Respect Among Hospital Employees is a Benefit for the Patient

Does your hospital have a problem with bad behavior among its employees to the extent that the staff is required to attend classes to learn proper conduct?

To her astonishment, during the year that Julie Salamon, a former New York Times and Wall Street Journal reporter, spent observing the goings-on in a large Brooklyn hospital, that is exactly what she found there.

Salamon has turned her experience as a fly-on-the-wall spectator into a book. Entitled Hospital, it is the subtitle that is the attention grabber: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God and Diversity on Steroids.

When the current president and CEO of the hospital Salamon observed took the leadership reins ten years ago, she instituted a Code of Mutual Respect in an effort to eliminate a longstanding atmosphere of "rudeness, incivility and bullying." Classes for doctors, nurses and other employees reinforce the tenets of courtesy, respect and basic good manners.

Salamon found among the provisions mentioned in the code are reminders not to use racial or ethnic slurs or profane or sexually explicit language. Employees are admonished to refrain from shouting, using foul language or throwing objects, prompting Salamon to incredulously wonder, "Slurs? Throwing things? Was this a hospital or a reform school?"

During my ten years of hospital nursing I witnessed several incidents of bad behavior, all by doctors. Shouting was the most common offense, often brought about by displeasure over the way a particular something was done. A procedure, perhaps, or the passing of a defective or wrong instrument.

A pediatrician, who was an attending in the hospital’s outpatient department where I worked, would on rare occasion arrive at the clinic in such a prickly mood that it was impossible to please him. He would shout and make insulting comments to the staff and to the patients’ parents. A couple of times he used his forearm to sweep all the instruments off the roll-about table in the treatment room and onto the floor. At other times he was at the opposite extreme, jovial, laughing raucously and extremely entertaining. Now, years later, I suspect his behavior was the result of a bi-polar condition, although I have no documentation that that was the case.

The hospital president mentioned above is of the opinion that disrespect by employees for one another is a roadblock to communication and that a breakdown in communication can result in harm to the patient. Her Code of Mutual Respect extends beyond doctors and nurses, to clerks and housekeeping—to everyone—so that lines of communication are kept open between one group to another: nurse to doctor, doctor to clerk, housekeeping to nurse and so on.

Does your hospital have a formal program for behavior training? How is it working? What do you like about it? If not, do you think such a program is needed at your facility?

Peace of Mind for Family is Priceless

In my last blog I addressed the issue of lengthy ER waits. Staff shortages, combined with increased patient use, have stretched the average ER visit to slightly more than four hours. Although it does nothing to shorten the wait, patients surveyed stated that regular updates from the ER staff would reduce the aggravation of long delays in being treated.

Today I witnessed a version of that sort of effective communication. I was in the waiting area of a clinic that provides a single, specialized procedure. Evidently, a patient was instructed to arrive at the facility earlier than her scheduled procedure because she needed to have blood drawn for lab tests. There were no delays at the lab, located elsewhere in the building, so she arrived at the clinic significantly ahead of schedule but was, nonetheless, escorted into the treatment area upon her arrival.

Standard information sheets are given to patients several days before the procedure takes place. Included in that information is what can be expected in terms of the overall length of time from arrival to dismissal.

Anyone who has worked in health care knows that such information is only an estimate. Variables such as unexpected difficulties with the procedure itself and the rapidity of the patient’s recovery from anesthesia can affect the time frame. It is a fact though, that a vast number of people who are not in the medical field, including several of my family members, consider such information to be set in stone.

I was impressed when a nurse came into the waiting area and spoke to a gentleman who had accompanied the above mentioned patient to the clinic. The nurse explained that, yes, the patient had been in the treatment area for awhile but, because she had arrived before her appointment, the procedure had not yet begun. "I don’t want you to worry that the procedure is taking longer than you expected," she said.

I know this example might seem trivial but it isn’t. A few years ago I underwent an outpatient procedure that needed to be performed at a hospital 50 miles from my home. My husband was told the approximate time that I would be able to go home. It seems he didn’t hear the word ‘approximate.’

I breezed through the procedure but there was a minor problem with my recovery from the anesthesia, which extended my stay by about 90 minutes. The problem was that no one told my husband. As the minutes ticked by, his imagination began to run wild and he became internally frantic (he would never outwardly show that he was frantic).

