Beyond Healthcare, How Nurses Have Shaped Modern Society

Brian Urban:
Yes, this is the Healthcare Rethink podcast. I'm your host, Brian Urban, and today we're so thankful to have on our podcast an author, a speaker, freelance journalist, and just an amazing person. And we're going to get to know Sarah Gregorio more on our show, talking about her second book. That's right. Taking care. So this is going to be such a treat. Sarah, welcome to our show. 

Sarah Digregorio:
O' Brian, thank you so much for having me. I'm so pleased to be here. 

Brian Urban:
This is so much fun. I'm thankful one for your book. Thank you for sending it here in very fast timeframe. Secondly, reading through this book, I noticed a couple of things immediately. So your book, taking care of the story of Nursing and its Power to Change the World is an amazing story. And I've looked at your background and I love it. You've taught in academia, you've done an amazing research across healthcare from your own experiences and from a third party observation. And also you do a lot of pieces too for I think food and wine and other industries. So we're going to dive into a lot of that and let's start there. Let's get to know your background. Before we jump into the book, I'm just so excited to Sarah tell us how you became to be a multiple book author and a journalist and a really a big influencer in a lot of ways. So how did you get here? 

Sarah Digregorio:
Thank you for that question. I studied journalism in graduate school, so I have a master's in journalism and for the first about 10 years of my career, I was an editor at magazines, primarily food magazines. I was a staff writer at the Village Voice. And then I moved on to being the food editor at Parade Magazine. I was on staff at Food and Wine. I was also the food editor at buzzfeed for a little while. And I've always been really interested in, in the ways that everyday experiences that people have express have a lot of meaning in them and express culture, express politics. I think there are stories in everything and important stories in wherever you look, and I feel really lucky to be able to tell some of those stories. So when my daughter was born prematurely, I was working as an editor and about a year after she was born, I decided I needed to go freelance because she was still medically rather complex and it was the right choice for our family, for me to be freelance. 

Sarah Digregorio:
But actually I am really grateful that I sort of had to make that choice and now I feel really grateful for it because it pushed me in a direction I probably wouldn't have gone. I loved being an editor. I loved being a food editor. I loved the collaboration in magazine work. But what happened when I went freelance was that I really had to start thinking about how my life had changed and the questions I had around that. And I had experienced a lot of, I had been in medical situations quite a bit as a child with my parents. Both of my parents were very ill, had chronic diseases that did end up killing them relatively young. And I had my daughter. And so I started reflecting on these questions that I had and realized that so many people have these questions. I mean, anyone who finds themselves in a complex medical situation has a lot of questions and I wanted to explore those in a way that I wasn't seeing those questions explored. 

Sarah Digregorio:
In general, we see a lot of coverage about how our healthcare system is broken because it is, but we don't see a lot of coverage of what it feels like to in healthcare to be navigating the healthcare system. We don't see a lot of reflection on the human experience of that, which is one reason actually I wanted to write about nurses because if you've been in a healthcare situation, you absolutely know that nurses are key fundamental to that experience, and that's not reflected in the way that the media in general covers healthcare. So it was really that grounding and personal experience and these questions that came up for me around these experiences I had in healthcare that made me want to sort of pivot to healthcare journalism. And that's where I've been for the last decade about, 

Brian Urban:
And I think a lot of your readers are probably so fortunate and excited that you took that very big leap of probably I would say, calculated faith going into this freelance work that you've done. And I found your book, and I have not read your first book early, but obviously based on your experience premature birth with your daughter, daughter Mira, and I think looking at your first book, it seems like it's an interesting step into taking care because taking care is an outward view, very and very broad looking at the whole history of nursing and how nursing has really impacted not only healthcare society but modern society as well. And you start off the book and I was reading it and just getting to know each other more recently, you are not a nurse by background. You look at it and you're like, Sarah's got to be a nurse. 

