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Public relations in our maternity wards
Public relations in our maternity wards PURVIS L. MARTIN, M.D. S T E WAR D H. S MIT H, M. D . San Diego, California
T II E time-honored goal of obstetricians is to make childbirth safe. And safety, expressed in terms of fetal and maternal mortality, is our usual yardstick for measuring the quality of obstetrical care. Our patients, however, are likely to use a different yardstick. Accepting today's safety as their just due, patients tend to jUQge the quality of their obstetrical care in terms of comfort and in terms of the amount of attention they receive from their doctors and from hospital personnel. Ideally, every childbirth experience should be a happy and satisfying event, as well as a safe one. However, those of us who practice obstetrics know that for many reasons, rnore or less beyond our control, the hospital experiences of some of our patients fall far short of this ideal. It is an enigma of modern obstetrics that what passes in the record as a normal labor and delivery may be bitterly rernembered by our patient as a terrifying experience. Doctors, and the hospital services they ~elp to direct, have been publicly attacked In lay magazine articles because of these ~,hortcomings. Titles include phrases such as, Cruelty in Maternity Wards," or, "Can YOll Trust Your Obstetrician?" Such ar-
ticles, especially those apparently written from collections of letters from dissatisfied patients, arc frightening for prospective mothers to read. They are of concern to all physicians interested in improving medical public relations. They arc read with defensive resentment by responsible obstetricians who know that obstetrical safety and obstetrical comfort are not always parallel, but nevertheless can recognize an element of truth in thc accusations. It is not casy to evaluate the true situation which must lie somewhere between the emotion-tinged reports of dissatisfied patients and the rufflcd feelings of obstctricians who are diligently continuing the reduction of fetal and maternal mortality. Arc a significant number of patients leaving our hospitals with emotional mJuries and resentment against the medical profession? Are there ways we could improve the comfort and happiness of thc hospital childbirth experiencc, without sacrifices in safcty and cost? The purpose of the present stud.y is to obtain a measure of the gap that seems to lie between the ideal and what actually happens, in typical metropolitan hospitals, as seen through the patient's eyes. From it we hope to devise ways to improve the comfort and satisfaction of our obstetrical patients. Pleased obstetrical patients will improve hospital and medical public relations. Furthermore, as insurance companies have learned, people who are pleased with kindness and consideration shown them by medical aides, are reluctant to bring medicolegal claims against either doctors or hospitals.
From the Department of Obstetrics and Gynecology, Mercy Hospital, and the Section on Obstetrics and Gynecology, The Donald N. Sharp Memorial Hospital. Presented at the Twenty-seventh Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Yosemite National Park, Calif011lia, Sept. 28-0ct. 1, 1960.
1079
1080 Martin and Smith
Method and material
A questionnaire survey of hospital experiences was conducted among alI of our partnership private patients who were delivered during the past 5 years. AlI but 1 per cent were delivered in two San Diego hospitals, Mercy Hospital and Sharp Hospital, hereinafter calIed "Hospital A" and "Hospital 13." Mercy Hospital is a large private general hospital with an organized intern and residency program. The obstetrical service averages more than 5,000 deliveries each year. Sharp Hospital is relatively new, with a modern decor, and averages over 3,000 deliveries each year. Both hospitals arc often filled to more than capacity. Both have new obstetrical units in the process of planning or construction. The questionnaire was constructed so that each patient could grade her own care at each stage in the hospital experience: (1) entering the hospital; (2) labor and birth; (3) postpartum care; (4) receiving the bill. Ample space was provided for the candid comments that were requested. Patients were asked what they liked best, and what they most disliked about the way they were treated. FinalIy, they were asked for their own suggestions which could be used to improve hospital care. Of the 1,886 questionnaires lJIailed, two thirds, 01' 1,048 were returned. Sixty-two per cent were from former Mercy Hospital patients; 37 per cent were from former Sharp Memorial Hospital patients. Some patients had more than one maternity hospital experience during this time period. In evaluating the results, only the most recent experiences were considered. The questionnaires, as they were returned, were studied first by ourselves and then by the adlJlinistrator of each hospital. They were then subjected to statistical analysis and to psychological interpretation by Dr. Oscar Kaplan, Professor of Psychology, San Diego State College. Results
1. Entering the hospital. The first question and patient replies folIow:
Am.
"How were the hospital?"
YOll
June, 1961 & Cynce.
