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Professional Sadness
Professional Sadness When Patient Care Clashes With the Bottom Line
Raymond J. Bingham, RNC, BSN
e It seems quaint to harken back to the good old days, but I believe that something really
Editor’s Note: Elsewhere in this issue of AWHONN Lifelines, we feature an expert roundtable discussion entitled “The Business of Nursing,” in which a panel of nursing and health care executives discuss the challenges inherent in managing the business aspects of nursing. In this commentary, nurse Raymond Bingham expresses frustration at what he sees as a clash between business “ethics” and patient care.
did change about
A Sad Day’s Night
health care in the
One night, I was lying on my couch, listening to sad love songs. One particular song resonated with me, and I played it over and over. Closing my eyes, I reflected on a recent day at the hospital, where I was a nurse in a NICU. I had taken care of a sad,
1990s.
450
tiny, premature infant. His name was Michael. The lyrics (from “C’est La Vie,” by Emerson, Lake & Palmer, 1977) that caught my ear were Like a song, out of tune and out of time All I needed was a rhyme for you C’ est la vie. And that was baby Michael. He was scrawny and lethargic, a premature infant born more than three months too early. In report that morning, the night nurse, Julie, told me he’d developed necrotizing enterocolitis, a devastating infection of the intestine common to preemies. The previous day, he’d undergone surgery to remove the diseased section of his bowel, but it hadn’t helped. Now, he was in
© 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Volume 10
Issue 6
septic shock, oozing blood from his incision, his belly darkened and bloated. Julie told me that she was surprised he’d survived the night. Out of tune, he was, and out of time. The song continued: Do you give, do you live from day to day Is there no song I can play for you C’ est la vie. With no respiration of his own, Michael was on maximum settings on a high-frequency ventilator. He was receiving multiple antibiotics, along with almost hourly transfusions of packed cells or plasma because of his third spacing and the oozing from his surgical incision site. He was on continuous infusions of dopamine, dobutamine and epinephrine to support his heart, but he still had borderline blood pressures. He had no urine output over the last 12 hours, indicating his kidneys had likely shut down. We had no song left to play for him. “Take good care of him,” Julie said before she left. “He’s been through so much.” Tiny and sick as Michael was, his parents, of course, still loved him. Around midday, they came in and sat by his bedside, holding his hand and talking to him. He gripped his mother’s finger weakly, and cracked open his swollen, yellowed eyes. I talked with them, and the attending physician came over to talk with them, and we tried to be as honest and straightforward as possible in describing the progress of the disease and the grim prognosis. Although they understood that there was little chance of recovery, they couldn’t give up hope and didn’t want to sign a do-not-resuscitate order. The father called me away from the bedside and asked me to show him where to store the frozen vials of the mother’s breast milk that they’d brought in. Once we were alone, he said, “I don’t want to stay here much longer. This waiting is torture for my wife. But is anything going to happen soon?” He was asking how soon his son would die. “At this point, we’re trying to keep him comfortable,” I said, “but there’s no way to know how much longer he can hang on.” So, shortly thereafter they left. And, shortly after 7:00 that evening, as I was getting ready to leave as the night shift nurses entered the unit, Michael’s monitor alarm rang off as his heart rate drifted down. Jeez, Michael, why did you
December 2006
January 2007
have to do this now? Five more minutes and I could have been out the door. We tried to resuscitate him, and it was a mess. We gave him more blood and medications and banged on his lungs and banged on his chest, without effect. When it was over, I looked at the blood-spattered bed and the dark, bloodied and bruised body. I was bathing Michael’s body when the parents rushed back in. The physician, the pastor and one of the night nurses escorted them to the conference room to deliver the news. After I finished cleaning up the bedside, changing his sheets, placing Michael in a clean T-shirt and diaper with a blue knit cap on his head and bundling him in a clean, soft blanket, I laid him back down and went to join the others. The mother was crying, and the father was holding her. We sat there for a long time in silence. Finally, the father asked to see Michael, and I accompanied him. At the bedside, we talked for a few minutes about our families. He asked me to take the final pictures of his son. He told me that he didn’t want his wife to see the body, thinking it would hurt her too much. But I looked him in the eye, and said, “She’s a strong woman. She’ll need to see and hold Michael to work through her own grief.” So, we brought him back. The mother took him from me right away and held him and cried a while longer. Then she looked up, and with almost a hint of a prideful smile, she started telling us about her son and about his brief life. “He knew of your love,” I told them, reminding them how he had opened his eyes to their touch and voice, the only movement I had seen from him the entire day. “I know he was a fighter. I believe his spirit left with you after your visit.” We talked a while longer, until they were ready for me to take Michael back to the bed. Then, we shook hands all around and said one last good-bye. Because the night nurse was new, I showed her how to shroud the body and accompanied her down to the basement. We placed Michael’s small body, wrapped in white plastic, alongside the other small, wrapped bodies on the morgue tray. So, I lay there on my sofa, letting these memories waft over me like they have from time to time in the days since, and I let the song wash over me.
