Nurses, according to author Alexandra Robbins, call their profession a “secret club because their experiences are so novel, their jobs so intimate and occasionally horrifying, their combination of compassion and desensitization so peculiar, that they imagine nobody else could understand what it is like to work in their once white shoes.” They are, at once, reporters serving as the linchpin of data for all members of the health care team. They are watchmen, alert to subtle changes in their patients’ conditions. They are also scientists constantly learning and applying new biological and social knowledge. And they are “lionhearted diplomats,” keeping their control when shaken by what they do and what they witness.
Robbins clearly respects and admires nurses—for what they do and who they are. She attempts to convince readers by scaffolding her book around the experiences of four nurses with four very different lives working in four very different hospitals’ emergency rooms (ER). We first meet Molly, an experienced, confident, and respected clinician who immediately resigns her position at the fictional but affluent Pines Memorial Hospital when its new corporate owners take one step too far in its cost-cutting measures. Molly’s later work at an agency that supplies temporary nurses to area hospitals brings her contrasting experience at Academy Hospital, a teaching hospital with an associated medical and nursing school, and Citycenter Medical, also a teaching hospital but overburdened with the charge of treating the poor and the homeless in a densely populated neighborhood. Besides treating ER patients at often the worst moments of their lives, Molly and her police officer husband have also begun infertility treatments in their quest for a child.
We next meet Lara, an ER nurse at South General Hospital serving the poverty stricken south part of the city. Lara, another superb clinician, is battling twin demons: a history of narcotic addiction and a womanizing, gambling husband she is reluctant to leave for the sake of her two young children. We then meet Molly’s friend Juliette, a single mother, who decides to stay at Pines Memorial after Molly leaves despite the refusal of an ER nursing clique to invite Juliette’s daughter to after-work social events with their own children. Finally, we meet Sam, a new graduate thrown into the disorganized, chaotic, short-staffed, and downright filthy ER at Citycenter Medical. Sam’s only professional goal is to not kill anyone and to survive. But, as a young and single woman, she also has to learn to navigate an intense interpersonal environment of sexual attractions and jealousies.
Robbins gets much right as she draws us into these women’s worlds. Theirs is an intense world as they move from trying to save a middle-age man who suffered a massive coronary attack to telling his grief-stricken wife and daughter that they were not successful. Theirs can also be a dangerous world. Robbins uses her nurses’ experiences to demonstrate why nursing is the nation’s third-most dangerous profession (after police and correctional officers). The Emergency Room is often home for intoxicated, agitated and cognitively impaired patients who physically lash out at their nurses when frightened or angry. And it is not always a comforting world. Rather it is one of political infighting, some “mean girls,” and dispiriting gossiping among the nurses themselves. Sam says it best. “It’s like high school except for the dying people.” Nurses cope as best they can. Some have found the balance between engaged compassion for their patients and the right to a different life when away from the ER. Others burnout from compassion fatigue and leave. And, given their easy access to narcotics, a few numb themselves. Nurses, like all other clinicians with easy access to narcotics, have addiction rates far higher than the general population.
Robbins also defends her nurses against the conventional caricatures surrounding sex and sexuality. But she also takes her critique in an interesting direction. Sex does occur in hospitals, and in homes with former patients.
But mainly Robbins paints a world where nurses and their concerns remain largely unsupported. Sometimes that lack of support comes from other nurses. Robbins presents a nursing administrator who refuses to close an over-extended ER because of the need to demonstrate strong revenue streams to the for-profit health care system that purchased Pines Memorial. Sometimes it is the hospital—quick to fire any nurse who threatens unwanted publicity through clinical errors or reporting assaults. The hierarchical structure of the health care encounter in the ER is also problematic. Nurses, often the most experienced, are still at the bottom of a long-standing tradition that places the physician—even the most inexperienced—at the top of a decision-making tree that only the most confident and experienced nurse would challenge. In Robbins’s ERs, nurse practitioners (nurses with master’s degrees) and physician assistants (college graduates with advanced training) now serve as intermediaries. But often they can be as condescending as some physicians.
Robbins also defends her nurses against the conventional caricatures surrounding sex and sexuality. But she also takes her critique in an interesting direction. Sex does occur in hospitals, and in homes with former patients. A complicated mix of relatively young people working long and hard together, and heady feelings of illicit relationships in a taboo place, often create an intoxicating brew. Not surprisingly, discretion is key. The greatest transgression, however, is getting caught. Then the nurse is vulnerable to losing her position, if not her license. But rarely does the physician. Robbins rightly deplores this double-standard.
