The assumption that the “rank and file caregivers”—a patronizing term to begin with—fail to grasp the importance of the patient relationship undermines the nursing profession. “In our staff meetings, we’ve had to practice role-playing and scripting to make sure the buzzwords in the patient satisfaction survey are covered,” a Washington, DC, nurse told me. “Rather than addressing the nurses being spread too thin to provide care that is good enough, they assume the nurses aren’t coddling the patients adequately enough.”
What annoys nurses is that the concept of “patient experience” has morphed patients into customers and nurses into “rank and file” automatons. Some hospital job postings advertise that they are looking for nurses with “good customer service skills” as their first qualification. University of Toledo Medical Center evaluates staff members on “customer satisfaction.” Even the AIDET audit forms explicitly refer to patients as customers.
By treating patients like customers, as nurse Amy Bozeman pointed out in a Scrubs magazine article, hospitals succumb to the ingrained cultural notion that the customer is always right. “Now we are told as nurses that our patients are customers, and that we need to provide excellent service so they will maintain loyalty to our hospitals,” Bozeman wrote. “The patient is NOT always right. They just don’t have the knowledge and training.” Some hospitals have hired “customer service representatives,” but empowering these nonmedical employees to pander to patients’ whims can backfire. Comfort is not always the same thing as healthcare. As Bozeman suggested, when representatives give warm blankets to feverish patients or complimentary milk shakes to patients who are not supposed to eat, and nurses take them away, patients are not going to give high marks to the nurses.
The hospital image
Recently, at a hospital that switched its meal service to microwaved meals, food service administrators openly attributed low patient scores to nurses’ failure to present and describe the food adequately. It is both noteworthy and unsurprising that the hospital’s response was to tell the nurses to “make the food sound better” rather than to actually make the food better. This applies to scripting, too: It does not improve healthcare, but makes it sound better.
The University of Toledo Medical Center (UTMC) launched an entire program based on patient satisfaction. iCARE University mandates patient satisfaction course work and training for every university student and employee. “Service Excellence Officer” Ioan Duca told a publication sponsored by Press Ganey, a company that administers the surveys for hospitals, “I am really focused on creating a church-like environment here. We want a total cultural transformation. I want that Disney-like experience, the Ritz Carlton experience, the Texas A&M experience. I want that kind of true belief.”
“Belief” is the pivotal word here. Those laminated cards that collar Massachusetts nurses include the phrase “I have the time” not because the nurses necessarily have the time, but because, consultants told The Boston Globe, “patients are more satisfied with their care when they believe nurses made time for them.”
UTMC is a good example of how an emphasis on patient satisfaction does not make for better care. Remember, this is the hospital that also spent $50 million on superficial changes (such as changing valet service vendors) and evaluates staff on “customer satisfaction.” At the time of this writing, according to government data on hospitals’ rates of readmissions, complications, and deaths, UTMC appears to be among the worst performers in the state, if not the country. UTMC has higher than average rates of serious blood clots after surgery, accidental cuts and tears from medical treatment, collapsed lungs due to medical treatment, complications for hip/knee replacement patients, and, more generally, “serious complications.” In addition, UTMC made headlines in 2013 when, during a transplant operation, hospital staff threw away a perfect-match kidney that a patient was donating to his sister. Instead of focusing so intently on “satisfaction,” UTMC should have spent those millions of dollars on improving its actual healthcare.
Many hospitals seem to be highly focused on pixie-dusted sleight of hand because they believe they can trick patients into thinking they got better care. The emphasis on these trappings can ultimately cost hospitals money and patients their health, because the smoke and mirrors serve to distract patients from the real problem, which CMS does not address: Patient surveys won’t drastically and directly improve healthcare—but hiring more nurses, and treating them well, can accomplish just that.
Nurse satisfaction
It turns out that nurses are the key to patient satisfaction scores, but not in the way that these hospitals have interpreted. When hospitals do hire enough nurses and treat them well, patient satisfaction scores intrinsically rise. A study comparing patient satisfaction scores with surveys of almost 100,000 nurses showed that a better nurse work environment raised scores on every HCAHPS question. Furthermore, the patient-nurse ratio also impacted patient satisfaction scores. The percentage of patients who would “definitely recommend” a hospital decreased with each additional patient per nurse.
There are a few things that good work environments for nurses have in common: favorable patient-nurse ratios, positive nurse-doctor relations, nurses who are involved in hospital decisions, and task-focused managerial support. University of Pennsylvania researchers have found that better nurse work environments lead to improved patient health, too, in the U.S. and in countries as varied as Australia, Canada, China, Germany, Iceland, Japan, New Zealand, South Korea, Switzerland, Thailand, and in the United Kingdom. The researchers observed, “Increased attention to improving work environments might be associated with substantial gains in stabilizing the global nurse workforce while also improving quality of hospital care throughout the world.”
