Insights from a Girl Who Knows Better
How Magnet, Press-Ganey and Obamacare are Taking the Nurse Out of Nursing
In 1983 the American Academy of Nursing Task Force on Nursing Practice conducted a study in hopes to attempt the identification of hospitals that were able to retain
their nurses while providing quality care to their patients. These hospitals were referred to as "Magnet" hospitals.
With nursing shortages continuing to be a growing concern, there was a definite need to help improve both patient satisfaction and staff retention. The program developed into a nationally recognized status for hospitals.
Whether a hospital meets those credentials depends on its capability of meeting five key components: Transformational Leadership; Structural Empowerment; Exemplary Professional Practice; New Knowledge, Innovations, & Improvements; and Empirical Outcomes.
It is a coveted recognition for hospital administrators across the nation. In America's hospitals, the very low percentage that actually meet Magnet standards (close to 7%) are considered to be upper crust and on paper they are, but what does it feel like to be a nurse employed by a Magnet hospital? When you add in Press-Ganey, the survey that random patients receive regarding whether or not they had a "very good" experience while in the hospital and the constant looming threat of Obamacare it all becomes pretty overwhelming. (Please keep in mind that Press-Ganey is the survey to be used by the government to determine a percentage of medicare/medicaid reimbursement that the hospital will receive)
Most nurses say they felt a "calling" into their field. They either had an experience that led them to nursing or have felt as though they wanted to help people from when they were a small child. There is absolutely nothing like the feeling
of saving a life, holding the hand of a patient who needs to feel loved, embracing a grieving human during a tragedy, holding a newborn as they take their first breath, the adrenaline rush of caring for a trauma victim knowing that seconds count, administering
TPA to a stroke victim and watching neurological deficits disappear... Each of these things are miracles in their own right. Those who chose nursing wanted to make a difference. It was a calling.
The problem is that not all nurses who heed to that calling are actually good at their job. Administrators are forced to create policy to govern the quality of care that we as nurses provide. Policies are merely tools for nurses, doctors and other staff members to help implement the notorious "right thing to do". We should all be completely on board with this, right?
Here is where it gets sticky: Gone are the years of entering a patient room, giving good care and trying to make a difference while applying knowledge and healing hands. The powers-that-be have dictated to us the methodology in which we must do this. We have been transformed into scripted robots who aren't allowed to step outside of our guidelines and tap into our humanity. "Hello, my name is Nurse A. I have been a very good nurse for 10 years at this very good Magnet hospital. My goal is to give you very good care. You shouldn't feel my necessary harried behavior and I cannot nor will not tell you that I have numbers and time frames to meet from the very beginning of your entry to the department. I cannot tell you that studies have been done regarding the amount of time you spend in this department and how they correlate with your satisfaction scores. What I must do is trick you into answering "very good" on the survey you receive in the mail."
The prudent nurse should round on each patient hourly, assess them, document vital signs, offer them a warm blanket, a smile and possibly a hand hold or hug when appropriate. During the in-between times they should be checking orders, administering medications, double-checking that the ordering physician hasn't made a mistake, triaging and assessing new patients, answering call lights for unforeseen necessities like going to the restroom, episodes of nausea or vomiting, anticipating patients that are "crashing", calling the lab to find out when results will be posted, transporting patients to radiology, working on getting patients admitted or discharged, and assisting the other nurses in their area. It's doable, right?
The answer is yes. It actually IS doable. Doable that
is until you tell THE REST OF THE STORY. In a Magnet hospital, nurses are expected to lead a committee, sit on a committee, implement projects not only to their department but also to other departments and hold a national certification which warrants an extra
80 hours of Continuing Education to be completed on their own time and often their own dollar. They receive 30 emails a day regarding changes that are being made or new responsibilities they must shoulder. They are held personally responsible for staff retention
and also the practice of their peers. (Side note- administration is ultimately responsible for the hiring of nurses who won't and don't stay but it is the STAFF who is HELD responsible for their retention) It is all a bit crazy.
So much emphasis is placed on retention that nurses are fast-tracked into leadership positions that they do not have the experience to handle. In the field of nursing, "baby nurses" are orienting "baby nurses" on how to be nurses just so the retention goals are met. Actually, having said that the reason babies are training babies is two-fold. Experienced nurses do not like the trend in nursing and do not want to be held responsible for the new graduates and the type of nurses they will grow to be, so they are not acting as preceptors. The newer nurses, less than 2 years of experience, are hungry for professional growth and the easiest place to start that growth is in the vacancies of the role of preceptors.