The Nurses’s strongest expression of ire, however, is reserved for the new Affordable Care Act requirement that Medicare reimbursements be tied to patient satisfaction. This has real economic impact on hospitals. In 2012, Medicare had the authority to withhold 1 percent of its reimbursements to hospitals who failed to meet acceptable results on patient satisfaction surveys; this percentage will double in 2017. In reality, the vast majority of questions on the survey relate, in one way or another, to the nursing care that patients received. And a veritable industry has arisen to teach nurses how to, in Robbins’s words, “game the system.” Posters hang in some hospital break rooms to remind nurses of key jargon they must use with patients. In other hospitals, nurses carry laminated cards reminding them to end each patient encounter with the words: “is there anything else I can do for you before I leave? I have the time while I’m here in your room.” One medical and surgical nurse told the Boston Globe this kind of directed conversation made her feel like a “Stepford nurse.” Robbins gets it right again. “Great nurses,” she writes, “are warm, funny, personal, or genuine. It can be hard for nurses, who are not actors, to appear heartfelt and compassionate when they all recite the same scripts.”
For all that Robbins gets right, she does get some things wrong. Early in the book, she claims “murses” is now the preferred term for male nurses. Perhaps there may be some regions of the country where that term is used, and the geographical place that Molly, Lara, Juliette, and Sam practice remains unidentified, but neither my colleagues nor I have ever heard of it. And, interestingly, the male nurses who talk about their lives and their commitment to nursing never use it in their own interviews.
The Nurses’s strongest expression of ire is reserved for the new Affordable Care Act requirement that Medicare reimbursements be tied to patient satisfaction. This has real economic impact on hospitals. In 2012, Medicare had the authority to withhold 1 percent of its reimbursements to hospitals who failed to meet acceptable results on patient satisfaction surveys; this percentage will double in 2017. In reality, the vast majority of questions on the survey relate, in one way or another, to the nursing care that patients received. And a veritable industry has arisen to teach nurses how to, in Robbins’s words, “game the system.”
The world of nursing education and practice can be its own intricate place, but Robbins mixes up terms and presents incorrect data that will only add to the confusion of a reader outside this world. She often conflates nurse practitioner with advanced practice nurses. Advanced practice nurses are a broader category that includes nurse practitioners but also nurse anesthetists, nurse midwives, and clinical nurse specialists. And a new degree, the doctorate of nursing practice (DNP), was not required for nurse practitioners in 2015. Robbins correctly captures the concerns of physicians about nurses who could call themselves doctors. But the DNP degree itself is only a recommendation. Certification organizations set educational requirements for advanced practice nurses. To date, only nurse anesthetists will require the DNP by 2025.
The Nurses could have given more analytic depth to some issues without compromising its readability for a non-nursing audience. It has a long section devoted to the intergenerational tensions within the discipline, as practicing nurses whose average age is 50-plus meet new graduates like Sam in their early 20s. Yet interpretation of Molly’s disparaging comments about the “baby nurses”— the new graduates of Academy Health’s School of Nursing—with whom she has to work when assigned to its hospital remain under developed. Similarly, Robbins’ provides a harsh critique of hospital administrators who fail to support nurses after assaults or other traumatic incidences. But, subtly, Molly’s hospital wanted to ban her assailant; Molly, however, refused to allow that. She wanted Pines Memorial to remain available to all in need. This tension between justice and compassion is also a critical part of nurses’ experiences.
I also found it surprising that Robbins did not consider the Magnet Hospital movement. During the severe nursing shortage of the 1980s, researchers examined the characteristics of hospitals that were able to attract and retain a strong nursing workforce. These, in turn, became the template for a separate hospital accreditation process that focused on an institution’s strength of and its support for high quality nursing practice. The Magnet Hospital is now a national movement that has moved from a traditional base in academic medical centers to more community-focused hospitals. It would have been interesting to know if any of her four hospitals had achieved Magnet certification, and if that certification made any difference in the issues of staffing, safety, hazing, and stress that nurses experience.
But Robbins’ heart is in the right place. As the book closes we get chapters on nurses as heroes, their perspectives of what patients and families need to know if they ever experience a hospitalization, and what the public, patients, and others can do to provide more active support of nurses. And by the end, her four nurses lives fall into place. Molly decides she likes the constant change of environments that working for an agency provides so she decides to continue that form of ER nursing. She also discovers that she and her husband have finally achieved their dream of having a child.
Lara manages to get through major abdominal surgery without the use of narcotics—not entirely by choice, but without the dread of falling back into her addiction. Juliette finally severs ties with Pines Memorial ER and finds a new professional life at another hospital’s ER that also comes with acceptance into that hospital’s social life, as well. Sam stays at Citycenter, but she discovers that the male nurse whom she respects, admires, and really likes has similar feelings for her. The book ends as they start a new relationship.