My husband would have been spared that emotional turmoil if only someone had taken a minute (or less) to inform him of what was happening in the inner sanctum of the OR, just as the nurse did today.

What are your thoughts? Does your employer have a system in place for communicating with family members?

Consistent Communication Increases ER Patients' Satisfaction

Anyone who has ever spent any time in the ER knows that emergency departments can be volatile places.

For one thing, it can’t be predicted how many patients will come through the door in a given day, but they most likely won’t arrive in an easily managed steady stream. For another, patients show up at the ER feeling anxious—they’re ill, injured and/or in pain. Nerves are frayed, tempers can flare and it seems no one is happy.

So, what would make ER patients feel better? Immediate treatment? No. Pain control? No. Although those two things are hovering near the top of the list, a recent survey of 1.5 million patients in over 1,600 ERs revealed that the most important factor in making the ER visit more tolerable for patients is that they be kept informed about how long they can expect to wait.

In 2007, the average emergency room visit was four hours and five minutes—which, I’m sure, feels like an eternity when the patient is in pain or simply feels too poorly to sit upright for that length of time.

Even though patient satisfaction decreased as the wait grew longer, the survey results showed that the ER staff’s consistent updates regarding delays gave the patients the sense they were cared about as a person and that they had not become invisible.

Here I go, climbing up on the Communication Bandwagon again. Communication is such a simple, common sense sort of thing that I find it puzzling that there are so many failures along that line.

I will draw the analogy of an ER to a restaurant. Recently a friend and I went to lunch at a new, moderately upscale place in town. It is small, perhaps only 12 tables and when we arrived only three tables were occupied. We were seated and the server, a woman in her fifties, entered the room carrying plates of food that she placed at one table. Then, she turned, walked right past us and left the room. She was gone for awhile, returned with more food for another table and left again to fetch a condiment from the kitchen that was requested by someone at that table. She had passed by our table four times without even acknowledging that we were there. Just a simple, "Be right with you," would’ve sufficed. We truly did feel invisible and it was annoying. We were just waiting for menus, not medical care, and the only pain we were feeling was due to mild hunger. Clearly, the annoyance we felt in a social setting would be greatly magnified in an ER waiting room.

It is easy to understand, then, that patients' agitation would be reduced by knowing that someone knows and cares that they are waiting (haven’t we all wondered, when waits drag on and we have no idea why, if our charts have been lost or misplaced?), that they have not become invisible and that there is a projected end to their wait. It doesn’t have to be a nurse, although that would be ideal, but someone needs to maintain communication with the patient. Communication solves or eases a plethora of problems.

Is your emergency department doing anything special to increase patient satisfaction? A fast-track system that separates patients with less serious injuries and illnesses from those who require more medical attention, perhaps? Please comment as to what is being done and how effectively it is working.

We are All Proud to Say We're Nurses---Aren't We?

I don’t know how to begin this; I don’t have a smooth segue into a story that lacks an earthshaking quality because it deals with a common emotion—embarrassment. But, it is somewhat intriguing—at least to me. I have a strong interest in people, their personalities, their jobs, what they do for fun and what motivates them to do what they do. The questions just pour out of me, to the point of bordering on interrogation. My friend says I’m curious, my husband says I’m nosy and my sister is puzzled as to why I would even want to know these things.

At my nursing school, our very first patient assignment was to simply chat at the bedside of a patient and learn as much as we could about that patient. We students and our instructor then congregated to share the information we’d gleaned from the patients. To restate the popular "boys with the most toys" phrase, "the nurse who asks the most questions wins." I always won. Things just kind of snowballed from there.

At an event at a Boulder, Colorado mountaineering shop last week, I ran into a friend who introduced me to a premier climber who writes magazine articles and books on climbing. So, the questions began (my friends call it playing The Glenna Game) and soon I learned that his fiancée is a RN. He introduced us via e-mail the next day and, yes, The Glenna Game ensued.

I learned she is a woman of the great outdoors, a climber and a wilderness EMT who has taught W-EMT to climbers, hikers and rafters. She is an ED nurse at a prestigious hospital for children and she told me she loves her job—really loves her job.