J. Obs!.
received as you entered Hospital A
Hospital B
74% 23% 3%
83% 16% 1%
Warmly "So-so" Coldly
Although very few patients stated they were received coldly, approximately 25 per cent felt their reception was not what it should have been. Remarks from the 25 per cent were studied and the great majority from each hospital who complained felt they were received in a routine, indifferent, businesslike manner. Remarks of many held praise, but room for improvement is apparent. Every patient should be received warmly. Typical verbatim remarks are now proving helpful in personnel retraining: 1. "Everyone was most efficient; however, a little more fri~ndliness would have been appreciated." 2. "They acted as if they were doing me a favor by signing me up." 3. "The nurses who received me were friendly and showed a genuine interest. This put me at ease." 2. Labor. Our next question was concerned with labor. With all that can happen in a busy labor room, it was here we expected the greatest number of complaints. Surprisingly, the reverse was true. Many patients seemed to feel that they received their best care and treatment from the nurseS during labor. "How were you treated by the nurseS during labor?" Hospital A Well treated 85% "So-so" 9% Poorly 3% Did not go into labor (cesarean, born on arrival, etc.) 3%
Hospital B
82% 12% 3% 3%
Derogatory remarks were studied and broken down, as follows: 1. Nurse described as unsympathetic, abrupt, rude, hostile, sarcastic
If ospital A
Hospital B
45%
29%
Volume 81 Number 6
Public relations
2. Patient neglected
3. 4.
5.
6.
during labor; nurses too busy for proper care Nurses indifferent, aloof, doing job routinely Nurse performed painful rectal examinations Nurses made errors in judgment, doctors not called soon enough No assurance given anxious patient
35%
36%
11%
18%
11%
9%
2%
7%
2%
7%
Hospital A
Hospital B
81% 14% 5%
90% 7% 3%
A great majority of patients felt that they had good treatment after the birth of the baby. Many made warm statements of praise. But abou t 20 per cent in one hospital and 10 per cent in the other felt that their treatment was not what it should have been. Complaints were hroken down as follows: I. Patient felt neglected; hospital understaffed, service slow
maternity wards
1081
2. Nurses unpleasant, rude,
Sample comments illustrate patients' experiences during labor and are useful in personnel training: 1. "As the nurse was getting me ready she was all business, but yet she took time to soothe me and tell me that everything would be all right." 2. "There was one nurse that was curt and short-tempered, but the rest were very nice." 3. "They yelled at me to he quiet because they could hear me in the hall. I hated them, and I'm sure they hated me." 4. "All the nurses were wonderful and helpful, explaining how and why they were doing things." 3. Postpartum care. The next question reported treatment after the birth of the baby. "How were you treated by the nurses after the birth?"
Well treated "So-so" Poorly
In
HOJpital A
Hospital B
56%
63%
sarcastic, reluctant to give service 32% 3. Nurses indifferent, treatment routine or assembly line 12%
31% 6%
Verbatim comments illustrate patients' experiences after the birth of the baby: 1. "They were obviously too busy to give more than perfunctory attention." 2. "Some of the nurses were very mce. Most of them were just ordinary and some seemed to resen t being there." 3. "No one ever told me the hospital rules. They just reprimanded me and others when we disobeyed them." -t. "There was one unfeeling, unsympathetic, disinterested nurse. The others were lovely. Why is there always one on every floor?" 4. The hospital hill. "What was your impression of the hospital bill and the way it was presented?"
Good Indiffercnt Bad
Hospital A
Hospital B
66% 26% 80/"
74% 21% 5%
There were a numher of complaints about the bill, even by those who checked "good" on their questionnaires. Most frequent complaints were as follows: 1. Hospital care too expensive ,) Patient fclt pressured to pay, using words like "bail," "hock" 3. Resented "extras" on bill +. Bill lllorC tha n estimated 5. Resented prepayment of bill
Hospital A
Hospital B
28%
33%
12%
27';{,
8'/',
13 '7r
10%
5 (i~'
7%
0%
Sample comments ilillstrate patient's impressions: 1. "The hill was far too high for maternity. I would like to see ambulatory patients get a break in the bill. I have read about this new system." 2. "The subject was brought up at the mothers' tea, so I was prepared for the bill."
1082 Martin and Smith
Am.
3. "I didn't feci overcharged because the food was good." 5. Additional impressions. A. "What did you like best about the hospital ?" Hospital A Food; its variety, attractive service Personnel; friendly, helpful Plcasan t, bright sursoundings Care; efficient and prompt Apprt'ciated husband in labor room
Hospital B
24% 34%
54% 34%
1% 12%
39%
6%
6%
15%
Many more or less isolated comments and compliments were received in answer to this question. Many of them referred to recent improvements in hospital equipment and hospital policy. Telephones next to the bcd, intercom system, daily shower, between meal snacks, and hospital cleanliness were appreciated. Verbatim comments illustrate what patients liked best about the hospital. 1. "I liked the immediate answering of the huzzer, the help with the bath, alcohol rubs, lovely treatment by all, and husbands allowed in the labor room." 2. "I liked the food! After nine months of dieting, the more and richer, the better." 3. "They let you sleep late, brought coffee before breakfast, served meals at decent hours, afternoon snacks, nice nurse, showers, choice of meals and drinks--I didn't want to go home." B. "What did you most dislike?" Hospital A Nothing disliked Disliked food Infant visiting policy Unpleasant personnel Patient neglected
28';'
12% J J '/r 9% 8%
Hospital B 34',1,;
0%
lorY, 8 '/r,
8%
There were many more individual comments and complaints given in answer to this question. A. large proportion appear to be hased on minor slip-ups in usual hospital routine and in personnel-patient relations. Sample comments to illustrate what paticnts most disliked about the hospital: I. "I didn't likc getting up at 5:30 A.r.L
June, 1961 & Gynec.