When hospitals improve nurse working conditions, rather than tricking patients into believing they’re getting better care, they actually provide it. Higher staffing of registered nurses has been linked to fewer patient deaths and improved quality of health, according to a study by influential nursing professor Linda Aiken, the director of the University of Pennsylvania’s Center for Health Outcomes and Policy Research. For every 100 surgical patients who die in hospitals where nurses are assigned four patients, 131 would die when they are assigned eight. When a hospital hires more nurses, failure-to-rescue rates drop. Patients are less likely to die or to get readmitted to the hospital. Their hospital stay is shorter and their likelihood of being the victim of a fatigue-related error is lower. Even in Neonatal Intensive Care Units, where medical issues could be disastrous for hospitals’ most vulnerable patients, the fewer the nurses, the higher the infection rates.
Hospitals and healthcare systems view nurses as one of the largest budget expenditures. However, by investing in nurses and treating them so well they want to stay, hospitals could earn millions in Medicare bonuses, avoid costs associated with employee turnover, and save money on healthcare expenses (with lower expenditures per patient, including shorter stays, less pharmaceutical use, and fewer tests).
And they would save lives. A Center for Health Outcomes and Policy Research presentation reported that in poor working environments for nurses, patient falls with injuries are 90 percent more likely to occur frequently (once a month, or more often), medication errors are 73 percent more likely to occur frequently, and hospital-acquired infections are 55 percent more likely to occur frequently than in good working environments. In good working environments for nurses, patients are 19 percent less likely to die after common surgical procedures. The presenters concluded that if all U.S. hospitals improved their nurses’ working conditions to the levels of the top quarter of hospitals, more than 40,000 lives would be saved every year.
The trade-off seems like a no-brainer. Would you rather be bribed during your hospital stay with made-to-order omelets or would you rather be, for example, not dead?
Even Studer Group, the survey “coach,” admitted that nurse communication is “the single
most critical composite on the HCAHPS survey.” (Indeed, one of the most effective ways to improve patient satisfaction scores, hospitals are finding, is to have nurses check in with patients every hour.) But Studer Group, which calls nurse communication “The Most Bang for Your Buck,” is thinking backward. Nurses are more likely to communicate well in hospitals that give them the time, energy, and morale to do so rather than in workplaces that spend those bucks on a script.
If hospitals really want more bang for their buck, then instead of splurging on gourmet meals for patients (who don’t select hospitals for the food), they could manage even just one covered meal break per shift for nurses; hospitals say they do this, but many don’t. They could let their nurses park at work for free rather than hire a fancier valet service for patients. They could quit trying to cheat both patients and nurses by diverting funds to superfluous perks instead of investing in staffing, and, therefore, in patient care and well-being.
And if CMS truly wants “to promote higher quality and more efficient healthcare,” as the Federal Register stated, it likely would meet that goal and have more accurate ratings in the process if it based reimbursement on surveys not only of patient satisfaction but also of nurse satisfaction. A simple measure of hospitals that would reflect healthcare quality, patient satisfaction, and nurse satisfaction could be to rank hospital departments by their nurse-to-patient ratios.
Instead, hospitals are responding to the current surveys and weighting system by focusing on smiles over substance, hiring actors instead of nurses, and catering to patients’ wishes rather than their needs. Then again, perhaps it’s no wonder that companies are airbrushing healthcare with a “Disney-like experience,” a glossy veneer. One of the leading consulting companies now advising hospitals on “building a culture of healthcare excellence” is, oddly enough, the Walt Disney Company.
Chapter 7
The Code of Silence:
Painkillers, Gossip, and Other Temptations
“I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug.”
—The Florence Nightingale Pledge (a nurses’ adaptation of the Hippocratic Oath)
“It’s insanely easy to steal medications. There have been plenty of times where I’ve emptied my scrub pockets at home and found ketamine, Dilaudid, morphine, and Ativan.”
—a Texas ER nurse
LARA SOUTH GENERAL HOSPITAL, April
Lara stood silently at the bed of a 9-year-old girl who had died of internal injuries sustained in a car accident. The car had crashed because the girl’s parents had been fighting in the front seat. In his rage, the father had swerved the steering wheel. Now the father, uninjured, was in the hallway yelling at the trauma team, “You killed my daughter!” The mother was being treated for shock.
Lara could not bring herself to leave the dead girl’s bedside. From the outside, it didn’t appear as if anything was wrong with the girl. She looked like a doll. She looked like she was sleeping peacefully. She could have been friends with Lara’s daughter. For the first time in her nursing career, Lara wept openly at the hospital, despite the bustle in the corridor, the other needy patients, and the footsteps that tapped into the room behind her.
An arm wrapped around her waist. Lara looked up. Brianne, a longtime ER nurse, embraced her. An elementary school nurse on her off days, Brianne was crying, too. Nurses mostly didn’t afford themselves the time to cry; they forced themselves to go on with their day. Lara believed that South General nurses were more “honest” about their emotions than nurses at other hospitals where she had worked. Lara felt they were “more real, more vulnerable, they let themselves feel the moment with colleagues and patients’ families. We let them know that we’re sad along with them.” Lara had seen South General nurses get on their knees with grief-stricken family members to pray with them.
