Change fatigue in health care

The patient was at the hospital for a straightforward same-day surgery but the admission process fell far short of efficient. She was directed hither and yon – first to the registration desk, then to the lab, then to another location for a pre-surgery assessment, then a fourth stop to collect a medical history.

When an accompanying friend asked one of the nurses why all these steps couldn’t be consolidated at the bedside, the response, delivered with a shrug, was “That’s the process – we’ve tried a lot of other things but they never work for long.”

What’s being described here is more than an obvious failure to be patient-centered. Tammy Merisotis, of GE Healthcare, sees it as a prime example of the apathy brought on by change fatigue.

“Change fatigue occurs when staff are expected to make multiple or continued changes in workflow process and patient protocols, without seeing the benefits of those changes in their everyday work,” she writes. “As they are bombarded with constant change, it is easy for people to become disengaged and resistant to change.”

Change fatigue is nothing new. But there seems to be much more of it these days, especially in health care, which is under intense pressure to change, change and change some more.

Although accurate estimates are hard to come by, it’s thought that as many as half of organizations overall are attempting to implement three or more major changes all at the same time.

In and of itself, change isn’t necessarily bad. A good chunk of the transformation taking place in health care is arguably for the better – more emphasis on evidence-based practices, more emphasis on safety, greater attention to how patients experience the health care system, and more awareness of the role of organizational culture in fostering and sustaining high-quality care, to name a few.

But the dark underbelly of all this transformation is that the people carrying out the work can grow tired of the continual demand to adapt and change, particularly when they may not see any immediate benefit. Burnout has always been an occupational hazard in the high-stress environment of health care; change fatigue is upping the ante even more.

Consider what nurses in an online forum had to say about the growing practice of “bedside report,” or including the patient and family in the exchange of information between nurses as they go on and off shift.

“I only hope it will be a short lived fad, but we were told by our new manager this will not be an option,” grumbled one nurse who was struggling with the logistics of how the bedside report process is supposed to happen.

Elsewhere, nurses shared their experiences with working in a unit that closed because of hospital restructuring.

“We were given practically no notice and they did not help us with a transfer, it was up to us to find a new opportunity,” one person wrote. “I’ve been in a new unit for about 4 months and it’s a constant struggle being the new one on the unit, learning a whole new way of doing things and just learning a new specialty.”

The sense of continually coping with change seems to extend throughout the health care world. Although the patient-centered medical home is viewed by many as the direction in which primary care needs to go, early adopters are learning that it requires deep, structural and sustained change in order to be successful.

Take, for example, an assessment of the first national demonstration project involving medical practices that were transitioning to the patient-centered medical home model. Even in physician groups that were highly motivated, change fatigue was a serious concern, wrote the authors of the analysis, which appeared in the Annals of Family Medicine:

The work is daunting and exhausting and occurring in practices that already felt as if they were running as fast as they could. This type of transformative change, if done too fast, can damage practices and often result in staff burnout, turnover and financial distress.

Surprisingly, there’s been little substantive research on how organizations cope with major changes. But in a study published a few years ago in the Personnel Psychology journal, researchers who tracked employees at a large government office going through major organizational restructuring found that the changes had a huge impact, not only on people’s emotional well-being but on their job performance as well.

Workers who perceived the changes as negative were at higher risk of calling in sick more frequently and performing more poorly on the job, the researchers found. These folks also were more likely to quit.

Another risk is that organizations may simply run out of steam, with new initiatives that go nowhere or fall short of what they intended to accomplish.

One lesson the researchers learned from their study: Although change is usually inevitable, change fatigue isn’t. Organizations that managed change most successfully were those that kept workers in the communication loop and emphasized what was positive about the changes, the researchers said.

“Communicate, communicate, communicate,” is the advice of Angelo Kinicki, one of the authors of the Personnel Psychology study. “In life, stuff happens. What matters is not so much what that stuff is, objectively speaking, but what matters is how we interpret it.”

The truth about nurses

It’s National Nurses Week this week, which means gratitude, a few days of attention and maybe some free cookies for the hard-working individuals who make up the American nursing profession.

Only I can’t quite get on board with the feel-good fuzziness that tends to accompany this annual celebration, because many nurses aren’t feeling the love these days. They’re overwhelmed, tired and angry – overwhelmed and tired with the workload and constant pressure, and angry at the persistent gap between how they’re so often perceived as handmaidens and pillow-fluffers and how much they actually do.