Nursing is physically and emotionally draining, and nurses must continually deal with the combination of difficult patients, taxing schedules, and arduous physical work.
Raymond J. Bingham, RNC, BSN, is a technical writer and editor at the National Institute of Nursing Research in Bethesda, MD. DOI: 10.1111/j.1552-6356.2006.00092.x
AWHONN Lifelines
451
The Business “Ethic” Intrudes
Research is now beginning to document what physicians, patients, and nurses themselves have long known: How well we are cared for by nurses
Then, another thought sprang up unwelcomed, a new one, arising out of a more recent experience. In the days after Michael’s death, I attended a mandatory seminar for the hospital nursing staff, delivered by a business management consulting firm and entitled “Delivering Exceptional Customer Service.” It was promised that this seminar would teach us new communication skills to use within the hospital and with our patients, improving the efficiency of our work and saving both time and money. At the door, we were given a notebook. My turmoil increased as we turned to each new section: Making Your Customer Satisfied, Defining Your Product and Process, Maximizing Your Customer’s Experience, Setting Your Customer’s Perceptions, Grabbing the Moment of Truth Opportunity and Finding the Yes! Each page filled with the shallow, self-interested deceit of a salesman. At the conclusion of the day, an oncology nurse, obviously confused by the blather of the business speak, asked how these principles were supposed to help her communicate with her cancer patients. “Never use the word ‘cancer,’” the instructor admonished sternly. “Customers tend to find that word scary, and they will associate it with the hospital. That could hurt repeat business.” Did the hospital management really think that this was the ethic appropriate to nursing? Was that how I was supposed to have treated Michael’s parents, like customers in a showroom? Should I not have mentioned the fact that their son was premature, infected, sick, dying? Was I instead supposed to “Find a Yes”? I left the seminar with my stomach in a knot. I dumped the notebook in the nearest trash bin. I felt polluted.
affects our health, and sometimes can be a matter of life and death.
452
AWHONN Lifelines
When the Bottom Line Conflicts With Patient Care It seems quaint to harken back to the good old days, but I believe that something really did change about health care in the 1990s. I graduated from nursing school in 1989, when there was a “nursing shortage.” By 1995, health maintenance organizations and other related corporate entities had greatly increased their influence within health care. Suddenly, it became an “industry.” Just as
suddenly, there was a mysterious “glut” of nurses. After all, nurses expected to be paid for their work; so they became an “expense” or a “cost center.” Only months after my encounter with Michael and his parents, I was laid off. I found a new job and continued to work as a nurse for a few years. By the late 1990s, the specter of the true shortage of welleducated nurses trained to care for an increasingly aging and acute patient population could no longer be denied. I don’t work in a hospital anymore, but I continue to read accounts and research findings about the current state of hospital care—about the poor staffing and overwork of nurses. Many nurses these days confess that they fear to let their relatives or loved ones stay alone in the hospital, even their own, because of the lack of nurses to provide oversight and care. In her book, Nursing Against the Odds, health journalist Suzanne Gordon (2005) describes the concerns of nurses in a health care system overrun by fixation on the bottom line. Nursing is physically and emotionally draining, and nurses must continually deal with “the combination of difficult patients, taxing schedules, and arduous physical work” (p. 235). However, in the 1990s, management consultants infested the health care industry, promising more efficiency and better outcomes at lower costs. As it turns out, most of these “consultants” were young graduates of MBA programs with minimal business experience, knowledge or acumen, and they were directed only to recycle rigid, cookie-cutter formulas derived from stale, unproven industrial models. By brilliant deduction, these consultants concluded that the quickest way to cut hospital costs was to cut the nursing work force and the pay and benefits of nurses. They considered it a strength to have little understanding of how hospitals worked, making it easier for them to propound with no factual basis that nurses could simply do more with less. After staffing cuts yielded the desired quick and fleeting budget changes, these consultants could depart before the adverse effects of their unwise staffing moves on the care of patients—the actual business of a hospital—became evident. As one administrator said, “Their job was simply to state the hypothesis that you could function with 25 percent fewer staff” (Gordon, p. 242). Another described as “galling” the experience of having young consultants
Volume 10
Issue 6