I learned through our e-mail conversations that she is currently mentoring a new nurse, a 29-year-old male who is also a climber. She asked why he hadn’t gone to nursing school as a traditional-aged college student and he admitted that it was because he was embarrassed to have to say he was studying nursing. He was working in the outdoor industry, and also as a wilderness EMT, teaching life-saving skills to backcountry warriors, mostly male. The stereotypical nurse image conflicted with his established macho image.

I don’t know how he managed to overcome his image issues and move forward with a nursing career but I’m glad he got past it—if he did. I say that because my new e-friend then dropped the bomb that she, too, has felt embarrassment when telling certain people, primarily the rugged climbing crowd she hangs with, that she is a nurse, particularly a neonatal ICU nurse, which she was in her first job.

She’d wanted to be a veterinarian but in her freshman year of college someone told her there was a glut of vets, jobs were scarce and if she wanted to have a job after college she’d be wiser to go to nursing school—so she did. She didn’t come with the built-in nurse gene. She didn’t want to be a traditional nurse and, to this day, the angel of mercy perception of nurses still chafes. Her nursing school graduating class even voted her "Most Likely to Change Careers." But, she has been at it for 13 years.

My impression is that her 13 years as a nurse have resolved her image issues but, as a
new graduate and for a few years beyond, she struggled when in the presence of certain company. AJN editor, Diana Mason, RN, PhD, FAAN was right when she said, "It does take something special to be a good nurse but it doesn’t have to be innate. With the proper desire, skills can be learned." Having pride in one’s profession also can be learned.

I’ve always been proud to be a nurse and feel that every nurse should be, but I won’t pass judgement on these two nurses. We all come with full sets of jam-packed baggage that shape our self-perceptions and how we want others to perceive us. Lots of factors are at work here, among them our country’s stereotypes of nurses, male and female. I think it just takes time to sort through our baggage in order to find our way to the place we need to be, to discover the person we are supposed to be and to become comfortable with that place and that person.

I also think every nurse has unique talents. Nurses aren’t made using the same cookie cutter, nor should they be. My e-friend’s favorite nursing experience was four months spent as a volunteer, assisting with surgeries in rural areas of Nepal. Not every nurse would or could do that, but it is wonderful that she did. I’ll even admit that I’m grateful that she, in effect, went in my place.

If you have had trouble coming to terms with being a nurse, I’d like to hear your story. Let’s hear your comments.

Communication is Key: Let's Give it More Effort

Communication is an art, a skill, an all-around tricky thing and vital to effective patient care. As nurses, we’ve all received some measure of training in how to communicate with patients and their families. I don’t know for sure, but I’ll assume that medical schools also devote at least a small portion of their curricula to arming doctors-to-be with effective communication techniques. Yet, failures abound.

A recent article in JAMA reported the results of a study that investigated whether or not doctors informed patients with terminal illnesses of their life expectancy. It was reported that, even when told, some patients either didn’t understand or chose to hear what they wanted to hear. So, the doctor knows that the patient doesn't understand or seems to be turning a deaf ear to the reality of his condition (the doctor did report these observations) and the doctor is going to leave it at that?

Receiving shocking news does have a way of turning off the senses initially, but I have my doubts that, for the long-term, there are many patients who are so much in denial that they entirely shut out information that is so important. I think what we have here (a la Cool Hand Luke) is a failure to communicate, and that the failure falls more onto the shoulders of health care workers than onto those of the patient.

A few years ago a friend was having a colonoscopy. Because of the anesthesia the procedure required, she asked me to be available to drive her home from the hospital. My friend, 41-years-old at the time, was six weeks post-op following a double mastectomy and just ready to resume her job as a teacher when abdominal pain prompted the scheduling of the diagnostic test.

Following the completion of the procedure I was waiting in a small office with my friend when her doctor appeared. After a few pleasantries he sat on a stool, rolled up to her knee-to-knee, took her hands in his, looked straight into her eyes and told her he had bad news. He had found a large tumor at the very top of her colon. At the moment those words left his mouth my friend visibly shut down. Her eyes actually glazed over into a fixed stare and it seemed she didn’t hear a single thing the doctor said to her after that. My observation was confirmed when, later in the afternoon, she couldn’t recall any part of her post-procedure conversation with the doctor.

