"Every year, nurses are responsible for thousands of patient deaths."

January 5, 2006 -- Today U.S. News and World Report ran Marty Nemko's long feature "Career Center: Most--and least--rewarding careers." The feature classifies different jobs as excellent, good, fair, or poor careers for 2006. "Registered nurse" makes the "good" category. Nemko identifies some of the real benefits of nursing, including good pay and job security, and the "nice reward" that nurses are "often critical to patients' recovery." However, his brief description is marred by some language that is sloppy, if not disrespectful or inaccurate. Nemko's only "caveat" about nursing is that people should consider it only if they are "truly caring and detail-oriented" because "[e]very year, nurses are responsible for thousands of patient deaths." Of course nursing errors (like physician errors) do result in patient deaths. But many nurses will bristle at the suggestion that the major problem in nursing today is that nurses themselves are so lethally careless. Indeed, short-staffing and other workplace difficulties nurses have faced in the last decade have made the job virtually impossible for many nurses to do well.

Some of the substance of Nemko's paragraph on nursing is good. He provides a basic look at some of the major benefits of the profession, with an emphasis on the tangible ones. He leads with the comment about nursing "often" being critical to patient outcomes. We might have said "almost always," but maybe that's quibbling. Nemko also mentions the average $57,000 salary for a "basic staff nurse" (actually that is based on early 2004 data), and notes that some urban nurses earn over $100,000 annually. He notes the profession's good job security, explaining that "just a two-year degree will generally land you a job," while a "four-year degree" will provide many options. With a "moderate amount of additional training," you can become an advanced practice nurse, which offers "a degree of autonomy approaching that of doctors." The autonomy statement is probably fair enough, and not something everyone knows about NPs, though it also implies that other nurses lack autonomy, which is incorrect. Registered nurses are managed by other nurses, not physicians. Finally, Nemko states: "Caveat: Every year, nurses are responsible for thousands of patient deaths. Please consider this career only if you are truly caring and detail-oriented."

Unfortunately, some of Nemko's summary is problematic. Bedside nurses are unlikely to appreciate being called "basic staff nurses." It seems unlikely that he would refer to physicians this way. Moreover, the phrase "just a two-year degree" isn't exactly a respectful way to refer to the associate's degree, and it's not really accurate, since once the prerequisites are taken into account, it now requires more like three years in the U.S. The "four-year degree" Nemko describes is more commonly known as a "bachelor's degree." The "moderate amount of additional training" most advanced practice nurses get is generally known as a "master's degree." Stop us if we're going too fast.

But the biggest issue we saw was the one about "thousands of patient deaths." The reference to being "detail-oriented" may suggest to many readers that all health care errors that result from inadequate nursing are caused by failures of nursing diligence. That is far from the case. Many nurses would argue that the great majority of "errors" that appear to be their "responsibility" are primarily the result of the devastating short-staffing that has crippled nursing practice in many settings since the 1990's. Other factors include a lack of other clinical resources, systemic communication problems, and poor relations with physicians. Nurses, like any professionals, make mistakes that are no one's responsibility but their own. And the profession certainly has problems that can cause errors, such as the difficulty some nurses have in asserting themselves. But to simply assign responsibility for thousands of deaths to nurses wrongly suggests that the big problem in nursing is that nurses are careless. A better statement might have stressed that because nursing is challenging and lives hang in the balance, candidates must be detail-oriented. And of course, Nemko's paragraph contains nothing about the more pressing issues discussed above, which would seem to be more important for career-seekers to know than this odd warning that people avoid nursing if they're not caring and responsible. The paragraph about medicine (which also appears in the "good" category) contains no such warning. Is it just nursing that tends to attract the sloppy and uncaring?

Other health professions figure prominently on these lists. The "excellent" section includes optometrists, physical therapists, speech therapists, pharmacists, and physicians' assistants. (Nurse practitioners have no listing separate from other nurses.) In the "good" section, we learn that physicians are "the top of the food chain." But the description mostly consists of Nemko's arguments that medicine is "more trouble than it's worth," what with supposedly declining pay, uppity Internet-reading patients, insurance and paperwork burdens, medical school expenses, and grueling, low-paying residencies. His conclusion? "Nurse practitioner or physician assistant might be a wiser choice."

This comment pretty clearly stems from Nemko's view that those alternatives are a lot easier. Of course, U.S. physician training requires real sacrifices, including eight years of college, long hours, and relatively low salaries for the first few years. However, becoming an NP in the U.S. generally requires at least six years of college--as we recall, that's called a master's degree--and many NPs have doctorates that take 8-10 years of college to acquire. Moreover, when physicians complete their residencies, they typically leap far ahead of NPs in pay and stay there for decades. Physicians earn more money than any other category of workers in the U.S. An accurate analysis of the financial rewards of a given field requires consideration of overall long term benefits, not just up-front costs.

On the whole, we appreciate this feature's inclusion of some of the positive aspects of nursing. But we wish the author had been more precise and accurate in how he described the profession. We might even suggest that influential national publications run pieces like this only if the editors and writers are truly "detail-oriented."

See Marty Nemko's article "Career Center: Most--and least--rewarding careers" from the January 5, 2006 edition of US News and World Report.

Sendy Marty Nemko your thoughts at mnemko@earthlink.net and please send a copy to the letters editor at US News and World Report at letters@usnews.com and please also copy us on your letter at letters@truthaboutnursing.org