May 10th, 2020

Thank You to Inpatient Nurses — The People Doing the Most Direct COVID-19 Patient Care

English stamp commemorating nursing care, 1999.

Anyone who does inpatient medicine or surgery knows well the major imbalance in time spent on direct patient care between doctors and nurses.

Nurses spend way more time actually with patients than we do — I’m referring to time in the rooms caring for patients.

While we round and review charts, document lab test results, bring up radiographic images, write orders, and debate the merits of the latest hydroxychloroquine or remdesivir study, they do direct assessments and respond most immediately to patient needs.

It’s been this way for years. The late Dr. Arnold Relman, former editor of the New England Journal of Medicine, sustained a major injury several years ago that required a prolonged hospitalization. Writing about the experience, he cited how doctors (vs. nurses) practice medicine today:

What I hadn’t appreciated was the extent to which, when there is no emergency, new technologies and electronic record-keeping affect how doctors do their work. Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their computers than at the bedside. Reading the physicians’ notes in the MGH and Spaulding records, I found only a few brief descriptions of how I felt or looked. Conversations with my physicians were infrequent, brief, and hardly ever reported. What personal care hospitalized patients now get is mostly from nurses.

Emphasis mine.

COVID-19 only brings this stark disparity into sharper focus. A diagnosis of COVID-19 means necessary isolation — single room, no visitors. Clinicians must put on (“don”) personal protective equipment (PPE) to see patients, then take off (“doff”) the PPE without contaminating oneself — a strategy best done with an attentive monitor. It’s not easy to get it right.

Since PPE supply chains have been strained right from the start, we must limit the number of clinicians with direct patient care. Bring on the telephone or iPad consults — that was never a thing before. Way fewer doctors in the room, both during rounds and the rest of the hospital day. But all patients still have the same amount of nursing care.

We ID specialists say this again and again about the risk of transmission of SARS-CoV-2, the cause of COVID-19. The riskiest activities involve spending prolonged time in close proximity to someone with the disease — especially someone who’s acutely ill and coughing.

And in the hospital, the health professionals doing most of this high-risk activity are the inpatient nurses.

I’ve thanked them before for this. But May 6-12 is National Nurses Week — an excellent reminder to be grateful again for what they are doing in this very challenging time.

6 Responses to “Thank You to Inpatient Nurses — The People Doing the Most Direct COVID-19 Patient Care”

  1. Stephen FELTS says:

    Amen Paul. It can’t be said too often that Nurses supply the vast majority of patient care.

  2. Shishir Gokhale says:

    Yes, I fully endorse. The work of nursing care is often given less importance than the heroics (which sometimes are misplaced) of doctors. As a conscientious doctor, it is necessary for us to acknowledge that the nurses are an equal if not greater partner in providing good health care.

  3. Luis A. Rico, MD. says:

    Totally agree. Nurses ARE always there and ARE the ones who do the work and in this time the ones MOSTLY exposed. And they do so naturally without a single complaint. And they do so EVERYWHERE, in my case I can say so from Spain. (U.S.) National Nurses Week should be International Nurses Week, or maybe it also is. My wholehearted gratefulness to all nurses.

  4. Gisell Miller, ARNP says:

    Dear Dr. Sax, as a nurse, I fully support the idea that nurses are doing more care management, however, you unfortunately missed a grand opportunity to thank Physician Assistants alongside nurses. Both nurses and Physician Assistants in the ER setting tend to be at the front lines more-so than doctors. I do not know your particular area very well but I can attest that Physician Assistants are the most unsung and forgotten heroes in many medical areas. In my department, the Physician Assistants tend to more directly involved alongside us and we are complementary of one another in the medical management roles.

  5. Mimi Breed says:

    I’m a retired nurse. You’re certainly right, Paul. I’ve been hospitalized as a patient a few times the past few years, too, and, yes, while it’s the nurses who give the most care, I’ve watched the computer screens they wheel from bed to bed — and are enslaved by — grow bigger and bigger, and the information demanded by those screens grow more and more detailed. I feel nurses, along with doctors, are being drawn further and further into the vortex of computer care and away from patient care. The good nurses give excellent patient care despite the obstacles, but it’s more and more difficult, I’m afraid, for the nursing techs and more ordinary professional nurses. This state of affairs is great for the data-wranglers (I suppose) and for research (maybe) and for software vendors (certainly). For patient care, I wonder.

    I’d like to also put in a word of praise for housekeeping. Many patients give them little respect, refer to them as “trash lady” or some other thoughtless name. Housekeeping staff work hard while trying not to call attention to themselves and I’m sure take the blame for a lot that isn’t their fault. And I hate to think what the salary scale must look like for these essential workers.

    Having said that, I spent a few days on a general medicine floor in a major Boston teaching hospital in January 2020, and I was appalled to realize how germ-riddled and, frankly, dirty, a two-bed patient room with shared bath actually is. (Despite good, hard-working housekeeping staff.) This was before most of us had an inkling of COVID-19, but I concluded that, if infectious disease is a concern for any patient (and it is, for every patient, as we know, with or without a pandemic) the future of hospital architecture must include planning for private rooms only. Shared rooms should become a relic of the past. Now more than ever, of course.

  6. Nancy Fitzpatrick says:

    Thank you very much for the acknowledgement, I have been an ICU nurse for 35 years and am now in a COVID19 ICU and just yesterday was at rounds with a multidisciplinary team discussing one of my patients and their daily care plan and realized that myself and the RT were the only ones who actually had seen and
    examined the patient recently and which made us more the realist and the other care members the idealist which made it a bit frustrating since the delirium state of the patient was lost in the care plan.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

Biography | Disclosures | Summaries

Learn more about HIV and ID Observations.