Rosie the Nurse

September 25, 2006 -- The cover story of this week's Business Week was Michael Mandel's lengthy "What's Really Propping Up the Economy." The piece offers a detailed argument that the massive growth in health care has been the only thing saving the United States economy from a "deep coma." Mandel stresses that the health care industry has added 1.7 million jobs since 2001, compared to "none" by the rest of the private sector. But he worries that the increasingly health care-focused U.S. economy is unbalanced. He suggests that "restructuring" and information technology may be able to streamline care, reducing spiraling costs--and the number of health jobs. Nursing is literally the poster child for the piece: the cover presents a version of the famous World War II "Rosie the Riveter" poster, but the tough-looking Rosie is now a nurse. Inside, the story points to the growth in nursing jobs, briefly describing the experiences of three enthusiastic second career entrants into nursing, two students and one recent graduate, who is male. But for expert commentary on what all this means, the piece turns to the usual suspects: economists, executives, physicians, and public health experts--and not one of these appears to be a nurse. More fundamentally, we're concerned about the presentation of the explosion in nursing vacancies as a measure of the strength of the profession. A key reason for this growth in vacancies is poor working conditions, like short-staffing. Pieces like this will not encourage society to allocate the resources nursing needs to resolve what is, in fact, a crisis. And while structural reforms and new technology can streamline care, it's important to pursue those with a full awareness of how nurses improve patient outcomes.

The piece spends most of its time marveling at how health care has grown as U.S. manufacturing declines. (The article notes that it's including as health jobs those in "pharmaceuticals and health insurance," but does not say how many of the new jobs were in those areas.) The piece does not completely ignore the problems in U.S. health care, referring to the "out-of-control costs, the vast inefficiencies, the lack of access, and the often inexplicable blunders." It notes that the high price of U.S. care has hurt competitiveness and left 47 million uninsured. But the only potential solutions it discusses are "restructuring" to reduce the number of jobs in health care delivery and more investment in information technology. It does not mention potential changes in health care financing, which is perhaps the most obvious thing that sets the U.S. system apart from that in other developed nations. Perhaps the failure to discuss this reflects a view that much of the magazine's readership does not wish to consider such ideas, but it would have made for a more balanced piece.

The focus on undefined "restructuring" and IT alone may serve to encourage nurse staffing reductions by those who may not fully understand what nurses do, while failing to address costly elements of the current system that some feel contribute little of value to patients. The piece quotes a physician and a public health expert to the effect that we can deliver quality care with fewer physicians, apparently as a general matter. On the other hand, another physician and an economist argue that there's no need to try to reduce the health care workforce because its growth is a natural and beneficial result of higher incomes. We suspect that too few physicians in a given clinical setting would lead to worse care. Obviously there must be some lower limit, and it's our sense that many physicians today feel their workloads prevent them from giving the level of care they would like to give. And as the economist suggests, doing geriatric health care right would require "a lot more geriatricians."

Research in the last decade has clearly shown that inadequate nurse staffing leads to worse patient outcomes. One well known study found that patient mortality increased 31% when nurse patient loads were doubled on post-surgical units. Although this piece ignores the staffing of nurses and all other non-physicians, implying that only physician staffing could really affect the quality of care, it is dangerous to plant the seed in the average reader's head that there is such gross inefficiency in clinical settings that we could just start cutting skilled care givers and patients would not feel it. This is the kind of thinking that helped spur the worst nursing shortage in history. No doubt technology and reforms may be able streamline clinical care in specific contexts. But it's important to consider exactly what a worker contributes--whether in a clinical setting or an insurance company office--before deciding that worker's job can be eliminated. And it's also important to assess whether the alternative being proposed, whether a different delivery structure, type of caregiver, or new technology, can really do the same work. Such alternatives should face the same rigorous scrutiny that nurse practitioners have faced in assuming responsibility for tasks traditionally the province of physicians.

One "online extra" is a "Table of Projected Job Openings, 2004-2014." Nursing leads the pack with 1.2 million projected openings, though that depends on splitting teachers into three different categories; based on these figures, there will be more openings for K-12 teachers alone than for nurses. But more basically, to see nursing vacancies as nothing but an expression of professional strength is to miss the big picture. Of course it's usually a good thing when a profession experiences rapid growth. And some of the current and projected growth is driven by demographic changes and new care technologies. In theory, market demand should result in better pay and working conditions for practicing nurses. But that theory assumes a rational market with accurate and complete information. And sadly, much of the explosion in nursing vacancies is driven by a severe undervaluation of nursing. That has led to poor working conditions and insufficient resources to train those who actually seek to become nurses. Vacancies don't mean much if these barriers prevent them from being filled in the long term. And happy talk about all the projected vacancies will not reduce those barriers.

An experienced nursing expert might have been able to provide some of this additional perspective. But that does not seem to be what the magazine was after for its nursing input. It offers three profiles of nursing entrants, but they are two students and one nurse who appears to have just graduated. The three appear to attend or have just graduated from the nursing school run by the Conemaugh Health System in Johnstown, PA. The choice of persons with so little experience suggests that the piece views nurses as subjects to be studied, not sources of valuable policy input. It is interesting that all three are second career entrants, and they do present good examples of workers who realized what nursing has to offer. One used to sell appliances at Sears; now he's the "only male nurse" at a NICU in Johnstown. The piece describes another of the new entrants as a "student nurse," a term that, while common, suggests that you're a nurse as soon as you get into school. We have yet to see the media refer to a "student physician." The piece also stresses that this student, who used to sell insurance door-to-door, can actually make more money now without traveling. More generally, it says health care "offers a full range of jobs, from home health aides making very low wages through technicians and nurses making middle-class salaries up to well-paid doctors." That's broadly accurate, but it doesn't do nursing justice in view of the range of nursing salaries, or the statement's implicit use of salary as a marker for professional worth--the piece did not say a "range of salaries," but a "range of jobs."

But the most striking nursing element here is of course the cover. It's a fairly exact reproduction of the famous "Rosie the Riveter" recruiting poster created by the United States War Production Coordinating Committee in 1943. Whereas the original poster presented a tough-looking wartime factory worker Rosie with a red bandana, Business Week gives us Nurse Rosie in the same pose, but with a nurse's cap and period nurses' uniform. We guess we can't complain much about the regressive uniform when it's an adaptation of an image from 60 years ago. But we wish the media could find a more updated graphic for nursing; we've seen plenty of press pieces employ similarly outdated images for no apparent reason. We do appreciate the image of strength, and the suggestion that nursing is critical to national wellbeing, which is not exactly the way nurses have traditionally been viewed. There are some key changes from the original Rosie. First, whereas the original Rosie came with "We can do it!" in her speech balloon, this one has the headline of the article: "What's Really Propping Up the Economy." This theme--"propping up"--is a bit less inspirational than the original. Moreover, factory Rosie was defying gender assumptions, helping to pave the way for women (eventually) to assume a wider range of jobs outside the home. Nurse Rosie arguably reinforces gender assumptions, though the piece does include a man as one of its three example nurses, well into the text. Of course, as noted above, to suggest that nursing is at a point of power now is highly misleading in view of the problems that have contributed greatly to the shortage. That will not help decision-makers or the public understand the need for resources and other measures to overcome the crisis.

We thank Mr. Mandel and Business Week for this serious, if somewhat distorted and incomplete, look at nursing's place in the U.S. economy.

See the cover story "What's Really Propping Up The Economy" in the September 25, 2006 edition of Business Week. Also see the associated sidebar "Table of Projected Job Openings, 2004-2014."