The Nurses: A Year of Secrets, Drama, and Miracles with the Heroes of the Hospital (46 page)

She was going to be a mom. This changed everything.

The agency sent Molly to a new hospital that bordered the city and the suburbs. Worldview was known for what healthcare workers colloquially called “concierge medicine”: The hospital took care of people with money and high expectations for customer service. Molly arrived early to take five written tests on medication administration, safe transfer/lifting, EKG interpretation, fire safety, and patient privacy. She scored 100 percent on all of them. Afterward, the staffing office representative walked Molly to the ER and introduced her to the charge nurse. Molly was impressed; at other hospitals, busy staff had pointed her in the general direction of the ER and left her to navigate her way alone. The charge nurse gave Molly a tour of the department and assigned her to a zone.

The Worldview staff was amicable, the ER manager was ever-present and interactive, and all of the doctors introduced themselves by first name. Molly couldn’t believe the contrast between Worldview and her other hospitals. The staff was happy because they were not overworked. She had only three patients at a time because two float nurses and several techs picked up some of the workload. Because the ER was relatively slow, Molly had enough time to spend with each of her patients, which made her feel like a good nurse.

Not long into Molly’s shift, the charge nurse, who had been watching her, said, “You have your act together. What are your scheduling preferences? When we have needs, I’ll call you first.”

In the middle of Molly’s shift, the computer system went down for several hours. Doctors could input orders, but other departments couldn’t view them. The radiology department didn’t know when the ER wanted to send in patients for exams, the lab wasn’t notified when nurses ordered tests, and the Pyxis didn’t have access to patients’ names for nurses to pull out drugs.

At every other hospital where Molly had worked, this shutdown would have been catastrophic. But no one at Worldview batted an eye. The nurses pulled out paperwork and charted manually.

At the end of Molly’s shift, the charge nurse wrote her a spectacular review for the agency’s required first-shift evaluation. She marked “exceeded expectations” for each of the dozens of skills listed, and added a note about Molly’s quick learning curve and willingness to take on anything. She also wrote that the nursing staffing office should make sure that Molly returned.

Was Worldview the hospital Molly had been looking for? Over the next few weeks, she took several shifts there. She learned that Worldview doctors and nurses were kind to each other and there was no nurse bullying. Patient flow was quick, with low wait times and not much volume. Techs did their jobs without being asked, and other departments pitched in; radiology picked up their own patients, for example, rather than waiting for nurses to bring them. The charge nurse told Molly that she was her favorite agency nurse because she was independent and didn’t complain.

But there were downsides to Worldview. The hospital didn’t see trauma or cardiac patients, so the ER transferred the sickest patients elsewhere. And, as at Academy, the work was so slow that the job, for Molly, was boring.

Molly had come to realize that there was no Holy Grail of ERs. “I liked some of the patients at South General because they actually listened and saw the nurse as a person to learn from. I like Academy because some of the staff is really nice. I actually do like Citycenter because of the ridiculousness that happens there. I like Worldview because it’s a welcome break from super-hard work,” she said. She decided to continue as an agency nurse so that she could work at the variety of hospitals on her own terms.

It had been a full year since she quit Pines Memorial. She was not wrong to leave. In an arena that mattered greatly to Molly—“being held accountable and doing your job well because it’s the right thing to do”—Pines was the worst of the bunch. At the same time, because of the high numbers of septic nursing home patients and highway-speed car accident victims, Pines treated some of the sickest patients in the area, which Molly valued because of the intellectual challenge. And Molly appreciated Pines’ experienced nursing staff because she learned something new every week. “That hasn’t existed at any other hospital,” she said. “If they could stick Academy management into the Pines ER, that might be the ideal place to work.”

But maybe the trappings didn’t matter so much. Molly hadn’t become a nurse because she wanted an ideal place to work. Ultimately, the tensions among nurses, disrespect from doctors, and bureaucratic inconsistencies weren’t what mattered. Ultimately, what mattered was helping people. That was what her mom had loved about nursing. That was the priority Molly wanted to pass on to her own child. Maybe it was time to let everything else go.

One night, Molly took a shift at Avenue Hospital. At 11:00 p.m., an elderly couple came in. The man, who was on hospice care because he was dying of cancer, was having trouble breathing. Typically, hospice patients didn’t come to the hospital, but sometimes families panicked and brought them in. Because Avenue had no beds available on the medical floor, the man boarded in the ER.

All night, the man drifted in and out of consciousness. His wife of sixty-eight years never left his side. At dawn, when Molly’s shift ended, the patient received a medical floor bed assignment. “I’ll come get him and take him up,” the oncoming nurse said over the phone.

“No, I’ll bring him,” Molly said. “I’ve been with them all night.”

As the elevator doors opened on the seventh floor, Molly saw the sun just beginning to glow through a tall window at the end of the hallway. She knew it would be the patient’s last sunrise. She turned to him. “Would you like me to take your bed to the end of the hall so that you can watch the sunrise together?” she asked.

The man nodded feebly. His wife whispered, “Yes.”

Molly wheeled the bed past the man’s assigned room and parked it at the end of the hall. On the bed, the couple held each other for the last time. As the sunrise unraveled warm pastels across the sky, Molly stood silently behind the head of the stretcher.

“Oh, John, isn’t it gorgeous?” the woman said to her husband.

He smiled weakly. “It sure is,” he whispered. He closed his eyes and passed away peacefully in his wife’s embrace, his needs met, his end loving.

That was why Molly had become a nurse.

“Nurses can work individually as citizens or collectively through political action to bring about social change.”

—
Code of Ethics for Nurses
, Provision 9.4

“Our clinical skills are essential in carrying out high-level nursing care, yet the complete package that defines nursing is one human being reaching out to support another.”