What other category of health professionals would be expected to put up with the likes of a recent NBA halftime show featuring the Mavericks Dancers gyrating in skimpy “nurse” costumes? Or sexy pseudo-nurses in heels and red lingerie appearing on TV with Dr. Oz to illustrate exercises for weight loss?

According to the venerable Gallup Poll, nursing consistently ranks as one of the most trusted professions in America. But it seems we often have trouble connecting the word “nurse” to the word “professional”, and it shows in how nurses are often portrayed in popular culture and even in how they’re treated by patients, families and employers.

There’s some provocative research on how the role of nurses in health care is often influenced by inaccurate or incomplete images of who they are and what they do. One study that analyzed the websites of 50 leading American hospitals found that nurses were mostly invisible. Another study ties a nursing shortage to the lack of attention they receive in the media.

The truth about nurses?

- There are some 3 million licensed registered nurses in the United States.

- Nurses are trained. About one-third of RNs hold four-year bachelor’s degrees or graduate degrees and about one in five holds an additional academic degree.

- Increasingly, nurses are gaining advanced practice degrees as nurse practitioners, clinical nurse specialists, midwives and certified registered nurse anesthetists. In 2008, the most recent year for which statistics are available, about half of RNs had a bachelor’s degree or higher. More than 600 million patient visits are made annually to nurse practitioners.

- While more than half of nurses work in hospital settings, they can also be found in nursing homes, medical clinics, ambulatory care centers, community health centers, schools and retail clinics. Nurses also provide care at camps, homeless shelters, prisons and in the military.

- About 12 percent of nurses with master’s degrees work as academic educators.

- The nursing workforce is increasingly diverse. Just under 6 percent of registered nurses in the U.S. are men, 4 percent are African American, 3 percent are Asian, Native Hawaiian or Pacific Islander, and just under 2 percent are Latino.

Although it might not always seem like it to nurses who are on the front lines of daily patient care, there are signs their profession is (finally) getting more respect. There’s been some landmark research in recent years by the Robert Wood Johnson Foundation on how nurses are uniquely qualified to lead efforts to transform care at the bedside.

A number of studies have directly linked the role of the nurse to safer, better care for patients and better outcomes. And a major new initiative by the national Institute of Medicine calls for more development of the nurse workforce of the future, with an emphasis on more education and training, allowing nurses to practice at the full extent of their license and giving them full partnership – along with physicians and other health professionals – in redesigning the U.S. health care system.

A nurse might fluff your pillows if you ask nicely because for most of them, their choice of profession still comes down to a desire to care for others. But it’s time to move past the limited, inaccurate stereotypes and embrace the truth about nursing – that nurses are, and are capable of, being key players in health care and that they deserve full inclusion.

Sources: American Nurses Association; American Association of Colleges of Nursing; Minority Nurse; The Truth About Nursing.

Health care bullies

His test results were late, so the patient jokingly asked the doctor whom to blame. The doctor pointed to the nurse and said, “If you want to scream at anyone, scream at her.”

Was this just an offhand comment? A not-very-funny attempt at humor? Or a subtle, belittling insult?

Theresa Brown, an oncology nurse and guest writer for the New York Times, took on the sensitive issue of physician-vs.-nurse bullying in a weekend piece titled “Physician, heel thyself.” She writes:

This vignette is not a scene from the medical drama “House,” nor did it take place 30 years ago, when nurses were considered subservient to doctors. Rather, it happened just a few months ago, at my hospital, to me.

As we walked out of the patient’s room I asked the doctor if I could quote him in an article. “Sure,” he answered. “It’s a time-honored tradition – blame the nurse whenever anything goes wrong.”

Brown then goes on to lay bare some of the internecine warfare that can take place between doctors and nurses. Much of it, she writes, doesn’t consist of blatant infractions such as surgeons throwing tantrums in the operating room. Instead it tends to be subtle: Sarcasm. Condescension. Passive-aggressive behavior such as not returning calls or pages, or belittling a nurse in front of patients and families.

It matters because patient safety is at stake when health care professionals can’t work well together as a team, Brown writes. And she issues a call for change to start at the top: “[A]longside uniform, well-enforced rules, doctors themselves need to set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them.”

As you might guess, the reaction to Brown’s opinion piece has been quite intense, especially from physicians who perceived themselves portrayed in an unflattering light. Uberblogger Dr. Kevin Pho called it “vicious” and “angry.”

