Journalist’s Tradedivided 363 sick and frail elderly hospitalpatients into two groups. The controlgroup received routine dischargeplanning and, if referred, standardhome care. Those who were in thesecond group were visited within 48hours of being admitted to the hospitaland then every 48 hours during thehospitalization by an advance-practicenurse who specialized in geriatrics.Once the patient was discharged, thesame nurse visited him or her at homeat least twice and was available in personor by phone for the next month.These nurses focused the patients’medications, symptoms, diet, activities,sleep, medical follow-up and emotionalstatus. They collaborated with physiciansto adjust therapies, obtained referralsfor needed services, set up supportsystems, and helped the patientsand their families adjust to life at home.The outcomes tell us a lot about theefficacy of this approach. Six monthsafter discharge, 20 percent of the groupwith master’s-degree nurses was hospitalizedagain compared with 37 percentof the control group. Only 6.2percent of the group monitored bynurses had multiple hospital readmissions,compared with 14.5 percent ofthe control group. When they occurred,hospital stays were much shorter forthe first group—1.5 hospital days perpatient compared with 4.1 days for thecontrol group. Health care costs forthe group with transitional care were$600,000 less than costs for the controlgroup. Medicare was saved an averageof $3,000 per patient. At a time whenthe mounting costs of health care areroutinely covered on the business pagesand on television news, the fact thatevidence such as this was ignored ispeculiar.Patients and their families know howdevastating cycling in and out of ahospital can be. As Mary D. Naylor,associate professor of nursing and thelead author of the study said, “We’restill relying on hospitals to respond towhat we know are, in many cases, preventablereadmissions. Our system ofcare is not responsive to the needs ofthe older community.” Nursing researchidentifies responsive care. Yethealth writers seem to have little acquaintancewith nursing research. One25-year veteran of the medical andhealth beat who reads several medicaljournals told me he couldn’t think ofthe name of a single nursing journal.Another health editor responded to acolleague of mine who raised the subjectwith, “Nursing what?” Even whennursing research receives the imprimaturof medicine by appearing in a topmedical journal, it is still likely to beignored.As journalist Suzanne Gordonpointed out in her recent book, “LifeSupport: Three Nurses on the FrontLines,” when coverage focuses exclusivelyon medicine, it reinforces thenotion that illness is an event ratherthan a process. When journalists coverhealth innovations only as medical interventionsthey create a simplistic andinaccurate picture of health care. Ifjournalists were to ask nurses how newtreatments really affect patients theywould have a truer picture of not onlythe efficacy of these treatments, but ofthe needs that patients have for carebefore, during and after medical encounters.While medical researchersand physicians develop these new treatments,nurses administer many of themand monitor their immediate and ongoingeffect on patients. Nurses are theones who know what impact thesemedical advances have not only onpatients’ cells, t<strong>issue</strong>s and organ systems,but on their lives.For patients and policymakers, agaping informational hole remains evenfrom the vigorous coverage of managedcare. As a recent Kaiser Family<strong>Foundation</strong> study confirmed, reportershave brought the denials of treatments,medications and experimentalprocedures under managed care to thepublic’s attention. They have exposedthe HMO’s that have tried to preventphysicians from candidly discussing apatient’s condition and appropriatetreatment options. They have attendedto the patient backlash as well. Evennursing won a moment in the news aspart of managed care coverage. A rashof stories reported that hospitals were“downsizing” and “deskilling.” But fewjournalists examined what these cutbacksmeant in terms of patient care.Pittsburgh Post-Gazette medicalwriter Steve Twedt is one who did. Hespent a year researching this questionand talking to nurses, nursing researchers,patients, families, aides, physicians,attorneys and policymakers. “In hospitalafter hospital across the country,”Twedt wrote in his resulting 1996 fourpartseries, “nurses with years of experienceare being replaced by unlicensedaides who get only minimal