J. Obst.
and then waiting two and a half hours for breakfast to be served. I also didn't like being awakened for a sleeping pill." 2. "My baby wasn't brought to me until twenty-two and a half hours after birth." 3. "I disliked not being permitted to bottle-feed my baby. Because I wasn't nursing, I could see the baby only once a day. He was fed in the nursery." 4. "I disliked the routine. The hospital must run for the benefit of efficiency, and God help the poor patient caught in the jaws of a machine that starts at 5:00 A.M. to the clatter of wash basins, and steams inexorably through the day with 77 bus boys, charwomen, Nurses Aides, Gray Ladies, etc., ad nauseam, ad infinitum, running in and out." 5. "I most dislikcd thc fact that two womcn arc in cach labor room. Women who are unprcparcd to facc thc discomforts of labor frighten womcn who arc having their first child and lead them to helievc that they, too, will eventually get to the screaming stagc. It is hard for someone who is trying to control herself during labor to have constant scrcaming in thc same room with her." , C. "Havc you any suggestions that would improvc your hospital care ncxt time?" Patients contributed many suggestions that, while they almost go without saying, still arc hclpful in planning our new obstctrical units and in personnel training. Illustrativc verbatim comments: 1. "There should be a radio or TV in the labor room." 2. "Nurses in the labor room should have frequent rcsts, to prevcnt short temper due to fatiguc." 3. "Permit mothcrs to see infants as soon after delivery as possible." 4-. "Have a rooming-in arrangcment for the mother and child." 5, "Patients who have had long labors should be given food shortly after delivery, even if the kitchen is closed." 6. "Coffee should be served to fathers who are waiting." 7. "Night nurses should move around quietly."
Volume 81 Numbe .. 6
8. "Husbands should be permitted to visit freely and stay long periods of time." 9. "Have folding doors instead of curtains between beds." 10. "Mothers who have had no postpartum difficulties should have a hotel-like atmosphere; they are not ill, just resting." 11. "Hospitals should examine their routines and decide whether tradition or logic governs their operation." 12. "Hospital routine should be planned to permit more rest for the mother." Comment
It is apparent that most obstetrical patients today accept the safety of having a baby, of which we are justly proud, without any special credit to the medical profession which is responsible. Patients tend to judge the quality of their obstetrical care in terms of comfort and the amount of attention they receive from their doctors and from the hospital personnel. No patient reported that she lost her child due to inefficiency or neglect. The damage that was done seemed to be all psyChological. Actually, there were far fewer complaints and criticisms than we had expected, particularly since both hospitals have been operating at higher capacity than Was ever intended when they were designed. On the other hand, it is apparent that much can be done to improve each patient's chances of experiencing a really happy hospital childbirth. Some women were not received warmly when they entered the hospital. It is indeed a discouraging experience to be met with bored indifference on one of the most important days of one's life. One patient stated it very well when she wrote. "Babies may be born every day of the week, but not MY baby." A need for careful selection, additional training, and constant supervision of admitting personnel seems apparent in both hospitals. We were surprised to find that many patients considered their best treatment was during the course of labor. With all of the sUdden surprises that do occur during seem-
Public relations
In
maternity wards
1083
ingly normal labor, with difficulties in controlling pain in unprepared patients, we had expected to find the severest criticisms during this period of the hospital experience. However, there appears to be room for improvement of the patients' experiences during labor. No labor nurse shollld ever be described as sarcastic, hostile, scolding, or impatient. Repeated comments indicated that one nurse alone created difficulties, while all the rest of the nurses were helpful and pleasant. The postpartum period seemed to elicit the greatest number of criticisms, comments, and suggestions. Here again, one single member of the nursing or aide personnel f requently destroys all of the happy atmosphere and good relations built up by all of the rest of the personnel. From the "cold wash cloth at dawn," through the day, a thorough review of hospital procedures during the postpartum period seems indicated. Perhaps for nurses there should be more nursing- and less charting, and for patients there should be regular periods set aside for quiet rest. As Norman Miller has forcefully pointed out, postpartum patients usually do not get enough rest. Tired patients are irritable and sensitive. Tired nurses are irritable. Clashes must be guarded against. The qucstionnaire and the large pool of patient comments have proved helpful in many ways. The questionnaire itself seemed to serve as a step in good medical public relations, since it indicated to the patient her doctor's concern over her feelings and her welfare. A hospital staff committee on public relations has been formed at Mercy Hospital. A director of public relations has been added to the administrative staff. Material from the questionnaire is being used in special seminars for nurses. Critical remarks from the questionnaire serve as reminders, and appreciative comments serve as rewards, in teaching personnel the art of pleasing patients. The School of Nursing is finding helpful information in improving training of student nurses. The hospital administrators and department heads have
1084 Martin and Smith
found a great deal of helpful material which is being llsed in planning the decor and the operation of the new obstetrical wings now under construction. Each hospital benefited by studying comments from patients in the other hospital. In an atmosphere of extra-friendly employees, it becomes very difficult for the patient to be hostile or uncooperative. Quoting -from an insurance committee report to doctors, concerning malpractice insurance: "We have had innumerable reports where there appeared to be some justification for a possible claim against the doctor, in which the patient has mentioned to the company claims adjuster his desire to avoid any legal action 'because the doctor and the office personnel are so friendly and courteous to Inc,' "
Summary and conclusions
Our questionnairc survey rcportcd thc hospital childbirth experiences of more than
Alii.