New nurses are being placed in the role of triage nurse or trauma nurse before they should be simply a because the department is trying to retain them and one of the easiest ways to do that is to make them feel important. It's all actually pretty dangerous. Bedside nursing is an art. It takes years to perfect it and even those that have perfected it have days in which they leave feeling inadequate. Gone are the days in which it was glory enough to work in a Level I Trauma Center. Now, every nurse feels the need to be on the top of the totem pole. This does nothing but create chaos and mayhem. The new generation of nurses is part of the generation where everyone, even the losers, received a trophy. The trophy in nursing isn't power. The trophy in nursing is the satisfaction of knowing you made a difference. If this isn't enough, maybe nursing isn't the field for you.
On another note, Lets face it. All of these committees are simply a mind trick to make nurses feel empowered. Administrators still make the decisions. Administrators still make the rules. Committees are a financial burden on hospitals who are drowning in debt. Nurses are an expensive necessity to hospitals. Their time on the clock should be utilized in productivity at the bedside not paying them to sit around a table at a bi-monthly bitch session in which very few problems are resolved. Hospitals could actually staff the departments better if they eliminated these committees because they could afford to do so.
Magnet Hospitals are only hiring nurses that have a Bachelor's Degree in nursing. These are generally nurses who want to become nurse practitioners or administrators of some sort. Why are all Registered Nurses not good enough in the eyes of administrators? Didn't they too pass the state-mandated tests to become a nurse?
Magnet has been twisted and turned until it is no longer a way to measure the best hospitals but instead has become an ugly virus of pointless responsibilities that are exhausting our nurses and reflecting on the care we actually provide for our patients. Sometimes the methodology of the past should be embraced. I would personally rather work in a hospital where the staff is actually happy regardless of whether it is reflected on paper or not.
Warning: This blog entry is intended for people with a sense of humor. If you do not have a sense of humor, please stop reading. By no means is this a reflection of the care that ER nurses give nor is it truly intended to act as a guide for patients regarding their illnesses. Only highly trained physicians are capable of diagnosing illnesses, both acute and chronic.
Our world is funny. Earlier as I sat at my triage desk watching patients trickle in and listening to their complaints, I realized the true impact of the "everyone gets a trophy" philosophy of our nation. So many people in this world have never had to solve their own problems and thus believe that it is someone else's job to do so. Now don't start cursing me yet. I am not talking about LEGITIMATE problems. I am not referring to unexpected illnesses or unmanageable chronic illnesses. Obviously if a person is doing their part by utilizing a sidewalk and the driver of a car loses control of their vehicle resulting in the pedestrian being struck down, the pedestrian doesn't really have any level of responsibility in the occurrence. What I am talking about is the person that almost refuses to do anything or solve anything for them self. Here are common occurrences that I face when I, the trauma junkie, am trapped in triage.
1. My blood pressure is high
One of the first questions that follow is whether or not you have an existing diagnosis of hypertension. If you don't, we will proceed without the voices in my head engaging in preparation for the rapid firing of silent insults that will begin pummeling you. If you do have an existing diagnosis of hypertension, the next question will be whether or not you have been taking your medication in the manner that the doctor has prescribed. If your answer to this question is no, you will be immediately discredited as a responsible human being and nothing you say matters to me from this point forward. Seriously, you might as well stop talking. I can already predict the path of your life and trust me, it isn't a pleasant path. You are technically suicidal. No? You don't think so? You, my friend are wrong. You ARE killing yourself. Slowly. Painfully. Deliberately. Eventually you will end up as a stroke victim, trapped inside your body and angry that you are in that situation. You will be rude to me and every person in this world that takes care of you when you come to the hospital. You will be so angry that your nurse couldn't get into the room to help you do simple tasks like pulling your blanket up higher or offering you a drink of water. Guess what? Not my fault. You did this. Nothing I did caused your current state. Another possible route for your life will be straight to the dialysis center. You, the patient that couldn't find the time to pop a pill once or twice a day will now be visiting a local dialysis center 3 times a week. You, the patient that isn't following doctor’s orders are obviously not caring about the end result: your kidneys will die. Did you get that? THEY WILL DIE. Not might die. Not could die. THEY WILL DIE. Again, this is your fault. Not mine. All yours. TAKE YOUR MEDICINE PEOPLE. I could go on and on with this but I will spare you.
