BOOK REVIEWS

Nursing Against the Odds. SuzanneGordon. Ithaca and London: CornellUniversity Press, 2005. ix + 489 pp.

DEBORAH SHELTON

University of Connecticut, School ofNursing

For those who aspire to be nurses, forthose seeking answers to why health careis an awful experience, and for those whosimply can’t quite figure out what nursesdo, this book is a must read. As a veteran inthe nursing profession, nothing in this bookwas new to me. What Suzanne Gordon hasdone, however, is tie all the loose ends to-gether, marking the odds against the pro-fession of nursing with the voices of nursesthemselves. This book consists of a “prac-tice narrative” (i.e., it offers the compellingand credible stories that describe the routineactivities and daily contributions of nurseswho make a difference to people they carefor). The ultimate aim, Gordon says, “is toilluminate the complexity of what seemsthe simplest nursing tasks” so that peo-ple can understand that nurses are educatedand why they need resources, good work-ing conditions, collegial relationships, andauthority within their institutions to do theirwork.

It is sad to realize how undervalued nurs-ing as a profession is. It is not until some-one is sick, hospitalized, or struggling torecover his or her health, or experiences thepain and suffering of someone they love, thatthe meaning of a well-trained and skillednurse hits home. One realizes that it is in the“caring” or “laying on of hands” that oneheals, both physically and emotionally. Thisrealization is in contrast to what this bookclearly documents—that in the modern hos-pital, caring is unimportant, thus nursing un-dervalued. In the scary environment called

the U.S. health care system, nurses shouldbe even more highly valued for their diverseabilities, despite an extremely fragmentedand chaotic system of care.

Suzanne Gordon artfully weaves the his-tory and origins of nursing through outthe book, bringing meaning and substancethrough interviews and statistics in supportof bedside nursing. Bedside nursing is spo-ken of in broader terms, looking beyond thenurse who works in a hospital to describethe nurse who is at the side of the patient—the person, wherever he or she might be.This could be in a hospital, the community,a clinic, a school, a psychiatric hospital, anemergency room, or a surgical suite. The factthat nurses are found in these and many moresettings speaks loudly to the importance ofnursing in the public’s health.

What is most painful to me as a nurse iswhat Gordon writes about what nurses havedone to themselves. This includes lack ofarticulation of nursing’s contribution to pa-tient care, not settling the entry into practicedebate, bearing the brunt of efficiency andcost cutting, allowing ourselves to be abusedby unreasonable workloads and coworkers,and trying to do the impossible—to keepeveryone happy, adapting ourselves end-lessly at the risk of destroying that whichwe love—being a nurse. With the knowl-edge that nurses comprise the largest groupof health care professionals nationally andaround the globe, this book points again tothe magnitude of the power the professioncould wield collectively to affect health carein a positive way. The book documents thefactors contributing to and aimed at prevent-ing this from occurring.

Nursing Against the Odds begins with apersonal accounting of an experience whereSuzanne Gordon had to be “the nurse” fora friend who had outpatient arthroscopic

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knee surgery. She shares a story of feelinghelpless and alone as she struggles to assisther friend who is on crutches and stillaffected by the anesthesia. The messagehits home—home care is not somethingthat most people are prepared to handle. Itis more than offering tender loving care; it’sabout avoiding complications of the surgeryand recovery. This experience, Gordonshares, was her first realization of what ahealth care system without nurses might be,something she perceived as unworkable.This experience sets the stage for thefollowing chapters that explore three areas:relationships between nurses and doctors,the media and nursing, and hospitals andnursing.

In the first section of the book, the firstfive chapters discuss the relationship be-tween nurses and doctors, the descriptionof nurses as an “oppressed people,” and theimpact on their ability to provide nursingcare. The emphasis in these chapters is onthe reports by nurses regarding “disruptivephysician behavior.” Nurses relate that thisbehavior has a serious impact on morale andnurse retention. Gordon discusses the train-ing of physicians, pointing to their lack oftraining about how to interact with otherhealth professionals. Separation of physi-cian notes and nursing notes, the lack of at-tention and recognition by physicians of thedata regarding how the patient is coping withand responding to treatment documented inthe nursing notes, and the interpretation byphysicians that interdisciplinary teamworkrefers to doing things “their” way contributeto the struggles for nurses, who perceivethemselves as team members, advocates forpatients, and responsible for patient safetyand positive outcomes. These and other fac-tors, including the responses by nurses, cre-ate what is termed the “invisible nurse” byconcealing the medical and technical mas-tery of nurses and challenge the authority ofnurses and nursing practice.

The next three chapters comprise thesecond section of the book, with a focuson the media and their portrayal of nurses.

