So Who Are You Really Working For?
Prioritize Your Health Care Practice By Putting Patients First
by Diana L. Gallagher MS, RN, CWOCN, CFCN
Frank Reagan's character in the popular TV drama, Blue Bloods, frequently explains his role as Police Commissioner, by saying, "I work for the people of New York City, but I serve at the pleasure of the Mayor." It is a very clear description of where his priorities lie. His statement leaves no doubt as to who he works for. This clarity of purpose clearly outlines his responsibility. It is a simpler view of the world that eliminates any confusion regarding whose needs take priority when priorities collide.
I am fortunate and have had very limited personal experience with the health care system. My role, like so many of you, has been as a clinician. When I began my career as a staff nurse, I always believed I had my patient's best interest at heart. As a specialty nurse, I hope that I have continued that same pattern. I was taught that one of my most important roles as a nurse was that of a patient advocate. It is a lesson that I have always considered a cornerstone of my practice.
In the past two weeks, I have had the opportunity to observe the health care system. It has given me the chance to reflect on how I practice today and how I have practiced in the past. Loyalties are not always as clear as on a TV drama, but I believe that I have maintained my patients' well-being as a top priority. The validation is that I have a history of occasionally being at odds with administrations and my physician partners. It began when my career started and continues today.
In my first blog (July 2013) I shared a memorable patient who was terminal. I recounted my experience with a challenging IV restart. That same patient was instrumental in shaping my career. I learned more than one lesson while caring for him and his family.
Defining My Responsibilities as a Nurse
Although it was clear to me as a novice nurse that this patient was terminal, I was surprised that no one had discussed his wishes. There was no DNR order on his chart. Now, at this point in my career, I am a graduate nurse. I have not received the results of my registration exam yet and in the hospital's hierarchy, my role was at the very bottom. I left a note for his physicians, encouraging that they discuss his DNR status. I waited and reviewed the orders with each new shift. I left another note and again I waited. I tried again in person but the conversation never resulted in any action.
As my patient's health declined and time became more critical, I boldly initiated the conversation that I wanted his physicians to have. I began with my patient and then his spouse and finally at their request called a family meeting and invited his primary care physician. I remember this meeting vividly. His older brother insisted that he wanted EVERYTHING done to save his brother's life. He was not willing to give up hope. I listened and then explained what would happen when his beloved brother's heart and breathing stopped. I detailed what would happen in a code and gently explained that there was nothing that medicine could offer to save his brother. Everyone was in tears but a decision was made and orders were signed.
At the time, I was waiting and hoping to become a registered nurse. I understood that this was overstepping my role and responsibility and may not be viewed positively by everyone. My job, however, was clear. It was my job to advocate for my patient and work for what was in his best interest. Looking back, my efforts on behalf of my patient may have been aided because I was too new to know my limitations. My courage may have not been as brave as it was risky. But the lesson that I took away was to always do the right thing for patients. Sometimes the right thing conflicts with what is easiest for me or best for my employer; however, patients' needs should always take priority. I learned so much from this man and his family. I owe them a debt of gratitude for their role in making me the nurse I am today. I owe the same debt to countless, wonderful patients and families. They are some of our best teachers.
Experiencing Health Care from the Other Side of the Fence
Earlier this month, I had the opportunity to stay with a very good friend who was hospitalized. She had been born at home and took pride in having never spent a single night in the hospital. She reluctantly agreed to be admitted when outpatient management was no longer adequate to manage a short-term crisis with persistent nausea and dehydration. Over five days, I had the opportunity to view physicians, nurses, and the health care system from "the other side". The experience left me thinking about how health care has changed, as well as Frank Ryan's clarity of what was important.
This hospital had followed the trend to replace primary care physicians with hospitalists. When the change was made years ago, I opposed it. I was in the process of selecting a new physician and selected a wonderful family practice doctor who insisted on rounding on her own patients. Sadly, that is no longer her option or my benefit! My opposition was based on the belief that my personal physician would know me and my individual health care needs better than a stranger. My experience with my friend solidified this opinion.
To be fair, all three of the hospitalists that I met over five days were board certified in internal medicine. They were well-educated, capable and polite. However, they were strangers who did not know my friend. They were not her physician. The history that they had was only what had been shared by her personal physician, the intake assessment, and her electronic record. There was little opportunity or time to develop a relationship. They ordered a marathon of tests that failed to provide any valuable information and when our patient had been afebrile and nausea-free for 48 hours, they were reluctant to allow her to go home. Using Frank Ryan's quote, I was left to question who was the priority?
Numerous organizations have addressed the over-ordering of medical tests and have encouraged only ordering an exam when there is a reasonable expectation of obtaining valuable information. My friend had an abundance of tests ordered. There were CT scans of the abdomen, chest and head. There was a cardiac scan done. Multiple blood tests were drawn every day; but, nothing was found. The screening tests did help eliminate a myriad of possible problems, but yielded little else. Patients, like my friend, are willing to endure any test that may be of benefit. They trust their medical team. Without question, they know that the goal is to help the patient. But, is that the ONLY goal?
Practicing defensive medicine has provided a security blanket of sorts for physicians. After all, look how hard they are trying to find a problem. Increased testing produces another benefit to their employer, the hospital. With each test, revenue is increased and profit margins are improved. When my weary friend had been afebrile for 48 hours and free from the nausea that led to her admission, she simply wanted to go home and rest in her own bed. She had suffered from a lack of sleep, continual discomfort related to the hospital bed and was beginning to have early skin damage. All of these could be improved with discharge. She just wanted to go home and sleep, uninterrupted in her own bed. She asked for this very appropriately and was encouraged to stay for at least one more night and maybe the weekend. There was no rationale given as to the benefit of staying except that the physician would "feel better". It goes without saying that these additional days would yield more profit. Again, who should we be working for?
Making Evidence-based Practice a Team Practice
The health care system is not about physicians but a team. In this facility, nursing staff made hourly rounds and signed their initials on a marker board to show that they had been in. They hung IVs, passed medication, offered beverages and asked if we needed anything. They were busy with tasks and their computers. What I did not see was nursing. I wanted to see nurses teaching and assessing. I wanted to see evidence-based practice. I wanted to hear someone ask what the patient's goals were. I wanted to see nurses gently lifting heels, checking skin integrity and then providing protection. I wanted to see linens smoothed to prevent wrinkles from causing skin damage. I wanted to see the caring and compassion that I believe are inherent to nursing. Please understand that over five days, there were several excellent nursing staff members including both RNs and a stellar CNA. They were caring, compassionate, and competent. But the culture of care still had gaps when it came to prevention and a focus on what was in the patient's best interest.
What I observed, as a whole, was adequate care focused more on the appearance of quality as opposed to the delivery of quality. My belief is that everyone deserves better. Adequate is not good enough and "good enough" should never be an acceptable goal. In a country as affluent as ours, there is no excuse for less than the best care. We have identified what excellent care looks like. Best practice guidelines outline what should be done. Evidence-based practice allows us to blend the best research with clinical expertise and individual preferences for our optimal outcomes. Our health care system has the resources to raise the bar and provide every patient evidence-based, personalized care. We are a part of that potential. It means that everyone must commit to providing our best care to our patients... after all, aren't they who we should be working for?
About the Author
Diana Gallagher has over 30 years of nursing experience with a strong focus in wound, ostomy, continence, and foot care nursing. As one of the early leaders driving certification in foot care nursing, she embraces a holistic nursing model. A comprehensive, head to toe assessment is key in developing an individualized plan of care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.