Nursing for Justice: Ideas for a More Equitable Nursing Practice

One of the nursing staff’s favorite person to take care of was a kind Latina woman. While there was a language barrier between us and she was experiencing some severe health challenges, she was extremely thankful for our care. She had come from South America to visit her daughter and suddenly found herself in the hospital, newly diagnosed with hepatitis. She had initially presented with pneumonia and kidney failure. We were running continuous dialysis to help clear her body of toxins, but she would require a liver transplant to survive long-term. A coworker asked how she was doing.

“Oh, you know–she’s okay, but she’s not really going to get better unless she gets a transplant,” I responded.

“See, that makes me mad. She came to this country illegally, she’s not even a citizen–and she thinks she can get a transplant? It’s hard for even citizens of this country to get transplants, and illegal immigrants think they deserve one? You think if I went to Europe and I got sick, I’d get a transplant?”

“I don’t know, but you might, if it was an emergency and you’d die without one. Because, you know, they have real healthcare.” I was furious. This nurse had taken care of her sick patient and seen her only through a lens of nationalism, racism, and classist hatred. She didn’t acknowledge that throughout our hospital, patients from all over the world receive transplants funded by their governments. Are their lives more valid because their governments are friendly to the United States, or they are lighter-skinned and wealthier? Are their lives more valid because the artificial borders were crossed with the mobility granted by a passport stamp?

Judging from the way healthcare in the US functions, or fails to, the answer is yes.

Systemic oppressions are embedded in healthcare. As a nurse, while I may not view myself as the perpetrator of oppressive practices, I willingly reinforce a healthcare system that is inherently unjust. Ideally, I would love to work in a healthcare setting that fights inequality and oppression on a daily and systemic manner. In reality, I have never worked in that setting.

While working within a flawed system, how can nurses combat the latent racism, classism, homophobia, transphobia, ableism and sexism that exist at our jobs? Here are some concepts to consider when walking into work.

1. Acknowledge Our Power. At work, nurses are with patients more than anyone else. We admit and discharge, which involves asking questions about their past and present. We advocate for patients, which can be as small as tracking down a meal tray during shift change and as big as getting the Ethics Committee or Patient Advocate involved when the patient or family is unsatisfied with care. We answer call bells, helping patients find comfort in a foreign environment. We give medications, which are sometimes life-saving and sometimes pain-relieving. We assess patients from head-to-toe, which is often redundant but sometimes can help catch new stroke symptoms or prevent an impending decline. We have power.

2. Recognize that Within Healthcare, Patients Are Often Margnialized. We stick needles in them, we tie them to beds, we stick a tube in a penis without even telling the person our name. Our patients are people, and we often forget this. We also forget context. Many of the people who get sickest are the people who have been marginalized in multiple ways. Race, class, and gender presentation may mean that access to wellness promotion, risk reduction, and health education have been limited throughout their lives. When a child is diagnosed with diabetes, hopefully parents are around to check blood sugars and appropriately give insulin. What if the parent works multiple jobs or has an addiction they are trying to manage? As an adult, this patient comes in with “poorly controlled diabetes” with “multiple complications related to noncompliance.” These words ignore context. When a middle-aged Black man comes in with stroke symptoms and has undiagnosed hypertension, we blame the patient for not seeing a doctor in decades. What if there are no affordable clinics within a reasonable distance of where he lives?

Our patients’ health does not exist in a vacuum. They often come to us with multiple marginalized identities. When they enter the hospital, we marginalize them once more. Our license allows us to do what is medically necessary, regardless of whether the patient wants it. Legally, the patient can refuse. Realistically, if a patient is in kidney failure and we need to monitor urine output, but they don’t want a catheter, we are going to do what we deem medically necessary.

3. Know Your Role. Nurses are not only involved in power dynamics with patients and their families, but also with nurse managers, administrators, and most importantly, doctors. We have distinctly different roles from doctors which allow us to be more acutely aware of what a patient is going through on a human level. We spend time with our patients and sometimes even see them as people, struggling to survive, rather than as the other. The expected power dynamics between nurses and doctors often are similar to the traditional expected roles between women and men, regardless of the gender of those involved. The nurse is expected to be ignorant, unscientific in her explanations, and needs the doctors to fix difficult patient situations. The doctor swoops in and fixes everything quickly, then leaves the nurse to clean up his or her mess. Nurses are expected to obey instructions, carry out orders, and avoid confrontation or dissent. Notice my use of the word expected. This is what many doctors expect us to do, but then act surprised when we ask why, tell them to clean up their messes, or ask them to have a conversation with a patient. While doctors write orders, nurses need to know the ins and outs of why we are carrying out these orders and we need to believe the rationale behind them. We need to be sure that the doctors have considered everything that is going in with this person-including their family involvement and what the patient really wants. So, we ask a lot of questions and demand a lot from the physicians. We are advocates. Confronting power, or perceived power, is part of the job description.