“Attacking physicians so personally only serves to drive a bigger wedge between doctors and nurses, when in fact, we need to be working together to solve this issue common to both professions,” he wrote.

Some of Dr. Pho’s commenters thought it was little more than doctor-bashing. But others disagreed. “Should she remain silent?” one commenter wondered. “It would seem to some that to point out any flaws or faults in physician behavior is doctor-bashing. Is the preference to sit quietly and let the misbehavers figure it out for themselves – sometime after an incident comes to light when the behavior results in the death of a patient?”

A number of commenters shared their own stories of doctor-on-nurse bullying, nurse-on-nurse bullying, nurse-on-doctor bullying, nurse-on-medical-student bullying and other variations on the theme.

Other bloggers have weighed in here, here and here. Clearly the topic has struck a nerve – not only among health care professionals but the public as well.

My take? Brown’s essay didn’t come across to me as doctor-bashing, and it certainly wasn’t vicious. Rather, it publicly called out the culture that often silently allows such behavior to take place, sometimes at the expense of good patient care.

I doubt that bullying is rampant in the health care world, at least no more so than in other workplaces. Most studies, including one done here in Willmar a few years ago, suggest this behavior is perpetrated by a small minority. Yet there’s no denying it does happen, and some of the dynamics within the health care culture – the pecking order among professionals, the high-stress nature of patient care, perhaps even the type A personalities who often are drawn to the health professions – may contribute to and reinforce bullying behavior in ways not seen in other settings.

Patient care is filled with risk and complexity. It can’t be carried out well in an environment that’s hostile, unhappy and dysfunctional. Although it may be painful for insiders to see these issues publicly exposed, perhaps that’s what it takes to create enough pressure for all of this to start changing.

Previous entries on this topic: Eating their young; Health care professionals behaving badly.

Eating their young

I confess to being a little addicted to “HawthoRNe,” the hospital drama/soap opera in its second season this summer on TNT (it airs at 8 p.m. each Tuesday).

Like so many television dramas, it often strains the boundaries of believability. I’m not even sure why I keep watching it. Maybe it’s the fact that it’s one of the few current shows whose main character, Christina Hawthorne, is a nurse. Maybe it’s the feistiness that actress Jada Pinkett Smith brings to her role as a director of nursing at a troubled urban hospital. If I were a patient, I’d definitely want Christina on my side.

This season started out with the shutdown of the fictional Trinity Hospital in Richmond, Va. Christina and the gang have been transferred to the James River Hospital, where they all miraculously have been given jobs and have promptly encountered nonstop drama, romantic entanglements and internal politics.

There’s all kinds of subplots cooking away this season. Viewers need a scorecard to keep track. The one that really made me sit up and take notice, though, occurred in last week’s episode involving Kelly Epson, a naive and perpetually perky rookie nurse, and two of her nursing colleagues with whom she unfortunately keeps clashing. These two nurses have personalities that are about as pleasant as a nuclear waste dump, and they’re out to get Kelly. I found myself thinking, “Yeah, right, like real nurses would ever do that.”

Or would they? As it turns out, you bet your sweet life they would. Nurses even have their own expression for it: “eating their young.” It takes many forms: hostility, bullying, back-stabbing, sabotage, intimidation. New nurses in particular tend to be the targets of this aggression – and it’s very real, as the online comments on a nurse managers’ forum attest. One nurse who entered the profession in her 40s said her “first and only job was a nightmare!”

Another RN confirmed that “this lateral hostility is still alive and festering.”

It seems more prevalent in the critical care areas (maybe because these nurses are many times aggressive by nature). Many critical care nurses feel their knowledge level is above “floor” nurses and they look down on them and consider them inferior.

Why would nurses, who profess to be so caring, behave this way? One nurse observer suggests it’s because nursing is a high-stress profession in which frustration with working conditions tends to be redirected against colleagues. Theresa Brown, an oncology nurse who writes a column for the New York Times health section, describes in vivid terms how this happens (and be sure to read the comment thread for reactions to the piece):

Spending our shifts feeling pulled in an impossible number of directions, day after day after day, can in the end be too much. A lot of nurses find a way to regroup and stay, while some burn out and quit. But a few nurses will, like cornered animals, bare their teeth and fight back.