Ju,lt', 1961 J. Obs!. & Gym'c,
1,000 private patients who were delivcred in two San Diego general hospitals during thc past 5 years. The great majority of patients seemed satisfied with their hospital carc in each of four stagcs of hospital expcricnce. No patient reported loss of her baby or physical injury because of neglect or poor care. Bitter criticisms of cruelty and ncglect, reported in popular magazines, wcre not confirmcd. A majority of complaints wcrc found to stem from poor personnel-paticnt relationships. At least half thc complaints can bc considered prevcntable. Personnel need training in the art of being warm and friendly toward patients. With such a training program, morc paticnts will achicvc our goal of a happy, as well as safe, childbirth experience. Happier mothcrs will rcsult in improvcd public relations for hospitals and for the medical profession as well.
Discussion DR. LEON Fox, Sail Jose, California. Gill' own survey in San Jose Hospital where we havc' averaged +,3(JO ckliVl'rics per year in tIl<' last 2 yC'ars in facilities desigl]('d for half this 11I11I1I)('r compares with the San Diq!;o experience. Both of thcs(' an'as haw (Towded faciliti('s which tend to I'!iminale tIlt' COl1llwtitive spirit between hospitals. To cope with these prohlc'ms wc' have ('vallIated our patients' complaints as \\"ell as our physicians' and nllrses' observations and have accomplished tIlt' following: I. A cOl1lmittc'c' of hospital p,'rsolllwl, admiIlistration and physician, known as the "Committee for tl](' IllIprovemeIlt of Paticnt Carl'" has been established and has I)('en givC'n authority to act. ~'fl~dical statf, administration, nursing, housekl'l'ping, and patients' probll'ms are evaluated and acted upon. 2. A tl'lephon('-dictating systcm has b('l'n instituted to rl'cord all complaints by anyone at any phone station in thl' hospital. These complaints go to the abo\'!' committt'!' for evalnation and action. :~. PrivatI' labor rooms arc a reality.
4. A pucrperal RC'covery Room is functioning '24 hours daily with gn'at satisfaction. S. DeliVl'ry rooms have been air-conditioned. (W!' should do tlIP same in our labor rooms.) G. Tntf'I'COIllS in labor, dl'livery, and postpartum areas ,'ave many steps and please patients. 7. The patient s('cs her baby with her husband imnwdiatf'ly aftc'r dl'livery, before going to the recovery room. 8. TV and com fort conveniences arc 111 the fathers' waiting room. 9. Tl'lephorIPs are in thl' patil'nts' rooms unless the physician ordl'rs otherwise. 10. Adequate showers arc available for ambulatory patif'nts. 11. Full al]('sthesi01ogy coverage is available 24 hours daily (M.D. ancsthesiologists and their own "mployt'd R.N. anesthetists). 12. There is an active auxiliary with "Pink Ladies" r('ceiving paticnts, accompanying patipnts to labor suitf's; providing coffee and tpa for fathl'rs and patil'nts; providing newspapf'rs, toilet articlt's, f1owl'rs, etc., for patients. 13. A continual training program is carril'd on
Volume 81 Number 6
for nursing personnel, auxiliary and house staff, on ncwcr mcthods, patient complaints, physician complaints, and other similar problems. 14. Medical Society cooperation is obtained in urging all nursing training programs in colleges, junior colleges, and hospitals to improve not only quantity but quality when possible. 15. Medical Society participation is obtained in urging hospital building programs at every opportunity. We now havc two new hospitals being complcted and one in thc planning stage. 16. Registcrcd nurses are being rcplaced with clerks, aides, and technicians in areas where nursing knowledge is being wasted on menial and clerical duties.
Public relations
III
maternity wards
1085
We're still overcrowded, inadequatcly staffed, and in necd of modernization of many of our wards, but our Committ('c on the Improvement of Patient Care has a grasp of the situation and our patients are presenting fewer complaints. DR. MARTIN (Closing). Just as medical public relations depend basically 011 the total of all the day-by-day doctor-patient relationships, hospital public relations depend basically on personnelpatient relationships. Our study has revealed room for improvement. Patients do not expect to pay $30 a day to be berated by nurses. Perhaps a public relations course for nurses and other personnel should be included in the organization of every hospital.