Speaking truth to power is not easy but I am looking for ways to speak my truth within my job as much as I can. I cannot claim to do all of these things all of the time, but am trying to practice nursing with justice on my mind. I would love to hear suggestions from other folks working towards a more just world.  In following posts, there will be more concrete ideas for how nursing practice can work towards justice. As this is coming from a Critical Care nurse, these concepts and ideas will be primarily centered around inpatient hospital care, but I would love to hear from nurses of all disciplines.

This post was born through conversations with rad nurses and came together with the encouragement and help of Carol Dreibelbis and Nwadiogo Ejiogu. Thanks for your editing skills and support!

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7 thoughts on “Nursing for Justice: Ideas for a More Equitable Nursing Practice

  1. Good thoughts. All true.

    But there is a really interesting conflict that gets all too little attention. Your patient was a foreign national. As appalling as your colleague’s comments were, there is a more difficult situation when we focus just on domestic patients. So, we can excuse your patient on the basis that she was simply visiting relatives and did not expect to be hospitalized. Of course we do not actually know that. She might actually have come to the US seeking care she could not get at home.

    On the domestic front, we have at least 4 classes of patients we care for:

    We have patients who are fabulously wealthy, they are cared for in special rooms, they may or may not seek to recover costs from insurers because they can easily afford the care they seek. Most of us never see these patients.

    We have people with very generous insurance coverage. They pay a lot to have top of the line insurance policies and they, and their insurers, view their transactions over the long run. They pay high premiums and they expect, over the course of their lives, decades, not years, to recover about 75% of their premiums in benefits. But they, and their insurers, recognize that if they are lucky they will recover far less than 75% and if they are unlucky they will recover far more.

    We have people who are members of health maintenance organizations, or have purchased cheap, high deductible insurance policies. These patients have chosen policies that significantly constrain the amount of care they have available, restrict them to providers who have agreed to accept far lower payments for their services than the revenues received from the out of pocket and high end insurance. Most of these people will never learn how deep these restrictions are because they will never need the kind, or duration, of care that will exceed the meager those stingy levels. We might also include Medicaid recipients with this group since Medicaid has similar constraints.

    Last, we have people who have no insurance coverage at all, some because they cannot afford insurance, but many of these people consider insurance to be immoral, creeping socialism or are just willing to play “No coverage roulette”, betting that they will never need insurance benefits. The patients who cannot afford any policies at all are interesting but they really aren’t going to help us understand our treatment dilemma. If they really are so poor that they can’t afford any coverage at all, they will likely become eligible for Medicaid at some point as their resources are spent, they lose any property they had.

    So now we actually have a patient come in. Let’s assume that like your patient, they will eventually need a transplant, and in order to get a transplant they will require costly care until they have an opportunity to get a transplant. Now we have a really interesting conflict.

    If the patient is in the first category, they may hire their own nurses, will set up their high end hospital room as one might set up a luxury hotel room. They may have private nurses 24/7 and these nurses won’t be anything like the nurses for the three other groups. So we really don’t need to discuss the first group any further. They are in a different world.

    So we have three classes of high cost patients that we are actually likely to care for: Patients with the high end insurance, patients with stingy MCOs/HMOs, high deductible insurance policies or Medicaid and then we have the patients who “chose” no coverage at all.

    Let’s say we have three identical patients who arrive simultaneously. The only difference is the type of coverage. We can only treat one patient, the other two will die.

    What choice should we make, as nurses? Do we flip coins until a random choice is made? What if we restrict ourselves to just the patient who bought an excellent insurance policy and the patient who chose nopt to buy any insurance at all?

    What exactly is the moral basis of our obligation to the patient who chose no coverage at all? If we select this patient, over the patient who chose not to buy coverage is it “Just” to ignore the fact that the patient with an excellent plan spent more money on insurance, who acted responsibly and planned for such a situation?

    What about the costs of caring for the patient. Should “our” hospital cover the costs of care for the patient who spent the money they could have used to buy insurance on a bigger house, a boat, an RV…?

    Why should we expect our employer to cover the costs of care for a patient that, in retrospect, made a bad choice?

    This is precisely what is playing out multiple times each day. We are no longer living in the 50s or 60s when far fewer patients came in with well defined benefits. Every patient we are likely to see comes to us with benefits they have elected to have available. Each patient either has a good insurance plan, a stingy plan or no plan at all.