coming to her to learn about the “core business” while telling her how to change it (Gordon, p. 242). Hospitals wasted millions of dollars in this process, and there is no evidence that it reduced health care costs by even a dime in the long run. In an illuminating anecdote, Ms. Gordon writes: Several years ago, at the height of the restructuring of American hospitals, I was speaking to about fifty RNs in the midwest. The nurses were deeply concerned about their patients’ well-being and their own ability to survive in their profession. One nurse who worked in a psychiatric hospital said she routinely cared for 35 patients on the night shift. Administrators insisted she could manage because they assumed that at night patients were all asleep. ‘Amazing,’ she noted. ‘Who was running the asylum?’ (p. 233). Who was running the asylum was a frequent question of me and my colleagues in the NICU and throughout our hospital. In the year prior to the onset of the “customer service” seminars, we were told repeatedly that reimbursements were down and that there was no money in the budget for raises. We had many hard-won benefits systematically pruned, and soon the hospital started losing staff. Yet, the hospital also managed to find more than a million dollars to pay for a team of consultants to come and inform us of the potential adverse financial consequences of the word “cancer.” It was outside the limited field of vision of these consultants that many people might come to our university hospital with its specialty cancer center specifically because they had been diagnosed with cancer, wanted to be told what kind of cancer they had and how to combat it, and wanted the best cancer care provided by the best, most experienced and knowledgeable cancer nurses. Many of us lost all faith and trust in a hospital
December 2006
January 2007
administration that could sanction such training so outside the core tenets of honesty and integrity ingrained in nurses. Dissatisfaction among nurses spread across the nation. In a survey conducted in 1998 to 1999, nurse researcher Linda Aiken (2001) found that 40 percent of nurses working in hospitals were dissatisfied with their current jobs, mostly due to poor staffing and workforce management issues. Fewer than 40 percent reported that there were enough RNs on staff in their units to provide highquality care. Many believed that they had insufficient time even for basic nursing duties, such as providing skin and mouth care, comforting and teaching patients and their families and updating care plans. Only 36 percent described the quality of care on their unit as excellent, and one-third believed that patients were discharged from their unit before they were prepared to handle their own care. Fewer than 30 percent believed that hospital administrators listened to their concerns, while more than 80 percent reported that their patient assignments were increasing. Many reported having to spend a significant portion of their shifts on non-nursing duties such as delivering food trays and handling housekeeping chores. These findings indicate significant breakdowns in the role of hospital nursing, with hospital mergers and reorganizations pushing nurses away from the bedside. Later research by Aiken (2002) explored the link between nursing
workloads and patient outcomes. By examining data on surgical patients in all hospitals in Pennsylvania, she found that higher nursing workloads were directly related to an increased risk of death, adverse postoperative events such as infections and “failure to rescue,” the ability of nurses to head off declines in a patient’s condition by their ongoing assessments. Higher workloads also increased the dissatisfaction of nurses with their jobs. The Institute of Medicine (2004) issued a report, Keeping Patients Safe, Transforming the Work Environment of Nurses, acknowledging the critical role nurses play in patient safety. “Research is now beginning to document what physicians, patients, and other health care providers, and nurses themselves have long known: How well we are cared for by nurses affects our health, and sometimes can be a matter of life and death” (p. 2). The vigilance of nurses improves the management of care and decreases the risk of adverse events. However, hospital restructuring along rigid business models has “been undertaken in ways that have damaged trust between nursing staff and management” (p. 4). In her book, Life and Death in Intensive Care, sociologist and health care researcher Joan Cassell (2005) relates an incident when nurses working in a surgical intensive care unit (SICU) were suddenly forced to cover two additional postoperative recovery rooms, with no additional resources or staff provided. As she reports, “Most of the nurses thought this was a terrible
Join the Discussion! What do you think about the issue of patient care versus the bottom line? Do you share the frustration voiced in this commentary? Or, do you think providing outstanding patient care and trying to increase revenues are not mutually exclusive? Tell us what you think. Write to Lifelines@awhonn. org and put “The Business of Nursing” in the subject line. Please include your full name, city and state and a phone number where we can reach you should your letter be selected for publication.
