Her aged father and 34-year-old daughter are both fatally ill. Yet a Silver Spring woman writes: "Let me give you some heartening news. They have recently had long-term hospitalization in three local hospitals. The truly tender, loving care they got from their nurses and everyone else was indeed wonderful."
Another woman, however, says about one of the same hospitals:
"I have to tell you about the poor quality of the nursing. I was throwing up, and I had no help from the nurses. They were supposed to measure my urine output -- they didn't bother. When I questioned them, they just didn't answer."
Contradictory stories like this abound. When you are in the hospital, the nurses can be your best friends and close allies. Or, in other cases, they can be just absent.
A patient in a big Boston teaching hospital tells how she was badly upset when a crucial operation had to be postponed because she suddenly developed a fever, and: "The staff was unbelievable. One nurse ate her lunch in my room, and another did her paperwork in my room so I wouldn't be alone.
"The nurses really care."
But a Harvard medical professor, recently a patient at another major Boston hospital, complains that "there's no such thing any more as nursing care -- there's data collection," nurses dashing in, reading the numbers and leaving.
Nonetheless, some hospitals seem to excel in nursing care. The first Boston hospital is known for its alert, caring administrator, and a similar attitude that pervades the hospital.
Yet the good and bad reports often come from the same hospital. All nurses today, like all doctors today, are under increasing pressures.
The technology of modern medicine and "data collection" can indeed devour nurses' time. With new cost controls, some hospitals are using more part-time nurses, especially on busy days, and rotating nurses from ward to ward.
And you, the patient, may accurately feel you rarely see the same nurse twice.
The nurses remaining must give sicker patients "more care in less time," Carol Lockhart, a Brandeis University nursing fellow, reports. Judith Yates Ryan, American Nurses' Association executive director, says: "In most communities, hospitals are adequately staffed for safety and surveillance." There is more to good care than safety and surveillance, however, and in some hospitals, she says, "there aren't sufficient positions to meet the needs."
Here is how one nurse (Barbara Huttmann in "The Patient's Advocate," Penguin, 1981) describes the usual frenzy at the nurses' station:
"Doctors dictate orders and progress notes, nurses draw up medications, secretaries transcribe orders . . . All departments communicate with one another," with interruptions only increasing the chances for errors, "and error is what we all avoid like the plague."
The interruption that is often put aside, while you wait, may be your call for a nurse's attention.
What can you, the patient, do?
A great deal, say former nurse Ryan and others, to help these busy nurses become your allies.
* "Right on admission," Ryan advises, "ask: 'What nurse is responsible for my care? What nurse is assigned to me?' It's important to find that out right away. You have every right to expect an opportunity to sit down with that nurse and find out what is expected of your hospitalization. What are its goals? And you should say what you expect."
* Have the same kind of talk with your doctor to ask: Are a responsible doctor and responsible nurse working together to get the results you and they want?
* If you don't understand what's going on, if you think the wrong things are happening, tell the nurses. Ask for the nurse "in charge of my care" and say you're worried. Most will respond to this kind of appeal.
* Recognize nurses' problems. The strains of working days, nights, holidays, weekends, on rotating shifts. The frustrations of modest pay, fatigue, death, disease, suffering. "Sixteen hours' work to do on an eight-hour shift," one nurse says.
* Rather than giving nurses orders, then, or saying "I want . . . ," try "Can you help me?" Dr. Judah Folkman of Boston Children's Hospital tells young doctors in training: "Avoid harsh words to nurses, lest they become afraid to call you until it may be too late." One might similarly say to a patient: Avoid harsh words lest the nurses avoid you, too.
* Try such tactics, at least, try to be friendly and cooperative. But you don't have to be passive. If courtesy fails, start screaming.
* Compliment good nurses. "The nurses sometimes feel they never get any compliments, just complaints," Folkman says. "Often a patient stops by my office to thank me before leaving, and I say, 'Please stop by the nurses and thank them.' When you do it, they're stunned. Both doctors and nurses need this feedback."
Not all the pressures in nursing are whittling away at considerate care. "I think we're seeing a trend toward getting the nurse back to the patient's bedside," Ryan says.
A survey shows hospitals have been hiring more registered nurses and fewer LPNs, or licensed practical nurses. LPNs and nurses' aides are expected to do bedside chores to relieve RNs for more specialized activities, often conducted away from the bedside.
But many hospitals are finding it more efficient to have one person, the RN, do several jobs. Nurses and patients like the closer contact.
There is also a strong recent trend toward "primary nursing" rather than "team nursing."
In team nursing, a creation of the 1950s, a professional nurse is "manager" of the "total care" given several patients by several people. One nurse may give the medications to 30 patients, another may take all their blood pressures and so on, with the "team" meeting daily to discuss each patient's needs.
Fine in concept, says a new American Nurses' Association report, but in practice "accountability" -- who really worries about the patient -- is often ill defined, and not enough managers and team members are well enough trained for their jobs.
In primary nursing, one nurse typically takes full responsibility from admission to discharge for two to three patients, develops their 24-hour nursing care plan and is responsible to see that it is carried out around the clock.
Most patients are not even aware that there is such a thing as a "nursing plan." But professional nurses are far more than bed-makers or urine-toters. They are the patients' caretakers and the doctors' eyes.
A nursing plan may include:
* Giving the drugs and other treatments.
* Monitoring and measuring treatment effects and watching for clues to assist diagnosis, and noting these things down for the doctors.
* Taking measures to prevent infections and other complications.
* Teaching the patient to use medications and manage after leaving the hospital.
* And -- though this may surprise many patients -- monitoring the patient's sleep and trying to maintain a quiet, unstressful hospital environment to promote recovery.
Such is the ideal, often not reached, as many patients will testify.
Nurses testify that they often must buck hospital administrators bent on economy -- meaning fewer nurses -- and some doctors who still consider them mere handmaidens rather than partners.
Florence Nightingale, founder of modern nursing, once wrote: "No man, not even a doctor, ever gives any definition of what a nurse should be than this -- 'devoted and obedient.' This definition would do just as well for a porter. It might even do for a horse," but will not do for a nurse.
By resolution of the American Medical Association, today's nurses are entitled and expected to question a doctor's orders if there seems to be reason and even to take emergency action contrary to standing orders, if no doctor is available.
Today's nurses, says Judith Ryan, expect to share responsibility for patients' care, and -- to get well in the hospital -- "patients need to be educated to know this and seek it."