About a year ago, after Eric Duncan died at Texas Health Presbyterian Hospital in Dallas and two nurses who cared for him were hospitalized with the same disease that killed him (Ebola), Texas Health Resources got an independent committee to review what went wrong. It was like a root cause analysis, but more so: these were outside doctors and one nurse, they weren't paid, and they were given access to everything that was charted and all the folks involved in the Presby debacle.
They came to a number of conclusions: first, that education was lacking--the staff wasn't aware of what exactly to do in case of a person with Ebola coming in; second, that communication was poor--the nurse who took Mr. Duncan's health history didn't communicate verbally to the doc that he'd come from an Ebola-affected area; and third, that the fear of poor patient satisfaction scores led the doctors and nurses to rush Mr. Duncan through the ED that first time, in order to keep other patients from waiting and getting mad.
The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.
Read that again. The fear of poor patient satisfaction scores caused the staff and doctors to rush the diagnosis of a man who had been in an Ebola-affected country.
I don't know what it's like in Dallas, but here in Bigton, every medium-sized hospital and most of the smaller ones have billboards touting how fast a person can be seen in their various EDs. Some of them even have big neon numbers that show the current wait times outside the hospital itself. A few even have those big neon numbers on billboards on the highways.
The entire focus of emergency-room care has become, at least in this area, about how fast you can be seen for belly pain. Or a broken arm. Or allergies. Yes, they advertise ED services for seasonal allergies. And it's all about the time it'll take for you to be seen. Come in with a head injury following a fall or a sore back that's been going on for a month? Doesn't matter--our goal is to have you back in a room in ten minutes or less and have you out the door in half an hour.
At the beginning of flu season here in Texas, that emphasis on speed, which is translated to patient satisfaction by administrators, contributed to already-stressed doctors and nurses missing a diagnosis that turned out to be fatal.
(There's a lot to be said on the communication front as well--why was the flag in the chart that the nurse filled out not enough to alert the doc? Was he, perhaps, rushed? Why the emphasis on verbally informing him of something, when the nurse might not actually see the doc face-to-face all shift because they're both busy? That'll have to wait, though.)
Let's take this down a notch. At Sunnydale General and Holy Kamole, there's a big push on to satisfy patients in every way possible. Press-Ganey cards are sent to each and every in- or out-patient within a week of their leaving the hospital or clinic, and the results are taken very seriously.
I work in a critical care unit. It's likely that the patients that I see will go on to spend a few weeks either on a floor or in rehab or both, and may or may not remember their time with me. Brain injuries tend to wipe out short-term memory. Even if they do remember the NCCU, they probably won't remember me by name. All this leads to a very minor chance that they'll be able to fill out a card that mentions me specifically.
Yet if I'm not mentioned by name by at least one patient in a year, preferably by two or three, I won't get a point on my employee review. It doesn't matter how many students or new nurses I precept, how many errors I catch, or how often my patients have good outcomes. What matters is that somebody who's stressed or ill, possibly without family support, remembers my name (perhaps weeks or months after seeing me for a day or two) and takes the time to mail back a postcard with my name on it. Missing that point can make the difference between a raise and no raise, or between a satisfactory or unsatisfactory review. It's weighted that heavily.
We no longer track how often certain nurses' patients get bedsores or UTIs or end up going back to the CCU. What we track now is how often they're praised by patients or family members.
As a result, I find myself doing all kinds of crazy shit to get people to remember me. We're not allowed to hand out the Press-Ganey cards or special-mention cards ourselves, so it's up to us to do everything possible to make ourselves stand out. Most of the time, for me, it's staying at the bedside a little longer to explain what's going on with the care plan, or the physiology of the disease we're dealing with, or why the patient is on a ventilator or has this or that tube.
Sometimes I have to sweeten family members or patients who are determined to be upset. I act as counsellor, waitress, and gofer. A lot of times, those patients or families take me away from jobs I ought to be doing just so I don't end up with a complaint--I didn't get them a cup of coffee, or something. If I have a patient I'm worried about because her neuro status is changing, I have to weigh the consequences of letting her go for another ten minutes versus the consequences of being seen as not "patient satisfaction oriented" enough.
The worst example of this happened after a patient, who was fully in command of all his faculties, took a swing at me. Only a complicated move reminiscent of the "Matrix" movies kept me from a broken skull. Afterwards, the assistant manager told me I had to go back and make nice with the guy. I told him no, that I would not, and further, that if he or any other patient ever tried to hit me again, I would be calling the cops and pressing assault charges, and maybe suing the hospital for making my work environment unsafe. I refused to reenter the room.
I got a note on my review that year that said "Jo is an excellent clinician but needs more work on her relationships with patients."
For all you folks who want to point out that service is part of nursing, and that serving is a holy and higher cause, you go right ahead. I serve every day that I work, from before the time that I punch in to whenever the job is done (whenever that is). Service to my fellow humans, though, does not mean martyrdom or risking personal injury. It certainly doesn't mean putting a patient's satisfaction scores ahead of their health or safety.
If you, Administration, want me to be a good nurse, then let me be a good nurse. Let me educate and comfort and calm. Let me commiserate and be compassionate and do all the things that I was trained to do, including catching med errors and fixing problems. Don't push the patient satisfaction side of the equation so hard that you forget what you hired me to be: the first, last, and best guardian of my patient's health and safety. Don't confuse happy people with good outcomes.
And for God's sake, and the sake of your patients, don't push my profession into waitress/hostess mode so hard that we all forget what nurses are here for.