The problem is that they don’t fight back against the people who put them in the corner. These overwhelmed and angry nurses take their frustration out on the rest of us stuck in the corner with them, or on anyone – like interns – they perceive as being less powerful than they are.

Not all nurses are like this. In fact, I’d venture to guess the majority are not. I’d also venture to guess that many, if not most, workplaces would like to see this nurse-on-nurse hostility stamped out, not only for the sake of nurses but for the sake of safe patient care.

In the case of “HawthoRNe,” it seems, art is imitating life – in fictionalized, exaggerated fashion, perhaps, but with a kernel of truth behind it.

On the night shift

The daily demands at a hospital never truly slow down, not even at night. If you’re a hospitalized patient, nighttime can in fact be one of the riskiest times in the entire 24 hours that make up a day.

The hazards of the night shift came under scrutiny yesterday after a spokesperson for Twin Cities hospitals, which are engaged in contentious labor negotiations with their registered nurses, was quoted as saying patients just ”sleep” through the night shift.

Putting aside the overheated atmosphere that accompanies labor disputes, there’s actually a sizable body of evidence that nights are one of the most vulnerable times when it comes to patient safety.

Even though the level of hospital activity – scheduled surgeries, lab and imaging tests, discharge planning – tends to wind down at the end of the day, patients are still sick and in need of care. Babies are still being born. Patients are still showing up in the emergency room. A child’s or elderly person’s condition can crash regardless of what hour of the day it is. The nurses who are managing all of this are fewer in number than during the daytime and often have less access to back-up help from other professionals.

A Wall Street Journal article that appeared a couple of years ago suggested it gives whole new meaning to the term “graveyard shift”:

The risks of seeking after-hour care are well documented. Recent studies show higher death rates for patients who arrive at the hospital with strokes after hours. This is also the case for patients who have a cardiac arrest when they are already in the hospital. And Stanford University researchers who examined close to five million hospital admissions in three states reported [in 2007] that rates of complications are significantly higher on weekends for surgeries including vascular procedures and obstetrical trauma during cesarean sections.

One study that looked at emergency-room nurses who worked the night shift found they were often sleep-deprived, which impaired their performance and made them less likely to catch medication errors or detect signs of deterioration in a patient’s condition. Fatigue is well established as a risk factor for medical error, not only among nurses but among physicians as well – and the stakes are huge, as a blogger with the Joint Commission describes:

If I come to work tired, worn out, stressed out, or a bit under the weather, it’s unlikely that anyone would get hurt. Sure, I might make a mistake, but chances are I will have a chance to correct it before the public sees it.

For health care providers, matters are different. An “off day” can have a long-term impact on a patient’s life and health. Fatigue poses a serious threat to patient safety and impairs human performance.

There’s been a lot of research on how to make night shifts easier for health care workers to handle. Working a permanent night shift vs. a rotating shifts seems to help; allowing nurses to take short naps during their shift at night also is thought to be helpful.

But working a night shift is hard on the human body, period. Health care workers do it because it comes with the territory. Even when all their patients are supposed to be sleeping, the need to provide care around the clock never rests.

Photo: Wikimedia Commons

How many nurses are enough?

How many patients can one nurse safely handle? Is there an optimal nurse-to-patient ratio? Does patient care suffer when there aren’t enough nurses per patient?

These aren’t just academic questions. They go to the heart of one of the more contentious issues in the hospital industry these days: the flashpoint where staffing levels, patient care and profitability collide.

If you’ve been following the news of a pending strike by 12,000 nurses at Twin Cities hospitals, you’ll know that staffing levels are one of the key issues at stake. The hospitals want the ability to adjust staffing in response to patient volume, a move the Minnesota Nurses Association contends is unsafe for patients.

As revenue continues to tighten and hospitals look for ways to become leaner and more efficient, the public can expect to hear a lot more in upcoming months about the nurse-to-patient ratio.

Not surprisingly, it’s an emotional issue. It’s also one that happens to be rather well studied, and most of the studies suggest patients fare better when the hospital is staffed with an adequate number of skilled nurses.

One of the most widely cited studies is this one, which appeared in the Journal of the American Medical Association in 2002 and examines the nurse-to-patient ratio, patient mortality and job dissatisfaction and burnout among nurses. The authors conducted a survey and collected data at 168 hospitals in Pennsylvania and, after analyzing the results, concluded there were “detectable differences in risk-adjusted mortality and failure-to-rescue rates across hospitals with different registered nurse staffing ratios.”

