Nursing Wounds
When arrogant docs drive nurses away, patients suffer
Irate doctors hurling surgical clamps at nurses are admittedly rare. So such acts, as outrageous as they are, can't really be blamed for the severe nursing shortage now hobbling hospitals. Nor is it low pay, says nurse Nicola Smith, an 11-year veteran working at UC-Davis Medical Center in California: "It's a matter of disrespect."
Nurses like Smith describe an accumulation of insults. "I've been told to give up my seat for doctors at some hospitals," she says, "and I've been yelled at by a doc who didn't like the way I put on a dressing." Angela Vandorn, a nurse at Hoag Hospital in Newport Beach, Calif., adds: "I've had them hang up on me when I've tried to give them patient information." Such anecdotes are adding up to a crisis. Last week, in an American Journal of Nursing survey of 1,200 nurses and other hospital staff, nearly a third said they knew of a nurse who had left a job because of physician abuse. "That number isn't surprising to me, unfortunately," says James Goodnight, chief of surgery at Davis. "I've seen the yelling and a few things thrown around." Hospitals now have 12 percent fewer nurses than they need, and abusive behavior is one of the big reasons why.
Patients get hurt by this, too. A shortage of nurses is associated with higher rates of internal bleeding and infections and a higher risk of death, according to a disturbing study published two weeks ago in the New England Journal of Medicine. "Nurse turnover is clearly related to these problems, and we see it throughout our organization," says Lillee Gelinas, chief nursing officer for VHA, a chain of 2,200 hospitals and clinics that holds a third of all patient beds in this country.
Fortunately there are solutions. Several hospitals have put "zero abuse tolerance" policies into effect over the past few years and have seen nurse turnover rates drop. They've also seen medical complications dip. "We all work as a team here now," says Smith. "That helps the patients, the doctors, and it helps me. If you offered me a $10,000 raise to work across town, I wouldn't go."
Escaping abuse. Nursing is not about the money, trite as that may sound. In the American Journal of Nursing survey, "we found that workplace environment was an even stronger factor than compensation when it came to satisfaction," says internist Alan Rosenstein, author of the study and medical director of VHA's West Coast division. In fact, salaries aren't altogether bad, says Diana Mason, editor of the nursing journal. "As a new nurse, at a New York City hospital, you can start at $60,000." Some hospitals elsewhere are offering signing bonuses of $30,000. "It doesn't matter," says Mason. "We won't stay in a place that's abusive."
What Rosenstein found in his research was that more than 90 percent of his respondents had witnessed yelling, public berating of nurses (and even patients) by doctors, and abusive language. Perhaps more alarming, he also found that doctors don't think such abuse is a big deal. At times, this is because doctors, facing an urgent situation, focus on speed and need rather than their people skills. Still, nurses have had to devise defenses, like announcing "Code White Coat" over the hospital intercom: Nurses hearing the code move to the beleaguered nurse's side and stare at the doctor, making it clear there are witnesses.
Yet hospitals often seem reluctant to discipline wayward doctors. "They bring patients to the hospital, and that's a source of revenue," Rosenstein says. "Executives can be reluctant to confront them." Couple this with the stress of today's hospitals, where only the sickest patients requiring the most intensive care are admitted. Add to that mix a large group of older nurses who are retiring and young people who don't want to go into this profession, and you have all the ingredients for a shortage--and a shortfall in patient care.
Hospital administrators are waking up to the dimensions of the crisis. "We decided we have to change our culture," says Al Stubblefield, CEO of Baptist Hospital, a 480-bed facility in Pensacola, Fla. In the mid-1990s, Baptist ranked in the bottom fifth in national surveys of patient satisfation. "We knew we had a problem. There was a lot of finger-pointing." So Baptist started trying some new things. Physicians were told there would be no more abusive behavior. Nurses were given power to change the way their wards operated. One thing that changed was the ER, says Diane Wilbanks, vice president of patient care services. A triage nurse replaced a receptionist, reducing waiting times. Nurses also started voting for an outstanding physician each week, and doctors soon began competing for the designation by spending more time teaching nurses.
"When I first heard about this, I thought, `Yeah, yeah, sure,' " says Wilbanks. "But it's made a big difference." Patient satisfaction ratings shot up. Nurse turnover dropped from 24 percent annually to 14 percent. Rates of patient bedsores, blood and urinary tract infections, and other problems dropped as well.
UC-Davis has also reduced turnover. "We have more say at this hospital," says Smith. Nurses now go on patient rounds with physicians at Davis--a practice that is benefiting the bedridden. For example, nurses have been able to teach traditionbound doctors a new and more effective way to treat bedsores--an innovation that would never have occurred under the old system.
Happier nurses are not, of course, a panacea for all ills. At Davis, for instance, some infection rates have gone up. One possible explanation is that while the hospital staff was learning to get along, the hospital became a referral center for the region, treating much sicker patients sent from other facilities. But even these patients feel they are getting better care. Davis is one of about 50 "magnet" hospitals with high nursing standards identified by the American Nurses Association; research has shown these have better patient outcomes than nonmagnet hospitals. So when doctors and nurses mix it up, it's to share information, and it's the patients who benefit.
Happier nurses, healthier patients
A Case Study
Baptist Hospital in Pensacola, Fla., turned a corner in nursing care two years ago. Nurses were included in medical decisions, and abusive behavior by doctors was prohibited. These policies may not be the only factors, but key patient health indicators improved in short order.
MEDICAL PROBLEM 2000 2001
Medication errors 2.5 pct. 1.6 pct.
Blood infections 3.6 pct. 1.9 pct.
(cardiac patients)
Urinary tract infections 3.1 pct. 1.6 pct.
(cardiac patients)
Bedsores 4.2 pct. 3.8 pct.
Source: Baptist Health Care
This story appears in the June 17, 2002 print edition of U.S. News & World Report.