Brian Urban:
No, but this is such a memoir and a love story for how nurses have come to be and some of the assumptions and also the ugly side of how nurses have been defined and looked at, but they're so critically valuable to the foundation of healthcare and modern society that you described. So pulling out one thing right from the beginning, I wanted to look at this figure that you had here, 27 million nurses worldwide and nurses. And midwives in particular. I'm glad you called that out because them doulas as well play a very big part in, I'd say healthcare costs reduction, better experience, better collaboration. And your first chapter, I told you earlier, it's very heavy emotionally, but if someone has experienced challenging complex births from a birth giver or partner side, it's very relatable. You can almost take yourself back to those experiences. So I love that you opened up on the personal side. It was like a home run. You didn't even get into chapter one. So going into taking care, I wanted to ask, Amal was mentioned, so the book dedication obviously is a beautiful story for nurses. Can you tell us about the book Dedication to Amal specifically? You had my curiosity. 

Sarah Digregorio:
He's my husband and he takes care of me. We take care of each other. Without him, I wouldn't have been able to write the book. I wrote it during the pandemic. A lot of it was written during the pandemic, a lot of research during the pandemic when we were home together, both of us working with our daughter, going to first grade on the computer. And I think partners, fathers in general are not always ways, are not always called out or lauded for their caring. And he is a very caring person. He is incredibly thoughtful and kind and smart, and so that's why the book is dedicated to him. 

Brian Urban:
Lovely. I just wanted to put that up front and have that elevated and thank you for 

Sarah Digregorio:
No one has asked me that yet. Thank you for asking. That 

Brian Urban:
Stood up. Well, first of all, Amal is not a very common name, Southeast Asian. I think in some orientation I have a good friend, Amal, who's a physician, and I was like, wait a minute. There's no possible possible way, but we're clarifying husband. Good way to elevate someone in your life. Right off the get go, I wanted to look at the hierarchy and maybe even a step before that you took us back to the very ancient civilizations and the founding of nursing being practiced by men and women. And then as we move forward in history, there seemed to be this interesting term, and I like how you called out actually during enslavement in a lot of different enslaved communities, nursing was practiced at will mainly by women as caretakers through multiple communities and populations within an enslaved area in the United States. And I don't think you touched globally, but United States specifically early on, I found that so interesting. Was that something that you found was the turning point where nursing became more affiliated with women or was it in the traditional sense of medical education being developed that men were predominantly are a physician of an MD or a DO at that time, md and then women were the task oriented deliver executors that were supporting that role. Where was it I guess in your research, did you find that pivot? 

Sarah Digregorio:
Yeah, I think there are a number of ways to answer that question. The way that I answer it and the turning point that I see a lot of evidence for is the establishment of the first medical schools in Europe, which started to happen in the middle Ages. And at that time medical schools were only for men and they were only for men of certain status. You couldn't just walking off the street and go to medical school. I mean similar to today. So you had to have money or status and you had to be male by definition. The only exception that I know of to that is the University of Saleno in Italy, which did accept a few women. But before medical schools were established, there was a healthcare, healthcare systems. It's not that there was no healthcare or that there was no system to it, right? 

Sarah Digregorio:
There was a healthcare economy, there were systems that varied across time and place, but certainly people often had access to the healthcare of their time. So for instance, you might go to a monastery or to a nunnery to get some healing herbs or to get advice on your child has a fever. It's very famous that did surgery and any kind of cutting because they had razors and they knew how to use 'em. So there were midwives, there were physicians, nurses, there wasn't so much emphasis on really delineating whether you were a doctor, a nurse, a pharmacist. Those are hallmarks of our current system. That's very important to us to say that you're one thing or another. But in the past that really wasn't the case. People had certain expertise and it wasn't as though you can necessarily say someone was only a nurse or only a physician. 

Sarah Digregorio:
What happened was that this new healthcare hierarchy came on the scene with the medical schools. Suddenly instead of learning by doing, learning by apprenticeship, perhaps by guild membership, by becoming part of a specific religious tradition, these were all ways that people gained the expertise of their time. They learned by doing, they learned by oral traditions sometimes also certainly by written traditions as well. But the system was quite different. Suddenly the medical schools are established and these new physicians come on the scene and it's not as though they have cat scans and chemotherapy, right? They are practicing under the same system that everyone else is practicing under. It's the theory of the humors, which is a theory that was accepted in the west for about a thousand years. And they needed to explain to people what made them different. They were in general more expensive than the traditional practitioners. 