AWHONN Lifelines
453
idea … good people were getting disgusted and leaving” (p. 28). The nurses hated being pulled away from their main unit, and the staff had to work many overtime shifts to cover the additional rooms. By the time the hospital hired 22 new nurses to the SICU, 24 had already quit. Said one nurse manager, “We used to talk about Starling’s Law … If you stretch a muscle fiber too far, it no longer stretches, it breaks” (p. 28). Ms. Cassell writes, “The strengths and problems of the nurses … reflected those of nursing in general. They may well have had higher morale than many other nurses in the medical center, and their knowledge and technical skills were, of necessity, superior. But their subordinate position made them vulnerable to attempts to economize, to the fantasy that morale and competence can be stretched thin and spread over wider and wider areas without breaking … For the SICU nurses, ‘we care’ was more than a catchy slogan to attract ‘health care consumers.’ They really did care. But their caring could be used against them as a weapon” (p. 31). Nurses know that patients need them, and thus they’re reluctant to step away from the bedside in the advent of short-sighted, even abusive, management practices. With the influences of managed care, hospital management has too often become ruled by the bottom line and has ignored the core value of health care that hospitals purport to “sell.” Meanwhile, as health care costs continue to rise, so have profits, allowing many “health care corporations,” if you will, to make a killing (Anonymous, 2005). Not so many years ago, the hospital hired me to deliver specialized nursing
454
AWHONN Lifelines
care to sick and premature infants on the cusp of life and death. That was what I was educated, trained and dedicated to do. Certainly, business has its place in the running of a hospital, and nurses need to be aware of revenue and costs. But such thinking can’t dominate the health care workplace. Although I weighed the babies under my care every day, I did so to check their growth, development and fluid balance, not because we sold them like meat in the deli, by the pound. In my nursing care, I did what was necessary to give my tiny patients the best shot at survival. Or, as was the case with Michael, I strove to maintain the care and dignity of my patients and help the families deal with loss. Nursing can be a great joy; it can also be unpleasant, wrenching and grim. Although I loved the NICU, I never once wished for a repeat customer. I hoped never to see Michael’s parents again. I hoped they would have as many babies as they desired and never have to see the inside of an NICU again. I would be glad to put the NICU behind me forever, to close the business down, after someone has found a preventive for prematurity, an antidote for neonatal sepsis, a vaccine for congenital anomalies and a cure for infant mortality. Until such a time, nurses like me are skilled at a difficult, demanding and stressful job that few people can hack. That is our profession. That was my value to the hospital and to society. And to my work, I tried to bring intelligence, honesty, caring, gentleness and humanity. Not customer service. With time, I accepted the sadness and grief I felt for Michael and his family, and I learned from it. I’m glad to have
been there, caring for Michael. I’m glad to have felt his spirit. The experience helped me to grow as a nurse and as a person. However, the sadness I feel at the intrusions of the business model and the bottom-line ethic into hospital care and at the efforts to erode the deeply caring profession of nursing into nothing more than customer service to enhance profits, I have found harder to resolve. References Aiken, L. (2001). Nurses’ reports on hospital care in five countries. Health Affairs, 20(3), 43-53. Aiken, L. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, 1987-1993. Anonymous. (2005). HMO profits jump 21% in first quarter 2005. Retrieved September 20, 2006, from Weiss Ratings, Inc. Web site: http://www.weissratings. com/News/Ins_HMO/ 20051024hmo.htm Cassell, J. (2005). Life and death in intensive care. Philadelphia: Temple University Press. Gordon, S. (2005). Nursing against the odds: How health care cost cutting, media stereotypes, and medical hubris undermine nurses and patient care. Ithaca, NY: ILR Press. Institute of Medicine. (2004). Committee on the work environment for nurses and patient safety. In A. Page (Ed.), Keeping patients safe, transforming the work environment of nurses. Washington, DC: National Academies Press.
