Caring for the sick?

For years, efforts have been underway to create a federal Office of the National Nurse. A designated National Nurse would be an opportunity to focus attention on pressing issues that have confronted the nursing profession for decades, such as the critical and growing nursing shortage and the need to improve education and training standards — issues that directly impact the quality of care received by every American and affect the future of healthcare. But, surprisingly, that’s not the focus for this position.

I probably don’t need to disclose that I think nurses are important. :-) But even I was astounded by how much this issue could impact all of us, not just nurses.

Several professional nursing organizations have opposed this initiative. However, it’s been challenging to learn the full range of critical reviews, as the lobbying has so intensely saturated online sources. Two articles have come out this month which are bringing attention to the controversy. We’ll try to avoid the power struggles among the various nursing organizations, and focus just on the soundness of the program’s goals.

Role envisioned for a National Nurse

The lead author of an Op-Ed on Medscape, Teri A. Mills, MS, RN, ANP, CNE, is the president of the National Nurse Organization, leading the lobbying effort for this initiative. Its slogan is: “Health care not sick care.”

As she explains, the role of National Nurse would be to support the Surgeon General and Department of Health and Human Services’ mission of prevention. Yes, the Surgeon General’s war on obesity, that began by slimming down Santa Claus.

As a full-time position at the Office of the Surgeon General, the title would actually be: “National Nurse for Prevention.” Mills says it would be created by elevating the current Chief Nurse Officer at the U.S. Public Health Service, which also serves as the Assistant Surgeon General, to a full-time position.

On the website and blog she created for her lobbying organization, she says the National Nurse will support the Surgeon General in creating a nationwide cultural shift to prevention, focus the public on healthy living, and intensify the role of nurses in community preventive health promotion. To encourage all nurses, students to retirees, to spread the preventive health message, they would be enlisted for National Service and asked to participate in Medical Resource Corps in their communities.

She says on her website that an office of National Nurse is needed: “To slow the growing epidemic of preventable diseases.”

She states agreement with the Robert Wood Johnson Foundation’s Trust for America’s Health report, “Prevention for a Healthier America,” and claims that community-based efforts focused on healthy eating, physical activity and smoking cessation could save the country more than $16 billion each year. The Office of National Nurse proposal, she says, has a simple focus: to get nurses to participate in prevention activities that have already proven successful.

In Medscape, she and co-authors write:

With 7 out of 10 Americans dying each year of a preventable chronic disease, it is imperative that we address poor health literacy and access to accurate information; both of these increase risk factors associated with chronic disease... In addition, in the past 2 decades, obesity has been rising dramatically in the United States... Obesity is a known risk factor for 45 conditions, including heart disease, the leading killer in the United States...

The recommendation is simple: The existing CNO of the USPHS would become a full-time position within the Office of the Surgeon General and be given the title of National Nurse. This title change is necessary to provide the authority, impetus, and recognition needed to capture the public's attention, encourage prevention, and raise awareness of a national push for health promotion efforts...

Gallup Polls have proven time and again that Americans trust nurses. Messages delivered from a National Nurse and then reinforced by volunteer nurses in their own communities would address and confront key health issues such as chronic preventable diseases. An Office of the National Nurse will strengthen our country, our schools, and the health of our citizens, and will empower nurses and healthcare professionals to build a foundation for the future health of our nation. The National Nurse would serve as a valuable public resource, complementing the work of the Surgeon General...

This reads troublesomely like the public image of nurses and nurses themselves are being used to push political agendas for the HHS and Surgeon General, rather than foster the nursing profession to provide the highest quality medical care. Nor is this program founded on evidence-based medical information.

Even the CDC’s own health statistics offer no support for a “growing epidemic of chronic diseases” — age-adjusted rates of the primary causes of premature death have been dropping for more than half a century — and there is no biologically plausible way to prevent aging. The Health of the Nation has never been better, with 91% of Americans in good to excellent health. We’re also living longer than at anytime in the history of our country. Our diets and activity levels are even better than in past generations, not worse. The claim that 7 out of 10 deaths are preventable through healthy lifestyles defies all credible evidence or sound science. So is the heartbreaking belief that victims of chronic diseases are at fault and to be blamed, and by following some certain diet or lifestyle and achieving optimal “wellness,” [see here, here, here, here, here,
here, here, here, here, here, and here] that cancers, heart disease, obesity or aging can be prevented.