    I can’t completely resolve the inherent conflict but I am very sure that not factoring in the decisions our patients made before they needed our care is neither just, ethical or practical. We need to consider the choices our patients made because refusing to care for the patients who have been most responsible is clearly not fair to them.

    • Thanks for commenting and contributing to the discussion.

      When considering the idea of responsibility, and giving healthcare on the basis of responsibility, it’s important to consider that the decisions which seem to be individual are often impacted by social and cultural factors. Buying food from healthy sources, having childcare for your kids so you can work and cook food for them, growing up in an environment where police patrol your streets and apartment buildings are all significant factors that affect physical and mental health.

      If we value life only to the extent that an individual buys health insurance, or makes subjectively “good” healthcare decisions, then I don’t know a single person who should be taken care of. After all, everyone I know makes bad decisions that impact their health. Riding the subway in NYC, drinking more than one drink a day, driving multi-ton death machines (cars), eating out at restaurants, could all be considered a subjectively bad decisions for health–but should that mean millions of people should not be taken seriously when they have the flu, get in car accidents, or have food poisoning?

      I think car accidents and pregnancy are potentially good counter examples. Whether a person gets in a car accident is often not their fault, but when they come into the trauma bay it doesn’t matter. When a person is actively in labor, the law is that we must treat them regardless of insurance. There often isn’t a “most responsible” party–just humans who need healthcare. We decide to unconditionally value their lives in these emergency situations. When we discharge them, they leave the hospital into a world that may not unconditionally value their lives.

      As an inpatient nurse, I don’t know anything about my patient’s insurance situation unless it affects the scheduling of a surgery or their ability to be placed with a rehab–and I only know this to the extent that they will be staying in the hospital longer. In my experience, the idea that we give better care to the person who is most highly insured/”planned” for their sickness best is somewhat false. Yes, I’ve worked in the VIP area of a hospital and witnessed the excesses of the wealthiest people. Outside of the VIP area, and outside of instances where VIP’s are in normal inpatient areas, I don’t believe insurance status has much to do with how patients are taken care of on an individual basis.

      Institutionally, though, patients with Marfan’s syndrome who have aortic aneurysms can have their non-emergent, but still life-saving, repair surgery denied or delayed because of lack of insurance. While one could argue that this patient should have been more responsible and purchased more adequate insurance coverage, most young people are simply not going to purchase the highest level of coverage. I don’t know any young people who would spend thousands of dollars a month when they don’t have any medical history. Unless insurance is no longer a question, unless profit is not the motivating factor when considering an individual’s and society’s health, I don’t think people will be adequately cared for.

      • MaryAnnThomas: Thank you for your thoughtful comments. You give some really good counter cases, but I think there may be some subtleties that remain unaddressed.

        But first, let’s deal with paragraphs 2 – 4. Let’s just assume that we all agree on these points. We all want to be good nurses and we all want to help our patients, as much as we can. If we didn’t we probably would not be signed up on “FB Rebellious Nurses”. This will free future posters, and posts, of having to go through the long lists of politically correct verbiage that we all agree on. Having addressed that, let’s deal with Paragraphs 2 – 4.

        You say: “As an inpatient nurse, I don’t know anything about my patient’s insurance situation unless it affects the scheduling of a surgery or their ability to be placed with a rehab–and I only know this to the extent that they will be staying in the hospital longer”.

        But this is precisely the point. You DO know about your patient’s insurance situation and you know that it affects the care you can provide your patient, how long your patient will be in the hospital and what options your patient has with regard to after hospital care such as a nursing home, rehab center or home health care.

        Your knowledge of these factors affects the degree to which you can provide care to your patient. From the moment you know that you are dealing with a patient who will not be in the hospital long enough to receive the usual standard of care, you are playing out your role as an arbiter of the care your patient receives.

        If you deal with a patient on the basis that they will be in your hospital for 5 days, when they will only be in for 2 days, you compromise the care your 2 day patient receives. If you do not provide the patient education that normally occurs on day 5, before your patient is discharged on day 2, you harm your patient. As well, if you provide the 5 day patient education on day 2, an entirely appropriate decision, you are offering different care to patients based on their entitlements.

        Let’s see how this plays out. Suppose you have a patient who should be discharged to a nursing home, a far lower cost environment that is entirely appropriate for them. But your patient cannot afford to go to the nursing home. Are you really suggesting that you will refuse to do the paperwork necessary to discharge the patient? Are you really willing to disadvantage other patients who actually need the bed/care that they will not get? Are you really willing to harm your employer financially by failing to do an appropriate discharge? Will it make any difference to you if the costs of caring for this patient will be so high that your hospital will go bankrupt and close?