2. I have a toothache
THIS IS AN EMERGENCY ROOM. WE DO NOT EMPLOY DENTISTS. CALL A DENTIST or better yet BRUSH YOUR TEETH. Please, in the name of GOD, please brush your teeth. Aside from the obvious breath equivalent to that which can be found in the mouths of the inmates at the local animal shelter, it's just pretty disgusting. Can't you feel those little sweaters of plaque that form on your teeth after you eat? NEWSFLASH- Toothpaste and a toothbrush will remove that. The simple task of brushing your teeth might actually raise your IQ and assist in your next job interview. It could also save you thousands of dollars in trips to the ER because of YOUR failure to brush your teeth. Seriously people. BRUSH YOUR TEETH. The only dental complaints that should ever present to your local emergency room are abscesses that could obstruct your airway or those that are causing fever (SIDENOTE- simply brushing your teeth can generally prevent these abscesses) OR trauma that has caused damage to your teeth. For example, if you are at a baseball game and you take a line-drive to the mouth resulting in broken teeth feel free to present to your local ER. The staff welcomes actual EMERGENCIES.
3. I have vaginal/penile discharge
You are an idiot. Don't sleep around and if you do you should visit the local health department for screenings at least 2 times a year. Snot coming out of your private IS NOT AN EMERGENCY. You are an idiot and I refuse to talk about this anymore.
4. I need a pregnancy test
Good for you. Hike on down to your local dollar store and buy one. We use the EXACT testing kit that you can buy for $1 at the DOLLAR store but we will charge you about $500. Good for the hospital. Bad for you. We don't fill out Medicaid paperwork so you will get your pregnancy test but you will be paying for another one at your local OBGYN office. You are also an idiot. (It now occurs to me that you probably won't actually be paying your bill. That will be left to the poor tax payers but that is a whole 'nother blog and I refuse to discuss it here.)
5. My blood sugar is high
This can actually be a legitimate complaint. These are the questions that your triage nurse will ask you. Have you been taking your insulin? If your answer is no you should be aware that much like non-compliance with the diagnosis of high blood pressure, non-compliance with diabetes is not my fault. Want to regulate your blood sugar? Follow the doctor's orders. (Brace yourself; this might hurt a little ) Part of what you can do is LOSE WEIGHT and EXERCISE. I know you don't want to hear it but it is a cold, hard truth. 90% of Type II Diabetes is caused by obesity. That being said, in the event that you are vomiting or have a legitimate infection, your blood sugar and doses could actually be out of whack and qualify as an actual EMERGENCY. If this is the case, the ER staff won't necessarily roll their eyes at you when you aren't looking.
6. I have a headache
Do you have a history of headaches? If not, proceed. Have you taken medication for your headache and it hasn't helped? If so, proceed. Is this the worst headache of your life and different than your usual headaches? If so, proceed. HOWEVER, if the answer to the above questions is the opposite of those I have provided, GET THE HELL OUT OF THE EMERGENCY ROOM. I also think it is simply adorable that most of our frequent flyers riddled with headaches are smokers. NEWSFLASH- Smoking causes headaches. Want to stop having frequent headaches? Drink plenty of water and stop putting poison into your body. YOU ARE CAUSING YOUR HEADACHES. I AM NOT CAUSING YOUR HEADACHES. Be prepared to sit in the waiting room because actual EMERGENCIES will be taken to a room before you. There is no need to holler and cry hysterically. I realize you are in pain. I also realize that you are more than likely unwilling to hold yourself accountable for the cause of your pain.
7. I am having a Sickle Cell Crisis
My first question to you is why? Are you drinking enough water? Did you stop smoking? Are you getting plenty of rest? Are you making healthy choices with your diet? If you answer NO to ANY of these questions, I need you to understand that IT IS YOUR FAULT THAT YOU ARE IN CRISIS. You are in pain because your blood isn't carrying enough oxygen to the tissues in your body. Do you know what a lack of oxygen does to the tissues in your body? IT CAUSES THE TISSUES TO DIE. THIS IS PAINFUL. Proper diet, hydration and just taking the time to practice good, healthy, behaviors will not only save you time, pain, and money but will also extend your life by years. Sickle Cell patients don't have long life expectancies. Rarely do we see Sickle Cell patients that live past their forties. I believe this could change if people would acknowledge their disease process, do the right thing and HOLD THEMSELVES ACCOUNTABLE.