Sarah Digregorio:
They needed to come up with a difference. They needed to come up with a reason. And so what they did was, and this took a long time, this took hundreds of years to really change the system. They came up with this idea that physicians were the ones who practiced safely. Everyone else, men and women who weren't licensed medical doctors from a university, those people were irregular practitioners and it was not safe to go to them. Now, meanwhile, people had been going to them for hundreds of years, so it wasn't such an easy case to make. They really had to work at it. And actually you do sort of see echoes of this even today, I would say from the American Medical Association. You see there's a very big emphasis from the American Medical Association on saying that care delivered by say nurse practitioners is not safe. It's not safe for patients. Now I would say there's not really evidence to suggest that that's true, but this is something that physicians groups have been saying literally since the middle Ages. And so this was very much a turning point. Now suddenly by definition are unlicensed, women by definition are quacks. 

Brian Urban:
They're 

Sarah Digregorio:
Put out, they're unlearned, they're dangerous men as well who weren't licensed, but women by definition. And so this sort of long slow change where physicians were put at sort of the top of the new healthcare hierarchy then demanded that other kinds of practitioners also have a kind of definition around that and that they get into a certain spot on the hierarchy. And so what that evolved into in this long slow process was the idea that well, women can practice but they can't give medicines and they can take care of children. So you could be a midwife for a while anyway. You could be a midwife, you could be a nurse, you can do the very hands-on sort of more, less lower status work in hospitals. And that was really how I think the gendering of this other kind of subordinate care. And I put big air quotes around subordinate care evolved into our current situation. 

Brian Urban:
I like how your book actually summed it up really well going into the chapter is essentially women essentially subordinate. And that kicked it off and very, very interesting kind of thought experiment. You laid out, maybe you intended to do it, maybe you didn't. But for me it worked was kind of, well, why did this happen? The big lie, this brand strategy around licensing this particular skillset or skillset that's learned or started to be learned. And then it's evolved since then and it's cut out a lot of populations. It's cut out very race specific, very gender specific. So I thought that was so unique to kind of kick things off, like how it evolved. And I think the one thing that was really interesting, coming back to your personal story, you described one nurse that you were hugging as you were getting an epidural and you called out the braid in her hair in particular. 

Brian Urban:
That type of reflection and hyper memory in that moment is meaningful. And the way you were describing nurses and you talked about the healthcare as a labyrinth. It is very complex, it's very messy. It's malfunctioning as its current operating model today and maybe it has been for a long time, but the individuals through that labyrinth that have made a positive impact is who you dedicate a lot of these amazing stories and investigation with. And I want to talk about through your experience with that particular nurse, there wasn't a clinical expertise of an unbelievable caliber that she had over anybody else, but the ability to be there as a human was incredibly impactful for your health at that moment. That was an emergency operation that you had very opened you up. That's so complex too. Can you take us back for a moment and describe how that person stood out and I guess maybe the value of that type of skillset that needs to be taught in all medical education. Can you give me a couple perspectives there? 

Sarah Digregorio:
Yeah. Well you mentioned sort of the vividness of that memory. I think that many people find that when they are in these extreme situations, their brains work differently. And you do sometimes remember with real specificity these details. I remember the feeling of her braids down her back. And as you say, I was getting an epidural for my C-section, an emergency c-section. My understanding at the time was that my daughter was potentially about to die in my uterus and that we had to get her out as quickly as possible to save her life. That is what the situation was. In terms of thinking about her practice, I think that this is interesting because I do tell a lot of different stories about nurses' practice. And this is one example that, and some of my examples are things like, this is not my story, but someone who gave me permission to tell the story of her son who died in the nicu and this nurse who gave the most exceptional care, just the most exceptional care that she carries with her forever. 