T II E time-honored goal of obstetricians is to make childbirth safe. And safety, expressed in terms of fetal and maternal mortality, is our usual yardstick for measuring the quality of obstetrical care. Our patients, however, are likely to use a different yardstick. Accepting today's safety as their just due, patients tend to jUQge the quality of their obstetrical care in terms of comfort and in terms of the amount of attention they receive from their doctors and from hospital personnel. Ideally, every childbirth experience should be a happy and satisfying event, as well as a safe one. However, those of us who practice obstetrics know that for many reasons, rnore or less beyond our control, the hospital experiences of some of our patients fall far short of this ideal. It is an enigma of modern obstetrics that what passes in the record as a normal labor and delivery may be bitterly rernembered by our patient as a terrifying experience. Doctors, and the hospital services they ~elp to direct, have been publicly attacked In lay magazine articles because of these ~,hortcomings. Titles include phrases such as, Cruelty in Maternity Wards," or, "Can YOll Trust Your Obstetrician?" Such ar-
ticles, especially those apparently written from collections of letters from dissatisfied patients, arc frightening for prospective mothers to read. They are of concern to all physicians interested in improving medical public relations. They arc read with defensive resentment by responsible obstetricians who know that obstetrical safety and obstetrical comfort are not always parallel, but nevertheless can recognize an element of truth in thc accusations. It is not casy to evaluate the true situation which must lie somewhere between the emotion-tinged reports of dissatisfied patients and the rufflcd feelings of obstctricians who are diligently continuing the reduction of fetal and maternal mortality. Arc a significant number of patients leaving our hospitals with emotional mJuries and resentment against the medical profession? Are there ways we could improve the comfort and happiness of thc hospital childbirth experiencc, without sacrifices in safcty and cost? The purpose of the present stud.y is to obtain a measure of the gap that seems to lie between the ideal and what actually happens, in typical metropolitan hospitals, as seen through the patient's eyes. From it we hope to devise ways to improve the comfort and satisfaction of our obstetrical patients. Pleased obstetrical patients will improve hospital and medical public relations. Furthermore, as insurance companies have learned, people who are pleased with kindness and consideration shown them by medical aides, are reluctant to bring medicolegal claims against either doctors or hospitals.
From the Department of Obstetrics and Gynecology, Mercy Hospital, and the Section on Obstetrics and Gynecology, The Donald N. Sharp Memorial Hospital. Presented at the Twenty-seventh Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Yosemite National Park, Calif011lia, Sept. 28-0ct. 1, 1960.
1079
1080 Martin and Smith
Method and material
A questionnaire survey of hospital experiences was conducted among alI of our partnership private patients who were delivered during the past 5 years. AlI but 1 per cent were delivered in two San Diego hospitals, Mercy Hospital and Sharp Hospital, hereinafter calIed "Hospital A" and "Hospital 13." Mercy Hospital is a large private general hospital with an organized intern and residency program. The obstetrical service averages more than 5,000 deliveries each year. Sharp Hospital is relatively new, with a modern decor, and averages over 3,000 deliveries each year. Both hospitals arc often filled to more than capacity. Both have new obstetrical units in the process of planning or construction. The questionnaire was constructed so that each patient could grade her own care at each stage in the hospital experience: (1) entering the hospital; (2) labor and birth; (3) postpartum care; (4) receiving the bill. Ample space was provided for the candid comments that were requested. Patients were asked what they liked best, and what they most disliked about the way they were treated. FinalIy, they were asked for their own suggestions which could be used to improve hospital care. Of the 1,886 questionnaires lJIailed, two thirds, 01' 1,048 were returned. Sixty-two per cent were from former Mercy Hospital patients; 37 per cent were from former Sharp Memorial Hospital patients. Some patients had more than one maternity hospital experience during this time period. In evaluating the results, only the most recent experiences were considered. The questionnaires, as they were returned, were studied first by ourselves and then by the adlJlinistrator of each hospital. They were then subjected to statistical analysis and to psychological interpretation by Dr. Oscar Kaplan, Professor of Psychology, San Diego State College. Results
1. Entering the hospital. The first question and patient replies folIow:
Am.
"How were the hospital?"
YOll
June, 1961 & Cynce.
