‘Necessary nursing care’

Several weeks ago, I was strolling past a bookstore on the Boulevard St Germain when a children’s book with a cover illustration of a nurse bandaging the finger of a small child caught my eye. The book displayed in the bookstore window was called Je sais qui me soigne (I know who takes care of me) and is part of a series to ‘educate in citizenship’ that is intended for children aged 9–13. The text begins with a typical case. Julien comes down with a high fever and begins vomiting. Julien then goes to the doctor. The book goes on to define sickness and care and the purpose of the healthcare system. Throughout the book, physicians — always presented with their last name and title, as in Dr Chevalier — are at center stage. The book devotes a number of pages to describing doctors’ training and knowledge. Nurses — who are given first names only such as Gaston, or Lucille — are defined in negative or mediated language. ‘Who is a nurse?’ the text asks. ‘The nurse’, it answers, ‘is not a doctor’. The nurse is, in fact, someone ‘whose studies give her or him just enough knowledge to follow and apply the decisions taken by the doctor or surgeon’. (Contrast this with the description of a physical therapist, who is ‘someone who has studied for a long time and has a great deal of knowledge about the human body’.) The nurse is not even directly connected to the patient whom she cares for. In all respects, the nurse–patient relationship is firmly mediated by the physician. (The physical therapist helps the patient directly, in a relationship unmediated by the doctor.) What this short text illustrates is not simply a French phenomenon. It is the inexorable global connection between health-care and medically necessary care and the exclusion from healthcare systems and the public imagination of the concept of necessary nursing care. Throughout most of the industrialized world, the concept of medically necessary care or services has become critical in all discussions of health-care. In the US and Canada, the term is used to elaborate which healthcare services will be covered under the US Medicare and Medicaid programs and under the Canadian medicare system. For example, the Canada Health Act, which was passed in 1984, stipulates that the medicare system covers ‘medically necessary hospital services’, ‘medically required physicians’ services’, and ‘medically or dentally required surgical dental services requiring a hospital for proper performance’. Although there has been a constant debate about what precisely constitutes ‘medically necessary care’, the US Medicare and Medicaid plans and private insurers are supposed to cover what is deemed to be ‘medically necessary’. Although the concept of medically necessary care and services was developed to structure and contain services, it transformed medicine’s growing de facto control of health-care into a de jure control. It is doctors, after all, who determine what is medically necessary, even when the services are delivered by clinicians or other healthcare workers who are not doctors. Despite recent curbs on physician autonomy and specialist referrals, most people — even under the degraded conditions of managed care in the United States — regard medically necessary care as the essence of their healthcare system. When they pay their taxes or insurance premiums, most people feel they are entitled to the services doctors provide and control. The public also understands that certain requirements must be fulfilled if they are to receive high-quality medically necessary care. First and foremost they understand that doctors are educated not born and that medicine has produced a serious body of knowledge that has led to great benefits for humankind. They thus take for granted that the doctors treating them have received a standardized medical education, are licensed by the state, and are certified in their specialty. Doctors, most people recognize, must also be constantly educated throughout their careers by reading publications that are widely heralded in the outside world and through meetings, seminars and workshops that will keep them up to date. Again, although their control is now increasingly contested, it is their knowledge and education that give physicians the right to control the practice of other healthcare clinicians and workers. While variations exist within different countries, spending on medical education, equipment, research, and salaries is widely supported as the price we must pay to attract top-flight talent and provide them with the best possible tools. Neither healthcare policy-makers nor patients view physicians as interchangeable parts in an assembly line system yet (although some HMOs are heading in that direction). Physicians are so important that they are a staple of mass media coverage of health-care, which highlights their accomplishments as well as their inadequacies. Like marriage vows, our social contract with medicine spans sickness and health and endures til death do us part. Although this contract may be shaky, it is nonetheless utilized to standardize ideals about what constitutes high-quality care, good healthcare outcomes and appropriate strategies for cost-containment. But it does a great deal more. It contains — in all senses of the term — the necessary care and services delivered by nurses and other nursing personnel during periods of human illness and dependence. It makes necessary nursing care invisible and prevents the public from creating a social contract with nursing that is analogous to that which it has created with medicine. Consider briefly how most people view nursing care. When patients are hospitalized they assume that nurses will be a caring presence without understanding what nurses will be doing for them. They don’t understand the educational process