Another key finding from this study: Nurses who worked at hospitals with a high patient-to-nurse ratio were much more likely to report job dissatisfaction and burnout.

These findings have important implications for patient safety and the hospital nurse shortage, the study’s authors wrote:

Our results document sizable and significant effects of registered nurse staffing on preventable deaths. The association of nurse staffing levels with the rescue of patients with life-threatening conditions suggests that nurses contribute importantly to surveillance, early detection, and timely interventions that save lives. The benefits of improved registered nurse staffing also extend to the larger numbers of hospitalized patients who are not at high risk for mortality but nevertheless are vulnerable to a wide range of unfavorable outcomes. Improving nurse staffing levels may reduce alarming turnover rates in hospitals by reducing burnout and job dissatisfaction, major precursors of job resignation. When taken together, the impacts of staffing on patient and nurse outcomes suggest that by investing in registered nurse staffing, hospitals may avert both preventable mortality and low nurse retention in hospital practice.

When the U.S. Agency for Healthcare Research and Quality undertook a review of the existing research, several more conclusions came to light. First, many hospitalized patients are very sick and require considerable care. The AHRQ cited research showing a 21 percent increase in the acuity level between 1991 and 1996 – but no net change in the number of registered nurses. In fact, many hospitals have sought to increase staff efficiencies by hiring nursing assistants to take over some of the more basic tasks of patient care, a move that tends to add to the supervisory workload of RNs.

The AHRQ’s report also attempts to quantify the cost of adverse events that might be associated with short-staffing the number of hospital nurses.  The report notes, for instance, that pressure ulcers account for at least $8 billion in health care spending per year.

Yet another study suggests the cost of having more nurses on staff is balanced by shorter hospital stays for patients and fewer complications and adverse events.

Is there a right ratio for how many patients one nurse can safely care for? This isn’t easy to pin down, as this position paper, produced by the New England Public Policy Center and the Massachusetts Health Policy Forum, demonstrates. It can depend on the hospital unit – intensive care patients, for instance, are sicker and require more care than a same-day surgery unit. It might also depend on the particular mix of patients who are hospitalized on any given day, and on the overall resources of the hospital. There may also be a point of diminishing returns beyond which the benefits of ramping up the nursing staff are minimal.

Patients and the public aren’t accustomed to discussing these policy questions. For the most part, the dialogue about nurse-to-patient ratios has taken place between nursing organizations and hospitals. And maybe that’s appropriate, but the public has a stake here too. If we’re ever hospitalized, or have a family member in the hospital, we’re going to notice if there aren’t enough nurses to go around and it affects the care we receive. We’re also going to notice if we end up paying more for hospital care. It seems only right to give the public more opportunity to become informed and to get involved in this important discussion.

Update, June 4: Check out MinnPost for this thoughtful take on the connection between numbers of nurses, hospital costs and quality of care.

Real nurses

It’s almost impossible to get through Rice Memorial Hospital’s annual “My Nurse Made the Difference” awards ceremony without at least half the audience getting sniffly and teary-eyed.

This year’s awards lunch, which I attended earlier today, was no exception. Rice Hospital has been kind enough to invite the media every year, and I’m always amazed at the depth and variety of individual patient stories that inspire the annual awards. No two are alike, and it doesn’t take much for each story to resonate with the audience.

There’s something about nurses. Most of us admire them. We see them as noble and saintly and caring. If we’re of an older generation, we might lament the fact they no longer wear starched white uniforms. If we’ve watched enough movies and/or TV, we might have other views of nurses that are antiquated, stereotyped, hyped-up or outright chauvinistic.

Real nurses are way more diverse and interesting than this. Real nurses work really, really hard. I wouldn’t last one day in the shoes of a real nurse. They put in 12-hour shifts, mostly on their feet. Their work is a tough and complicated blend of cognitive processing – all those meds, all that charting – and bedside caring.

Real nurses are smart. They have to be. Their field is changing all the time, and they have to know more than they ever did before.

Real nurses have both responsibility and authority. They’re the front-line professionals when it comes to patient safety and quality of care. How often does it happen that a nurse’s sharp wits are the only thing standing between a disaster for the patient vs. a good catch? Probably more times than any of us could count.

