Response to a CEO’s Newsletter on Four Current Health Issues
(My letter to a MN Health Care System CEO)
- Standardization? – A health care pipeline or patient progression is much different from an auto assembly line – too many independent variables.
I was thinking about the word “standardize” in reference to operations in the article you sent. We do need to be more efficient with our “systems,” especially our support systems. My concern revolves around some people’s interpretations of standardizing patient care. Find me a standard patient and I will write a standardized care plan for all – cannot be done! We still need individualized care plans due to all the variables that patients carry with them. No two patients are alike in their chemical, physical, and mental makeup. Factors that affect their healing situation include, but are not limited to: various chronic conditions and combinations of those conditions, especially during an acute illness, symptoms, age, gender, stress, genetics, rate of healing, depression/mental status, family support, education, motivation, and the list goes on.
Consider these two cases for comparison: A 56 year old male, Sam, with a history of diabetes who is admitted for deep vein thrombosis (DVT) may have different needs than an 84 year old male, Gus, who also has a history of diabetes being admitted for DVT. What caused the situation in both cases? What are their personal variables?
Imagine that Sam (age 56) had been very active, exercising and had his blood sugar under control with diet and hypoglycemic drugs. During assessment of his situation, we find out that his spouse died six months ago; he was not eating properly, became depressed and stopped exercising. His blood sugar levels were out of control. We cannot just treat the DVT. We need to help him with his ability to cope with the death of his wife, as well as getting his diabetes under control through diet and exercise. What are the priorities for his care so that he doesn’t relapse or have further problems?
Gus (84) was also active and had his diabetes under control. Upon further examination, we notice that his right, large toe is swollen, red and appears infected. He says, “Oh, yaw, I cut my toenail too short; I’ve been having pain in that foot so I haven’t been able to get my daily walk in.” His care plan will include antibiotics, wound and foot care, educational prevention so that he can get back to his daily walks.
Both of these patients will have different degrees of atherosclerosis which can encourage the development of a DVT. Atherosclerosis is a condition not just of aging, but also due to diabetes. Other variables for these two may be extent or location of the DVT, effectiveness of the antithrombotic medications on each and their rate of healing. (Recognize that the 2 cases used for purposes of discussion in this paper are simple compared to most of our more complex cases.)
- Unrealistic expectations motivated by money. This is where controversy hails true.
The national trend for health care has been to hospitalize patients in their acute/critical phase and transfer them to a TCU (Transitional Care Unit), nursing home or rehab facility, or home with possible home health care. I can envision both Sam and Gus getting through the deep vein thrombosis crisis and stabilizing their diabetes in the hospital setting. It is what happens to them and their other issues after discharge that raises concern.
Three years ago, I did a limited, educational, clinical experience (1 week) working on a highly rated TCU. The TCU patients we saw were clearly the type of patients formerly seen on general medical/surgical units in hospital settings. However, the care provided was not the same. The RN/patient ratio clearly utilized fewer RNs than before. They were utilized for management or passing medications. Usually these RNs had limited experience or were from outside agencies. LPN’s and aides did the “nursing care.” The RNs who were most qualified and educated to do assessments, patient teaching, nursing care, and evaluation of that care often did not have time to do so. So, dealing with Sam’s depression, diabetes, and antithrombotic medication, etc. might be left to aides and LPNs who are not qualified to do critical thinking – they follow restricted assignments. Or worse yet, Sam may have been discharged to home with follow-up appointments that he may or may not comply with due to his depression – the reason that led to the acute situation in the first place.
Gus has had a previously bad experience on a TCU and refuses to go to any TCU. However, he will probably do well with home health care and check-ups anyway. (We often have patients who refuse to go to a TCU due to a previous experience.) That further leads me to think; do we need to establish better systems for healing on our TCUs than we currently have?
With proper supervision, TCUs are excellent facilities for new RN graduates to practice what they learned in school without the stress or need for advanced practice and knowledge. It can be a perfect setting for them to learn organizational skills and prioritization. Instead, we are employing new RN graduates for advanced practice settings (hospitals) without encouraging them to get the basics under their belts first. We may be creating unreal expectations with many of them drinking alcohol regularly after work; some admit that they often cry all the way home after completing a shift. Because of HIPAA privacy rules, they have limited avenues for processing their emotional/stressful involvement connected to the care or issues they faced during their shift – no way to debrief without fear of violating confidentiality. That cannot be good for either the patients or the employees in the long run or even hospital care ratings. However, today, most new RN graduates want to go to a hospital setting because that is where the higher salaries are and they CAN get hired. Most do not have enough knowledge about what nursing entails, yet, and therefore, may not be making mature decisions.
Dysfunctional situations may occur when we expect direct, primary care givers to understand, compile & evaluate data, and execute a plan of action, with every new idea, case, or experience starting from a “scratch” position (having never encountered the situation before) in the timeframe we have to provide that care. Every patient we face in the acute care setting needs our immediate synthesis of data based upon our education and experience. Decisions need to be made more quickly in an acute care setting than on a TCU. New graduates do not have enough experience to draw upon to be comfortable or expedient with their actions – some admit they are “swimming.” Others are afraid to admit that because they want the money and won’t ask for guidance – false confidence.
