oversight because much of this burgeoning field is devoted to the most significant health care issue of our time—the care and treatment of those with chronic illness. Thanks to the many biomedical, surgical and acute care advances of the last half century, instead of being quickly killed by serious illness, large portions of our population live for lengthy periods and into advanced age with chronic diseases or conditions. These include cancer, heart disease, arthritis, high blood pressure, birth abnormalities, osteoporosis, diabetes and so on. Increasingly the “diagnosis and cure” medical model is inadequate in this environment. Ongoing care and management of these conditions is needed, and that care is the crux of nursing research.
A case in point is the JAMA study. Penn nursing researchers randomly divided 363 sick and frail elderly hospital patients into two groups. The control group received routine discharge planning and, if referred, standard home care. Those who were in the second group were visited within 48 hours of being admitted to the hospital and then every 48 hours during the hospitalization by an advance-practice nurse who specialized in geriatrics. Once the patient was discharged, the same nurse visited him or her at home at least twice and was available in person or by phone for the next month. These nurses focused the patients’ medications, symptoms, diet, activities, sleep, medical follow-up and emotional status. They collaborated with physicians to adjust therapies, obtained referrals for needed services, set up support systems, and helped the patients and their families adjust to life at home.
The outcomes tell us a lot about the efficacy of this approach. Six months after discharge, 20 percent of the group with master’s-degree nurses was hospitalized again compared with 37 percent of the control group. Only 6.2 percent of the group monitored by nurses had multiple hospital readmissions, compared with 14.5 percent of the control group. When they occurred, hospital stays were much shorter for the first group—1.5 hospital days per patient compared with 4.1 days for the control group. Health care costs for the group with transitional care were $600,000 less than costs for the control group. Medicare was saved an average of $3,000 per patient. At a time when the mounting costs of health care are routinely covered on the business pages and on television news, the fact that evidence such as this was ignored is peculiar.
Patients and their families know how devastating cycling in and out of a hospital can be. As Mary D. Naylor, associate professor of nursing and the lead author of the study said, “We’re still relying on hospitals to respond to what we know are, in many cases, preventable readmissions. Our system of care is not responsive to the needs of the older community.” Nursing research identifies responsive care. Yet health writers seem to have little acquaintance with nursing research. One 25-year veteran of the medical and health beat who reads several medical journals told me he couldn’t think of the name of a single nursing journal. Another health editor responded to a colleague of mine who raised the subject with, “Nursing what?” Even when nursing research receives the imprimatur of medicine by appearing in a top medical journal, it is still likely to be ignored.
As journalist Suzanne Gordon pointed out in her recent book, “Life Support: Three Nurses on the Front Lines,” when coverage focuses exclusively on medicine, it reinforces the notion that illness is an event rather than a process. When journalists cover health innovations only as medical interventions they create a simplistic and inaccurate picture of health care. If journalists were to ask nurses how new treatments really affect patients they would have a truer picture of not only the efficacy of these treatments, but of the needs that patients have for care before, during and after medical encounters. While medical researchers and physicians develop these new treatments, nurses administer many of them and monitor their immediate and ongoing effect on patients. Nurses are the ones who know what impact these medical advances have not only on patients’ cells, tissues and organ systems, but on their lives.
For patients and policymakers, a gaping informational hole remains even from the vigorous coverage of managed care. As a recent Kaiser Family Foundation study confirmed, reporters have brought the denials of treatments, medications and experimental procedures under managed care to the public’s attention. They have exposed the HMO’s that have tried to prevent physicians from candidly discussing a patient’s condition and appropriate treatment options. They have attended to the patient backlash as well. Even nursing won a moment in the news as part of managed care coverage. A rash of stories reported that hospitals were “downsizing” and “deskilling.” But few journalists examined what these cutbacks meant in terms of patient care.
Pittsburgh Post-Gazette medical writer Steve Twedt is one who did. He spent a year researching this question and talking to nurses, nursing researchers, patients, families, aides, physicians, attorneys and policymakers. “In hospital after hospital across the country,” Twedt wrote in his resulting 1996 four-part series, “nurses with years of experience are being replaced by unlicensed aides who get only minimal training before caring for patients.” His investigation, he wrote, produced “example after example of hospital patients throughout the nation who were injured or killed by the mistakes or negligence of aides performing duties they weren’t equipped to handle.” His most troubling conclusion was, “Despite the profound impact on patients, no one is systematically monitoring this sweeping change in health care.”
