where the writers are
Another Kind of Diversity

This morning as I parked my car at the health sciences university where I work, I pondered the value of the bright orange sticker attached to my rear window: my parking pass. I pay about $1200 a year to park behind and down the street from my building on the far south side of campus, which equals about $5 per working day. No other hospital in town charges nurses for parking. No other university in town charges faculty for parking. Ours justifies it by reminding nurses, faculty and other employees that our location makes adding more parking spaces impossible, which is mostly true, but fails to satisfy me. A part of me cannot help suspecting that parking is a sign of another kind of subtle discrimination, a lack of respect for diversity that is subtle enough to be enforced without attracting much attention.

This other type of diversity that goes all but unmentioned is respect for diverse disciplines. We have schools of medicine, nursing, dentistry, dental hygiene, and engineering, but it is plain that the medical school and medical doctors are the privileged. The medical school is referred to by upper management as “The School.”  Medical students receive free priority parking, while nurses and nursing faculty (including those of us with PhDs) can wait 5 years or more to claim one precious parking space on campus. Then we pay dearly for the privilege.

Medical residents are happily given free meals in the cafeteria, while RNs like me carry on our persons just the minimum needed to buy lunch and a coffee during our shift. Going to a locker would waste 5 precious minutes of break time. And there is no way I’ll carry a wallet in my scrubs, risking contamination by who-knows-what body fluid.

The university’s executive leadership group consists of the CEO, who has an MBA, and three MDs. One of these MDs is the president, another is the dean of "The School", and the third is the Vice President and Chief Administrative Officer.  Although nursing care is the reason people are hospitalized, although 24/7 nursing care is the one service no hospital can operate without, although the School of Nursing at my university is a $30 million enterprise with 800 students and 250 faculty, although the university employs some 1500 nurses, no nurses sit on the esteemed executive leadership team.

Last year, I took a course with a group of physicians. One of them mentioned that fiscal cutbacks had meant reducing the funds she received for continuing education and for travel to enhance her knowledge of clinic operations. In the School of Nursing, faculty apply for a piece of a shared pool of continuing education funds that is usually depleted before the year is over. An Emergency Department physician in the course stated that, in the ED, he is in charge, then the fellows and house officers are next, then the nurses, and then the paramedics and nurse’s aides. He was apparently unaware that no nurses report to him, and nursing practice is not supervised by physicians.

In my clinical practice, I observe that it is fine for a physician to openly criticize, and even to insult, nursing practice, but a nurse who questions a medical decision will carefully approach the physician one-to-one, often planning the discussion ahead of time and carefully choosing words that will not offend. I have heard nursing faculty coaching students to pretend to have a question about treatment in favor of plainly questioning a decision made by the physician. I assume this strategy was advised to shield the student nurse from the anger that may be engendered when a nurse hints that she has knowledge the physician lacks. This strategy is not merely dishonest, it fuels the separation between nurses and our physician colleagues. Collaboration among health care providers improves patient outcomes, so we should embrace it, not shrink from it.

Perhaps the most obvious example of the strict health care hierarchy is simply that physicians, even those we’ve worked alongside for years, are customarily called “doctor” while nurses are customarily called by our first names. Even with a PhD, I, too, fall into this trap. The rituals of health care are so pervasive that no nurse's credentials can trump them.

Health care got this way legitimately. Hospitals were historically religious or military institutions, perhaps the two most hierarchical systems ever on the face of the planet.  So the rigidity of health care has a very long history that makes change even harder to come by.

Medical privilege is not found just at my university. Federal funding for medical education outstrips that for nursing education by several hundredfold. Reporters seeking a health care provider to interview will typically seek out physicians, not nurses. Health-related sound bites with oversimplified advice from Dr. Oz are regularly featured in women's magazines. And so on.
 
Nurses have fought mightily to change this discriminatory system, and have made many gains as a result of our efforts. Overt signs of mandated nurse submission, like being expected to give  up one's chair to a physician, are gone. But a part of the reason nursing has not made more scientific and political headway is the subtle discrimination that places one discipline at the top of every organizational chart. Everything nurses accomplish takes longer and requires harder work when we strive to achieve the same aims as our medical colleagues. Lack of support staff, resistance from administrators and small obstacles like parking spaces further from our offices collectively impede our work and add up to frustration, and often, surrender to the insurmountable "system." 

The hierarchical culture of health care reinforces medical dominance, and we are socialized to accept this as the status quo. But if we are to improve communication and collaboration, preventing errors and, yes, saving lives, then nurses, therapists, counselors, chaplains, and other health care providers, must defy the hierarchy. Respecting diversity must include leveling the playing field among all health care disciplines. Our patients, our colleagues, and our profession, will benefit.