Real nurses are tough. You don’t mess with a real nurse, not when he or she is on a mission on behalf of the patient (yes, men are real nurses too). Real nurses know how to advocate. They solve problems. They’re flexible and creative.

Real nurses are team players. Real nurses are leaders.

Real nurses work in hospitals, surgery centers, cancer centers, emergency rooms, home health care, nursing homes and outpatient clinics. They specialize in occupational health, infection control and public health.

Real nurses have terrible days sometimes. Sometimes they make a mistake that harms a patient, or sometimes, no matter how good the care they provide, their patient dies. Over the years, real nurses store up an entire mental library populated with joyful, funny, outrageous and heart-wrenchingly sad memories of the patients and families they’ve encountered. I’m pretty sure real nurses cry rather often, but not always in ways the rest of the world would notice.

I’m told that Rice Hospital gets dozens of entries from patients each year for the “My Nurse Made the Difference” awards, which are always announced in conjunction with National Nurses Week. A judges’ panel has the difficult task of sorting through them all and selecting three – only three! – that are the winners.

Many nurses at Rice will probably never be nominated. Perhaps they’re outstanding nurses but they work in the operating room or the post-anesthesia care unit, where patients don’t see or don’t remember them. Or maybe they’re managers or supervisors whose contributions aren’t directly visible to patients and families. All real nurses are winners, though, whether they’re officially recognized or not.

Real nurses do what they do because they care about being a good nurse. But they appreciate being thanked once in awhile, and it’s never too late to let a real nurse know that he or she helped someone in a way that made a difference.

HealthBeat photo by Anne Polta

Missing voices in the health care debate

You don’t have to look far to find a lot of rhetoric and discussion about health care reform. But who’s doing all the talking – or at least talking the loudest? That’s right: For the most part, the national debate seems to be dominated by the policy wonks, not by doctors and nurses who actually take care of patients, or by the patients themselves.

Look for the tables to be turned on Friday, when Better Health hosts a discussion between elected officials and several notable medical bloggers at the National Press Club in Washington, D.C. The theme: "Putting Patients First."

Dr. Val Jones, a rehab physician, a blogger and founder of Better Health, organized the event to give a voice to those in the trenches of health care. As she explains it,

… the intent of the press conference was to give medical bloggers an opportunity to speak directly to politicians inside the Beltway about their health care reform concerns. I have invited medbloggers who have been the most outspoken about reform and who have the largest reach.

This A-list includes several of the medblogosphere’s stars, such as Dr. Kevin Pho, emergency room nurse Kim McAllister, Dr. Rob Lamberts, and cardiologists Dr. Westby Fisher and Dr. Richard Fogoros.

The speakers’ panel unfortunately does not include any patients, the one group that arguably has the most stake but the least voice in the national discussion on the future direction of health care. Not surprisingly, and probably rightfully so, this omission has led to a bit of an online fracas.

To be sure, doctors and nurses have a lot to contribute. Over the years I’ve covered numerous meetings between politicians and the local health care community, and at times I’ve had the impression their views don’t seem to carry as much political weight, perhaps because it’s perceived – unfairly so – that they’re motivated by self-interest or have an axe to grind. In fact, doctors, nurses, hospitals and clinics are uniquely positioned to see the system from the inside. They know better than anyone else what works in American health care and what doesn’t work. Their daily encounters with patients give them unique insight into what individual patients face, as well as the overall health of their community. Moreover, every doctor and nurse will at some point be a patient themselves, or have a family member who’s a patient.

There’s value, however, in also hearing from ordinary people – average schlubs who haven’t been to medical school, don’t know where their spleen is located and are often bewildered and frustrated with trying to navigate the health care system. Who’s listening to them or seeking out their opinion? Unfortunately, patients are such a diverse group that it’s unlikely they could ever coalesce into something with enough critical mass to wield clout in Washington – and so their voices often are too muted to be heard.

Several of the bloggers who’ll be participating in the panel discussion tomorrow are trying to remedy this on their own blogs.

At Emergiblog, Kim McAllister is asking her readers for their thoughts:

So, what about you?

What do you think health care reform should accomplish?

What are the three most important aspects that should be a part of any health care reform system?

She’s already had more than a dozen good comments. Over at his blog, Dr. Westby Fisher is looking for feedback too and promises to report on the event afterwards.