necessary to produce the kind of expert nurse they assume or hope will answer their call bell. Nor do they understand the kind of scientific, emotional, and social knowledge and skills that the nurse calls upon to fulfill her or his mandate to care for the sick. Most people — and this sadly includes too many nurses — believe that nurses are born not educated. Most patients fail to comprehend the organizational and social structures and resources that must be in place if good nurses are to provide good nursing. Tragically, it seems that many high-level administrators and policymakers do not grasp what Linda Aiken and her colleagues, as well as Patricia Benner and others have so compellingly documented — that expert nursing is an organizational and social intervention dependent not just on individual attributes, but on institutional characteristics and complex education and skills. Nursing historian Joan Lynaugh has observed that, ‘we know that, when we’re sick, we can’t get into a hospital without a doctor. But we’re still surprised to discover that patients can’t get out of a hospital, in any healthier condition, without a nurse’. We are equally surprised to learn that nurses are educated not born, that their practice is supported by research not feminine intuition, that they are not interchangeable cogs in the healthcare machine (an oncology nurse is not the same as a pediatric nurse), and that they work for money as well as love. As Julian Tudor-Hart pointed out in an essay called ‘Caring effects’, too many people believe that care will be provided to the sick and dependent no matter how little attention is paid to the systemic supports that underpin that care. It is increasingly clear that this care calculus is deeply flawed and makes it difficult, if not sometimes impossible, for societies to provide the kind of knowledgeable care-giving sick and dependent people need. To secure the necessary respect, recognition, resources and rewards that will attract and retain knowledgeable caregivers demands a societal concept of necessary nursing care. The need for this concept becomes particularly acute as women have more career options and as healthcare systems — whether under the tutelage of private insurers or government bureaucrats — become ruled by the cost-containment/cutting imperative. Throughout the globe, healthcare system ‘reforms’ are being implemented at the expense of necessary nursing care. But the consequences of this implementation may go unacknowledged until far too late — if at all — in great part because the content of and supports for necessary nursing care are so little understood. It is time our societies understood that a healthcare system and the people it serves need necessary nursing care as much as they need medically necessary care. Like the concept of medically necessary care, the concept of necessary nursing care would involve different components. If our societies elaborated a concept of necessary nursing care, the education and deployment of nurses and the organization of nursing care within hospitals and other healthcare institutions, and also in the home and community, would be seen as no less important to patient outcomes than medicine’s role in diagnosis and treatment. The dangers of radically reduced hospital stays, combined with insufficient nursing care in other settings, would be more widely understood. Health insurance would cover necessary nursing care. However, rather than putting doctors in charge of determining the content and duration of these benefits, registered nurses and other nursing personnel would, with public oversight and patient input, determine what kind of nursing care is necessary as well as the appropriate duration of these services. The media, political and policy community would understand the skill and complexity of necessary nursing care and would analyze, investigate, discuss and highlight the relevant issues, accomplishments, and innovations in the field in media reports, scientific studies, and policy reports and commissions. There would also be greater respect and understanding of the role of non-registered nurses and family caregivers in helping to deliver necessary nursing care. And there would be better pay and treatment, and greater social recognition and respect for nurses, other healthcare workers and family caregivers. Our contract with those caregivers who provide necessary nursing care would be, in effect, that we must care about them if we want them to care for us. But if this contract is to be implemented, nurses and other caregivers must make the components of necessary nursing care visible to a wider public. In our book, From silence to voice: What nurses know and must communicate to the public (Buresh and Gordon 2000), Bernice Buresh and I describe strategies that nurses can use to make their work known. Physicians were able to garner the resources and recognition essential to the development of public appreciation of the components of medically necessary care through a variety of mechanisms. But public visibility — physicians’ willingness to speak about and describe their work outside their profession — was and is critical. The public will never defend and promote knowledgeable caregiving until nurses explain what it means to think like a nurse, to act like a nurse, and to care for the sick like a nurse. They will never raise their children with a different view of who takes care of the sick unless nurses translate their private yearnings into public action. Necessary nursing care will only be understood when caregivers help the public understand that nursing is more than the heart of health-care — it is part of the complicated brain that controls how patients — and the healthcare system itself — functions, survives and thrives.

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