8. My back hurts
Does it affect only one side of your lower back? If so, it might be a kidney stone which is a legitimate ER visit. Did you injure it in the last 24 hours? Please, come in. You might need to see a doctor. However, if your back injury happened more than a year ago and you already have a pain management doctor GO SEE THEM. Honestly, it is ridiculous for you to come to the ER. The strongest medication we will prescribe in the ER is Ultram. Deal with it. I wish we would send everyone out with Lidoderm patches and stop feeding candy to chronic pain patients. Have you ever dropped a Cheeto at the beach? Every seagull within a mile can smell that thing and will be headed your way within seconds. Lortab prescriptions are the ER equivalent to Cheetos at the beach. Chronic pain patients can smell it before the ink is dry and will present wanting one of their very own.
9. My fibromyalgia is acting up
I literally have no words and am moving on.
10. (Anything) that happened yesterday
Chances are that if it happened yesterday and you are just now presenting to the ER this is NOT AN EMERGENCY. Period. Find an urgent care or a primary doctor to listen to your story. I am so sorry that someone, somewhere, conveyed to you that you might be able to get some HUGE settlement from Wal-Mart because you failed to notice the bright red ketchup spilled on the white tile floor. NEWSFLASH: It isn't Wal-Mart’s fault that you have the observation skills of a newborn kitten. It is YOUR FAULT that you failed to use common sense. Seriously.
11. Can you get my prescriptions filled? I don't have any money
NO. NO. NO. NO. NO. NO. NO. NO. NO. You smell like smoke and told me to "Hold On" while you answered your iPhone 6. Let me repeat- NO. NO. NO. NO. NO. NO. NO. NO. NO. NO. It is not appropriate for you to save your last $30 for your manicure or your beer or your cigarettes. You can afford a prescription. MAKE IT WORK. Everyone else has to take care of themselves; I think you can also manage.
12. Can you call me a cab?
No. This is not the Ritz. Call your own damn cab or call one of your friends that you just HAD to talk to during your triage assessment. No. I won't give you a bus pass. How did you get to the ER? How do you get to the mall or the grocery store? No. No. No. FIGURE IT OUT. YOU ARE NOT MY PROBLEM. IT IS NOT MY FAULT THAT YOU CAN'T FIND A RIDE. Period. Also, it is crucial that you understand that I am not a waitress. It is against hospital policy for me to accept tips. Now I don't mind getting you the things that would make your stay better; For example, warm blankets or the occasional cup of ice water. However, if I don't do this in a timely manner it is absolutely not because I am punishing you. I AM BUSY. I AM SAVING LIVES AND STAMPING OUT DISEASE. Again, I am not a waitress.
13. I have a rash
Seriously? Unless the rash is inside of your mouth and trachea, I DO NOT CARE. THIS IS NOT AN EMERGENCY. Find an urgent care clinic or go to your primary doctor. Have you visited your local pharmacy? Tried Benadryl or Cortisone cream? A small part of me dies every time someone checks in for a rash. Literally DIES.
So it all boils down to this: Use your brain. Follow doctor's orders. Take care of yourself. Save your emergency room visits for EMERGENCIES. Please. I absolutely LOVE my job. I love being an ER nurse although I am sure you have questioned it a few times while reading this post. I love EMERGENCIES. E.M.E.R.G.E.N.C.I.E.S. Emergencies. Do me and every other ER nurse and patient with an EMERGENCY a favor: Stay out of the ER if you don't have an emergency because no matter how many times you present with one of the above complaints we will take care of you and we will do so with a smile on our face and pretend to respect you while you are in our department. The problem is that more than likely, while we are doing all of that pretending, there is a patient with a real emergency that is waiting for the bed you are occupying. Think of it as your own personal contribution to the health and well-being of the world. Who knows? Maybe if everyone adhered to this train of thought and methodology things would improve. Maybe the next time you present to the ER with an actual emergency you won't have to wait for the doctor to start the crucial steps needed to save your very own life.