Determining Actual Working Conditions Of Nurses

Commenter Jennifer (welcome!) wrote:

One thing that scares me about going in to nursing is stories about the bad conditions. How do you find the conditions where you work?

What a good question!

I don’t know how to guarantee that with anything near 100% accuracy, but I can help anyone considering a new nursing position how to find out the “real” from the advertised and help close the credibility gap.

First off, know a couple of things:  nurse recruiters, who may or may not be nurses themselves, are working to fill slots.  They are almost always working to meet quotas, and they are not YOUR agents.  They work for the employer.  So take anything and everything they say with healthy amounts of skepticism.  In other words, “trust AND verify.”  Ask them to verify in writing, any claims they make about staffing, patient case load assignments, time off scheduling policies, education support, assignment to your desired setting/shift/work schedule/patient population, etc., etc.

Let’s start with orientation:

Things to ask the recruiter/tour guide/interviewer:

What method of orientation is used - mentorship, classroom, laboratory, guided practice, formal education, self-directed instruction, web-based, etc.

How long is orientation?

What is the work schedule during orientation?

Who are the teachers?  What are their credentials?

What is the curriculum?  (Ask to see it.  If it’s not in writing anywhere, warning flags should be flying.)

Things to ask yourself:

Is this the style of teaching I do well with?

Is this long/short enough or do I need something else?

Is it guaranteed out of staffing orientation (translation:  if you are counted in staffing, you will be expected to pull a partial or full patient assignment, regardless of your “orientation” status.  Beware.)

Are the instructors qualified to teach the content and are they clinically expert in my field?  (translation:  are the instructors experienced, competent and familiar with your specific nursing specialty.  Critical care nurses teaching critical care nursing, perioperative nurses teaching perioperative nursing, orthopedic medical and surgical nurses teaching orthopedic and rehabilitation nursing, etc.)

Do you have free and open access to a healthcare research-based library?  Can you access it online from your nursing workplace?

Does the curriculum progress from novice to competent independence in nursing in your field?  Is it based on current practice and evidence, and is it specific enough to serve your individual needs? (These will vary based on your entry-into-practice nursing program, whether this is a first professional nursing position, whether this is a new position but in your field of clinical expertise, or whether this is a new clinical field, but in the same employment setting, etc.)

You’ve decided that the orientation generally meets your needs, and you’re still interested, so the next thing is to determine whether you will be satisfied in your work setting.

Take a tour with a nurse who works on the unit or in the department you are considering during the hours you most likely will be working.  In other words, if you are going to be a night owl, take a midnight tour. And meet and greet all of the staff you come into contact with on that unit. It may be that the person who “sets the tone” is the unit coordinator or a nursing assistant, or an environmental service worker.  See who speaks to whom, and get a feel for the overall tenor of the unit.  Is it formal?  Stuffy?  Boisterous?  Chilly (and the thermostat is just fine)? Openly hostile?  Competitive?  Cutesy? Friendly? Something else?

And most important, does it feel comfortable to you?

Chat up the other nurses.  Do they generally have enough time to take care of patients to their preferences?  Do they have any immediate safety concerns for themselves or their patients?  How’s security?  Have nurses been assaulted, bullied?  If so, by whom?  What was done?

Do they get away from the unit for meals and for breaks?  How’s the cafeteria or local eateries?  Is there a potluck culture (celebration by food)?  Do any of the nurses socialize outside of work?

Is anyone attending school?  Does the employer support them in doing that?  How about childcare issues and taking sick time?  What’s that like?  Are nurses able to schedule vacations and time away without undue hassle?

Do you see enough clean linen, sterile supplies, IV poles, IV pumps, PCA machines, pulse oximeters, pillows, etc.?  Do the nurses feel that supplies and equipment are in good working order and are available when they need them?  If not, get the specifics of when, where, how often, why, and what is done or not done to remedy the root cause of the shortage. Are you familiar with the equipment used?  if not, how will you learn to use it?

What do the patient meals look like?  How are they delivered?  Do the patients like the food?  Is it hot/cold enough?  Is it visibly and aromatically appealing? How do nurses obtain meals for patients admitted during closed cafeteria times? What is the quality of that food?  Special diet accommodation?

What are the patients like?  How are physician relations and communication?  Are there any problematic physicians?  If so, find out what the nature of the problem is and how the nurses deal with it/how the employer supports the nurses.

What is the general communication style of the nurse you will be accountable to for your evaluation and direction?  Does your style mesh well?  What are her expectations of you as a new nurse?  Six months after starting?  Will you be assigned charge responsibilities?  If so, when and how will you be oriented to that role?  Does that make you exempt from collective bargaining?  Overtime?

How is nursing practiced on the unit or in the department?  Are you familiar with that method of delivering care?  If not, how will you be oriented to it?

How long have the nurses who will most likely be working with you practiced in that setting?  If there is a lot of turnover, why?  Are nurses generally satisfied working there?  If so, why?  If not, why not? (warning flags again - ask, ask, ask)

Finally, if you can, ask to shadow a nurse for at least a half a shift.  You can learn a lot by watching, listening, smelling (does the unit smell clean?), and in meeting some of the cast of characters.  You will get a better feel for the patient population, too, and the culture of the immediate work setting as well as for the overall organization. Listen to how nurses give and receive reports: are they polite, collegial, cordial, friendly, hostile, remote, abrupt, suspicious, accusatory, etc.?  That often gives a strong clue as to the overall nursing culture in an organization.

The American Association of Colleges of Nursing has a helpful white paper on What Every Nursing School Graduate Should Consider When Seeking Employment. The guide is helpful for all nurses investigating a new position. The objectives include:

Maintain clinical advancement programs
based on education, certification, and
advanced preparation.

Create collaborative relationships among
members of the health care team.

Utilize technological advances in
clinical care and information systems.

Other statistics and information to
request from a potential employer:

RN vacancy rate and RN turnover rate
· Patient satisfaction scores (preferably
percentile ranking)
· Employee satisfaction scores
· Average tenure of nursing staff
· Education mix of nursing staff
· Percentage of registry/travelers used
· Key human resource policies, i.e. reduction
in workforce (tenure vs. performance
criteria)
· Copy of the most recent JCAHO report and
the number of contingencies cited
· Are nurses unionized?
· Copy of a contractManifest a philosophy of clinical care
emphasizing quality, safety, interdisciplinary
collaboration, continuity of care,
and professional accountability.

Recognize the value of nurses’
expertise on clinical care quality and
patient outcomes.

Promote executive level
nursing leadership.

Empower nurses’ participation in
clinical decision-making and
organization of clinical care systems.

Demonstrate professional
development support for nurses.

Refer to the guide for the specific questions and data to obtain.  In general they are on point and are critical for you to know. I find the AACN website of great use for its white papers and research into the nursing shortage, key nursing education issues and nursing career development.

Finally, I’d ask how many  nurses are active in nursing organizations related to their practice.  Which organizations are represented?  Do nurses participate in nursing research, journal clubs, group presentations, on-unit educations presentations, nursing grand rounds, etc.?  Are nursing students on the unit?  If so, from which programs?  What is the role of the clinical nurses with the students? Is the instructor on site?  Do staff interact with the instructor?  If so, how?

That’s where I would start in my investigation into the working and practice conditions.  I would be able to get a sense of the informal culture, of the usual work demands, and of the caliber and commitment of the nurses.

