A Nursing Morality Play in 3 Acts

August 28, 2007 -- Today The New York Times ran "Code Blue: A Medical Morality Play in 3 Acts," by physician Larry Zaroff (right), a regular contributor to the Times who now teaches medical humanities at Stanford. The "Cases" piece includes physician-centric descriptions of a 1961 incident in which Zaroff helped to save the life of a cardiac patient--a man who later showed little appreciation. Center director Sandy Summers sent Dr. Zaroff a detailed analysis of the piece. She explained that it presented nurses as peripheral physician subordinates and suggested that Zaroff alone saved the patient, effectively giving him credit for nursing work. Dr. Zaroff's short but extraordinary response did not hide behind feeble excuses. Instead, Dr. Zaroff acknowledged the error, apologized, and noted that nurses are "the most vital part" of patient care because they "make the first decision," and have often alerted him to key problems of post-surgical ICU patients before residents were aware of them. We thank Dr. Zaroff, and we hope his and other future media accounts of care will reflect the fair-minded approach in his response to us.

Act One:   Larry Zaroff's August 28 "Cases" Piece

Dr. Zaroff's piece describes efforts, while he was a surgical resident in Cambridge (Massachusetts), to save the life of a cardiac patient whose heart had stopped. Several years later, Zaroff rented part of a house from this same man, who did not recognize him. When Zaroff and his family were moving out at the end of the lease, the man angrily demanded $300 to repaint a mantel on which Zaroff's children had colored. This was an unreasonable sum that the family could not easily afford. Zaroff reminded the man of their previous meeting: "I was the one who saved your life." This information pained the man, but he still did not relent on the $300. Zaroff concludes:

Older now, I would not have told him. In 40 years of practicing and teaching, I've learned this much: his agony was not worth $300 to either of us.

Act Two: The Center's August 31 letter to Larry Zaroff

Truth executive director Sandy Summers sent Dr. Zaroff the following letter about his "Cases" piece:

Dear Dr. Zaroff,

I am writing in concern about your recent "Cases" piece entitled "Code Blue: A Medical Morality Play in 3 Acts." The story is an interesting one, but unfortunately, it gives readers the impression that only physicians have anything to do with life-saving during codes or heart attacks. I will give a few examples by quoting your article below:

When I heard the Code Blue bugle call, I ran up two flights to a private room, where a respiratory therapist and a nurse were desperately trying to keep the patient alive, punishing him with blow after blow to the chest.

Were they abusing him? Doing something wrong-headed, destined to fail, while awaiting the physician who would know what to do?

I took over, asking for the usual: check oxygen level, call anesthesia to insert breathing tube, get the defibrillator, notify the family -- "tenderly, please, just say 'turn for the worse, please come back to the hospital.' "

"I took over" makes it sound like everyone else was shooed from the room and you did everything by yourself. Would not "I took charge" be more accurate? (FAQ: What? Did the Center really just say that?). As you mention in the next sentence, there is much work to be done on a coding patient. Surely the nurses had begun at least half of this work on their own, but your description of directing them to do things they were likely already doing makes you sound brilliant and commanding, while it makes the nurses sound empty-headed, without knowledge on how to proceed in a code.

The defibrillator arrived ("Everyone away!" "Hit it!") and current flowed through the patient, a tsunami of an electric wave.

Here it looks to me like it's possible the person doing the defibrillating may not have been you--but I doubt many other readers will get that. It seems like the defibrillator arrived by wheeling itself and the current flowed on its own by some sort of brain signal you sent it. Or maybe the hospital walls orchestrated this work. That is often how nursing work is described in the media. Nobody does it, it just gets done. Most readers, however, will probably assume you did the defibrillating (and it even seems designed to give readers this impression while remaining technically accurate). This gives you credit for the work that nurses do.

When physicians get credit for the work that nurses do, they get the respect, admiration and funding to do research on this work and to improve and provide for it in clinical practice. This is one of the reasons that nursing is in such dire straits--people think nurses don't do anything of value, so nursing clinical practice and research is underfunded. When the profession is underfunded, nurses are understaffed, schools have a dearth of faculty and building space which is insufficient to educate the number of nurses we need to resolve the shortage. And nurse researchers are starved. For instance, nurse researchers get only 0.75% (yes, less than 1 percent) of the NIH budget for their research even though nurses make up the largest body of health care professionals in the US. This is an indication of how undervalued and pathetically underfunded the nursing profession is.

Why tell him I resuscitated him, remind him he almost died?

Here again, it appears that you did the resuscitating all by yourself.

Don't raise your head from the exposed heart even if the orderly knocks over the rinse basin or the nurse drops a tray of instruments.

Nurses and other staff are just a bunch of clumsy bumbleheaded fools who make mistakes while threatening the work of the heroic physicians who are doing all the serious life-saving. It seems as if you don't have anything positive to say about your non-physician colleagues.

"Well, I was the one who saved your life, brought your heart back."

Again, it seems as though you were single-handedly responsible for saving his life.