        So what I think you are actually saying is that you so routinely adjust to the impact of different patient entitlements that you no longer see them as something unusual or worthy of comment.

        Now in your last paragraph you really open Pandora’s box. You say: “…most young people are simply not going to purchase the highest level of coverage. I don’t know any young people who would spend thousands of dollars a month when they don’t have any medical history.”

        Firstly, we aren’t talking about thousands of dollars a month but we are likely talking about hundreds of dollars per month. But this is precisely the problem we face. With all the talking heads over at FauxNews saying that young people will not protect themselves from financial harm by purchasing health insurance we have hundreds of thousands of people who ought to be buying health insurance, who are not buying health insurance. Worse still, they actually fall for the crap FauxNews dishes out and tend to severely underestimate their risk exposure.

        When they have the accidents, or become critically ill, their failure to protect themselves will impact their care. A spinal cord injured patient may spend a month in a hospital but their access to physical therapy and rehabilitation will be vastly different depending on the decisions they made to buy, or not buy, health insurance, long term care insurance and disability insurance.

        Now I am about to discuss health, life, auto and pension pricing based on gender. I really don’t want to get into a banal discussion of gender identity. The financial issues are already complicated enough. So let’s just assume that people will be allowed to choose their gender and other statuses. So everyone gets to say whether they are Male, Female, MtF, FtM, Gay, Straight, Bisexual, Celibate, Sex-addicted, Pansexual… If we let them, actuaries will be more than happy to calculate premiums for any possible typology we specify but the number of people who self-identify themselves into the smallest groups will pay astronomical premiums because that is what happens when you appropriately price insurance.

        Now this is a really cool. Insurance pricing has got to be one of the most interesting arenas for political correctness suicide. Young men under the age of 25 pay higher rates for auto insurance than identically aged young women. Do you believe that we should not use gender in pricing auto insurance? Do you want all people under age 25 to pay the same rate? This will increase the premiums of young women and reduce the premiums paid by young men. Should young women subsidize their young male counterparts in the name of gender equity?

        Retirement plans tend to be gender neutral despite the fact that women tend to live longer, after the age of 65, than men. Should male and female retirees receive identical monthly pension benefits or should women receive lower monthly benefits because they will receive benefits over more months? Alternatively, we could just give both men and women a single retirement payout. Should these payments be identical? If you give women the same payout as men, despite their longer expected lifetime, you disadvantage women who have to prepare for a longer life span.

        There are many different ways to price health insurance, life insurance, retirement funds, auto and homeowners insurance and workers compensation in a gender neutral or gender specific manner. But each approach advantages one group compared to another unless we have a one premium fits all approach, but even that implies that people with lower expected losses are subsidizing people with higher expected losses.

        We can all choose to remain oblivious to the environments we work in, putting on our blinders when we walk in the door, and taking them off when we leave work, but we will be making decisions based on the choices our patients made before they needed our care regardless. I, for one, think this is worthy of reflection.

    • By Kaity Molé:

      Thomas, 1. Have you researched Medicaid coverage gaps? Where you don’t qualify for Medicaid but still cannot afford insurance? This is a huge percentage of the population.

      2. Your response completely fails to consider the intersecting systemic obstacles and barriers of oppression based on race, immigration, gender, orientation and disability or (often justified) distrust of government and healthcare in considering who is able to access insurance and how the struggle to survive in an unwelcoming environment can take precedence over purchasing medical insurance.

      3. Your reply focused largely on the “morality” of who should get care and “bad decisions”. As nurses, it’s usually none of our business who made what decision and why, we’re ethically bound to provide care and education and listen to patients non-judge mentally should they want to share their story. Qualifying “who deserves care more” is poor nursing practice. Particularly because many of us in America live with the systemic privilege of being cisgender, White and straight (and 50% male) and cannot possibly understand what life as a displaced or immigrant individual is like, or any of the other intersecting oppressions that people face. Your reply assumes at the very foundation that everyone has grown up with the same access to education, knowledge of how health insurance works and even the ability to read or speak English. This is simply not the case.

  2. After reading the post and the comments that followed, it seems that Thomas is more interested in patients as statistics than as fellow human beings. Its unfortunate that he has not been able to muster the empathy and understanding necessary to view the larger realty of things. He, like many in society genuinely believe that their own hard work and right “choices” are predominantly responsible for whatever “success” has been achieved. I would propose that had Thomas been born in a poor country without the luxury of choice, he would be singing an entirely different tune!

    What might be more beneficial, would be to reflect on why you feel you are in a position to judge whether people are deserving of health care or not.

    “If no one had too much…everyone would have enough!”

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