This is only a starter list.  Your mileage will vary.

Hospital Surge Capacity Myth Busters

The Washington Post’s Spencer Hsu presented a two part series (parts one and two) about the House Oversight and Government Reform Committee’s hearings on Emergency Department Surge Capacity and Medicaid funding cuts. I posted about the stark picture behind the experts’ testimony a couple of days ago. Today, I’d like to elaborate a little on that and call out the fact-free BushCo loyalist testimony of Michael Leavitt, the Sec DHHS and Michael Chertoff, Sec DHS. I’ll leave you with the facts and the trends, and you can decide for yourselves what needs to be done.

Hsu reported:

Two Bush administration Cabinet members yesterday acknowledged gaps in the capability of U.S. hospitals to deal with a mass-casualty terrorist attack or other disaster, but they said a congressional effort to block pending Medicaid cuts will not fix the problem.

Testifying before the House Committee on Oversight and Government Reform, Homeland Security Secretary Michael Chertoff and Health and Human Services Secretary Michael Leavitt said lawmakers could target funds at the shortcomings more directly, such as by financing the stockpiling of hospital beds, ventilator units or medicines, if needed.

I commented:

Hsu is to be commended for the two part reporting on these hearings. Well done!

It’s important to understand a few things:

One is that the hearings were designed to specifically address a mass casualty event related to terrorism so that Chertoff from DHS would be compelled to testify about the abdication of that agency relative to assurances of providing services and timely support to healthcare. But realistically, a mass casualty event can result from a variety of problems: weather (hurricanes, tornadoes, flooding, earthquakes), communicable disease (bird flu, tuberculosis, measles, smallpox, anthrax, influenza), bioterrorism, chemical spills, toxic substances leaks, explosions, fires and all manner of other large scale accidents, disasters and hostile events.

What hospitals are screaming all across the country is that they are already at or very near full capacity on a daily routine basis. There aren’t more resources in the pipeline to be able to flex up, regardless of the need. There aren’t “extra” beds, ventilators, medications in the pharmacy, sterile supplies, nurses, physicians, support staff, etc. - all the things and people needed to care for more patients.

And in an emergency situation, realistically, those staff “at home and off duty” may not be able to get to the hospital (remember New Orleans), or they may choose not to return to work for their own and their family’s safety, as in the case of a pandemic bird flu.

To cut a major source of reimbursement is an insult to an already gasping non-system system.

Patients already clog the emergency departments across the country. Admitted patients wait hours and days on end for beds to become available - especially if they have diagnoses of multiple chronic medical problems, where reimbursement rates tend to be the lowest.

What comes through loud and clear is the BushCo loyalism of Chertoff: “not my responsibility - it’s Mike’s over at DHHS”. And the other Michael - Leavitt - spins his testimony through the sewage pipe of Republican framing: “Medicaid creates a burden on the taxpayers, and it’s only for Medicaid services. Never mind that the US doesn’t have extant bed or emergency department capacity. Never mind that graduate medical education is going to be cut off at the groin, and never you mind that there is a baseline shortage of clinically expert trauma, emergency and critical care nurses and infrastructure to care for existing need and demand. Trust me - it will be just fine in a mass casualty. I’m confident. I don’t have any facts, but I’m sure things will work out OK.”

Oh, look - here’s what Committee Chairman Henry Waxman had to say:

On Monday, we heard from leading experts that the emergency rooms in our nation’s premiere trauma centers have little or no surge capacity.

We learned from them that many Level I trauma centers do not have the capacity to respond to a terrorist bombing like the one that happened in Madrid in 2004.

And we learned that the Administration’s new Medicaid regulations are expected to make these problems worse by cutting off crucial funding.

The hearing left us with a number of important questions, which we hope to answer this morning.

Why would the Department of Health and Human Services, knowing that the nation’s emergency care system is already stretched to the breaking point, withdraw billions of federal dollars from the hospitals that provide the most comprehensive emergency care to the most seriously injured?

Why would the Department of Health and Human Services take this drastic step without first considering the impacts of its actions on emergency preparedness or consulting with the agency with lead responsibility for homeland security?

Why would the Department of Homeland Security, which is the federal agency with lead responsibility for protecting the nation against terrorist attacks, stand by while local emergency surge capacity is compromised?
The impact of the Medicaid regulations on our health care safety net is not a partisan issue. Last month, Republicans in the House joined with Democrats in passing bipartisan legislation that would postpone the regulations and give Secretary Leavitt and Secretary Chertoff an opportunity to reevaluate their implications for homeland security.

The issue we are considering today is one that concerns all Americans: how to ensure we have a robust response capacity in our emergency rooms.

If the unthinkable happens — and we’ve learned that the unthinkable can happen — lives will be lost unless emergency care is immediately available. If a major city experiences a terrorist bombing like the one that occurred in Madrid, there will be a “golden hour” that determines whether the most severely injured survive or die. The federal government’s job is to do everything possible to ensure that emergency care resources are ready during that golden hour.

Certainly, our government should not be taking actions that undermine the prospect of an effective emergency response.

Conway-Welch’s testimony is all about the effects of Medicaid cutbacks on just those things that Leavitt and Chertoff deny with wishful thinking and willful ignorance. One could make a case that they are criminally negligent and are committing fraud against the American citizenry. No wonder they testified on a separate day without any of the experts in the room. They’re naked - of facts, accuracy and good faith, and their Republican henchmen on the Committee are the only ones who will cover for them.]

The Medicaid legislation in question is H.R. 5613, the Dingell-Murphy legislation, to stop the Medicaid cuts and protect the ability of safety-net hospitals with trauma centers to maintain this critical public health function, overwhelmingly passed in the house and sent to the Senate for completion. The Congress should also enact and fully fund the National Trauma Center Stabilization Act, H.R. 5942.

When Bad Is Good: The Dow(n) Is Up World of the Wall Street Journal

The Wall Street Journal just loves misery. Here’s the latest celebration of it with a nursing twist. Its related blog post echoed its story sentiment.

The ailing economy is helping to ease the nursing shortage.

With house prices falling and the cost of gasoline and food rising, many nurses are going back to work, in some cases to make up for the income of a spouse who has lost a job. Hospitals say part-time nurses are taking on extra shifts. And nursing schools are seeing an increase in people applying for refresher courses on the ins and outs of modern hospitals. Some older nurses are putting off a planned retirement.

Ain’t it grand? I bet the hospital administrators and other nurse employers just luuuuuv it! Let’s see:

We are seeing a temporary lessening of the nursing shortage,” says Jane Llewellyn, vice president of clinical nursing affairs at Rush University Medical Center in Chicago. But, she says, “as soon as the economy turns up we’ll see them staying home again.”

Whaddya know?

A nursing administrator is so appreciative. She can stay under the command budget and use nurses until they fall over with exhaustion, and then usually, she can make work conditions so horrific that the nurse voluntarily leaves before any pension or vestment kicks in. How professionally loyal! To her employer, that is. The odds are in favor of Llewellyn being a member of the American Organization of Nurse Executives, which is a subsidiary of the American Hospital Association.

You’re the patient, and your nurse just picked up a fourth twelve hour shift:

It’s a familiar pattern during economic slowdowns. For years, the high demand for nurses has allowed them to design work schedules that suit their financial and family needs. Many start off working full time on difficult shifts and then reduce their hours when they have a family — the profession is more than 90% female — or as they approach retirement. But when the economy goes sour, many nurses go back to work full time.