Sarah Digregorio:
That's a very extreme and very, that's a very heavy and extreme example. But whenever I bring that up, I also like to say there are very routine moments in practice that are not ever routine for patients. What's happening is not routine for you, even if it is something relatively simple. Just the fact that you are a patient in a healthcare setting, it puts you in a different space. It takes away some of your power. You feel a bit stripped perhaps, of your full humanity. And what happens in those moments when nurses can invite you, can allow your whole self into that encounter is that you feel put back together and that you feel seen and understood, and that is good for your health, it's good for your outcomes, it's good for your health. But what I like to think about in terms of nursing practice are these levels. So what I experienced of her practice in that moment was what it meant to me to be allowed to hug someone In this moment, my husband was still outside the room. He couldn't come in yet. I wasn't sure if he would even make it in. I wasn't sure if my daughter would live. And this nurse was like, just put your arms around me. You need to be still. And for me what that was was a human connection and a human. 

Sarah Digregorio:
The actual bodily contact at that moment was what I really needed. But she was practicing on different levels and some of those were invisible to me. So she was making sure that I didn't move so that they could get the epidural in without harming me. So that was an element of her nursing practice that I wasn't necessarily thinking about at that moment. But she was doing that not just to comfort me, but also to make sure that I was safe and got the care that I needed and the care that I needed really quickly. She was also, I am sure doing things like monitoring my vital signs, communicating with the other members of the healthcare team, prepping this, that the other things that I was not aware of that she was also doing. And so I think that what is special about nursing practice is that not only are they engaging with your physiology and making sure that you're getting the care that you need, and they're quite good at being sort of air traffic control, thinking about the respiratory therapist needs to come in now, has anyone gotten informed consent? 

Sarah Digregorio:
All of these questions about the flow of your care, is it happening correctly? Nurses are thinking about that, but they're also then engaging with you on a human level. And that is not a small thing. It's not unrelated. Do you know what I mean? It's not an extra special thing that just makes you feel good. It is an integral part of nursing practice and it is quite essential to your health. And even just that exchange of information that wasn't happening at that moment for me, but when you listen to patients, you get information that you need. And when the patient listens to you, they get information that they need. And so this exchange of information and insight about what's happening, what needs to happen for the care of a particular patient, it's very complex and it's very complex. And so that particular moment stands out to me. And I think I say in the book, she might've been thinking about lunch and that's okay. That's okay 

Brian Urban:
Because 

Sarah Digregorio:
It was to me was this human presence and what it meant to her was like a Sunday at work. 

Brian Urban:
Yeah, the way and probably a lot more for her on that side. And I like it. It was a moment of brevity there on that comment. But for her on the nursing end, it was probably was a lot to be able to put herself in a loving situation too. But what's interesting, and I want to go forward a little bit into this patient nurse ratio regulation that was put in place in California in early two thousands, unfortunately with Arnold Schwarzenegger at the time being the governor. But before I get to that, I want to ask you something that just came to mind really when reading about this. Do you think the natural evolution of nursing, registered nursing practice, how that just happened in our world, do you think that's helped those that practice nursing become more of a high performing emotional athlete? Dare I say, do you think through the way that nursing has come to be today that inherently nurses are able to give more of themselves, not just the analytical thinking part of their brain or the execution side, but they can give more of themselves? Do you think that's possible? Is that what's happened? 

Sarah Digregorio:
I don't know if that is what has happened. I think that it's hard to answer that the evolution of registered nursing is a real double-edged sword. I think nursing is an independent scientific discipline that is an academic pursuit, is a clinical pursuit. All of those things like the quote, professionalization of nursing, I think nursing is a profession. It is an independent scientific discipline. And the way that nursing in this country has been sort of codified and has come to work within the healthcare system, I think has a lot of problems that I think in some ways is prevents nurses from practicing to the fullest extent of their abilities. So what I mean by that, for instance, is that there have been a lot of struggles within nursing about who is a nurse and who gets to call themselves a nurse and who gets invited into the professional clubs, for instance. So there are problems within nursing like that at for example, licensed practical nurses and licensed vocational nurses, which is simply, it's a different licensure than rn. Those nurses are not included in the American Nursing Association. 