Volume 10
Issue 6
Raymond J. Bingham, RNC, BSN
e It seems quaint to harken back to the good old days, but I believe that something really
Editor’s Note: Elsewhere in this issue of AWHONN Lifelines, we feature an expert roundtable discussion entitled “The Business of Nursing,” in which a panel of nursing and health care executives discuss the challenges inherent in managing the business aspects of nursing. In this commentary, nurse Raymond Bingham expresses frustration at what he sees as a clash between business “ethics” and patient care.
did change about
A Sad Day’s Night
health care in the
One night, I was lying on my couch, listening to sad love songs. One particular song resonated with me, and I played it over and over. Closing my eyes, I reflected on a recent day at the hospital, where I was a nurse in a NICU. I had taken care of a sad,
1990s.
450
tiny, premature infant. His name was Michael. The lyrics (from “C’est La Vie,” by Emerson, Lake & Palmer, 1977) that caught my ear were Like a song, out of tune and out of time All I needed was a rhyme for you C’ est la vie. And that was baby Michael. He was scrawny and lethargic, a premature infant born more than three months too early. In report that morning, the night nurse, Julie, told me he’d developed necrotizing enterocolitis, a devastating infection of the intestine common to preemies. The previous day, he’d undergone surgery to remove the diseased section of his bowel, but it hadn’t helped. Now, he was in
© 2006, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Volume 10
Issue 6
septic shock, oozing blood from his incision, his belly darkened and bloated. Julie told me that she was surprised he’d survived the night. Out of tune, he was, and out of time. The song continued: Do you give, do you live from day to day Is there no song I can play for you C’ est la vie. With no respiration of his own, Michael was on maximum settings on a high-frequency ventilator. He was receiving multiple antibiotics, along with almost hourly transfusions of packed cells or plasma because of his third spacing and the oozing from his surgical incision site. He was on continuous infusions of dopamine, dobutamine and epinephrine to support his heart, but he still had borderline blood pressures. He had no urine output over the last 12 hours, indicating his kidneys had likely shut down. We had no song left to play for him. “Take good care of him,” Julie said before she left. “He’s been through so much.” Tiny and sick as Michael was, his parents, of course, still loved him. Around midday, they came in and sat by his bedside, holding his hand and talking to him. He gripped his mother’s finger weakly, and cracked open his swollen, yellowed eyes. I talked with them, and the attending physician came over to talk with them, and we tried to be as honest and straightforward as possible in describing the progress of the disease and the grim prognosis. Although they understood that there was little chance of recovery, they couldn’t give up hope and didn’t want to sign a do-not-resuscitate order. The father called me away from the bedside and asked me to show him where to store the frozen vials of the mother’s breast milk that they’d brought in. Once we were alone, he said, “I don’t want to stay here much longer. This waiting is torture for my wife. But is anything going to happen soon?” He was asking how soon his son would die. “At this point, we’re trying to keep him comfortable,” I said, “but there’s no way to know how much longer he can hang on.” So, shortly thereafter they left. And, shortly after 7:00 that evening, as I was getting ready to leave as the night shift nurses entered the unit, Michael’s monitor alarm rang off as his heart rate drifted down. Jeez, Michael, why did you
December 2006
January 2007
have to do this now? Five more minutes and I could have been out the door. We tried to resuscitate him, and it was a mess. We gave him more blood and medications and banged on his lungs and banged on his chest, without effect. When it was over, I looked at the blood-spattered bed and the dark, bloodied and bruised body. I was bathing Michael’s body when the parents rushed back in. The physician, the pastor and one of the night nurses escorted them to the conference room to deliver the news. After I finished cleaning up the bedside, changing his sheets, placing Michael in a clean T-shirt and diaper with a blue knit cap on his head and bundling him in a clean, soft blanket, I laid him back down and went to join the others. The mother was crying, and the father was holding her. We sat there for a long time in silence. Finally, the father asked to see Michael, and I accompanied him. At the bedside, we talked for a few minutes about our families. He asked me to take the final pictures of his son. He told me that he didn’t want his wife to see the body, thinking it would hurt her too much. But I looked him in the eye, and said, “She’s a strong woman. She’ll need to see and hold Michael to work through her own grief.” So, we brought him back. The mother took him from me right away and held him and cried a while longer. Then she looked up, and with almost a hint of a prideful smile, she started telling us about her son and about his brief life. “He knew of your love,” I told them, reminding them how he had opened his eyes to their touch and voice, the only movement I had seen from him the entire day. “I know he was a fighter. I believe his spirit left with you after your visit.” We talked a while longer, until they were ready for me to take Michael back to the bed. Then, we shook hands all around and said one last good-bye. Because the night nurse was new, I showed her how to shroud the body and accompanied her down to the basement. We placed Michael’s small body, wrapped in white plastic, alongside the other small, wrapped bodies on the morgue tray. So, I lay there on my sofa, letting these memories waft over me like they have from time to time in the days since, and I let the song wash over me.