Dana Goodin, a nurse at Chicago’s Rush University, worked three evening shifts a week for nearly two decades, giving her time to raise her four children. But after her husband, a carpenter, was laid off late last year, Ms. Goodin began working four days a week to boost the family’s income and to qualify for cheaper health benefits. Although her husband has since found a new job at a retail warehouse, he makes just half of his former salary, and Ms. Goodin is looking for another shift to push her above full time.

Not that you care, but research demonstrates that nurses’ error rates climb significantly for every hour they work after twelve in a row, and that they also are higher during shift hours which result in forty or more hours being worked in a week’s time. They will also be interrupted and distracted throughout each and every work period, and that results in preventable errors, too.

Nurses who worked shifts lasting at least 12.5 hours were three times more likely to commit an error, such as giving a patient the wrong medicine or the wrong dose, than nurses who worked less than 8.5 hours, about a regular shift, according to a new study from the University of Pennsylvania School of Nursing.

Nurses reported that they committed errors on 103, or five percent, of the 2,057 longer shifts and made near errors on 97 of those longer shifts. Near errors are errors nurses intercepted before they reached patients, such as bringing the wrong medication to a patient’s bedside but catching the mistake before injecting it. Meanwhile, nurses made errors on just 12, or 1.6 percent, of the 771 regular shifts, and near errors on only 20 of those shifts.

Working unplanned overtime at the end of a shift also increased the likelihood of making a mistake, regardless of how long the shift.

But back to our story. There are wait lists for almost every accredited entry-into-practice nursing program. So what’s the problem?

Lack of qualified faculty is the number one issue:

The nursing profession also is attracting greater interest among new recruits, drawn by expanding job opportunities and rising wages in some places. Nursing school enrollment surged in the wake of the Sept. 11, 2001, terrorist attacks and the economic slowdown that followed. Enrollment continues to grow apace, though at a reduced rate, and schools are turning away thousands of qualified applicants for lack of faculty. Even so, nursing experts predict shortages will grow in future years as demand for nursing services outpaces the number of professionals entering the field.

No - enrollment does NOT continue to grow - in fact, it’s slowing.

The American Association of Colleges of Nursing (AACN) today released preliminary survey data that show that enrollment in entry-level baccalaureate nursing programs increased by 4.98 percent from 2006 to 2007. Though this marks the seventh consecutive year of enrollment growth, the rate at which nursing schools have been able to increase student capacity has declined sharply since 2003 when enrollment was up by 16.6 percent. While this increase represents a positive trend, AACN is concerned that more than 30,000 qualified applicants were turned away from baccalaureate nursing programs last year due primarily to an intensifying shortage of nurse faculty.

Faculty? You mean those overpaid, underworked ivory tower folks?

In nursing, faculty on the tenure track often earn less than the most novice two year technical school associate degreed nurse. They travel to clinical sites and oversee groups of up to ten nursing students. They also teach didactic and laboratory courses, and they serve on curriculum and other faculty committees. They are expected to remain clinically competent and expert in their specialties, and they are expected to participated in research and to publish about the profession and contribute to the advancement of nursing.

I’ll cite my own time spent on the serfdom track: I taught full time, pursued my doctorate full time, published, researched and worked an every weekend twenty four hour (really 26 hour) a week critical care staff nurse job so that I could hope to stay clinically current - oh - and pay the rent, since the faculty salary for a nine month appointment meant spreading it over twelve months, and working during those unpaid three months on curriculum design and course preparation, publishing, advising students, etc. I didn’t have a family, and I could only marvel at my serf-colleagues who did, because they were in the same sinking boat.

Because so very few universities offer joint clinical/academic appointments, the average clinical nurse practicing across all settings will rarely bump up against nursing researchers and academicians on a casual basis. And so nursing researchers and faculty don’t get to expose their work to the broader nursing audience, and nurses are deprived of their work and contributions. The American Association of Colleges of Nursing provides much more in its Nursing Faculty Worksheet White Paper.

Now the WSJ resorts to creative fiction:

The nursing shortage began in the 1990s as older nurses started retiring and there were fewer newcomers to take their place. The crunch got worse as baby boomers got older and demand for health care increased. By 2001, there were 126,000 vacant nursing positions in the U.S., according to the American Hospital Association. That means about 13% of all nursing jobs were unfilled.

Bogus, bogus.

Nursing shortages have been cyclical as hospital administrators looked at nurses and professional nursing as bottom line adjustable assets embedded in the hotel room and board rates until prospective payment and managed care roared in during the early 1980s. Since that time, administrators replaced professional nurses with licensed practical nurses and unlicensed nursing assistants (using a variety of job titles), and they decimated nursing’s ability to advocate for its members with manageable and safe patient case loads and tolerable work conditions while they hogtied them so that they became ineffective and unable to adequately advocate for patient safety and patient care.

In the 1990’s, hospitals began to close and to merge into systems, and this displaced senior nurses, who after losing pensions and seniority in benefits often fled the profession. Nurses were right-sized, out-sized, down-sized and done-in. The average age of practicing nurses is about 46 years in the US.

The WSJ touts the use of foreign nurses coming to the rescue.

To attract nurses, hospitals have increased wages and beefed up recruiting, including from overseas, and have offered potential hires signing bonuses of cash or even new cars. Hospitals have also taken steps to keep older nurses in the work force by making their jobs easier, including replacing hand cranks used to lift beds with automated lift devices, bringing in lift teams so nurses don’t strain themselves picking up patients, or putting supplies closer to patients’ rooms to cut down on walking. By the end of 2006, the nurse vacancy rate had fallen to 8.1%.

Wage and salary compression has always been a major dissatisfier and factor in nursing turnover. Wages are catching up to the responsibilities of the work involved, but they have a long way to go in many areas, such as the nursing faculty issue mentioned above and in many practice settings, such as nursing homes and public health agencies.

But the WSJ really has gall when it opines that scavenging nurses from countries where nurses are already in critically short supply and sponsoring them to work in the US on H1B visas solves or ameliorates a problem is negligent. There are so many problems with this, but I’ll just highlight a couple. One is that those nurses are often intimidated from taking action to advocate for themselves and for patients because their employer sponsors their work visas. Make a peep, and they can be sent home. There is a powerful disincentive for those nurses to act professionally when the employer exerts almost total control over their livelihood. And many of those nurses have been used and abused by employers. Consider the case of the Filipino nurses in Long Island.

THEY are recruited in their homeland with perks like free airfare. Some have been offered thousands of dollars in bonuses to relocate. And in the process, they have become a mainstay of the New York area’s hospitals and nursing homes.

They are nurses from the Philippines, and they are highly prized here because they speak English, are trained in American-caliber medicine and enjoy a reputation for tender care — the legacy of a society in which families tend to their own sick and aging relatives.

“We’re honest, industrious and don’t complain a lot,” explained Elmer Jacinto, 32, a registered nurse.

His voice, however, carried a palpable note of sarcasm. He and nine other Filipino nurses on Long Island did complain, and now they find themselves caught in what he called “a nightmare” — a disturbing new chapter in the upbeat story of one of this nation’s most successful immigrations.

The 10 nurses are under indictment in Suffolk County on charges of endangering the welfare of five chronically ill children and one terminally ill man. They are accused of walking off their jobs at the Avalon Gardens Rehabilitation and Health Care Center in Smithtown in April 2006 without providing sufficient notice for the nursing home to replace them on coming shifts.