Sarah Digregorio:
Why? I don't have a good sense of why that is, but it does seem to, it's a sort of walking away from solidarity with all who nurse, and it is a kind of gatekeeping that I think is not helpful. Also, there has been a de-emphasis on associate's degree pathways into registered nursing. There are reasons for this. There is a debate about this that I think is worth having. However, I would point out that in the context of what is called a nursing shortage and in the context of nursing being disproportionately white and what that means then for patient care, why would we be putting barriers on people coming into nursing who have been historically excluded? So that's what I mean about sort of these problems within nursing, which I think come out of a desire for registered nursing to hold itself up as professional, which it is. 

Sarah Digregorio:
But also this sense, I think that nurses have that they are not considered professional and that they're not considered equal to say physicians. And so sort of trying to get a seat at that table by kind of restricting who we call nurses or who we invite into the profession, which I think has a detrimental effect actually. So that's sort of within nursing. And then there are a lot of forces working on nursing that are detrimental again to nursing care. So for instance, the fact that in hospitals, nursing care is generally wrapped up into the room and board fee that payers pay out, that sort of obscures the incredible essentialness of nursing care. Nursing care is billed for meals or supplies. It's not that at all. Right? And it also means that when hospitals look at the balance sheet, nurses are labor and they are an expense, again, air quotes around expense instead of being revenue drivers like physicians who bill. But in fact, the research tells us that nurses just as key to patient outcomes as physicians. And so I would just say that the way that nursing as a profession has evolved in the United States within itself and then also the way it has to interact in our healthcare system, a lot of that actually prevents and is sort of detrimental to nurses really expressing their expertise and their full scope of caring. 

Brian Urban:
I like that you went there. There's a couple things I'm glad you touched upon that I was not intending to get into, but we're going to do that just for a moment here. Yet nurses overall are hindered from practicing at the top of their licensure or overall skill sets. There's a cultural displacement of I'm not good enough or I am next to AMD or do not that. And that's a shame. I think that's always existed mainly in the west and the US healthcare society. But what's always existed as well is the operating flow of a business. So you mentioned revenue execute revenue drivers being a md, being a do expertise of cardiology, orthopedics, et cetera. And the way that that is coded into billing and how that flow works, and that has been there for so long in the way that RNs appear. I like how you said that in terms of just a hospital's example, that balance sheet, they're an expense. 

Brian Urban:
They're not a revenue driver, but they touch so much of a healthcare continuum for an individual in and out of a facility telephonically. Then there's administrative work. There's a lot end to end that RNs touch. And I think that's been such a long road and a big barrier, a humongous a hundred foot wall for the healthcare society in the us. But I want to ask you something now in terms of, and we talked to a lot of healthcare systems, they're still hemorrhaging a lot of money on filling RN roles, going to staffing agencies who now have the upper hand charging multiple times the regular rate. When is this going to break? Do you think that someone leadership level or below in a healthcare system is going to say, Hey, there's be a better way we could do this or else we're going to never get into a positive operating model and we're going to have patients suffering because of that? What's the breaking point? I thought covid would be that was the next pandemic, the breaking point. What do you think, Sarah? 

Sarah Digregorio:
That is a great question. I don't think anybody knows. I have asked a lot of people that same question and really nobody can answer. In particular, nurses are feeling really very discouraged and in some cases hopeless about when will this change? Because going back to what we just talked about, I would just ask what is the purpose of a hospital? And I don't think it's clear what the purpose of a hospital is as it currently stands. I think I know what the purpose of a hospital should be, which is to produce good outcomes, as good as possible in its patient population. But also the purpose of a hospital is to make money. And those goals are sometimes in opposition with each other. And so intel hospitals commit to their purpose being outpatient outcomes. I don't know that anything will change because right now, and I hear you, that hospitals are perhaps not making as much money or they may be hemorrhaging money to these staffing agencies. 

Sarah Digregorio:
My suggestion would be, and I know it's not quite this simple, because I think it really also depends on where you are in the country and what kinds of nurses you're looking for. So certain specialties of nurses are truly hard to find depending also if you're in a rural area, this is very difficult. So I don't mean to be glib or suggest that it's easy. I do think that in many cases a lot of this problem could be solved by looking to the California model. In the California model, the hospital association said, we can't possibly abide by this ratio law because there are not enough nurses. There aren't enough nurses for us to abide by this law. But when the law was passed and they had to do it, what happened? Well, they had to pay nurses more to come back to the bedside shift there. 