Nursing is physically and emotionally draining, and nurses must continually deal with the combination of difficult patients, taxing schedules, and arduous physical work.
Raymond J. Bingham, RNC, BSN, is a technical writer and editor at the National Institute of Nursing Research in Bethesda, MD. DOI: 10.1111/j.1552-6356.2006.00092.x
AWHONN Lifelines
451
The Business “Ethic” Intrudes
Research is now beginning to document what physicians, patients, and nurses themselves have long known: How well we are cared for by nurses
Then, another thought sprang up unwelcomed, a new one, arising out of a more recent experience. In the days after Michael’s death, I attended a mandatory seminar for the hospital nursing staff, delivered by a business management consulting firm and entitled “Delivering Exceptional Customer Service.” It was promised that this seminar would teach us new communication skills to use within the hospital and with our patients, improving the efficiency of our work and saving both time and money. At the door, we were given a notebook. My turmoil increased as we turned to each new section: Making Your Customer Satisfied, Defining Your Product and Process, Maximizing Your Customer’s Experience, Setting Your Customer’s Perceptions, Grabbing the Moment of Truth Opportunity and Finding the Yes! Each page filled with the shallow, self-interested deceit of a salesman. At the conclusion of the day, an oncology nurse, obviously confused by the blather of the business speak, asked how these principles were supposed to help her communicate with her cancer patients. “Never use the word ‘cancer,’” the instructor admonished sternly. “Customers tend to find that word scary, and they will associate it with the hospital. That could hurt repeat business.” Did the hospital management really think that this was the ethic appropriate to nursing? Was that how I was supposed to have treated Michael’s parents, like customers in a showroom? Should I not have mentioned the fact that their son was premature, infected, sick, dying? Was I instead supposed to “Find a Yes”? I left the seminar with my stomach in a knot. I dumped the notebook in the nearest trash bin. I felt polluted.
affects our health, and sometimes can be a matter of life and death.
452
AWHONN Lifelines
When the Bottom Line Conflicts With Patient Care It seems quaint to harken back to the good old days, but I believe that something really did change about health care in the 1990s. I graduated from nursing school in 1989, when there was a “nursing shortage.” By 1995, health maintenance organizations and other related corporate entities had greatly increased their influence within health care. Suddenly, it became an “industry.” Just as
suddenly, there was a mysterious “glut” of nurses. After all, nurses expected to be paid for their work; so they became an “expense” or a “cost center.” Only months after my encounter with Michael and his parents, I was laid off. I found a new job and continued to work as a nurse for a few years. By the late 1990s, the specter of the true shortage of welleducated nurses trained to care for an increasingly aging and acute patient population could no longer be denied. I don’t work in a hospital anymore, but I continue to read accounts and research findings about the current state of hospital care—about the poor staffing and overwork of nurses. Many nurses these days confess that they fear to let their relatives or loved ones stay alone in the hospital, even their own, because of the lack of nurses to provide oversight and care. In her book, Nursing Against the Odds, health journalist Suzanne Gordon (2005) describes the concerns of nurses in a health care system overrun by fixation on the bottom line. Nursing is physically and emotionally draining, and nurses must continually deal with “the combination of difficult patients, taxing schedules, and arduous physical work” (p. 235). However, in the 1990s, management consultants infested the health care industry, promising more efficiency and better outcomes at lower costs. As it turns out, most of these “consultants” were young graduates of MBA programs with minimal business experience, knowledge or acumen, and they were directed only to recycle rigid, cookie-cutter formulas derived from stale, unproven industrial models. By brilliant deduction, these consultants concluded that the quickest way to cut hospital costs was to cut the nursing work force and the pay and benefits of nurses. They considered it a strength to have little understanding of how hospitals worked, making it easier for them to propound with no factual basis that nurses could simply do more with less. After staffing cuts yielded the desired quick and fleeting budget changes, these consultants could depart before the adverse effects of their unwise staffing moves on the care of patients—the actual business of a hospital—became evident. As one administrator said, “Their job was simply to state the hypothesis that you could function with 25 percent fewer staff” (Gordon, p. 242). Another described as “galling” the experience of having young consultants
Volume 10
Issue 6