Although their resignations were prompted by a seemingly commonplace dispute with their employers over what the nurses say were broken promises and shabby working conditions involving a total of 26 Filipino nurses and a physical therapist, the 10 defendants could each be sentenced to a year in jail and lose their nursing licenses. Their trial was scheduled to start Monday, but it appears that it will be put off until March.

But you’re the patient. You don’t care that your nurses will do whatever the employer says, because hospitals only want what’s good and right for you, isn’t that so?

For the past few decades, nursing has been a kind of reverse economic indicator. In periods of economic weakness or recession — including in the early 1980s, the early 1990s and earlier this decade following the technology-company bust and the Sept. 11 attacks — the number of full-time nurses grew at an average annual rate of 3.5%. By contrast, in times of healthy economic expansion, the increase has averaged just 2.4%, according to an analysis of government data in “The Future of the Nursing Workforce in the U.S.,” a book by Peter Buerhaus, director of the Center for Interdisciplinary Health Workforce Studies at Vanderbilt University Medical Center, Douglas Staiger, a Dartmouth College economics professor, and David Auerbach, a principal analyst in the Health and Human Resources Division of the Congressional Budget Office.

Last year, there was a net increase of about 113,000 nurses in the work force, the largest increase since 2002, and most of the added nurses were over 50 years old, according to the Census Bureau. The pattern has continued this year. Although the U.S. economy lost 20,000 jobs in April, the fourth monthly decline in a row, health-care employment rose by 37,000 and is up 365,000 jobs over the past 12 months, according to Labor Department data released last week.

“In bust periods, unemployment is rising, which means there is a lot of pressure on married RNs to be working,” says Mr. Buerhaus.

That’s right: nurses are pressured to work during this time of economic meltdown.

But you’re the patient.

Your overworked, distracted, pressured nurse who is likely to have been assaulted at work (more than 70% are, you know), who’s working her fourth twelve hour shift this week, and who is worried about her underemployed spouse, the increase in health benefit costs, and her sick child who she sent to school because there wasn’t any last minute child care availability - well, she’s your nurse (never mind the other four patient on her assignment of which three are being discharged and three more are awaiting to be admitted).

She won’t make any mistakes, will she?

Happy Nurses Week, patient.

Open Humanities Press Resource

Open Humanities Press just launched, and I included a blurb about its purpose and function as well as provided a link in the blogroll.  Enjoy.

Open Humanities Press is an international open access publishing collective in critical and cultural theory.

Open Humanities Press journals are fully peer reviewed, scholarly publications that have been chosen by OHP’s editorial advisory board for their outstanding contribution to contemporary theory. OHP’s journals are independent, published under open access licences and free of charge to readers and authors alike.

Grand Rounds 4.33 at Suture For A Living

RLBates stitches her way through life, and she has pieced together an amazing quilt of healthcare blog posts interspersed with facts and fotos of her home of Arkansas at this week’s Grand Rounds carnival.

Emergency Department Surge Capacity: There Ain’t None

[UPDATE 05-07-2008 Day Two of the Hearing is today with Michael Leavitt, Sec DHHS  and Michael Chertoff, Sec DHS testifying. The House Oversight and Government Reform Committee added their testimony and that of Dean Conway-Welch, and the links are at their names.

What comes through loud and clear is the BushCo loyalism of Chertoff: "not my responsibility - it's Mike's over at DHHS". And Leavitt spins his testimony through the sewage pipe of Republican framing:  "Medicaid creates a burden on the taxpayers, and it's only for Medicaid services.  Never mind that the US doesn't have extant bed or emergency department capacity.  Never mind that graduate medical education is going to be cut off at the groin, and never you mind that there is a baseline shortage of clinically expert trauma, emergency and critical care nurses and infrastructure to care for existing need and demand. Trust me - it will be just fine in a mass casualty.  I'm confident.  I don't have any facts, but I'm sure things will work out OK."

Conway-Welch's testimony is all about the effects of Medicaid cutbacks on just those things that Leavitt and Chertoff deny with wishful thinking and willful ignorance. One could make a case that they are criminally negligent and are committing fraud against the American citizenry. No wonder they testified on a separate day without any of the experts in the room.  They're naked - of facts, accuracy and good faith, and their Republican henchmen on the Committee are the only ones who will cover for them.]

[UPDATE: The Medicaid legislation in question is H.R. 5613, the Dingell-Murphy legislation, to stop the Medicaid cuts and protect the ability of safety-net hospitals with trauma centers to maintain this critical public health function, overwhelmingly passed in the house and sent to the Senate for completion. The Congress should also enact and fully fund the National Trauma Center Stabilization Act, H.R. 5942. I found one link to a comment made by Dr. Colleen Conway Welsh, the Dean of the School of Nursing at Vanderbilt University and an expert in emergency preparedness (yes, she IS a nurse):

"If Medicaid dollars are reduced in these three areas, a reduction in personnel and readiness will occur in our hospitals and emergency departments across the country," she said. "And even worse, it will occur in the midst of a serious and intractable nursing and nursing faculty shortage and limit our ability to respond to a disaster, particularly a blast or explosive injury with serious burns."]

If I can figure out how to do this, I’ll try to add some C-SPAN video of yesterday’s House Oversight and Government Reform testimony about the nation’s hospital emergency departments’ surge capacity in the event of a large scale emergency - what’s known in the trade as a “mass cas” - mass casualty event. But I’ve got links galore to testimony and to the emergency dpeartment surge capacity report, by Chairman Waxman, to the cities surveyed - Chicago, Washington DC, Denver, Houston, Los Angeles, Minneapolis, New York, and by experts, Hoffman, Meredith, Lewis and Kaplowitz. As usual, the sole nurse testifying didn’t make it to the published testimony yet, but I’ll add the link if it becomes available.

Witnesses testified at a hearing about the ability of hospitals and medical facilities to respond to large-scale disasters. Among the issues they addressed were emergency planning for natural disasters and terrorist attacks, current response plans, medical and personnel assets needed to meet demands of large surges in immediate care needs, and the current state of emergency care facilities. They also talked about the impact of current Medicaid regulations on the ability to provide emergency treatment.

Because I worked in NYC and have been involved in emergency preparedness post 9/11 for it, I include the snapshot for NYC that was part of the seven cities surveyed, and I think it’s right on target for its estimation of capacity and resource utilization:

SNAPSHOT OF EMERGENCY SURGE CAPACITY IN NEW YORK CITY

At 4:30 p.m. on Tuesday, March 25, 2008, the majority staff of the Committee on Oversight and Government Reform surveyed 34 Level I trauma centers in seven cities, including the New York City, New York area.1 Level I trauma centers are hospitals that have the staff and facilities to offer the most comprehensive, around-the-clock trauma care. This snapshot survey found that there was little or no emergency surge capacity — the ability to handle a sudden influx of casualties — in the Level I trauma centers in any of the seven cities.

Sixteen of the 21 Level I trauma centers that serve over 12.6 million residents in the New York City area participated in the survey. New York City is classified by the Department of Homeland Security (DHS) as a Tier I city — a designation given to “high-threat, high-density urban areas” that are at the “highest risk” for acts of terrorism.