J. Obs!.
received as you entered Hospital A
Hospital B
74% 23% 3%
83% 16% 1%
Warmly "So-so" Coldly
Although very few patients stated they were received coldly, approximately 25 per cent felt their reception was not what it should have been. Remarks from the 25 per cent were studied and the great majority from each hospital who complained felt they were received in a routine, indifferent, businesslike manner. Remarks of many held praise, but room for improvement is apparent. Every patient should be received warmly. Typical verbatim remarks are now proving helpful in personnel retraining: 1. "Everyone was most efficient; however, a little more fri~ndliness would have been appreciated." 2. "They acted as if they were doing me a favor by signing me up." 3. "The nurses who received me were friendly and showed a genuine interest. This put me at ease." 2. Labor. Our next question was concerned with labor. With all that can happen in a busy labor room, it was here we expected the greatest number of complaints. Surprisingly, the reverse was true. Many patients seemed to feel that they received their best care and treatment from the nurseS during labor. "How were you treated by the nurseS during labor?" Hospital A Well treated 85% "So-so" 9% Poorly 3% Did not go into labor (cesarean, born on arrival, etc.) 3%
Hospital B
82% 12% 3% 3%
Derogatory remarks were studied and broken down, as follows: 1. Nurse described as unsympathetic, abrupt, rude, hostile, sarcastic
If ospital A
Hospital B
45%
29%
Volume 81 Number 6
Public relations
2. Patient neglected
3. 4.
5.
6.
during labor; nurses too busy for proper care Nurses indifferent, aloof, doing job routinely Nurse performed painful rectal examinations Nurses made errors in judgment, doctors not called soon enough No assurance given anxious patient
35%
36%
11%
18%
11%
9%
2%
7%
2%
7%
Hospital A
Hospital B
81% 14% 5%
90% 7% 3%
A great majority of patients felt that they had good treatment after the birth of the baby. Many made warm statements of praise. But abou t 20 per cent in one hospital and 10 per cent in the other felt that their treatment was not what it should have been. Complaints were hroken down as follows: I. Patient felt neglected; hospital understaffed, service slow
maternity wards
1081
2. Nurses unpleasant, rude,
Sample comments illustrate patients' experiences during labor and are useful in personnel training: 1. "As the nurse was getting me ready she was all business, but yet she took time to soothe me and tell me that everything would be all right." 2. "There was one nurse that was curt and short-tempered, but the rest were very nice." 3. "They yelled at me to he quiet because they could hear me in the hall. I hated them, and I'm sure they hated me." 4. "All the nurses were wonderful and helpful, explaining how and why they were doing things." 3. Postpartum care. The next question reported treatment after the birth of the baby. "How were you treated by the nurses after the birth?"
Well treated "So-so" Poorly
In
HOJpital A
Hospital B
56%
63%
sarcastic, reluctant to give service 32% 3. Nurses indifferent, treatment routine or assembly line 12%
31% 6%
Verbatim comments illustrate patients' experiences after the birth of the baby: 1. "They were obviously too busy to give more than perfunctory attention." 2. "Some of the nurses were very mce. Most of them were just ordinary and some seemed to resen t being there." 3. "No one ever told me the hospital rules. They just reprimanded me and others when we disobeyed them." -t. "There was one unfeeling, unsympathetic, disinterested nurse. The others were lovely. Why is there always one on every floor?" 4. The hospital hill. "What was your impression of the hospital bill and the way it was presented?"
Good Indiffercnt Bad
Hospital A
Hospital B
66% 26% 80/"
74% 21% 5%
There were a numher of complaints about the bill, even by those who checked "good" on their questionnaires. Most frequent complaints were as follows: 1. Hospital care too expensive ,) Patient fclt pressured to pay, using words like "bail," "hock" 3. Resented "extras" on bill +. Bill lllorC tha n estimated 5. Resented prepayment of bill
Hospital A
Hospital B
28%
33%
12%
27';{,
8'/',
13 '7r
10%
5 (i~'
7%
0%
Sample comments ilillstrate patient's impressions: 1. "The hill was far too high for maternity. I would like to see ambulatory patients get a break in the bill. I have read about this new system." 2. "The subject was brought up at the mothers' tea, so I was prepared for the bill."
1082 Martin and Smith
Am.
3. "I didn't feci overcharged because the food was good." 5. Additional impressions. A. "What did you like best about the hospital ?" Hospital A Food; its variety, attractive service Personnel; friendly, helpful Plcasan t, bright sursoundings Care; efficient and prompt Apprt'ciated husband in labor room
Hospital B
24% 34%
54% 34%
1% 12%
39%
6%
6%
15%
Many more or less isolated comments and compliments were received in answer to this question. Many of them referred to recent improvements in hospital equipment and hospital policy. Telephones next to the bcd, intercom system, daily shower, between meal snacks, and hospital cleanliness were appreciated. Verbatim comments illustrate what patients liked best about the hospital. 1. "I liked the immediate answering of the huzzer, the help with the bath, alcohol rubs, lovely treatment by all, and husbands allowed in the labor room." 2. "I liked the food! After nine months of dieting, the more and richer, the better." 3. "They let you sleep late, brought coffee before breakfast, served meals at decent hours, afternoon snacks, nice nurse, showers, choice of meals and drinks--I didn't want to go home." B. "What did you most dislike?" Hospital A Nothing disliked Disliked food Infant visiting policy Unpleasant personnel Patient neglected
28';'
12% J J '/r 9% 8%
Hospital B 34',1,;
0%
lorY, 8 '/r,
8%
There were many more individual comments and complaints given in answer to this question. A. large proportion appear to be hased on minor slip-ups in usual hospital routine and in personnel-patient relations. Sample comments to illustrate what paticnts most disliked about the hospital: I. "I didn't likc getting up at 5:30 A.r.L
June, 1961 & Gynec.