From children’s books to television shows,nurses are portrayed as “handmaids, harlotsor harebrained,” rather than being depictedas having the knowledge and intelligenceit takes to be a nurse. Numerous examplesare shared recounting situations and eventswhere the media reinforce the image of thedoctor as “smart” and the nurse as “kind butdumb.” The invisibility of nursing is aptlyportrayed in the example where over 400articles and over 900 direct quotations wereanalyzed in three major newspapers for thefirst quarter of 1990. Thirty-two percentof the sources quoted doctors and only1 percent were from nurses. Even whenthe subject was about nursing, physiciansand administrators were sought out forcomment.

Distressingly, Gordon notes, the “sidelin-ing” of nursing is so common that it is hardlynoticed. Well-known and respected healthinstitutes including the World Health Orga-nization diminish the expertise of nurses,their primary role in clinical research, andtheir contributions to public health. Nursesthemselves add to this, as there is much re-sistance among nurses to public communi-cation. As one respondent suggests, nursesdesire a better image, but think that someoneelse should make things change. Anotheragrees in pointing out that nurses do not liketo be connected with anything that appearsto be controversial or overly political.

The next chapters, organized as the thirdand last section of the book, focus on hospi-tals and cost cutting. Gordon describes howhealth care downsizing has been at the ex-pense of nurses and nursing care, with animpact that reaches far beyond the hospitalsetting and nurses at the bedside. The effectsof restructuring, temporary traveling nurses,and migration of nurses (particularly fromdeveloping countries) further fragment thenursing workforce and magnify the nursingcrisis. Nurses, frustrated with bedside care,move into advanced practice and exacerbateshortages in bedside caregiving and serveto fuel tensions within the nursing profes-sion, making it more difficult to create viable

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solutions for making nursing a sustainablecareer.

The emotional and physical stress felt bynurses who deal daily with pain, suffering,and death as the distinctive feature of theirwork is described. Caring for sick peopleis not a 9-to-5 job, and is more demand-ing than many other professions or occu-pations. Simply said, nursing is hard work.In an environment as described above, withfewer and fewer rewards and in combinationwith difficult patients, taxing schedules, andstrenuous physical work, nurses with yearsof experience and even those with only a fewyears of practice are bailing out of a career indirect care. Although history demonstratesthat nursing shortages are cyclical in nature,many nurse leaders have described this nurs-ing shortage as “different.”

Gordon describes this as a three-tieredshortage. First, there is a lack of nurses will-ing to work at the bedside under the currentconditions and wages. This dissuades oth-ers from going into nursing as direct careproviders at a time when the population isaging and dealing with more chronic illness.Cost cutting produces a third and more “elu-sive” shortage. Even in an environment of anadequate number of nurses, health care insti-tutions budget for an amount of nursing carethey deem adequate, leading to a shortageof nursing care patients receive. Researchshows that along with the reduced nurs-ing care per patient, comes negative con-sequences as the burden of care is placedon the ill-prepared patient and their fam-ily. Increased errors in assessing patients’responses to treatment are seen when cost-saving untrained “assistive personnel” workin expanded capacities. Errors are also as-sociated with large nurse workloads and fa-tigue in caring for patients who are sickerand in need of more complex levels of healthcare. Clearly, the healing connection be-tween the availability of nursing care andthe contribution to quality patient care andis getting lost. The United States spendsmore per capita (approximately $6,000 perperson), yet has poorer health outcomes as

seen in the number of uninsured and infantmortality rates to name a few. Promises byindustry as they restructured have not ma-terialized, creating a situation of extremestress for nurses.

The conclusion of the book describeswhat can be done to “change the odds,” call-ing on us to remember two things aboutnursing: the specificity of the work and thatnursing is work. Based on information fromthe numerous “high-level summits,” out-of-the-box solutions made by nurses, such asunion activity, government regulation, safestaffing ratios, and universal health care areconsidered “off limits.” In settings wherenurses did organize themselves and utilizedtheir combined political strength, they haveinstituted positive changes that have demon-strated improved patient outcomes. As anexample, there is mounting evidence thatreduced nurse staffing ratios have beenshortsighted and counterproductive. Otherexamples demonstrate that when nurses areoffered better pay, and have a voice in gov-ernance, the workforce stabilizes and costsassociated with staff turnover are reduced.Gordon further supports unionization, rec-onciling physician and nurse communica-tion through use of common language, anddeveloping some form of universal healthcare that would end the chaos created by amarket-driven system.

As I finished this book, I, as a nurse, hadmixed feelings. I felt angry that things havegotten so out of control that profit has be-come more important than people, and I wasdisheartened by a profession I love that can’tseem to get its act together. The book pro-vides a thorough assessment and outlines thechallenges in a manner that offers a more ob-jective examination of health care and nurs-ing practice. In terms familiar to nurses inthe form of the nursing process, the assess-ment and diagnosis are completed, what isneeded is an organized plan and interven-tion. But let’s be clear about who the patientis—the patient is nursing. By caring for ourprofession, and ourselves, we care for everypatient wherever he or she may be.