The survey assessed the capacity of the Level I trauma centers in New York City to respond to a terrorist bombing of a size similar to the 2004 Madrid bombing. According to the Centers on Disease Control and Prevention, the 2004 Madrid bombing, in which over 2,000 were injured and more than 270 patients were taken to one hospital within 2.5 hours, is an appropriate standard for assessing mass casualty preparedness.

The survey found that on Tuesday, March 25, 2008, at 4:30 p.m. local time:

• More than half of the emergency rooms in the Level I trauma centers surveyed in New York City were operating above capacity. When an emergency room reaches “capacity,” new patients can be accommodated only in overflow spaces, such as hallways, waiting rooms, or administrative offices. Of the 16 Level I trauma centers surveyed in New York City, ten were operating over capacity, meaning they had no available treatment space in the emergency room to accommodate new patients. The average emergency room was operating at 114% of capacity in the Level I trauma centers in New York City.

• The total number of available treatment spaces in the emergency rooms of the Level I trauma centers surveyed in New York City was insufficient to respond to a Madrid event. After the Madrid attack, 270 victims were transported to one hospital for emergency care. New York City did not have sufficient treatment spaces in emergency rooms of their Level I trauma centers to handle the volume of victims treated at one Madrid hospital. In total, the emergency rooms in the 16 Level I trauma centers in New York City had only 56 available treatment spaces, less than 21% of the demands faced by a single hospital in Madrid on the day of the bombing.
1 Committee on Oversight and Government Reform Majority Staff, Emergency Surge Capacity: The Failure to Prepare for the “Predictable Surprise” (May 5, 2008). The other cities are Los Angeles, Chicago, Washington, D.C., Houston, Denver, and Minneapolis.
2 Department of Homeland Security, Tier I Urban Area Security Initiative Jurisdictions (online at www.dhs.gov/xlibrary/assets/grants-2007-program-overview-010507.pdf).
3 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. In a Moment’s Notice: Surge Capacity for Terrorist Bombings (Apr. 2007).

Surge capacity depends on more than sufficient space in the emergency room. A hospital must also be able to provide sufficient critical care and inpatient resources, such as beds in intensive care units and burn units, and general inpatient beds. If these beds are not available, patients who require hospitalization are frequently “boarded” in the emergency room until they can be moved to an intensive care unit or inpatient bed. On the day of the survey, there were also acute shortages of these critical care and inpatient beds in the hospitals surveyed.

• None of the Level I trauma centers surveyed in New York City had enough critical care capacity available to treat the casualties from a Madrid event. After the Madrid attack, 29 patients arrived at one hospital in critical condition. None of the Level I trauma centers surveyed in New York City had the critical care capacity to handle this volume of severely injured victims. On average, the trauma centers surveyed had an average of only five intensive care unit beds available. Two hospitals (13%) had no available intensive care unit beds.

• None of the Level I trauma centers had a sufficient number of regular inpatient beds available to absorb the casualties from a Madrid event. In Madrid, 89 casualties required admission to a hospital bed. No Level I trauma center surveyed had enough beds available to accommodate a surge of this size. On average, the Level I trauma centers in New York City had only 23 beds available.

After conducting the “snapshot” survey on March 25 at 4:30 p.m., the Committee staff sent follow-up questionnaires to the hospitals surveyed. Twenty-three of the hospitals responded to the questionnaire. Their responses indicate that the level of emergency care they can provide is likely to be further compromised by three new Medicaid regulations, the first of which takes effect on May 26, 2008. According to these hospitals, the new Medicaid regulations will reduce federal payments to their facilities by $623 million per year. If the states choose to withdraw their matching funds, the hospitals could face a reduction of about $1.2 billion. The hospitals told the Committee that these funding cuts will force them “to significantly reduce services” in the future and that “loss of resources of this magnitude inevitably will lead to curtailing of critical health care safety net services such as emergency, trauma, burn, HIV/AIDS, neonatology, asthma care, diabetes care, and many others.”

Twelve of the Level I trauma centers in New York City responded to this financial impact survey. Based on the estimates of the administrators who responded, these hospitals could lose a total of $384 million in federal funds each year as a result of these Medicaid regulations. If the state were also to withdraw matching funds, these two hospitals could lose as much as $768 million per year. (emphasis added)

There are many aspects to a locality’s ability to respond effectively to a widespread emergency situation, whatever the cause and nature of the problem. It’s a huge field of study, and a single blog post won’t do it justice. So instead, I’ll link to some primary sources as I mention some of the factors, and I’ll focus this post on what happens as soon as a “mass cas” is announced in a large academic teaching level one trauma center. Moreover, I’ll prognosticate on where the bottlenecks and system failures will occur inside the medical center walls and outside to its service area.

First off, emergency departments are almost universally overwhelmed and understaffed as they become the de facto shredded safety nets in the US non-system “system” of free market healthcare for the richest. Primary care providers - family physicians, general internists and pediatricians - are also on the front lines of those squeezed for “cost savings” while their more highly reimbursed brethren - largely the specialists and boutique hospitals and surgery centers - skim the remaining cream from the souring milk of healthcare reimbursement mechanisms.

But emergency departments, none the less, are expected to have all doors open and the wheels greased ready at a literal moment’s notice to accept surges of patients for days - weeks - on end. And while communities and regions drill for overall emergency preparedness, nowhere does the rubber meet the road as in the emergency department.

Most emergencies don’t conveniently occur during Monday through Friday administration carpet row business hours between 9 and 5. So for reality sake, let’s speak about a weekend evening event - one that occurs when staff is skeletal, services are constricted and daylight has wained.

For the sake of our post, let’s posit that a hurricane has struck land at an Eastern Seacoast city, and that in so doing, two passenger planes have crashed - one coming down on the runway, and the other going into the water just off the end of the runway. Simultaneously, flood walls are failing, and the city is experiencing rapidly flooding roadways with encroachment into the infrastructure: the subway is inoperable, buses can’t pass to evacuate residents, and trains can no longer run. The ferry system around the city is inoperable due to the high wind and waves. Sound familiar - I gave it a ring of Katrina, but as our populations are heavily concentrated on the coasts, the numbers lean in favor of this kind of event.

The city has declared a mass casualty, and the governor has been notified, as well as all of the local governmental, law enforcement, fire, emergency responder and hospital agencies. Residents have been instructed to evacuate from the three fourths of the city that are closest to the coast, and the remainder are being instructed to shelter in place.

Shortly after the first public announcements, one of the television stations reports the crashes of the two airplanes and intimates that it could be due to terrorism.

Now the roadways are clogged with all manner of vehicles. People are standing in the dark roadways calling out for rides from passersby. Dispatched police officers are attempting to divert traffic away from flooding and flooded areas, but are themselves being driven back by rising waters. A few inflatable craft and rowboats are being deployed for use by police.

Back at the trauma center, the nursing supervisor (this being off hours, there is no administrator in the house, and the nursing supervisor wears all of the hats: administrator on site, media relations, staffing coordinator and nursing director, among the most common), has pulled out the facility’s emergency preparedness policy and procedure manual based on HEICS, and she’s contacted the safety and security department, as well as the administrator on call and the emergency department. Because the hurricane has not abated, she has been working with shorter staffing than usual due to many staff being unable to travel to the hospital, and she has been making walking rounds to assure that all safety precautions during the hurricane have been followed - keeping patients away from windows, drawing curtains, moving patients to interior corridors, and deploying staff to reassure and comfort patients distressed from the noise of the storm.

