Translating between two worlds: the contradictions of healthcare

When someone is training to become a nurse, generally speaking, they are taught that nurses stand between two worlds. Nurses are intermediaries between those who analyze and decide on treatments and those who get treated, in one way or another. Or anyway that is how things are supposed to work (the practice doesn’t work out that way exactly). Nurses are translators, they take the world of medicine and translate it into the world of patients. Good nurses do it well, bad nurses not so well, but nursing is in large part about communication and translation.

The world of medicine is most clear in its most concentrated and unadulterated domain, the hospital. The hospital is the pure stuff of medicine. People go about their daily lives, doing whatever it is we do with our time, and somehow end up in an institution dedicated solely to disease. The flow of the hospital itself is itself alien. Everything is organized around the treatment, which itself evolves as more of the picture gets filled in with diagnostic procedures, and laboratory data, and people poking  and tapping and listening and commanding you to raise a leg or close an eye or any number of bizarre and seemingly cruel things to do when you’re sick. Like any job, hospitals and all the trades within them have their own words and technical slang for everything.

All of this is somewhat inevitable. Disease is strange, unfair, terrible, and frightening. If you need to go to a hospital, something is wrong and it most likely won’t be pleasant on some level.  With a good translator or an advocate, these transitions can be softened especially if you understand what is happening to you, why, what could be and what has been (there are laws in fact that say that must happen but…).

Imagine the following scenario though. Hospitals make money not for the time put in, not for the work they do, and not for the patients they have cared for, but rather based on what comes down to averages. More or less, funding in the hospital comes from tracing why someone is there, seeing if whatever is done is justified based on the data, and saying this is what we pay for when this sort of thing happens. The problem is that at the end of the day, the money doesn’t add up. Hospitals can’t make money, when they get paid on the rules made up by companies dedicated to not paying. To make it work, hospitals went into survival mode, for a few decades. Patients are to be sent home or to the street as soon as medically possible. The highest level of work possible from the fewest number of skilled workers necessary is the unspoken rule. Any unskilled tasks that take away from maximizing skilled labor should be assigned to unskilled workers with minimal pay and training. Most importantly, management strategies developed to increase profits in factory  production should be applied to hospital staff (by way of high paid consultants).

In practice this means a lot is lost in translation. A nurse working on a typical medical-surgical (i.e. standard hospital) floor in Miami has anywhere from 6 patients to even 12 per shift. To give comparison, all the data has shown that hospital errors, infections, hospitals stay length, etc., drops dramatically when nurses have a sane ratio of patients to nurses (somewhere in the realm of 4:1). For your 8 patients, you could have 20 or so doctors working on their cases on a bad day. You would have at least 10 doctors writing orders throughout your shift, 10 doctors to call to update about the patient’s improvement or decline, and 10 doctors to catch up with. The doctors themselves have huge amount of patients, with the average doctor visit being somewhere around 3 minutes.  That is 3 minutes patients get to, in theory, understand why they need surgery, what will happen, and what the consequences could be. Much of this, legal or no, falls on nurses, nurses who have another 7 patients all in the same boat. When hospitals began to send patients home early (hospital stays are expensive, and there is in reality little accountability in the system) patient deaths after discharge rose as did patients coming back worse off to the hospital (and not living as long).

Nurses themselves only can do the work for so long. We work 3 days a week if we’re lucky. The 12 hour shift is so insane sometimes it’s hard to do the necessities let alone go above and beyond. When shift changes occur, or patients move floors, or get sent to a procedure, all the gaps between the doctors and nurses, the nurses and techs, the nurses and nurses, get multiplied. As weeks go on, things get missed sometimes even with the patients themselves aware of the gaps, and no one there to listen.

If this weren’t bad enough, in Miami we live in a distinctly multilingual environment. Many nurses first language isn’t the first language of their patients. Nurses speak Tagalog, Malayali, Kreyol, Spanish, English, Mandarin, etc. Patients may speak one of those languages, but patient assignments aren’t done by language and more often than not there are gaps in staffing for bilingual nurses in a patient’s native tongue. Legally a patient is entitled to a certified translator to understand their care at all times. I have literally never seen a translator in a hospital. I’ve heard about them, I’ve been told I am one even though I am monolingual with a little competency in a few languages, but I have never seen one translating. Worse than that is seeing health care providers translating, who stop translating intentionally. I have seen a medical student stop translating when doing so would have meant dealing with consequences the medical team didn’t want to face.

In this environment, patients are sent home without understanding their treatment, their conditions, and what they are supposed to do if it was even right in the first place. Here we come to a basic contradiction. Hospitals have a function, to treat disease and facilitate health in our community. This is a basic human need. Yet the economic forces that shape everything about how hospitals function in our time push right up against that function. It shouldn’t be that surprising then to know that the first hospitals in Europe were designed as places to confine the sick and society’s downtrodden. Hospitals were places you were taken to die or be held, often against your own will. There is a need for communication and for understanding our own bodies and how it all connects with our daily life. Against this need, everything is broken into pieces, and no one is able to translate between the tasks and the fundamental problems.

The only time this is overcome is when there are ruptures, small as they may be, with the way things are done. Sometimes nurses spend extra time to make sure a patient understands their medication, or fights throwing them out on the street without proper treatment and resources. Other times it can mean putting everything on the line and refusing to work in conditions that are literally killing patients. The whole healthcare system relies on this solidarity and humanity, without it literally the healthcare system would crumble. Yet, at every step the forces acting on the hospital hold back both patients and providers from flourishing, because this is against the bottom line. Ultimately only through driving a wedge between humanity and capital can we uproot the disease that is growing in our hospitals and communities. By organizing together both as healthcare workers and patients’ organizations we can create healthcare in our own interests.