—a family nurse practitioner in Michigan

A solution to many of the issues in this book, and one that would go a long way toward fixing American healthcare, is relatively clear: Treasure nurses. Hire more. Nurses are perennially the number-one most trusted profession in America, according to an annual Gallup poll rating honesty and ethical standards. They are called to an exhausting commitment in which mortals must sustain an unwavering grace at the edge of life and death, almost divinely slowing heartbeats, hurrying them along, or pounding them back into existence. Nurses are exceptional. So why aren’t they treated accordingly?

As new healthcare laws funnel more patients into the system and 6 million baby boomers are reaching the age of greatest healthcare need, nurses are absolutely vital to the health of the country. Every year through the end of this century, 2 to 3 million people will age into Medicare, which increases demand for services.

While hospital finances are tight, the margins are still positive in most institutions, said ANA senior policy fellow Peter McMenamin, a healthcare economist. “Hospital finance people are skittish particularly when it comes to uncertainty, and the monster under the bed is what’s happening with Medicare,” he said. Hospital administrators fear further Affordable Care Act cuts in payments to hospitals, which could explain why hospital industry employment numbers that were increasing in 2012 and 2013 were virtually flat in 2014. But over the next several years, hundreds of thousands of RNs and APRNs are expected to retire. “A hospital that now may be seeing two to three longtime staff members retiring [per] year, eventually could be holding retirement parties once a month,” McMenamin said. “Hospitals should be looking at the longer run. If they wait five years to get back into the job market, they’re going to be competing with all the other hospitals that waited five years and they’ll be competing for the same cohort of experienced nurses. If they start hiring new nurses today, they could be developing their own experienced workforce. It’s a sound long-term strategy.”

It’s also a way to quickly improve patient care. Researchers have proven that patient-to-nurse ratios directly affect patient mortality; medical errors and adverse events; patients’ length of stay; risk of heart attack, hospital acquired pneumonia, or infections; failure-to-rescue rates; patient falls; readmissions; nurse retention; and patient satisfaction. Lightening patient loads reduces nurse stress, burnout, bullying, and exhaustion.

The bottom line is that hospitals could save money, patients, and nurses by investing in staffing. Policymakers could help by providing grants, fellowships, and other subsidies for additional nurse hires.

Before hospitals implemented the checklist mentioned in
Chapter 5
, medical professionals couldn’t imagine reminding physicians to wash their hands. When infection rates dropped to zero, the checklist ably demonstrated that small changes can have big payoffs. Here are additional tips to help people receive—and staff provide—better healthcare.

Directly involving nurses in decision-making processes is a good strategy for developing efficient policies, making nurses feel like valued workplace contributors, decreasing occupational burnout, and increasing morale. As frontline healthcare providers, nurses have important insights and day-to-day perspectives that can inform everything from patient-care procedures to workplace policies. Currently, many workplaces do not include nurses in these strategic meetings.

Inter-office politics affects patient care, as evidenced by Dr. Bitch’s and other doctor bullies’ power plays over nurses. One strategy to curb bullying is to establish a contact person or inter-staff committee to whom nurses can report disruptive behavior without risking retaliation, according to the
Online Journal of Issues in Nursing
. This point-person could also handle reports of assaults by patients and visitors as well as concerns about physician mistakes. Nurses will be far more effective at checking doctors and caring for patients if they are expected to speak up. They must feel empowered to protect their patients. Hospitals can develop protocols for nurses to report urgent concerns to an administrator who can and will intervene. As the Institute for Safe Medication Practices suggests, workplaces should have a no-retribution policy for employees who report worrisome or disrespectful behavior.

It’s unrealistic to expect even seasoned nurses to recover immediately from handling trauma victims or unexpected patient deaths or complications. A range of resources could help nurses cope with tragedies and/or manage burnout, second-victim syndrome, and other longer-term work-related emotional issues. Accessible on-site counseling would be ideal. Debriefing sessions can help to find lessons, meaning, or closure after certain patient cases.

Some hospitals have trained colleagues across departments to provide support, comfort, resources, and counseling referrals to any staff member dealing with a difficult situation; a liaison is on call at all times. At the least, hospitals could provide a quiet room in which nurses can relax and compose themselves. Ohio nurse practitioner Barbara Lombardo has suggested soothingly colored walls, comfortable chairs, and relaxing music to relieve stress. Advocate Lutheran General Hospital in Illinois gave nurses a small budget to furnish a retreat in a break room; the nurses purchased a massage chair and some puzzles, if only to refocus coworkers’ thoughts with a brief distraction.

Compassion fatigue, stress, burnout, and other mental health issues not only wear nurses down but also drive them out of the field. Administrators’ efforts to prevent these issues could demonstrate care for their employees and save money in absenteeism and job attrition.

In many workplaces, nurses are called by their first names, while doctors are not. Requiring doctors, nurses, administrators, and other staff members to call each other by their first names is a no-cost strategy to reduce the appearance of hierarchies among the professions. One of the reasons Pines Memorial nurses liked working with Dr. Preston was because they could call him Clark, which blurred the doctor–nurse tiers. “Using a colleague’s first name can help break down artificial barriers that may impede effective communication,” the ISMP recommends. This simple way to help equalize the playing field could help to decrease disrespectful and disruptive behaviors and lessen the “us versus them” attitude.

Getting assaulted by patients and visitors should not be tolerated as “part of the job.” Hospitals have had success by assigning uniformed security personnel to make frequent rounds in patient care areas. The Joint Commission recommends wand-screening visitors for weapons or conducting bag checks. Some hospitals also might consider installing metal detectors. Within six months after Detroit’s Henry Ford Hospital began using metal detectors, staff had confiscated thirty-three handguns, ninety-seven chemical sprays, and more than 1,300 knives.