The telephone system has just failed, and the power has flickered. She has contacted the building’s facilities personnel to assure that the backup generators are functional, and that the emergency phone system is operational. She has also been instituting the organization’s emergency call-in telephone tree to begin to call in available staff for the now declared emergency.

Meanwhile, the emergency department is communicating with the local emergency response team about receiving the casualties from both the hurricane (flood, electrocution and motor vehicle accident victims) and the aviation accident victims (burns, drowning, multiple trauma, prolonged extrication, crush injuries).

The nursing supervisor is continuing to follow the algorithm of the mass cas protocol and is toggling between communicating with the emergency department charge nurse about anticipated needs of inpatient beds, OR and PACU time and staffing, as well as emergency procurement of ventilators and other equipment needed to care for critically ill and injured patients. She is making lists of staff who can be transferred to the OR, PACU and critical care units by virtue of their clinical competence and availability. She is also making lists of patients who may be able to be discharged if they are deemed stable, have a means to travel outside the hospital and a place to go. If not, she is planning a holding area in unused waiting rooms for these patients to make room for the victims on the way.

Meanwhile, staff throughout the trauma center are being informed that a mass cas has been declared and that they will not be released from duty at the end of their scheduled shifts until relief staff arrives. The nursing supervisor is working with safety and security to create sleeping and rest places for staff in unused call rooms, former patient care areas and anywhere that cots or beds can be moved into place and where restroom and shower facilities are accessible to staff.

This is just the first fifteen minutes, folks.

But this is enough for you to get the underlying principle: the use and prioritization of scarce resources.

Interestingly, PhysOrg published a story yesterday about physicians’ triage list for use of scarce services and resources during a flu pandemic. A pandemic also qualifies as a mass casualty event, and so I include it here for your perusal.

Now, an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn’t be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals “so that everybody will be thinking in the same way” when pandemic flu or another widespread health care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.

The idea is to try to make sure that scarce resources - including ventilators, medicine and doctors and nurses - are used in a uniform, objective way, task force members said.

But wait, according to the Republican testimony yesterday, emergency departments are just empty and waiting for victims to appear on their doorsteps, and this is what yesterday’s testimony was refuting. The Washington Post reported it in terms of political affiliation, but this is not a political issue: it’s an issue of using already strained and overstretched resources which operate at over 100% capacity and expect them to do the impossible.

Hospitals in seven major U.S. cities would be overwhelmed if any of the cities were struck by a terrorist attack on the scale of the 2004 train bombings in Madrid, and shortages of emergency room capacity and intensive care beds will grow worse if Bush administration Medicaid changes are implemented, House Democrats charged yesterday.

In a survey by the House Committee on Oversight and Government Reform, more than half of 34 hospitals in five U.S. cities deemed at greatest risk of attack and two cities that will host this summer’s national political conventions said they had no emergency room treatment space available to accept severely injured patients.

[snip]

President Bush has threatened to veto legislation passed by the House last month that would impose a one-year moratorium on Medicaid reimbursement changes sought by HHS. States argue the changes would shift costs of the program to them, but the White House argues that states are padding their overall budgets with the reimbursements.

Planned changes to the program, which provides medical insurance for the poor, would eliminate reimbursement for residents and interns at teaching hospitals and payments to public hospitals. The Congressional Budget Office says the moves would reduce federal spending by about $17.8 billion over five years.

Jay Wayne Meredith, chairman of the general surgery department at Wake Forest University Baptist Medical Center, testified yesterday that the changes would cost his hospital $36 million, on top of $4.5 million it spends on its trauma center and $13 million to care for the uninsured. “We will go under,” he said, warning that the hospital would have to kill its trauma center. “I just beg you, stop the Medicaid cuts.”

[snip]

Hospital officials and Republican aides said the statistics are misleading because emergency room space and inpatient beds would be cleared in an actual emergency. Other cities surveyed were Chicago, Houston, Denver and Minneapolis.

Really? Emergency Room space and inpatient beds will be cleared in an emergency?
Well, fellas, I hate to tell you, but patients haven’t convalesced in hospitals since the early 1980s with the advent of prospective payment and HMOs. The only patients with a chance of being medically cleared would be the few referenced above: those stable, with a means of transportation and place to go.

In all likelihood, on a Saturday evening during a hurricane - or during any other mass casualty event, the last place law enforcement personnel want anyone is out on the street. So discharging them in all likelihood is fantasy and not feasible.

That means that the already present emergency department patients will be stabilized as rapidly as possible and dispositioned as discharged, but held in place - stay safe in the shelter of the hospital, or admitted and placed in the first available bed, which as you may remember from the top of the post - the hospital is already baseline short staffed due to the hurricane and weekend staffing pattern.

Then add trying to get additional staff, equipment and resources in when transportation has already been drastically curtailed, and you do the math. In all probability, only a few replacement staff will make it in, equipment will only be forthcoming if the suppliers haven’t made identical emergency supply contracts for the same stock of equipment with other local facilities, the just in time materials management systems will have depleted in-house stock to just a few days’ worth for an average daily census and not for a surge census, and resources will likely be scarcer - and not more robust - during and immediately after the hurricane and air crash victim rescue and recovery period.

Now back to our emergency department: Using the ICS - incident command system algorithms, the ED staff has cleared out all but a couple of patients, and it is doubling up resources in each trauma bay, as well as the medical resuscitation bays. Nurses from the PACU have come to the department to augment staff, and the critical care units are triaging patients as they can out of their units. Residents and interns are evaluating all patients throughout the institution for their stability, prognosis, resuscitation status and use of resources.

All of that information is being sent to the nursing supervisor in real time, and she is communicating with the emergency department attending physicians and charge nurse so that there is a working plan to triage and treat patients as they arrive.

One of the worries is about the number of ventilators that might be needed - especially in light of anticipated patients who are drowning victims, and the availability of them. Moreover, because of the nature of the injuries anticipated by the aviation victims, OR time, resources and critical care bed availability is going to be an issue.

As the first patients arrive via EMS and private cars, the emergency department goes into full mass cas operation, triaging and tagging patients by the nature of their injury, the severity and by prognosis. A supply of body bags and extra stretchers are nearby to take DOAs directly to the morgue, where they will be able to be identified and will be out of the way of the clinical staff.

Security staff maintain the morgue registry and oversee the access to it. There is no possibility of funeral homes or the coroner’s office of arriving to claim bodies during or immediately after the event.

And on it goes. But that’s reality. And that’s what the emergency departments face, regardless of the type of the event. There isn’t any flexibility and resilience in the ability of emergency departments to staff up and accommodate more patients. So when they arrive - and they will - patients will suffer and patients will die preventable deaths.

And what I didn’t spell out before, I will now: the primary resource that will determine who lives and who doesn’t is the availability of clinically competent registered nurses to provide the care from door to discharge for all of the patients. There are not enough professional nurses now, and in a large scale emergency, there will be even fewer than needed to adequate provide professional nursing care to patients. That, my friends, is in ever-increasing short supply.

Happy Nurses Week.