It has similarly escaped the notice of journalists that proposed remedies to the problems of managed care do not address nursing care. The so-called patient bills of rights in state legislatures and Congress focus on medical care. With limited exceptions (childbirth and mastectomies), these bills do not constrain insurers and hospitals from restricting patients’ access to nursing care. The bills that do address nursing care—those that mandate minimum levels of nurse staffing in hospitals and nursing homes—have gotten very little attention.
Reports on the effects of Medicare cuts in the Balanced Budget Act of 1997 are also too narrowly focused. For example, Bob Herbert in his New York Times column (April 15, 1999) discussed the disastrous impact reduced Medicare payments are having on teaching hospitals and their ability to educate future physicians. Nursing was not mentioned once in his description of the dire effects the cuts are having on staff levels, hospital treatment and care, and professional education.
Yet teaching hospitals are nursing institutions as much as they are medical institutions. Hospitals are the primary site of nursing education. Nursing education suffers when hospital revenues drop. In fact, one of the major missed stories of this decade has been the effect of the dismissal of clinical nurse specialists and other hospital nurse educators on nursing education and practice. Nursing education has taken a direct hit in other ways, not the least of which is the reluctance of good candidates to enter a field that is being decimated and abused by market-driven health care.
Not surprisingly, the country now faces a serious nursing shortage. Although this has been reported largely as a demographic aging-of-the-nursing-workforce phenomenon, it is much more complex and interesting as evidenced by the frenzied recruiting hospitals are engaging in even while, in some cases, continuing to lay off nurses. To be sure, it is not easy to cover nursing. Although some nursing organizations and nursing schools have knowledgeable media specialists who understand the needs of journalists, in general nursing research studies and innovations in nursing practice don’t arrive in the newsroom in prepackaged print or electronic form. It takes work to ferret out significant stories.
Then there is the problem of getting nurses to talk. Reporters need to understand that most nurses are employees of large institutions, and many are afraid of retribution if they say anything. Even a very small percentage of those theoretically protected by unions will go on the record. Then, too, some nurses feel so rejected by the press they have given up trying to interest journalists in developments in their discipline.
With 2.6 million members, nursing is our largest health care profession. There are many reasons to cover nursing, including the fact that press scrutiny tends to keep any important field on its toes and accountable to the public. Like medicine, nursing should be covered warts and all. One more thing to think about. Editors should lose the nurse nostalgia bit. Not long ago The Atlantic Monthly inserted sentimentalized images of nurses complete with angels’ wings into a book excerpt on contemporary nursing, and Working Woman illustrated a nurse employment trend piece with a decades-old picture of a lineup of nurses in starched uniforms and caps. What editor today would illustrate a medical story with a doctor wearing an otolaryngeal mirror strapped around his head? Registered nurses haven’t worn white caps since the 1970’s, yet such pictures abound. These images lose their romantic appeal when you realize that you wouldn’t want a nurse with 19th Century or even 1950’s education and training to take care of you any more than you would want a surgeon with training limited to those periods to operate on you.
It’s time for the journalistic community to recognize nurses for what they are—flesh and blood professionals who, unlike angels, need to be paid for the extremely hard and critical work that they do and who, like their patients, are endangered in our health care system. By reporting on the vital roles nurses play in patient treatment and care and by seeking out their perspectives in any coverage of health care, journalists would add critical dimensions to the ongoing debates about what health care is going to be like for Americans in the 21st Century.
A contemporary image of nursing. Photo by Stan Grossfeld, The Boston Globe.
Bernice Buresh is a freelance writer who has been a reporter for The Milwaukee Sentinel and a correspondent and Bureau Chief for Newsweek. She taught journalism for many years at Boston University and has been a Knight Journalism Fellow at Stanford and a fellow in the Joan Shorenstein Center on the Press, Politics and Public Policy at Harvard’s John F. Kennedy School of Government. She is President of the Writers’ Room of Boston, which provides affordable, quiet and secure workspace for writers.