It's possible that some of her memory failure was related to the anesthesia but I think the shock of the news was responsible for most of it. Either way, what would’ve happened if I hadn’t been a nurse and able to recount to my friend the doctor’s words? If the person sitting alongside the patient is a family member, the news would be as emotionally traumatic to that person as to the patient, so then what would we have? Not just one, but two people who aren’t hearing and absorbing what is said to them.

In every similar situation, it is incumbent upon the doctor or the nurse to make sure someone understands what is going on. It is always a good idea to ask the patient or the person accompanying the patient to repeat what has been said to them. We also need to put ourselves into the patient’s place and imagine ourselves with no knowledge of medical terminology. Medical terms roll so easily off our tongues but don’t translate so clearly into the ears of our patients. We need to remember that.

The friend I mention here (now seven years post-op and healthy) later had the opportunity to accompany a friend who was facing an emotional surgery to a pre-op doctor appointment. She asked questions of the doctor and made notes. Sure enough, her friend didn’t remember a lot of what the doctor said, so my friend recapped the conversation and handed over the notes for future reference.

My friend is involved in supporting other cancer survivors and says that it is common that patients don’t hear anything after, "You have cancer." I know time is always at a premium but taking just a little more time to clarify a patient’s situation would likely save even more time on down the road and would be an immediate comfort to the patient.

Although cancer figures significantly into my examples here, I hope it is evident that excellent communication carries over into all areas of patient care. Explain, explain, explain and never assume that you are the world champion of clarity. Ask your patient what he heard you say. You might be surprised to learn that there is a big gap between what you said and what the patient thought you said.

End of Life Patients Benefit from Knowing their Life Expectancy

You’ve just received news that hit you right between the eyes—hard! Your doctor has delivered a diagnosis with a potentially fatal outcome. Treatments might help or they might not. Do you want the doctor to lay the facts on the line or would you prefer to embark on the treatment pathway while being kept in the dark about your chance of survival?

Sure, we hear the occasional story of a patient who was given only a year to live—five years ago. We know doctors can be wrong and odds can be beaten, that fighting the good fight sometimes results in a miraculous victory. Is that reasoning enough to warrant withholding negative possibilities from the patient? Does telling the patient that a cure is a long shot throw him into a depression and diminish the chances of curative success?

To the contrary, studies show that patients who have been told, in the face of a dire diagnosis, what their life expectancy might be are no more emotionally depressed than are those from whom such information is withheld.

I am all for giving a patient hope but I am totally against giving a patient false hope. False hope can, for instance, lead a patient to begin a new and debilitating chemo regimen when it has become obvious that he cannot survive longer than a month. Rather than living my last month in a weakened state, ill from futile chemo treatments, I would prefer to spend it in more meaningful ways, peacefully with my family, sharing remembrances and saying my goodbyes.

A study reported in the Journal of the American Medical Association this week revealed that 37 percent of the doctors surveyed did not tell patients how long they have to live, even when the patient asked. Often doctors are uncomfortable with such conversations, sometimes families don’t want the patient told and other times, even when told, there is a lack of understanding on the part of the patient and the family.

My friend, Rita, is an oncology nurse who often receives letters of thanks from family members for the care she has given a loved one. One expressed gratitude for Rita’s having answered honestly when asked how much time the young mother of two little boys might have left. Rita’s answer, that the woman probably had two good weeks remaining before she began to slip away, was important because a birthday party for one of the little boys was scheduled beyond that ‘good two weeks’ window of time. The family moved up the birthday celebration and the mother was able to participate in it.

It might seem that placing a limit on life expectancy would rob the patient of hope, but, in Rita’s experience, that is not the case. Instead, the reality gives hope for a good death, by providing the opportunity for the patient to tie up loose ends, whatever they may be, before death occurs. There is a peace and serenity, Rita says, that comes from knowing one has not left unfinished business.

I’ll go on record as saying that I want to know. I am a procrastinator and need a deadline (no flippancy intended) to give me the impetus to reach goals, finish projects and say what I need to say. So, I want my doctors to give me their best guess.

What are your opinions?

Motivational Interviewing is an Effective Way to Connect with Patients

Because my job doesn’t involve direct patient contact, there are times when I come across what I believe to be a new bright idea for improving patient-nurse interaction that turns out to have been around awhile. Such is the case with a practice called Motivational Interviewing, a plan a nurse can use to forge a partnership with the patient who needs to make lifestyle changes in order to lessen risks to his health.