Nurses Week 2008: “There Were No Nurses”

I wrote this post over a year ago, but the more things change, the more they stay the same. The first week in May - to be more precise, May 6-12 - has been designated - mostly by hospital and nursing employers’ marketing departments - as Nurses Week. It’s usually filled with Twinkie-like chemically induced diabetic utterings of nothingness - candy, emotion-laden meaningless tributes, throwaway trinkets, toys and a free meal or ice cream - of which the on-shift nurses will not be able to attend due to overwhelming patient case loads. Many newspapers publish “special” nursing tribute sections - all sponsored and paid for by the marketing departments of nurses’ employers. The more creative papers even lure nurses to write and submit their own tributes, thereby having the targets of the marketers do the work for them free-of-charge. How fitting.

The reality of nurses’ practice settings in the US is that 70% or more will be assaulted, battered or worse. Globally, it’s even worse. The leading categories of offenders are from most frequent to least; physicians, fellow nurses, patients, patients’ families and visitors and other healthcare workers. Charming.

Moreover, in every health section on every television station, newspaper and online healthcare website, nursing issues get zero reportage, and nurse experts are not consulted for stories. Nor is nursing research reported in any meaningful and significant manner. Nurses are considered background noise, and nursing is considered too unimportant to investigate, analyze and report.

See for yourself. On any health story in any venue, do a search for the terms nurse and nursing. You will shortly realize that in healthcare, there are three entities which are covered: physicians, payers and hospitals.

Here’s the way it looked last year and how it still looks today:

Captain Leslie Haines, a wounded soldier sent to outpatient care at Fort Knox, KY, reported that “there were no nurses,” in a story by the reporters, Anne Hull and Dana Priest in the March 5, 2007 edition of the Washington Post.

“The living conditions were the worst I’d ever seen for soldiers,” he said. “Paint peeling, mold, windows that didn’t work. I went to the hospital chaplain to get them to issue blankets and linens. There were no nurses. You had wounded and injured leading the troops.“(emphasis added)

What will it take to wake nurses up?

Nurses’ silence is causing patient harm to those who are serving on the front lines, to those who get back to the US only to languish in settings inappropriate to the care that they need, to those who eventually get released from the quagmire of the military processing system, to those who languish in the unprepared VA system, to those who become homeless from untreated PTSD, to those who become criminalized after episodic violence from untreated mental illness, to those who are left to fend for themselves as they are least able to.

And those are just the military personnel - active and veterans - from Iraq and Afghanistan.

How about the 47 million uninsured patients, some who die from want of simple preventive care, such as a dental exam? And how about the 75 million more who are under-insured, and who are going bankrupt as a direct result of a single healthcare problem? How about the 200 million working poor who can’t afford to take time off work to see a healthcare provider, lest they lose their jobs, and thus, lose their employer-based health insurance?

Nurses are refusing to let the public and government officials know what every one of them does: the lack of professional nursing care in the appropriate care setting harms and kills people.

Nurses are refusing to step up and voice their outrage. There are few, if any, letters to the editor authored by nurses. And for the very few who do write, they may well be threatened - even with sedition, as was Laura Berg, a psychitric nurse who works in the VA system. The New York Times explained in an editorial:

The PEN American Center, the literary organization committed to free expression, is honoring an American most people in this country have never read or even heard of: Laura Berg. She is a psychiatric nurse at a Veterans Affairs hospital who was threatened with a sedition investigation after she wrote a letter to the editor denouncing the Bush administration’s bungling of Hurricane Katrina and the Iraq war.

That’s right, sedition: inciting rebellion against the government (emphasis added). We suppose nothing should surprise us in these days of government zealotry. But the horror and the shame of that witch hunt should shock everyone.

Ms. Berg identified herself as a V.A. nurse when, soon after Katrina’s horrors, she sent her impassioned letter to The Alibi, a paper in Albuquerque. “I am furious with the tragically misplaced priorities and criminal negligence of this government,” she wrote. “We need to wake up and get real here, and act forcefully to remove a government administration playing games of smoke and mirrors and vicious deceit.”

Nurses who are in positions to do so refuse to blog or engage in web-based communications with other nurses and the public. Nurses in academia and research don’t communicate informally with clinical and service-based colleagues. There isn’t a meta nursing community. Discrete employer and school-based silos of communication dominate, and rarely do nurses speak across clinical specialties and patient populations to one another.

Nurses refuse to change the status quo, and they are content - or malcontent, but acquiesce anyway, to being pushed, pulled, bullied, threatened and coerced into working in unsafe conditions, in organizational structures that encourage and reward cannibalizing nurses - most often by the so-called nurse leaders, who in another Orwellian nightmare, actually lead nurses to their own oppression and failure, and practice conditions that are unsafe for patients and which do not lead to patient health, rehabilitation, recovery or peaceful deaths.

Nurses have passively waited for hospitals, their employers, unions, the “government”, their “nurse leaders”, or the public to cede them power, when they know full well that they must take that power and professional autonomy for themselves.

All the while, patients are suffering, and patients are dying from preventable errors and preventable harm.

Nursing is at the very edge of the precipice of breaking the social contract to keep patients safe, to advocate effectively for patients and to assist patients in attaining, regaining and maintaining health. The public has a right to professional nursing.

If today’s nurses won’t provide it, then the public has a right to remove the trust it has placed in nursing, remove the financial and other supports for it and put something else in its place.

American Nurses Association - WHERE ARE YOU?
Registered Nurses - all 3 million of you - WHERE ARE YOU?
How dare nurses abandon their primary obligation?

And patients/public: Demand professional nursing. Demand that nurses live up to their social contract.

It’s not just Walter Reed. It’s not just a few isolated problems.

It’s the very heart of the United States - abandoned by its president, plundered by its vice president and former secretary of defense, pandered to by lobbyists and corporations copulating with elected officials to steer monies to stockholders, but it’s also in the heart of every single professional nurse who tolerates the status quo, who doesn’t protest, who doesn’t engage in self-governance, who doesn’t whistle-blow, who doesn’t advocate for patients and nurses and who turns away and doesn’t support those who do have spines, who do take the awful risks of advocacy and who do move nursing self-governance forward.

Physicians diagnose and treat disease. Physicians do not provide professional nursing. They aren’t educated to know what professional nursing care is, and frankly, only a few recognize it when it’s smack dab in front of them. It’s not physicians’ duty to advance professional nursing.

It’s the invisible nurse, content with discontent, inarticulate and in the background, who makes the difference between life and death, recovery and morbidity, rehabilitation and lifelong disability.

Addendum: Nursing Advocacy.org was invited to participate on this blog. After more than a month, the reply was “no thanks - too busy.” It’s too Hollywood-oriented to be of use. As of today, no response to the military healthcare problem appears on its website, nor has any professional nursing organization with a direct reference to the military healthcare system problems or problems with the standard of care at the VA system. I invite all readers to provide links to ANY professional nursing responses, calls for action, plans of action - anything related to addressing these two issues - to this blog.

The National Nurse Organizing Committee is not charged in its mission with representing professional nursing in the US. It does not advocate for the use of professional practice groups. It competes with the ANA and does not attempt to reach consensus with it, hence, no support from this quarter for that particular mission. Indeed, it is an offshoot of the California Nurses association - a breakaway union which is headed by a social worker - not a nurse.

The American Nurses Association IS CHARGED in its mission for representing professional nursing in the U.S. Nurses have the obligation to hold it accountable for implementing that mission.

As to negative and stereotyped media coverage: that is the expectation because nurses don’t provide any alternative. Every nurse has a duty to the profession to advance it. One way is to serve as a media and political resource.