Dr. Zaroff, we are in the midst of a global nursing shortage of unprecedented proportions that is taking lives in droves. The shortage exists in large part because society does not understand what nurses do to save lives and improve patient outcomes. The media relentlessly tells the world that physicians do everything of importance and nurses play a minor, insignificant role in serving the physicians (as compared to the patients). Society does not know, because of myriad inaccurate depictions, that nurses are autonomous professionals whose care matters.

Your depiction is not the sole inaccurate media depiction. Your colleague Lawrence Altman wrote an article in the New York Times recently that was also very bad for nursing. Hollywood, from ER to House to Grey's Anatomy to Scrubs, portrays physicians as being the sole life-savers, as flawed but glorious heroes whose work is of vital importance to patients. Of course, with all but two of the dozens of major characters on these shows being physicians, the physicians spend much, if not most of their time doing nursing work--thus giving credit for nursing work to physicians and their profession. Meanwhile, nurses are shown to be supervised by physicians (when they are supervised by nurses in real life), and as in charge of menial work like answering the phone, getting things for physicians, or getting other physicians for physicians--not exactly the sort of depiction that is going to get the profession a lot of respect or funding.

In order for the global nursing shortage to resolve, the media must play a larger role in telling the truth about what nurses really do to save lives and improve patient outcomes. If I can help you accurately describe the work of nurses in the future, please feel free to call on me for assistance.

Sincerely,

Sandy Summers, RN, MSN, MPH
Executive Director
The Center for Nursing Advocacy

Act Three:   Larry Zaroff's August 31, 2007 Response

Dear Ms. Summers,

I am corrected by your keen observations. Nurses are the most vital part of patient care. They make the first decision. Nurses are especially important in cardiac surgery in the ICU. And many times nurses have alerted me to a problem before the resident was aware of the changes.

My apologies,

Warmly,

Larry

-----

Larry Zaroff, M.D., Ph.D.
Stanford University
Consulting Professor
School of Medicine & Program in Human Biology
Senior Research Scholar
Center for Biomedical Ethics

Epilogue: A Better Tomorrow?

Public acknowledgments of this sort by media creators are rare, and that is certainly no less true of health professionals who create influential media about health care. (A number of the writers and key advisors for Hollywood hospital shows are physicians.) We thank Dr. Zaroff for his apology, which includes enough detail to indicate that he does understand our basic point. We hope more in the media will follow his example, and in particular, that all health professionals who create media will try to provide fair depictions of the role nurses play in health care.

Please send Larry Zaroff a note of thanks for reflecting on how his writing has affected the nursing profession and give encouragement for improved depictions of nursing in the future. His email is

Please copy us on the letter at letters@truthaboutnursing.org. Thank you!

FAQ: Did the Center really just say that it would be fair to describe the physician role in a code as "taking charge?"

We did. Some may find the statement an odd one coming from the Center, since we often focus on nursing autonomy. However, in terms of running a code, we believe that having one person coordinate the entire code team will generally limit chaos and improve care. And in this situation, nurses do normally yield overall direction to the physician when s/he arrives at the scene, because it is helpful to have medical diagnostic expertise for this task. (An advanced practice nurse might well be qualified to run a code, since such nurses have advanced diagnostic training, can we be strong and they do run codes.) Of course, if a person "running" a code is missing something or guiding the team down a dangerous path, then nurses should advocate a different course.

However, it is important to stress that we are talking about one vital but relatively infrequent set of emergency procedures. The Center does not see physician leadership of codes as inconsistent with nursing autonomy, since nurses continue to assess, diagnose, plan and intervene for patients. Nurses perform these tasks while physicians are present and giving overall direction, and nurses do not cease autonomous activities during codes. Physicians may ask for IVs to be started, blood to be hung, chests to be cracked and bleeding to be stopped. Nurses will already have begun most of these tasks anyway, but physician requests provide an important double-check to ensure that key tasks are addressed in a timely way. And nurses still decide on the order that self-prescribed or physician-prescribed tasks are being done, based on priorities as assessed by the nurse. No competent nurse will stand checking numbers on a bag of blood to be infused while a patient is blue and choking with an unattended airway, because nurses are autonomous professionals who focus on the best interests of the patient moment-to-moment, regardless of who is providing overall direction in the code.

Of course, physicians "taking charge" in a code does not mean physicians control nursing practice, that they hire, fire or supervise nurses, or that nurses are untrained assistants who follow physician "orders" mechanically. This is why we take exception to the entertainment media's common portrayal of codes, in which physicians are the commanding heroes who do everything that matters--including things nurses generally do, like defibrillation--while nurses are mute helpers who hand them things. In such scenes, we would like to see nurses acknowledging physician input and direction, but intervening for the patient and reordering priorities according to a nursing assessment. We would like to see such nurses question physician direction when appropriate, suggest interventions that physicians had not thought of, advocate for an end to the code according to the patient's wishes, or fight for an extended code when the patient is viable. In other words, we would like more reality, or at least less of a wild tilt against a fair depiction of nursing skill. We would like the public to get some sense that even in codes where physicians may take the lead, nursing expertise is vital to patient survival and wellbeing.

Go back to the point in the letter I left off