coming to her to learn about the “core business” while telling her how to change it (Gordon, p. 242). Hospitals wasted millions of dollars in this process, and there is no evidence that it reduced health care costs by even a dime in the long run. In an illuminating anecdote, Ms. Gordon writes: Several years ago, at the height of the restructuring of American hospitals, I was speaking to about fifty RNs in the midwest. The nurses were deeply concerned about their patients’ well-being and their own ability to survive in their profession. One nurse who worked in a psychiatric hospital said she routinely cared for 35 patients on the night shift. Administrators insisted she could manage because they assumed that at night patients were all asleep. ‘Amazing,’ she noted. ‘Who was running the asylum?’ (p. 233). Who was running the asylum was a frequent question of me and my colleagues in the NICU and throughout our hospital. In the year prior to the onset of the “customer service” seminars, we were told repeatedly that reimbursements were down and that there was no money in the budget for raises. We had many hard-won benefits systematically pruned, and soon the hospital started losing staff. Yet, the hospital also managed to find more than a million dollars to pay for a team of consultants to come and inform us of the potential adverse financial consequences of the word “cancer.” It was outside the limited field of vision of these consultants that many people might come to our university hospital with its specialty cancer center specifically because they had been diagnosed with cancer, wanted to be told what kind of cancer they had and how to combat it, and wanted the best cancer care provided by the best, most experienced and knowledgeable cancer nurses. Many of us lost all faith and trust in a hospital
December 2006
January 2007
administration that could sanction such training so outside the core tenets of honesty and integrity ingrained in nurses. Dissatisfaction among nurses spread across the nation. In a survey conducted in 1998 to 1999, nurse researcher Linda Aiken (2001) found that 40 percent of nurses working in hospitals were dissatisfied with their current jobs, mostly due to poor staffing and workforce management issues. Fewer than 40 percent reported that there were enough RNs on staff in their units to provide highquality care. Many believed that they had insufficient time even for basic nursing duties, such as providing skin and mouth care, comforting and teaching patients and their families and updating care plans. Only 36 percent described the quality of care on their unit as excellent, and one-third believed that patients were discharged from their unit before they were prepared to handle their own care. Fewer than 30 percent believed that hospital administrators listened to their concerns, while more than 80 percent reported that their patient assignments were increasing. Many reported having to spend a significant portion of their shifts on non-nursing duties such as delivering food trays and handling housekeeping chores. These findings indicate significant breakdowns in the role of hospital nursing, with hospital mergers and reorganizations pushing nurses away from the bedside. Later research by Aiken (2002) explored the link between nursing
workloads and patient outcomes. By examining data on surgical patients in all hospitals in Pennsylvania, she found that higher nursing workloads were directly related to an increased risk of death, adverse postoperative events such as infections and “failure to rescue,” the ability of nurses to head off declines in a patient’s condition by their ongoing assessments. Higher workloads also increased the dissatisfaction of nurses with their jobs. The Institute of Medicine (2004) issued a report, Keeping Patients Safe, Transforming the Work Environment of Nurses, acknowledging the critical role nurses play in patient safety. “Research is now beginning to document what physicians, patients, and other health care providers, and nurses themselves have long known: How well we are cared for by nurses affects our health, and sometimes can be a matter of life and death” (p. 2). The vigilance of nurses improves the management of care and decreases the risk of adverse events. However, hospital restructuring along rigid business models has “been undertaken in ways that have damaged trust between nursing staff and management” (p. 4). In her book, Life and Death in Intensive Care, sociologist and health care researcher Joan Cassell (2005) relates an incident when nurses working in a surgical intensive care unit (SICU) were suddenly forced to cover two additional postoperative recovery rooms, with no additional resources or staff provided. As she reports, “Most of the nurses thought this was a terrible
Join the Discussion! What do you think about the issue of patient care versus the bottom line? Do you share the frustration voiced in this commentary? Or, do you think providing outstanding patient care and trying to increase revenues are not mutually exclusive? Tell us what you think. Write to Lifelines@awhonn. org and put “The Business of Nursing” in the subject line. Please include your full name, city and state and a phone number where we can reach you should your letter be selected for publication.
