Three weeks ago, I changed jobs. I left a high-tech, high-volume teaching hospital in one of the largest medical centers in the U.S. for the greener pastures of a small, private community hospital. Why? I needed a less stressful position, lower acuity patients and to be rid of the madness of commuting.
I am a registered nurse with experience in emergency and trauma nursing, critical care, electrophysiology and cardiovascular surgery. I was offered the position after a 2-hour conversation with the director of critical care. We had a meeting of the minds and were in agreement about many topics related to patient care, integrity in our profession and clinical advancement. We discussed the hospitals nascent cardiovascular surgery program, the current climate of the unit and accountability.
I’ve had a few weeks to settle into my new position. Some important pieces of this narrative to note are: I am working in a hospital with less than 100 beds that is privately owned by a group of physicians. The unit where I work is growing a cardiovascular surgery program, so we are caring for patients that are not overly complicated. The intentional selection of these patients increases the odds of excellent outcomes. Good outcomes without complications are harbingers of success; they ensure reimbursement and generate referrals.
Two days ago, I was speaking with my director and the CEO walked over. His icebreaker was a comment about my tiny nose stud.
“Hey, you’ve got something on your nose!”
Needless to say, as I sat there in my regulation scrubs embroidered with the company logo, my nails trimmed and unpolished, my small stud earrings and my neatly styled hair, I was dumbstruck that this was the one thing he had to say to me. I didn’t even know how to respond, so I said nothing. He did not ask how my new position was working out or if I had questions or concerns. I wish he had: There were nurses on the unit who had three patients (The AACN staffing ratios for critical care are 2:1.)
The next day my assignment included a critical patient that required 1:1 nursing care (for at least a few hours) and the two patients I had the day before. Not a big deal right? The other two patients were stable. One was going to the OR for a procedure, and the other was told conflicting information about his plan of care from various providers. The first patient’s spouse was the type of person who required a particular level of attention. The second patient was a linear person who had a genuine need to know what the exact plan was. The third patient was critically ill, required time sensitive lab draws, interventions, medications, and nursing care.
So, here is the crux of my sordid tale. The nurse that night had done less than the bare minimum. The required labs were done, and medications were given per protocol, but critical labs that should have been initiated and completed were not.
Oral care was not done. This is important for many reasons. One of which is avoiding ventilator-acquired pneumonia. Another reason? The patient’s front tooth was fractured during intubation, and her mouth was full of dried blood. She did not have a gastric tube and was in danger of vomiting which can lead to aspiration pneumonia.
I don’t believe this patient was ever repositioned. She was found “down” at home and had an area on her buttocks that pale and cool. The previous nurse did not place a barrier on it for protection or reposition the patient off this part of her body to prevent further damage.
The patient was in restraints without an order; there was no sedation or pain medication ordered. The nurse did not notice that urine and sputum cultures we not ordered and had administered antibiotics. The patient had multiple infusions going through unlabeled lines that were in a state of disarray.
I want to blame this nurse, but I cannot. She had three patients, and this patient was critically ill. Also, I am sure that she had another admission and possibly moved another patient out. She was stretched too thin.
The bottom line? I assumed that working in a small, private hospital would allow me to practice the art and science of nursing to the standard that patients require. The reality is that the epidemic of poor staffing and doing more with less exists in the private sector as well. This problem has an impact on everyone in health care.
I was reading Better by Atul Gawande MD this evening. He talks about the frustration of having his hands tied, and the difficulty in executing his vision of high-caliber patient care. He addresses staffing shortages as a looming obstacle in a particular surgical case. My takeaway is this: Physicians experience the same frustration as nurses. They want to leave at the end of the day knowing that they didn’t just “fix” a problem but that they made a connection with and had an impact on another person’s life.
That’s all we want: To feel good about what we’ve done, that we did our best, that our patients and families felt our authentic presence and concern.
Our patients and their families recognize this. They feel it. If I am not overburdened my demeanor is more relaxed; I have time to answer questions, to be present, to understand both my patient and their family, to notice subtle changes in my patients’ condition, to intervene.
The truth is patients have a choice in their care facility, and nurses are with them 24/7, better patient outcomes with fewer complications are connected to excellence in nursing care, overworked and understaffed nurses cannot cross all the Ts and dot all the Is. Lack of attention leads to hospital acquired infections, bedsores, and medication errors. This seems pretty straightforward to me
Or, to put in their language, mistakes cost the hospital money. Hospital-acquired infections mean no Medicaid reimbursement and lawsuits evolve from something avoidable like a bedsore. Are nurses really that expensive that we can’t have enough of us on the same unit at the same time? I don’t think so.
It’s a win, win situation. If patients and families are very satisfied, they refer. If a work in an environment is one where professional integrity is valued, nurses won’t leave and the cost of orienting nurses to replace those who leave diminishes. Less fall out on hospital-acquired infections means more reliable reimbursement — ergo more money for the hospital.
I know that the physicians who invested in the hospital take this seriously. I saw one of them today with the wife of one of my patients, just being and talking, problem-solving and connecting. This tells me that he values patient/provider relationships. By extension, I could postulate that he values nurse/patient relationships. Take that a step further; I would say that he values nurses.
So, while the CEO focuses on my nose piercing (which no one else has ever commented on), the nurses are stressed, and the patients are receiving substandard care. Furthermore, the hospital is burning capital due to employee turnover and paying a premium for contract nurses to fill staffing holes.
I am not sure what my next steps will be. What l I know is this: Patients are someone’s person, and they deserve the best care possible. Nurses require a minimum amount of kudos and support to feel appreciated, and the feeling of being valued and supported is transmitted to their patients. Patients are revenue, and revenue keeps hospitals viable.
It seems pretty simple to me. But what do I know; I’m just a nurse.
The author is an anonymous nurse.
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