The Ph.D. with the Lamp
Nurses in an Oklahoma City hospital have been told to keep their fingernails short. I imagine that some enterprising member of the Trial Lawyers Association has by now picked up this story from the New York Times, where I found it (3/24/00), and launched a lawsuit against the hospital for infringing the nurses' rights. The hospital, however, was acting with good cause. From January 1997 to March 1998, sixteen babies died in their neonatal intensive care unit. Epidemiologists who investigated the deaths came to the conclusion that the principal cause was infection by bacteria dwelling under the long — in one case artificial — fingernails of the nurses. In the months since the nail-clipping order went out there have been no deaths associated with the relevant bacteria.
Nobody that has spent any time in a modern American hospital will be much surprised by this story. Three years ago my ankle was smashed in a traffic accident. "Smashed" is almost an understatement: the state of affairs revealed by the X-rays was what might be expected if the ankle had taken a good swinging blow from a 14-pound sledgehammer. My attending orthopedic surgeon — may his name, P. Warwick Green of East Northport, New York, live in honor and glory for ever! — performed a miracle of reconstruction, and was a model of concern and professionalism, visiting me daily while I was in the hospital and coaxing me through the long processes of recovery and physical therapy with never-failing patience and good humor. I am bound to say, though, that I was not nursed. During my ten days in the hospital — a highly-regarded institution in a prosperous suburban district — I was, for example, never bathed, nor asked if I wanted to be. My bedding was changed just once. My wife tells me that when I got home I stank like a bear.
My mother would have been shocked, though not surprised. She was a nurse herself — a professional Registered Nurse in England — for her whole working life. She had trained in English hospitals in the early 1930s, under a regime something like a U.S. Marines boot camp. Discipline was tremendous. In part this was due to the senior nurses having done their own training on the battlefields of WW1. (See Vera Brittain's Testament of Youth for insight into what that involved.) All bed linen was bleached, starched and changed daily. Daily inspections of the wards were carried out like a military parade: for example, all the open ends of the pillow-cases had to be facing the same way. Sheets and blankets had to be tucked in with precise "hospital corners," somewhat similar to the technique used in wrapping a parcel — I still do "hospital corners" myself when making a bed. "Sister Tutors" — the senior nurses in charge of training — were objects of terror; house surgeons expected to be, and were, regarded with reverential awe. Trainee nurses lived in a residential block known as "Virgin Villas," guarded by unblinking concierges … and so on.
Nursing at that time was not a job, and certainly not a profession. It was a vocation. Attention to hygiene was at the forefront. Patients who could not be moved to a bath were given daily "bed baths" — rolled or lifted onto a double thickness of blankets then scrubbed all over with soapy cloths. I was the object of this treatment myself a few times, at home, and still wonder at the speed and efficiency with which a trained nurse could carry out a bed-bath without leaving a drop of water on the bed. The creed, often repeated by my mother, was: "A nurse's job is to keep the patient clean and comfortable." (Compare Field Marshal Montgomery's similarly reductionist idea of soldiering, as expressed in his preface to the postwar British Infantry Training Manual: "The task of the infantry is to find the enemy and kill him." Such simple times!)
Hospital work sixty years ago had not altogether shaken off the mentality of the pre-modern era, when hospital was a place where poor people went to die. Surgical procedures — the introduction of anesthetic was well within living memory — consisted mainly of cutting things out. There were few other treatments for serious diseases. TB was widespread but incurable until the arrival of streptomycin in the late 1940s, and TB treatments amounted to little more than quackery. Most popular was the fresh air treatment, under which patients were put in wards open to the elements. Mother remembered brushing snow from her patients' blankets. Antibiotics were still new. Hence, of course, the obsessive attention to cleanliness. Sepsis was routine; sputum, feces and pus the raw materials of a nurse's working day. If you asked Mother "What's the matter?" in any context, she was liable to reply: "It hasn't come to matter yet. When it does, I'll put a poultice on it."