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idea … good people were getting disgusted and leaving” (p. 28). The nurses hated being pulled away from their main unit, and the staff had to work many overtime shifts to cover the additional rooms. By the time the hospital hired 22 new nurses to the SICU, 24 had already quit. Said one nurse manager, “We used to talk about Starling’s Law … If you stretch a muscle fiber too far, it no longer stretches, it breaks” (p. 28). Ms. Cassell writes, “The strengths and problems of the nurses … reflected those of nursing in general. They may well have had higher morale than many other nurses in the medical center, and their knowledge and technical skills were, of necessity, superior. But their subordinate position made them vulnerable to attempts to economize, to the fantasy that morale and competence can be stretched thin and spread over wider and wider areas without breaking … For the SICU nurses, ‘we care’ was more than a catchy slogan to attract ‘health care consumers.’ They really did care. But their caring could be used against them as a weapon” (p. 31). Nurses know that patients need them, and thus they’re reluctant to step away from the bedside in the advent of short-sighted, even abusive, management practices. With the influences of managed care, hospital management has too often become ruled by the bottom line and has ignored the core value of health care that hospitals purport to “sell.” Meanwhile, as health care costs continue to rise, so have profits, allowing many “health care corporations,” if you will, to make a killing (Anonymous, 2005). Not so many years ago, the hospital hired me to deliver specialized nursing
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care to sick and premature infants on the cusp of life and death. That was what I was educated, trained and dedicated to do. Certainly, business has its place in the running of a hospital, and nurses need to be aware of revenue and costs. But such thinking can’t dominate the health care workplace. Although I weighed the babies under my care every day, I did so to check their growth, development and fluid balance, not because we sold them like meat in the deli, by the pound. In my nursing care, I did what was necessary to give my tiny patients the best shot at survival. Or, as was the case with Michael, I strove to maintain the care and dignity of my patients and help the families deal with loss. Nursing can be a great joy; it can also be unpleasant, wrenching and grim. Although I loved the NICU, I never once wished for a repeat customer. I hoped never to see Michael’s parents again. I hoped they would have as many babies as they desired and never have to see the inside of an NICU again. I would be glad to put the NICU behind me forever, to close the business down, after someone has found a preventive for prematurity, an antidote for neonatal sepsis, a vaccine for congenital anomalies and a cure for infant mortality. Until such a time, nurses like me are skilled at a difficult, demanding and stressful job that few people can hack. That is our profession. That was my value to the hospital and to society. And to my work, I tried to bring intelligence, honesty, caring, gentleness and humanity. Not customer service. With time, I accepted the sadness and grief I felt for Michael and his family, and I learned from it. I’m glad to have
been there, caring for Michael. I’m glad to have felt his spirit. The experience helped me to grow as a nurse and as a person. However, the sadness I feel at the intrusions of the business model and the bottom-line ethic into hospital care and at the efforts to erode the deeply caring profession of nursing into nothing more than customer service to enhance profits, I have found harder to resolve. References Aiken, L. (2001). Nurses’ reports on hospital care in five countries. Health Affairs, 20(3), 43-53. Aiken, L. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288, 1987-1993. Anonymous. (2005). HMO profits jump 21% in first quarter 2005. Retrieved September 20, 2006, from Weiss Ratings, Inc. Web site: http://www.weissratings. com/News/Ins_HMO/ 20051024hmo.htm Cassell, J. (2005). Life and death in intensive care. Philadelphia: Temple University Press. Gordon, S. (2005). Nursing against the odds: How health care cost cutting, media stereotypes, and medical hubris undermine nurses and patient care. Ithaca, NY: ILR Press. Institute of Medicine. (2004). Committee on the work environment for nurses and patient safety. In A. Page (Ed.), Keeping patients safe, transforming the work environment of nurses. Washington, DC: National Academies Press.
Volume 10
Issue 6