From then on, Lara asked to work with Brianne whenever she had the chance. She got to know her as a good nurse and a good person. She watched the comforting way Brianne interacted with patients and families and she tried to emulate her. “I just felt closer to her after that. She’s a genuine person who makes people feel better just by speaking with them, and I want to learn how to have that quality, too,” Lara said.
After the 9-year-old’s death, the trauma team could have used the Relationship-Based Care committee’s debriefing room—the calm space Lara had wanted to set up for staff members to catch their breath after traumas—but it still didn’t exist. The committee hadn’t met in months. Lara thought she knew why. Originally, management had promised the committee that they would find coverage for the members to attend meetings. But the administrators didn’t do so for the last few meetings, effectively canceling them. Even the huddles had dissolved after a couple of weeks because only Lara, Rose, and Holly attempted to gather the group when they were on duty.
Without meetings, the committee couldn’t get anything done. The administrators also refused to provide any resources for the debriefing room. Now that the managers had essentially squashed the idea, Lara was out $50 for the paint she had purchased.
One day, Lara was in the resuscitation room, where nurses sent the sickest patients or performed CPR. Five other nurses, all African American, walked in, including Makayla. Makayla was obsessive about bringing her own cleaning products to the ER to make sure her area was clean, although outside cleaning products were not permitted in the hospital. Nurses knew when they were in Makayla’s assigned zone because they were knocked sideways by the overpowering smell of bleach. Apparently, someone had complained, because Makayla told the other four nurses, “And one of our latte nurses felt the need to write me up that I had wiped down the area to make sure it was clean.” The other nurses clucked sympathetically.
For the moment, Lara didn’t say anything because she was outnumbered. There were only three white nurses left in the ER. When the black nurses left, Lara called Makayla back. “Makayla, I have to talk to you,” Lara said, speaking slowly to think through how to avoid putting Makayla on the defensive. “I respect you as a nurse and I know that you work hard. But I have to tell you, your comment about latte coworkers is racist. It wasn’t cool and I was sitting right here. I’m surprised to hear a comment like that coming from you.”
Makayla balked. “Oh no no, oh my gosh, no. I call people my mocha sisters and my latte sisters, but it has nothing to do with color!”
Nevertheless, for the next month, Makayla went out of her way to be nice to Lara. Normally, Makayla was the type of nurse who shopped online while other nurses ran around taking care of patients. Now she leaped up to help Lara, greeting her enthusiastically. Lara wasn’t going to waste energy resenting Makayla, so she let the incident slide.
• • •
Lara was giving report on the phone when she heard one nurse say to another, “Your girl’s marked off the schedule permanently.”
“That bitch is not my girl,” the other nurse replied.
Lara put her hand over the mouthpiece. “Hey, you guys, you shouldn’t gossip without me! Hold on!”
After Lara hung up, they told her what had happened. The day before, Fatima had been in other nurses’ rooms again, hovering around patients. To the other nurses, her behavior was simply annoying. To Lara, this was an obvious sign of an addict; she was hopping from room to room in search of narcs. One of the nurses Fatima tried to “help” happened to be Ursula, who notoriously preferred to work alone, which Fatima, a night shift nurse, wouldn’t have known.
Fatima saw an order for Dilaudid and took the medication from the med room. She charted that she gave the patient the medication, then apparently put it in her pocket.
Two hours later, the patient was still rolling around in pain. “Did anyone give you pain medication yet?” Ursula asked. “I see it was ordered.”
“No one’s been in here yet,” the patient said.
Ursula looked up the patient’s file and saw that someone had taken out Dilaudid under the patient’s name. She rounded up the charge nurse and the nursing supervisor and they pulled Fatima into an office. They told her their concerns.
“No, no, I was just helping medicate the patient,” Fatima said.
“Did you medicate the patient?” the supervisor asked.
Fatima tried to evade the inquiry.
“You need to answer this question: Did you give that patient the pain medication that you took out under his name?”
Again, Fatima gave a nonanswer.
“We believe you are taking narcotics. This has been a concern for a while. We need a urine sample.”
“No,” Fatima said, changing tactics. “I have the pain medication right here! I just didn’t have the chance to give it yet.” Ostensibly, she went to pull the patient’s vial from her pocket. Lara wondered later if Fatima had been so nervous that she didn’t think about what she was doing. The average Dilaudid dose was 0.5 milligram to 1 milligram. Fatima pulled out three 2-milligram vials.
“We’re going to have to ask you to leave if you won’t give a urine sample.”
Fatima wouldn’t provide the sample. She quit on the spot.
After the nurses told Lara the story, Lara tried to refocus their slant so that the narrative wasn’t about Fatima’s character. The South General nurses didn’t know about Lara’s own addiction. “Wow, she’s got a horrible disease,” Lara told them. “I hope she’s going to be okay. I’m going to say a prayer for her because I’d hate for her to overdose.”
Her coworkers were more empathetic toward Fatima than Lara had expected. “Drug addiction is more rampant than people would like to admit, and everyone knows it,” Lara theorized. “It’s not like ‘Oh my God, what a shock.’ It happens a lot.”
The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital Page 27