When my mother left hospital nursing in the 1970s, she was Assistant Matron — that is, number two in the nursing hierarchy — of a large geriatric hospital. She was glad to leave, and had been grumbling for years about the quality of nurses she was supervising — their carelessness, ignorance, unwillingness to take orders or do unpleasant tasks, and inflated opinion of their own abilities. As with other kinds of vocational work — teaching and soldiering — politics had begun to creep in, and also bureaucratization, and credentialism, and academicization. Discipline in civilian occupations was seriously out of fashion.
Nowadays. of course, things have gone much further, on both sides of the Atlantic. You can now take a Ph.D. in nursing — for example at Johns Hopkins University. The average large American hospital has more administrators than had British India. Feminist theory has fixed its clammy grip on the whole nursing enterprise, and the old notion that nurses (mostly female — in Mother's day male nurses were assumed to be homosexual unless they presented convincing evidence to the contrary) were the handmaidens of doctors (mostly male) is Jim Crow to the new generation of nurses. Keeping the patient clean and comfortable has given way to "analyzing and transforming health care data into information that can be used by health care providers to evaluate patient care and economic outcomes," as the Johns Hopkins course brochure puts it.
Now, much of this transformation has been inevitable, indeed well-founded. A woman of my mother's generation, from working-class origins, had very few options in life. Three, basically: teaching, nursing, or household drudgery. The nurse training programs therefore had a captive audience: pay attention and follow the rules, or resign yourself to a couple of decades of child-bearing and floor-scrubbing. Monetary compensation followed suit; having been raised in a family whose principal financial support was often Mother's nursing wage, I can testify that nurses in the 1950s and 1960s were atrociously underpaid. The woman of today has far more choices, and no reasonable person would wish to return to that earlier dispensation. Hospital work is, too, vastly more complicated now than fifty years ago, with countless new specialties, treatments and techniques. The average salary for U.S. hospital nurses was $40,097 in 1996, though with wide regional variations. Neonatal nurses in San Francisco can make $90,000. Good luck to them. There is a case for the high-end nurse. There is probably a case for the nursing Ph.D.
There is, however, no case for leaving a patient to lie in his own sweat for days on end in an unmade bed — my experience in 1996 — or for allowing babies to die because nurses want to wear their fingernails long. While "keeping the patient clean and comfortable" is no longer the main focus of a nurse's work, it still needs doing. Of what use is it to drill nurses in "analyzing and transforming health care data" if they do not know how to — or are unwilling to — give bed-baths?
And to be sure, the dread specter of infection no longer hovers so obviously over hospital patients as it did in the days before antibiotics; but Nature driven out with a pitchfork will yet find her way back in. The dirty little secret of the high-tech, computerized hospitals of today is that they are germ farms. There are now entire species of "superbugs" found mainly in hospitals — like the terrifying VRE (vancomycin-resistant enterococci). The Centers for Disease Control estimated about 10 hospital-acquired infections per 1,000 patient-days in the U.S. for 1995, up from 7 twenty years earlier, with some 90,000 resulting deaths — two of them known to me personally. While nurse-training programs have silted up with courses in "diversity awareness" and "informatics," elementary hygiene seems to have gone by the board, or to have been delegated to ill-trained and unmotivated auxiliary staff.
It ought to be possible to fix the problem. For all the social changes of the past few decades, it is hard to believe that the vocational impulse is altogether dead. Plenty of people do difficult, often unpleasant work for the love of it. Ministers of religion toil away on pittances. Combat units of the armed forces get plenty of recruits. Cops still tell you, with obvious sincerity, that "all I ever wanted to be was a cop." Is there really no place in the modern hospital for un-bookish types who have no desire to spend years studying for college degrees but just want to look after sick people — keep them clean and comfortable? If there is not, our society has a malaise that no quantity of nursing of any kind will cure.