Sarah Digregorio:
Interesting. Right? And so salaries went up, but not, it's not as simple as salaries. Salaries went up, but also because nurses were guaranteed that staffing ratio because it's really, so much of this burnout is about the feeling of moral injury when you have too many patients and you can care for safely. Nurses came back to the bedside and the number of licensed nurses in California went up after that law was passed. And it was because hospitals had to, were forced to incentivize nurses to come back, and nurses were assured that they would be in a situation where they could provide the kind of care that they can provide when they have appropriate levels of staffing. And so I would suggest that of all, it's not perfect, but I would suggest that of all of the models that we know of within our, I mean without throwing away our entire healthcare system and starting again, which maybe is what we should actually do in the current situation that we have today, I would suggest that the model of California is just really instructive. 

Sarah Digregorio:
And until hospitals are forced to entice nurses into staff jobs that have appropriate compensation, safety, staffing support, nurses are going to continue to quit or they're going to go to these travel agencies where I have had nurses say to me, well, you can treat me like crap or you can pay me like crap, but not both. And so it was a very adversarial relationship and it doesn't have to be that way, but until decide that until hospitals are either forced to do this or until hospitals decide that what they're actually in the business of is helping people get better as much as possible. I don't know. 

Brian Urban:
Yeah, I like that you went into, where I was hoping we could talk about was that patient RN ratio that was passed in California in the early two thousands. It's amazing. And not any other state that I am aware of has taken that as really an innovative step to incentivize, but also right size fit nursing and their abilities and their pay. It's kind of a very interesting economic view in healthcare, similar to one across the us, if you have higher payments for middle class workers, if you incentivize more of the middle class in the us, they'll use that money more economically to be put out into society more. Same with this nursing law here is you got them to come back and now they're doing better work, like the economic effect in a microscopic view in a state view. It's very obvious. So it's interesting. So I haven't looked beyond what you've reported on here, but do you see other states, progressive states or conservative states maybe adopting something like this? I mean, now would be the time. Do you foresee that happening in the future at all? 

Sarah Digregorio:
I think there's some movement towards this, and in particular, I think so because more and more nurses are joining unions and it is generally unions that have gotten these, either they have lobbied for it in a legislative sense, they are actually lobbying for it on a federal level, but also within states also, this can be achieved on a contract level. So you can put staffing requirements into a contract and then if that's not adhered to, there can be actual repercussions for the hospital. I think that there has been some movement. Unfortunately a lot of it has been very, very incremental and sometimes so incremental as to be not functional. So for instance, here in New York, there was a lot of process around this new hospital staffing law. And basically there was, they end up passing a compromise bill. And the compromise Bill said that the hospitals have to have a staffing committee and certain percentage of the staffing committee has to be bedside nurses. 

Sarah Digregorio:
They have to come up with a staffing plan, and then they have to make their staffing plan public. And I think the part of this that's really important too, is making it public problem. The whole thing kind of falls apart because they added a loophole into the law saying that the leadership at the hospital, the CEO, can throw out the staffing plan. They can basically weigh in and say they have to negotiate on it, but if they can't come to an agreement, they can just be like, overrule it. Thanks for that, but no thanks. We're going to go with this. Now they have to make that public. But it is, I have actually, I've tried very hard to find these staffing plans for hospitals in New York State. It's supposed to be on hospital websites and also at the Department of Health website. If they're on hospital websites, I can't find them. 

Sarah Digregorio:
I found 'em on the Department of Health. But they are basically impenetrable spreadsheets. So you see, you can kind of make out, this is the staffing ratio that was recommended by the staffing committee. And then actually this is the one that the hospital administration overruled them with. It's very hard to read. Every single, every single floor is different, which makes sense. It has to be different, but you have to be able to read it. And I do this for a living. I found it very hard to read these staffing plans. One thing that I do think would be good is that if we can't agree, if we can't pass a staffing law the way that California has, I do think that making staffing ratios public in a real way, in a way that people can actually understand would be quite powerful. 