Most of us (RNs) started our careers on a general medical/surgical unit. It was our “internship” period; and yes, we were paid less during that time because we were not ready to be more independent practitioners. We needed mentoring by our more experienced, mature peers. We were required to have two years general experience before we could specialize and another three years of experience before we could get into management. That is investing in the quality of the RN pool.
Being concerned with health care costs matters. It is a balancing act. We are very good at creating spread sheets and bottom lines, and choosing least expensive routes, esp. when it comes to personnel. It might surprise you to take a look at individual annual salaries of your RN employees and see who is making the most money, based upon who does double shifts, etc. Some newer RNs are making more money than experienced nurses, annually, by “racking up” double shifts. Many mature nurses won’t do double shifts because they know that being tired increases chances for mistakes. We need to ask ourselves, “Are we getting the most benefit and quality of work out of salaries we are paying?” I for one have not been in favor of any nurse doing double shifts unless there is a major snow storm (2 feet) and there is no other option. Double shifts are not cost effective or safe. I have worked a few “doubles” during my career, but was always exhausted for 2 days afterwards. (My charting was not as complete at the end of my second 8-hour shift.) And I do not like working with nurses when they are doing doubles because they may be too tired to help out when needed. Some seem to “disappear.” Let’s creatively staff our needs without offering double shifts, especially on nights. Treating our night staff like adults with more respect and appreciation for their contributions may increase retention, so that doubles are not required for night shifts. Get to know and value the night staff – “the invisible crew.”
- Heal thyself first before you can heal others.
Doctors and nurses need to have opportunities to build team spirit, laugh and support each other, network and share. We have similar emotional, physical and social needs because we share similar burdens, concerns. We need to “have each other’s backs.” In some hospitals where I have worked, music and laughter were recognized as therapeutic to healing, both for patients and staff. We need time to “lighten-up.”
- Data integrity: the 4th item to be added to Maslow’s Hierarchy of Needs under Safety and Security?
Because of electronic medical records (EMRs), we have instituted policies preventing staff from going into a patient’s chart when they no longer care for that patient. We cannot ask about the patient if he/she is transferred or discuss the case in any way. We need to preserve data integrity for each patient. Terminate employment if anyone abuses the use of client data. The key word is abuses. Amen, I agree, wholeheartedly.
However, our method of practicing data integrity is a profound, pathetic loss of professional closure. We are treating data like classified military secrets. Previously, we had opportunities to learn whether our care made a difference or not and we also learned what we could have done better. Debriefing a case was very important for caregivers, professionally and psychologically. We have no idea what will happen to Sam or Gus after they leave our care unless they are reassigned or readmitted to us later. Did we discharge them correctly with all the education and support they needed? We cannot even go back into their charts to find out. Worse, an even greater loss to our education and closure is the ignorance of what happened to our patient we transferred to ICU or that died on another shift. This detrimental situation defeats quality control when we cannot analyze outcomes and integrate that learning into our own personal experience. “I was trusted in caring for the patient, but I am not trusted with case closure.” Talk about being trained to be a “cold fish.”
Ironically, our computers may not even have secure firewalls anyway when being opened to Web surfing – a potential for hacking without a user trail. Anyone can use our computers to go to the Web, Facebook, online shopping, gaming, etc. without being able to trace users because no password is required to do online surfing. Many people are doing these non-professional activities during on duty time, including some housekeepers who use computers in empty patient rooms. Each employee who needs the internet for their job should have their own online password for our computers so that we can trace use for professional business only. Even public libraries require a photo ID to obtain a password to use their computers due to possible inappropriate use – criminal activity or porn. If an employee does not need the internet for their job, like PCA’s, they should not have access to the Web. Using a computer for personal use that also has entry into any EMRs pathways during break-times should not be made possible either – may provide lines for hacking.
More employees carry their personal iPhones, cell phones, etc. and use them during non-break times than employees who leave their phones in their lockers because that is now the new norm. These phones have capabilities to photograph staff who may not wish to be photographed without their knowledge. Employee data integrity should be valued, also. Texting is commonplace. Some employees sit at their computer as if they are charting, but are busy with a phone in their lap, texting. This inappropriate use of paid on duty time is very costly and irritating to other staff members who choose to focus their whole shift on patient care. Personal phones should be left in lockers during on duty time – period, and enforced. Managers should follow these rules, also, to role model compliance.
Dealing with issues identified in the last two paragraphs will increase staff productivity, as well as increase our focus on patient care. It will also help to “police” those employees and their priorities that elect not to “police” themselves or appropriately prioritize their own activities. Perspectives/comments discussed in this paper may not be popular, but then I am not obsequious. J
Respectfully submitted on 6/13/2014,
Donna Setterholm, RN, BSN, MA