J. Obst.
and then waiting two and a half hours for breakfast to be served. I also didn't like being awakened for a sleeping pill." 2. "My baby wasn't brought to me until twenty-two and a half hours after birth." 3. "I disliked not being permitted to bottle-feed my baby. Because I wasn't nursing, I could see the baby only once a day. He was fed in the nursery." 4. "I disliked the routine. The hospital must run for the benefit of efficiency, and God help the poor patient caught in the jaws of a machine that starts at 5:00 A.M. to the clatter of wash basins, and steams inexorably through the day with 77 bus boys, charwomen, Nurses Aides, Gray Ladies, etc., ad nauseam, ad infinitum, running in and out." 5. "I most dislikcd thc fact that two womcn arc in cach labor room. Women who are unprcparcd to facc thc discomforts of labor frighten womcn who arc having their first child and lead them to helievc that they, too, will eventually get to the screaming stagc. It is hard for someone who is trying to control herself during labor to have constant scrcaming in thc same room with her." , C. "Havc you any suggestions that would improvc your hospital care ncxt time?" Patients contributed many suggestions that, while they almost go without saying, still arc hclpful in planning our new obstctrical units and in personnel training. Illustrativc verbatim comments: 1. "There should be a radio or TV in the labor room." 2. "Nurses in the labor room should have frequent rcsts, to prevcnt short temper due to fatiguc." 3. "Permit mothcrs to see infants as soon after delivery as possible." 4-. "Have a rooming-in arrangcment for the mother and child." 5, "Patients who have had long labors should be given food shortly after delivery, even if the kitchen is closed." 6. "Coffee should be served to fathers who are waiting." 7. "Night nurses should move around quietly."
Volume 81 Numbe .. 6
8. "Husbands should be permitted to visit freely and stay long periods of time." 9. "Have folding doors instead of curtains between beds." 10. "Mothers who have had no postpartum difficulties should have a hotel-like atmosphere; they are not ill, just resting." 11. "Hospitals should examine their routines and decide whether tradition or logic governs their operation." 12. "Hospital routine should be planned to permit more rest for the mother." Comment
It is apparent that most obstetrical patients today accept the safety of having a baby, of which we are justly proud, without any special credit to the medical profession which is responsible. Patients tend to judge the quality of their obstetrical care in terms of comfort and the amount of attention they receive from their doctors and from the hospital personnel. No patient reported that she lost her child due to inefficiency or neglect. The damage that was done seemed to be all psyChological. Actually, there were far fewer complaints and criticisms than we had expected, particularly since both hospitals have been operating at higher capacity than Was ever intended when they were designed. On the other hand, it is apparent that much can be done to improve each patient's chances of experiencing a really happy hospital childbirth. Some women were not received warmly when they entered the hospital. It is indeed a discouraging experience to be met with bored indifference on one of the most important days of one's life. One patient stated it very well when she wrote. "Babies may be born every day of the week, but not MY baby." A need for careful selection, additional training, and constant supervision of admitting personnel seems apparent in both hospitals. We were surprised to find that many patients considered their best treatment was during the course of labor. With all of the sUdden surprises that do occur during seem-
Public relations
In
maternity wards
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ingly normal labor, with difficulties in controlling pain in unprepared patients, we had expected to find the severest criticisms during this period of the hospital experience. However, there appears to be room for improvement of the patients' experiences during labor. No labor nurse shollld ever be described as sarcastic, hostile, scolding, or impatient. Repeated comments indicated that one nurse alone created difficulties, while all the rest of the nurses were helpful and pleasant. The postpartum period seemed to elicit the greatest number of criticisms, comments, and suggestions. Here again, one single member of the nursing or aide personnel f requently destroys all of the happy atmosphere and good relations built up by all of the rest of the personnel. From the "cold wash cloth at dawn," through the day, a thorough review of hospital procedures during the postpartum period seems indicated. Perhaps for nurses there should be more nursing- and less charting, and for patients there should be regular periods set aside for quiet rest. As Norman Miller has forcefully pointed out, postpartum patients usually do not get enough rest. Tired patients are irritable and sensitive. Tired nurses are irritable. Clashes must be guarded against. The qucstionnaire and the large pool of patient comments have proved helpful in many ways. The questionnaire itself seemed to serve as a step in good medical public relations, since it indicated to the patient her doctor's concern over her feelings and her welfare. A hospital staff committee on public relations has been formed at Mercy Hospital. A director of public relations has been added to the administrative staff. Material from the questionnaire is being used in special seminars for nurses. Critical remarks from the questionnaire serve as reminders, and appreciative comments serve as rewards, in teaching personnel the art of pleasing patients. The School of Nursing is finding helpful information in improving training of student nurses. The hospital administrators and department heads have
1084 Martin and Smith
found a great deal of helpful material which is being llsed in planning the decor and the operation of the new obstetrical wings now under construction. Each hospital benefited by studying comments from patients in the other hospital. In an atmosphere of extra-friendly employees, it becomes very difficult for the patient to be hostile or uncooperative. Quoting -from an insurance committee report to doctors, concerning malpractice insurance: "We have had innumerable reports where there appeared to be some justification for a possible claim against the doctor, in which the patient has mentioned to the company claims adjuster his desire to avoid any legal action 'because the doctor and the office personnel are so friendly and courteous to Inc,' "
Summary and conclusions
Our questionnairc survey rcportcd thc hospital childbirth experiences of more than
Alii.