If people understood what nurses did and if people understood that that was happening, the reputation of these hospitals would suffer. But people don't really know what nurses do and they can't really find out what the staffing ratio is. So to me, there's a certain possibility of solution in simply educating the public about what's happening, because I do think that might go a long way. 

Brian Urban:
I think you're right. I think that's a step in transparency is showing what those ratios are. And that's probably the build that we need to get to be able to have hospitals take better ownership and responsibility of the individuals that are providing care there, especially nurses. So Sarah, I want to look at one part of the book, which so many parts of your book, not being a nurse myself, medical science trained whatsoever, I identify with and I've really been drawn to, so endings, this is a part later in the book, and it's about palliative care. Nurses are a critical part of the ending of someone's human life. And the story was beautiful because the individual happened to do better. They were diagnosed with sepsis. And anyone that's familiar with sepsis, it's the toxicity of your blood. You can pass away within 24, 36 hours, 48 hours very quickly because something has gone wrong, exacerbated condition among many other problems. 

Brian Urban:
So the story that you go into, I found it very interesting from a perspective of a son losing a father son, losing an uncle who I was there with their last breath, but the nursing, it was at home. Some people forget. There's a lot of at-Home Care, a lot in palliative, and it's the comfort and the one-to-one connection. You can't get through telephonic telemed, you can't get through apps, wearables, all this stuff. That's starting to be a keystone in our healthcare experience. I wanted to talk about how your observation was in that, an amazing nurse that was providing care here. This was out of Boston, the Boston area. Brighton area. So can you take us to that kind of opportunity you had to observe and to learn of this story? What did that mean to you personally, and what do you think are maybe untold values of nurses in palliative care? 

Sarah Digregorio:
Yeah, thank you for bringing that up. This was one of my favorite chapters to report. So I had the opportunity to report on the work of Good Shepherd Community Care, which is a hospice nonprofit located in Newton, Massachusetts, which is just west of Boston. And I was able to go along with a nurse named Mariana for her visits one day. And the first visit was with this gentleman who, as you say, had sepsis and he was still alive months later, and it was unexpected to him. It was unexpected to his family. And Mariana said, there's just, there's so much that we can't always say about exactly when someone will die, but you reach a point, he had reached a point where he didn't want invasive treatment in the hospital anymore. He wanted go home. And that doesn't mean that he didn't need healthcare, right? It doesn't mean that he didn't need care. 

Sarah Digregorio:
He needed to be comfortable and to understand what was happening to him. And so what I witnessed there was that he's at home in his apartment, he's in his bed. He has lots of books nearby. He has EVAs of fresh flowers. His wife is there, Mariana comes into his room, she sits down, she chats with him. How are you feeling? And she did a lot of listening and I could see that they had this connection. They had this really nice, very comfortable rapport with each other. And she described to me how part of her goal in hospice is to never let a situation spiral. So it feels really scary and out of control because a lot of, in my own experience, I know that this happens where there's an event and then it's like, oh gosh, what should we do? What should we do instead? 

Sarah Digregorio:
She's really taking it different paradigm. She's saying, okay, here are all the possibilities of what might happen. So she has medications available for him before he even has these symptoms. Right before he was ready to take narcotics, she had narcotics there, painkillers for him to take. He was having a lot of AFib. He was having a lot of heart problems that were very uncomfortable and really gave a feeling of anxiety. So she made sure he had anti-anxiety medication there and that he knew what might happen. He knew what to take if he had this symptom or that symptom. And the whole goal, the entire goal is for him to feel comfortable and for him to understand what's happening. And that fear doesn't have to be part of it. Of course, there are so many emotions right around dying, but that there is a way of caring for people towards the end of their life that anticipates needs and really maximizes their human experience, right until the end. 

Sarah Digregorio:
And I found it very powerful. And I think that this is quite relevant to nursing practice because of course physicians also practice hospice medicine, palliative care medicine. But in general, physicians practice is about curing people in general. The idea that there's a procedure or there's a medication, that this is very much part of medical practice and orientation. Whereas for nursing, there is a sense that nursing is oriented toward comfort in general, even in cases when it's not an end of life situation. So that nursing is not necessarily focused on cures, on medications, on procedures, but nursing is in general focused on the whole human being and trying to maximize the whole human being's sense of wellness and wellbeing. And so I think that nurses are uniquely situated to provide hospice care. And what I witnessed in the case of Mariana giving this gentleman care was just, it's a real sense of ease and sort of normalcy, which I think was wonderful. 