Using the Motivational Interviewing (MI) technique, the nurse takes on the non-confrontational roles of counselor, cheerleader and partner to, for and with the patient. Such strategies can encourage the patient to more closely follow guidelines that lead to optimum health. MI, which got its start in 1991 in the area of treating addiction, is significantly helpful in the self-management of chronic illness, when a longtime, perhaps even lifelong, commitment to change is required of the patient.

Simply knowing what we should do doesn’t always equate to our doing it. I know, because of my high cholesterol levels, that I should avoid animal fats in my diet. But, when Granny’s homemade yeast rolls are passed around the table, do I send the butter dish past without slicing off a pat? Not always. It takes an unusually dedicated person to always make the best and healthiest choice, and I suspect there are precious few of us who are that perfect. Those in the know point out that the ability to make changes is influenced more by motivation than by information, so that puts most of us in the position of needing something (i.e. quality of life) and/or someone (a motivational interviewer) to guide us along and encourage us.

The nurse in this situation must abandon a strictly instructional role and become a facilitator who can put frustration aside when the patient is lackadaisical about following the path to best health. The MI nurse’s role requires empathy when the patient is non-compliant, while continuing to promote healthy choices and to assist the patient in identifying not-always-obvious reasons for his resistance and devise solutions to break through the road blocks. It can seem like a never-ending task in some cases, I’m sure, but worthwhile for the patient and gratifying for the nurse when even small victories come about.

There is special training available for nurses who’re interested in this approach to patient education and health management. Information regarding the MI approach and training can be found at www.motivationalinterview.org/training/index.html.

Nurses Give Their Best to Those Injured in a Divisive War

I urge all of you to find a copy of the American Journal of Nursing (May 2008), turn to page 7 and read the editorial by the journal’s editor-in-chief, Diana Mason, RN, Ph.D., FAAN. There is a great deal of wisdom and thought-provoking information on that one page of print.

The editorial carries the innocuous title, "Anniversaries," yet its subject stirs strong emotion. The title refers to the 100th anniversary of the Navy Nurse Corps and the fifth anniversary of the war in Iraq. Mason deftly intertwines aspects of each to present a concise and subtly powerful piece about the far-reaching effects of the Iraq conflict on Iraqi citizens, the loss of American lives and the emotional toll on military nurses who care for injured American servicemen and women.

Mason, an Army Nurse Corps veteran, puts forth harsh statistics of the devastation the war has wrought on the Iraqi people—statistics we’d rather not hear. In March, Los Angeles Times reporter Marjorie Mills described the war as "a story that people want to go away." It is so much easier and painless to ignore the war and its ramifications than to deal with tragic truths.

Just this week the news services carried a dramatic photo of a group of bicycle racers being struck from behind by a car with a drunk driver at the wheel. The photo was a freeze-frame of many Lycra-clad bodies and bicycles impossibly high in mid-air, a crash that claimed one life and resulted in many injuries. I sent a link to the photo, along with my comment that I was outraged by the incident, to a number of people who, like my husband, are bicycle racers.

My outrage hit a nerve with one of my cyclist friends, who passionately let me know that my outrage was misdirected. He wondered why I wasn’t outraged by the war, why news services release images of significantly less consequential incidents when they should be exposing the dire repercussions of the war. That is a can of worms I probably shouldn’t and won’t try to sort out here. But, it certainly does seem that the longer the war goes on and the worse the news becomes, the more John Q. Public seeks the anesthesia of fluff news. As inane and irritating as the latest escapade of Paris Hilton might be, it is infinitely less wrenching than the reality of war.

In her editorial Mason honors the dedication of military and VA nurses to saving and restoring the lives of injured American service members. Theirs is a nursing job like no other. Seeing and treating injuries so horrific they defy imagination, bolstering families who know their lives have been forever altered, listening to shockingly dreadful stories of the war zone brought back by the injured soldiers—all of it puts the nurses at risk for secondary post-traumatic stress disorder. Yet, whether or not they support this war, they endure and persevere because they know their patients are entitled to the best care they can give.

In addition to the military men and women who have lost their lives in this controversial conflict, the returning injured and the nurses who care for them are my heroes. And, my thanks to Diana Mason for opening my eyes to a much bigger and more profound picture of the war than I had realized existed.