Ju,lt', 1961 J. Obs!. & Gym'c,
1,000 private patients who were delivcred in two San Diego general hospitals during thc past 5 years. The great majority of patients seemed satisfied with their hospital carc in each of four stagcs of hospital expcricnce. No patient reported loss of her baby or physical injury because of neglect or poor care. Bitter criticisms of cruelty and ncglect, reported in popular magazines, wcre not confirmcd. A majority of complaints wcrc found to stem from poor personnel-paticnt relationships. At least half thc complaints can bc considered prevcntable. Personnel need training in the art of being warm and friendly toward patients. With such a training program, morc paticnts will achicvc our goal of a happy, as well as safe, childbirth experience. Happier mothcrs will rcsult in improvcd public relations for hospitals and for the medical profession as well.
Discussion DR. LEON Fox, Sail Jose, California. Gill' own survey in San Jose Hospital where we havc' averaged +,3(JO ckliVl'rics per year in tIl<' last 2 yC'ars in facilities desigl]('d for half this 11I11I1I)('r compares with the San Diq!;o experience. Both of thcs(' an'as haw (Towded faciliti('s which tend to I'!iminale tIlt' COl1llwtitive spirit between hospitals. To cope with these prohlc'ms wc' have ('vallIated our patients' complaints as \\"ell as our physicians' and nllrses' observations and have accomplished tIlt' following: I. A cOl1lmittc'c' of hospital p,'rsolllwl, admiIlistration and physician, known as the "Committee for tl](' IllIprovemeIlt of Paticnt Carl'" has been established and has I)('en givC'n authority to act. ~'fl~dical statf, administration, nursing, housekl'l'ping, and patients' probll'ms are evaluated and acted upon. 2. A tl'lephon('-dictating systcm has b('l'n instituted to rl'cord all complaints by anyone at any phone station in thl' hospital. These complaints go to the abo\'!' committt'!' for evalnation and action. :~. PrivatI' labor rooms arc a reality.
4. A pucrperal RC'covery Room is functioning '24 hours daily with gn'at satisfaction. S. DeliVl'ry rooms have been air-conditioned. (W!' should do tlIP same in our labor rooms.) G. Tntf'I'COIllS in labor, dl'livery, and postpartum areas ,'ave many steps and please patients. 7. The patient s('cs her baby with her husband imnwdiatf'ly aftc'r dl'livery, before going to the recovery room. 8. TV and com fort conveniences arc 111 the fathers' waiting room. 9. Tl'lephorIPs are in thl' patil'nts' rooms unless the physician ordl'rs otherwise. 10. Adequate showers arc available for ambulatory patif'nts. 11. Full al]('sthesi01ogy coverage is available 24 hours daily (M.D. ancsthesiologists and their own "mployt'd R.N. anesthetists). 12. There is an active auxiliary with "Pink Ladies" r('ceiving paticnts, accompanying patipnts to labor suitf's; providing coffee and tpa for fathl'rs and patil'nts; providing newspapf'rs, toilet articlt's, f1owl'rs, etc., for patients. 13. A continual training program is carril'd on
Volume 81 Number 6
for nursing personnel, auxiliary and house staff, on ncwcr mcthods, patient complaints, physician complaints, and other similar problems. 14. Medical Society cooperation is obtained in urging all nursing training programs in colleges, junior colleges, and hospitals to improve not only quantity but quality when possible. 15. Medical Society participation is obtained in urging hospital building programs at every opportunity. We now havc two new hospitals being complcted and one in thc planning stage. 16. Registcrcd nurses are being rcplaced with clerks, aides, and technicians in areas where nursing knowledge is being wasted on menial and clerical duties.
Public relations
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maternity wards
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We're still overcrowded, inadequatcly staffed, and in necd of modernization of many of our wards, but our Committ('c on the Improvement of Patient Care has a grasp of the situation and our patients are presenting fewer complaints. DR. MARTIN (Closing). Just as medical public relations depend basically 011 the total of all the day-by-day doctor-patient relationships, hospital public relations depend basically on personnelpatient relationships. Our study has revealed room for improvement. Patients do not expect to pay $30 a day to be berated by nurses. Perhaps a public relations course for nurses and other personnel should be included in the organization of every hospital.