An article in Advance for Nurse Practitioners, a peer-reviewed clinical and professional journal, went past the marketing to reveal more precisely what the National Nurse program has planned for fixing this purported crisis of preventable chronic diseases and build a new foundation for public health. Ann Nowlin, RN, describes the strategic plan proposed for the Office of the National Nurse:

Appointed at the federal level, the National Nurse would work side by side with the Surgeon General to educate and focus the American public on prevention and wellness. The ONN would plan and deliver a weekly broadcast on wellness and healthy lifestyles. Each week, a different nurse specialist would be invited to participate and deliver these messages, since it's not possible for a single nurse to be the expert on everything. Topics could include "How to Have a Healthy Heart" or "Get Ready, Get Set, Get Fit." All of the information given would be put on the Internet in multiple languages to reach a diverse population.

Mills suggested that individual states have a nurse coordinator and an additional public health nurse. These nurses would help assemble teams of nurses to organize and deliver four educational programs yearly in their own communities...

These are not evidence-based preventive health interventions, as is being claimed. In fact, no objective review of the clinical evidence has found any support for the effectiveness, let alone huge cost savings, of diet and/or lifestyle behavioral counseling and public health messages also for:

· weight loss — Agency for Healthcare Research and Quality review of 46 randomized controlled clinical trials of dietary counseling published over 17 years found a mere -0.1 BMI unit change, which was regained the first year; studies making weight loss claims were of moderate to poor quality, with high rates of missing data and drop-out rates.

· obesity — U.S. Preventive Services Task Force review found insufficient evidence to recommend counseling of any intensity or behavioral interventions for promoting sustained weight loss in overweight adults, and limited data to support benefits on overall mortality, mental health and functioning.

· childhood obesity — U.S. Preventive Services Task Force review found no quality evidence that dietary or behavioral interventions improves health outcomes or physiological measures or fitness in overweight children or teens.

· type 2 diabetes — Cochrane Systematic Review of 18 randomized controlled clinical trials found no evidence to support the efficacy of any dietary advice (low-cal, low-fat, low-carb, etc.) for improving diabetic complications, mortality or quality of life among type 2 diabetics.

· promoting a healthy diet — U.S. Preventive Services Task Force found insufficient evidence to recommend dietary or behavioral counseling to promote a healthy diet in general adult populations.

· improving illness-related malnutrition — Cochrane Systematic Review of 15 randomized controlled clinical trials reported lack of evidence for dietary advice in the management of illness-related malnutrition.

· improving quality of life for cancer patients — Systematic review of randomized controlled clinical trials reported dietary counseling didn’t appear to offer QOL benefits for patients with cancer.

· heart disease — No observational study or clinical trial of heart healthy diets reviewed by the American Heart Association showed any benefit for the primary prevention of heart disease in women.

While the National Nurse program would press every nurse in the country into service to provide these ostensibly prevention activities, they aren’t evidence-based. These wellness programs have nothing to do with proven preventive public health measures, such as vaccines, preventive dentistry, safe drinking water, and ensuring the poor have enough to eat. This isn’t about resolving health disparities that are primarily the result of economic-social factors — issues that all the apples in the world won’t fix. This isn’t about bringing needed medical care to people, helping the sick and injured. Nor is this about improving the nursing profession or addressing the nursing shortage.

This is about making patients or customers of healthy people. This is based on a belief that the public is “health illiterate” and unable to decide what's best for themselves. And, what is even more troubling, is the growing infiltration of politics and anti-science modalities into nursing.

While nurses are combing their neighborhoods as nurse corp volunteers, making sure people are eating what the Surgeon General says, are following the requisite exercise regimens and taking their medicines — they won’t be studying science and developing critical-thinking skills to ensure the clinical care and information they provide is evidence-based, they won’t be updating their skills to keep up with the increasingly high-tech medical field, and they won’t be at the bedside providing medical care for patients.

Sadly, many consumers already don’t believe that there are any healthcare professionals left who care about people and aren’t trying to sell them something or in it for political motives. [Regular JFS readers will know exactly what I’m talking about here.] Our culture seems to have become so saturated with misinformation and corruption, that anyone trying to help people is seen with distrust. Tragically, many consumers seem to have reached the point that they can’t even imagine that caring, morals and ethics, alone, could be what most drives a nurse to want to help people.

But this could become a self-fulfilling prophesy. When the official national voice of nurses becomes more about politics rather than evidence-based medical care and health information, rather than advocacy for people, and rather than improving the professional practice of nursing, the public’s trust in nurses will be forever tarnished. Most concerning is that this voice won’t speak for many of the best nurses and future nurses, and as they’re driven away, all of us, who might need a highly-trained nurse someday, will lose.

© 2008 Sandy Szwarc