Write and telephone to offer nursing and healthcare system expertise to US senators, representatives, the Secretary of Defense, and the former presidential commission co-chairs, former Sen. Dole and former DHHS Secretary Shalala. Write to healthcare reporters and provide a nursing perspective on stories which should have included nursing’s contributions. Offer to put reporters in touch with appropriate nurse experts.

Every nurse must take this opportunity to write the same people and entities explaining why professional nursing nursing is needed, what benefits it provides for the patients in need (be specific and speak to TBI, burns, complex wounds, complex fractures -open and closed, amputations - immediate post op and long term rehabilitation, mental illness, psychiatric nursing for PTSD short and long term - as these are the top diagnoses by incidence in both the military and VA system), and how nurses coordinate and manage healthcare so that patients DON’T GET LOST. Speak to the education and experience needed to achieve clinical specialty expertise. Speak to the need for nursing positions so that reasonable patient caseloads can be maintained. Quote expert nurses.

Choose your area of expertise and strength and SPEAK UP!

This is what supporting the troops is all about! That’s what the essence of patient advocacy is all about.

Live up to your obligation as a citizen, as a nurse, and as a professional. The way to combat stereotyping is to provide an overwhelming vision of leadership, of professional competence and of professional autonomy and ownership.

Own nursing practice.

Own the future of nursing.

So Happy Nurses Week, except that there still are no nurses.

Fringe Kooks

Frank Rich writes about race and the free ride that McCain is receiving from the corporate media. He understands some of the issue, but he still dances rings around that elephant.

Mr. Hagee is not a fringe kook but the pastor of a Texas megachurch.

Hagee and his Elmer Gantry brethren are indeed fringe kooks of the worst kind.

Indeed, it is simply folly for any political candidate to pander to any religious figure in any capacity. One’s religious affiliation is not a criteria for political office competency. Period.

However, every political candidate should make known his or her beliefs and assumptions about fundamental issues of race, equality, liberty, civil rights, the ability to carry out the oath of office and how they translate beliefs and assumptions into foreign and domestic policy. How do they plan to address poverty, education, health care, the domestic economy, foreign relations, the global economy, the infrastructure of the nation, the military, their perspective on the roles that federal regulation plays, the quality of life of the citizenry. etc.

In reviewing the corporate media coverage, the exact opposite is in evidence: attention ad nauseum about the personal, religious and unrelated trivia that mean absolutely nothing relative to the candidates’ qualifications and abilities for office. With one exception - the reportage of Charlie Savage of the Boston Globe in investigating the candidates’ views on the usurpation and use of executive power and signing statements, no “reporter” has even bothered to ask a single substantive question, let alone investigate candidates’ voting records, past experience and relevant work history to policy and conduct.

Of course corporate media has given their corporate candidate a pass: McCain is the candidate - albeit tepidly accepted - of the corporate oligarchy which is in bed with the Republican, and to a lesser extent, the Democratic party.

None of this is to say that two wacky white preachers make a Wright right. It is entirely fair for any voter to weigh Mr. Obama’s long relationship with his pastor in assessing his fitness for office. It is also fair to weigh Mr. Obama’s judgment in handling this personal and political crisis as it has repeatedly boiled over. But whatever that verdict, it is disingenuous to pretend that there isn’t a double standard operating here. If we’re to judge black candidates on their most controversial associates — and how quickly, sternly and completely they disown them — we must judge white politicians by the same yardstick.

The real question is this: who is the candidate of the citizenry? Who can best lead the country to a Constitutional restoration? Who can re-introduce a vigorous and effective global diplomatic effort? Who can hold the criminals now ensconced in government accountable for their unchecked criminal activity? Who can bring the warring country together under an umbrella of democratic ideals and not religious dogma?

The only places to find those questions being asked is on the progressive blogs and in the global media. The US corporate media is fully an organ of propaganda and it no longer serves the public interest.

There is not just a double standard for black and white politicians at play in too much of the news media and political establishment, but there is also a glaring double standard for our political parties. The Clintons and Mr. Obama are always held accountable for their racial stands, as they should be, but the elephant in the room of our politics is rarely acknowledged: In the 21st century, the so-called party of Lincoln does not have a single African-American among its collective 247 senators and representatives in Washington. Yes, there are appointees like Clarence Thomas and Condi Rice, but, as we learned during the Mark Foley scandal, even gay men may hold more G.O.P. positions of power than blacks.

A near half-century after the civil rights acts of the 1960s, this is quite an achievement. Yet the holier-than-thou politicians and pundits on the right passing shrill moral judgment over every Democratic racial skirmish are almost never asked to confront or even acknowledge the racial dysfunction in their own house. In our mainstream political culture, this de facto apartheid is simply accepted as an intractable given, unworthy of notice, and just too embarrassing to mention aloud in polite Beltway company. Those who dare are instantly accused of “political correctness” or “reverse racism.”

An all-white Congressional delegation doesn’t happen by accident. It’s the legacy of race cards that have been dealt since the birth of the Southern strategy in the Nixon era. No one knows this better than Mr. McCain, whose own adopted daughter of color was the subject of a vicious smear in his party’s South Carolina primary of 2000.

And while racism and bigotry are indeed corrosive and destructive forces which are concealed by a thin varnish of media bloviation, it is but one toxin of many which have been produced in ever-increasing and virulent quantities to erode, to infect and to destroy this country from within.

About The Relationship Between “Credibility” And Readership/Market Share

Sorry for such tangentialism today, but I can’t help but try to weave a few waving threads from recent examples:

NBC is refusing - in a very bare and brazen way - to address the evidence brought by the NYT, Glenn Greenwald and others relative to disclosure of actual and potential conflicts of interest and the promulgation of propaganda as news.

The WaPo in both the news and editorial division, unfailingly produces propaganda which repeats WH and Bush appointee talking points. Somalia as another opportunity to repeat Iraq? Bring ‘em on! - the no-bid contracts and war profiteering, that is. Also - I think that today’s Somalia editorial was to soften up the readership for air assaults on Iran. “If we can do it in Somalia, think of the opportunities in Iran….”

ABC subverts a Democratic presidential candidate debate by inserting questions which are Republican ad hominem attacks against the candidates at the expense of evidence-based substantive policy and credentials questions.

Both television and print news media report steadily declining readerships and revenues, thus gutting news rooms of adequate budgets to produce and gather investigative news stories which are factual, evidence-based, well-sourced and portrayed in a contextually accurate manner.

No corporate media source has (to my knowledge) called for the impeachment of Bush/Cheney/Bush appointee.

Since the revenue streams continue to decline, the media consolidation results in corporate owners which all have government contract/military/political ties, and the media steadfastly continues to produce propaganda as news, isn’t the emerging picture that of the corporate “parents” in concert with their parasitic hosts using consumers as propaganda recipients and fuel, and not as a public which has a right to be informed? I don’t think they are worried about advertising revenue and market share - the readership/viewership’s purpose is all about softening and supporting the corporate parent’s overriding interests: government contracts/military/industrial interests.

I know that this has been touched on in the blogs, but if that is the overriding purpose of news divisions, it changes the dynamic of how we - the supposedly informed minority segment of the public - should in turn treat the media.

And maybe it isn’t with the righteous indignation of GG and other experts who blog. Instead, maybe it should be with “parallel” news divisions which look, feel and interact like the corporate monsters for the purpose of planting real evidence and