Sarah Digregorio:
In my own experience, my mother died in a rehabilitation center attached to a hospital. There was no one told her that there was a change in her prognosis. It was very unclear to me what was happening. She died in a way that I think it's hard to second guess what happens, right? But I don't think my mother had a good death. She was going to die no matter what. But we do have choices. We should have choices, and we should have information about those choices. It's very hard sometimes for in particular, I think intensive care physicians to, or at least in my experience, it's maybe difficult for intensive care physicians to not just sort of suggest the next thing that might possibly take care of this particular problem in this particular organ system. Instead of stopping take a step back. And this is described by other people. I mean aul, Gawande's being mortal for instance. The willingness to stop and look at the entire picture. What is right for this person? What do they want? Do they understand what's happening? What are the choices that they need to understand? And I thought Nurse-led hospice is just a very, very powerful kind of care. 

Brian Urban:
It is it, I can relate from my own experiences as well. And thank you for sharing that in the book and personally about your mother, Sarah, and your experience with Mira, your daughter. I think the blend of your experiences and your journalism shines through here as a very thorough and thoughtful display of your experiences with nurses and how they've come to be in our society and the good and the bad. And you know what? I knew we were going to get deep in a lot of this stuff, so I'm glad we did. One thing I want to end on, let's go into the future a little bit. Let's go five, 10 years out. So we're taking a big leap here in terms of healthcare out there. So what's going to be the next thing for nurses to be able to shine through and show their value in the healthcare society or society at large? What's the next pivotal thing that is going to open people's eyes to the value of nurses? 

Sarah Digregorio:
That's a great question. So I'm going to speak out of a place of hope. I'm going to speak about what I hope for nursing and for our healthcare system. I do think as baby boomers are aging, there is going to be, and we are sort of reaching this point of real pressure on the healthcare system that I think is only going to get worse. And I think that in that potentially there is hope for change. I wonder if home-based care and care that comes out of hospitals into the community more into community settings might become more prevalent because it is very effective, especially for elders and people who are having chronic illnesses. Someone who is 80 years old and dealing with diabetes, for instance. Bringing them in and out of the hospital is bad for their quality of life. It's not cost-effective, it not the best care for them. 

Sarah Digregorio:
Probably what they might need is a visiting nurse to come two or three times a week, or perhaps there's a nurse practitioner who has visiting hours at their synagogue or church or there's a visiting nurse who they see at Walmart. I mean, there are so many different opportunities for us to bring nursing care closer into where people are. And I do think that nurses are quite adept at this. I think it's cost effective. I think it's the best, often the best kind of patient care to have someone who can really sort of see you in your setting and your life and sort of solve problems in your everyday life. And so I'm hoping that with the baby boomers reaching these ages where they are going to need more care. But I do think there is also a rising tide of people wanting to age in place. They want to age at home, they want care in their home. And I think that this is an opportunity for us to change the way that we deal with, in particular chronic disease diseases of aging. And to stop having the default being let them get pretty sick, bring them to the hospital, sort of fix the immediate problem, send them back out, and then do it again. It's not good for people, it's not good for the system. And I just think that this is an opportunity. 

Brian Urban:
I couldn't agree with you more. I think the way through clinical innovation is nurses leading the way out of our sick care model. And I'm excited if Book three comes out over those next five years or so as well. I've thoroughly enjoyed our albeit brief conversation, but I have your book and I think so many others would enjoy taking care as well. And just being able to hear your background to it and the whole why is just so beautiful. Sarah de Gregorio, I'll say author, speaker. I also say a voice for nurses as well. Thank you so much for joining our show here today. 

Sarah Digregorio:
Brian, thank you for such a great conversation. I just loved talking to you. Thank you so much. 

Brian Urban:
And for more exciting insights and excerpts, please visit us@finthrive.com.