Dr. Rob Lamberts is hosting a lively to-and-fro in the comment section of his recent post, "Speak to Me." He also has posted an online poll, allowing readers to pick their four top health care concerns. When I checked the results a short time ago, the leading concern was "the conflict of interest as insurance companies are in charge of the money," followed by "the continued rising cost without better care."

So go and vote in the poll, leave a comment or two on the blogs, or just read the discussion. And check back later for a report here on the conference.

Real nurses sound off about TV portrayals

OK, I admit to being curious about the entertainment world’s latest foray into nurses-as-fodder-for-television-drama.

The new TV nurses on the block are Christina Hawthorne ("HawthoRNe," premiering at 8 p.m. June 16 on TNT) and Jackie Peyton ("Nurse Jackie," which premiered at 9:30 p.m. Monday on Showtime).

Here’s the spin on "HawthoRNe" from TNT’s Web site: "the tough-yet-caring Chief Nursing Officer at Richmond Trinity Hospital. She prides herself on standing up for her patients and preventing them from falling through the cracks of hospital bureaucracy." She’s also widowed and raising a teenaged daughter. Jada Pinkett Smith is in the title role.

Jackie Peyton is tough too, but in a different way. Her character, played by "Sopranos" veteran Edie Falco, is an emergency-room nurse who, we’re told, is "far from ordinary. As an ER nurse, she navigates the rough waters of a crumbling healthcare system, doing everything she can to provide her patients with the best care possible." In the show’s inaugural season, watch her tell off a doctor, forge an organ donor card and pop prescription pain pills to get through the day.

It makes for good drama, but is it true to life? What do real nurses think about how these two shows portray their profession?

Emergency-room nurse and uberblogger Kim McAllister weighed in on this issue recently at her blog, Emergiblog: The Life and Times of an ER Nurse. She gives a thumbs up to Christina Hawthorne – "Unrealistic? Yeah. Am I going to watch? Absolutely."

Readers offer their own critique in the comments. "But yeah, a manager getting her hands all germy? I can put up with that fallacy if the show offers a reasonably accurate portrayal of nursing," one person wrote.

Someone else comments on Christina Hawthorne’s slim, toned shape:  "She must not touch those Dunkin Doughnuts in the breakroom."

The discussion really heats up, however, over "Nurse Jackie."

Some of the commenters take issue with the show and its image of nurses:

- Drugs, sex and more nursing stereotypes. Here we go again…

- Television is a place of fantasy certainly, but this seems to be just a pathetic, cliched soap opera. There’s enough drama and comedy in what real nurses experience that they didn’t need to go down this sorry path. The drug use aspect troubles me as others have mentioned, but I was horrified by her forging a signature.

Other commenters think Jackie Peyton is closer to real life than many nurses might like to admit:

- For once it’s not about the doctors. And guess what… I’m 25 years sober and I’ve worked with many an altered nurse.

- Sure, 97% of nurses are normal, hard-working saints, but I have never worked in a single ER that didn’t have at least one "Nurse Jackie" type. For whatever reasons, ERs have always been a hotbed of sexual tension, and I can recall at least one nurse/doctor hookup in the supply closet that got busted and wound up in firings. Three nurses I’ve worked with in the last year have been fired for prescription drug abuse. They were all generally regarded as great RNs.

I’m not saying that these are normal people or even a small majority of nurses, but it’s not exactly like this type of character only exists in drama. I honestly think I would be bored senseless watching a show about that 97% of great, moral nurses.

And some commenters are just plain skeptical about the entertainment industry’s ability to capture reality:

- What bothers me is that I keep seeing enthusiastic posts and tweets about how nice it is to have a "realistic" medical show that finally shows "the truth" behind the scenes. (I assume this includes sex in the middle of the pharmacy, apparent abandonment of patients in favor of kicking off your shoes and taking a rest in the chapel, and habitual unnoticed stealing of narcotics.) Really? Could the public possibly be that stupid?

- If you expect Hollywood to give you a real, true story or even truth, don’t hold your breath.

The Truth About Nursing, an organization that seeks to increase the public’s understanding of the role of nurses, offers its own perspective here, suggesting that people "keep an open mind and watch the show in full." It also has launched a thoughtful online discussion that’s worth reading.

Do you plan to watch "HawthoRNe" or "Nurse Jackie"? Why or why not? If you’ve seen the opening episode of "Nurse Jackie," what did you think about it?

Update, July 2: Registered nurse Theresa Brown, who guest-blogs for the New York Times Well blog, gives her perspective.