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Tuesday, 18 May 2010

Nursing

I’ve been in nursing, one way or another, for more than twenty years now. Given my somewhat complicated biography, it wasn’t my first choice of career and the decision to enter it at the end of my twenties was more a rational one, taken at a period of my life where (I felt) I had to put myself on some kind of steady job/career path – I found myself with a young family to support.

It’s a decision I’ve reflected on frequently since taking it, but one that I have never really regretted. However, I freely admit that I do not belong to that group of colleagues (who I really admire), who seem to have been born for the job and who never seriously considered doing anything else. In that sense, it has been more of a profession for me than a vocation. Not that there’s anything wrong with that; indeed, as the years have passed, I have found myself increasingly regarding the idea of professionalism as being very useful for the long haul in this kind of work, helping me to integrate it into my life in general, giving me the capacity to combine genuine empathy with the necessary distance to be able to carry on daily dealing with the (often shocking) human suffering, pain and misery with which nurses are confronted without burning out or going crazy.

That said, I want to sound off about the way people working in the nursing area are often regarded by and treated in what is frequently called the “health industry” and our society in general. Our high-octane, performance-driven, (selectively) cost-conscious culture has developed all sorts of mechanisms and instruments to increase efficiency, frequently given such titles as “quality assurance” or the increasingly ubiquitous “total quality management” (TQM). I don’t want to completely demonise such processes – they can be very useful in many ways – but we should remember their origins in assembly-line based production industries and be wary about giving them unquestioned supremacy in areas which have to do with people and relationships (and the nursing process is fundamentally about relationships), particularly when these have to do with people in extreme situations – and people who are in a position where they need nursing (of whatever sort) are generally in situations which can be described as extreme. You just can’t treat someone suffering from terminal cancer or dementia in the same way as you can a carburettor and then decide that the time a nurse should need to help such a person to wash themselves or go to the toilet can be computed in the same way as the time someone on the factory floor needs to connect the carburettor to the rest of the engine.

But this is, in fact, what is increasingly happening in the health care area. Some of it is understandable. In a world in which medical advances make more and more possible it is becoming increasingly clear to everyone that such progress is not cheap. The fact that a basic driving mentality in our modern culture is to see every difficult situation as a series of problems to be solved exacerbates this. The end result of all of this is that modern societies (particularly in the so-called “developed” world) are faced with continually increasing costs in the health area and the issues of how we are going to pay for all this and how we can be sure that we are really getting value for the billions we are spending already become ever more critical.

Nursing care is, by its very nature, labour intensive. And this is where the problems really begin. Faced with (frequently conflicting) demands for high quality and efficient costing, the easiest quick fix is to look at staffing levels and organisation. The easiest reaction for medical institutions of any kind coming under economic pressure is to try to reduce labour costs. For all sorts of obvious reasons, for example, a hospital confronted with a choice of not buying the latest sexy piece of diagnostic equipment or getting by with a couple of nurses less will almost always choose the second option. The basic view of those making the decisions seems to be that there is always some slack in the nursing care area; that more rational organisation will always lead to a situation where fewer people can do the same amount of work.

In the nursing/care area this kind of thinking is made easier by the fact that it usually brings results – in the short term. These has a lot to do with the fact that people who work in such jobs are generally conscientious, highly motivated and are driven by an ethos which makes them try to ensure that their patients don’t suffer as a result of such efficiency drives. So they work harder, put in more (frequently unpaid) overtime, etc. Often the pressure becomes too much, some become ill and have to take sick-leave. The resulting gaps are filled by their colleagues, who have to do even more as a result. And almost everything they do has to be done almost immediately, whether that’s at night or on Sunday afternoon. The pressure increases. This increased pressure can – and sometimes does – lead to mistakes being made. But there are ways around that too, you just have to make sure that every step of the work done is adequately documented so that in the case of a mistake being made it can be quickly identified and rectified. Of course, this obligation to document everything also increases the work-load further. In an iconoclastic mood, I sometimes ask fellow health professionals the question; what is worse, to do something and not document it, or to document something and not do it? Ethically, the answer is simple but, in terms of basic self-protection, it is often better to be sure that your documentation looks complete.

And, should an institution or a department do their job really well, then that’s a sign that there’s obviously more potential for savings there. And so the screw is turned a bit more …

So, the next time you’re in hospital, in pain, and you ring for a nurse, don’t be surprised if it takes her/him a quarter of an hour to answer your call. Chances are there are only two or three of them on the shift responsible for around forty patients. The next time you see a couple of nurses drinking a cup of coffee on duty, consider that they may just have finished changing the dressing on a stinking open tumour, or that a patient may just have died (probably when they weren’t there, because the amount to be done in every shift doesn’t allow them to simply spend twenty minutes just being there for someone who’s dying). Of course, it’s also possible that they may simply be a bit burnt out – too many night shifts, too much suffering and pain witnessed, a relationship failed because their partner couldn’t deal with them being frequently exhausted or stressed out during their irregular free time. And the next time you hear a discussion about the costs of health care, think about what the managers of health insurance or pharmaceutical companies earn compared with a nurse. Or consider what you paid the electrician per hour the last time you had to call him/her because your washing machine was broken. Nurses would be very glad to work for that kind of money

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