trainingbefore caring for patients.” His investigation,he wrote, produced “exampleafter example of hospital patientsthroughout the nation who were injuredor killed by the mistakes or negligenceof aides performing duties theyweren’t equipped to handle.” His mosttroubling conclusion was, “Despite theprofound impact on patients, no one issystematically monitoring this sweepingchange in health care.”It has similarly escaped the notice ofjournalists that proposed remedies tothe problems of managed care do notaddress nursing care. The so-calledpatient bills of rights in state legislaturesand Congress focus on medicalcare. With limited exceptions (childbirthand mastectomies), these bills donot constrain insurers and hospitalsfrom restricting patients’ access to nursingcare. The bills that do address nursingcare—those that mandate minimumlevels of nurse staffing in hospitals andnursing homes—have gotten very littleattention.Reports on the effects of Medicarecuts in the Balanced Budget Act of1997 are also too narrowly focused.For example, Bob Herbert in his NewYork Times column (April 15, 1999)discussed the disastrous impact reducedMedicare payments are havingon teaching hospitals and their abilityto educate future physicians. Nursingwas not mentioned once in his descriptionof the dire effects the cuts arehaving on staff levels, hospital treatmentand care, and professional education.Yet teaching hospitals are nursinginstitutions as much as they are medicalinstitutions. Hospitals are the primarysite of nursing education. Nursingeducation suffers when hospitalrevenues drop. In fact, one of the ma-<strong>Nieman</strong> Reports / Fall 1999 53
Journalist’s TradeAn image from the past when white caps gave nursing its aura. Reproduced from originalsin the Center for the Study of the History of Nursing, School of Nursing, <strong>University</strong> ofPennsylvania.jor missed stories of this decade hasbeen the effect of the dismissal of clinicalnurse specialists and other hospitalnurse educators on nursing educationand practice. Nursing education hastaken a direct hit in other ways, not theleast of which is the reluctance of goodcandidates to enter a field that is beingdecimated and abused by marketdrivenhealth care.Not surprisingly, the country nowfaces a serious nursing shortage. Althoughthis has been reported largelyas a demographic aging-of-the-nursingworkforcephenomenon, it is muchmore complex and interesting as evidencedby the frenzied recruiting hospitalsare engaging in even while, insome cases, continuing to lay off nurses.To be sure, it is not easy to covernursing. Although some nursing organizationsand nursing schools haveknowledgeable media specialists whounderstand the needs of journalists, ingeneral nursing research studies andinnovations in nursing practice don’tarrive in the newsroom in prepackagedprint or electronic form. It takeswork to ferret out significant stories.54 <strong>Nieman</strong> Reports / Fall 1999Then there is the problem of gettingnurses to talk. Reporters need to understandthat most nurses are employeesof large institutions, and many areafraid of retribution if they say anything.Even a very small percentage ofthose theoretically protected by unionswill go on the record. Then, too, somenurses feel so rejected by the pressthey have given up trying to interestjournalists in developments in theirdiscipline.With 2.6 million members, nursingis our largest health care profession.There are many reasons to cover nursing,including the fact that press scrutinytends to keep any important fieldon its toes and accountable to the public.Like medicine, nursing should becovered warts and all. One more thingto think about. Editors should lose thenurse nostalgia bit. Not long ago TheAtlantic Monthly inserted sentimentalizedimages of nurses complete withangels’ wings into a book excerpt oncontemporary nursing, and WorkingWoman illustrated a nurse employmenttrend piece with a decades-old pictureof a lineup of nurses in starched uniformsand caps. What editor todaywould illustrate a medical story with adoctor wearing an otolaryngeal mirrorstrapped around his head? Registerednurses haven’t worn white caps sincethe 1970’s, yet such pictures abound.These images lose their romantic appealwhen you realize that you wouldn’twant a nurse with 19th Century or even1950’s education and training to takecare of you any more than you wouldA contemporary image of nursing. Photo by Stan Grossfeld, The Boston Globe.
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