Celebrate Nurses Week by not overworking them

http://www.progressive.org/national-nurses-week

By Suzanne Gordon, May 6, 2013

National Nurses Week is from May 6 to May 12, and we should honor the work that nurses do, and insist that they get their long hours reduced.

The hours worked by registered nurses (RNs) – the largestt profession in health care – have actually increased over the past several decades.

The average hospital nurse now works a 12-hour shift. Studies on nursing hours have documented that most nurses do not leave after 12 hours but actually work 13 or 14 hours. (In some hospitals, nurses are required to work mandatory overtime, which could mean another eight to 12 hours at work.) When combined with commute times, nurses may be spending 16 or even 17 hours at work and getting to work. This significantly limits the time they have to rest between shifts.

To make matters worse, there are no regulations limiting the amount of back-to-back 12-plus-hour shifts a RN works. As a result, many RNs suffer from chronic sleep deprivation.

Nursing unions have been adamant that banning mandatory overtime is critical, since working extra hours is unsafe to both nurses and patients. The Massachusetts NursesAssociation, for instance, has successfully lobbied for legislation banning mandatory overtime in the Commonwealth.

But bans on mandatory overtime, while certainly necessary, do not address the safety issues inherent in 12-plus-hour shifts. Errors that lead to patient harm increase after eight hours and rise dramatically after 12 hours, particularly when a nurse suffers from chronic sleep deprivation.

Plus, the harm to nurses themselves is significant. Fatigue increases the chance of a needlestick injury, makes concentration on complex tasks more difficult, and creates the kind of irritability that makes it hard for RNs to be empathic or function effectively. What’s more, numerous nurses suffer from injuries sustained
while driving home when fatigued.

Ideally, nurses should go back to the eight-hour shift that so many working people fought for over the last 150 years. Until that happens, 12-hour shifts should be banned at least for those working in critical care area – intensive care units, emergency rooms, and laabor and delivery.

Similarly, working more than three back-to-back 12-hour shifts should not be permitted.

Airline pilots aren’t allowed to fly for more than eight hours, and truck drivers aren’t allowed to drive for more than 11. Both professions have minimum rest periods between their shifts.

So how can we countenance 12-plus hour shifts for the RNs upon whose skill, alertness and judgment so many patients’ lives depend?

(Journalist Suzanne Gordon’s latest book health care or nursing is Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety published by Cornell University Press. She is co-editor of the Culture and Politics of Health Care Work Series at Cornell University Press and can be reached at Lsupport@comcast.net)

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1. Nurses Week Oped on Nurses’ Hours
2. Nurses and Sleep and Patient Safety
3. New York Times Article on Changes in Resident Hours

Time to pull the plug on 12-hour nursing shifts

Bostonglobe.com

When the voluntary abandonment of the opportunity to sleep is compounded with overtime things become even more complicated for nurses and patients. Sleep studies document that errors go up. Nurse researcher Ann Rogers has reported that “risks of making an error were significantly increased when work shifts were longer than twelve hours, when nurses worked overtime, or when they worked more than forty hours per week.” But the impact of lack of sleep isn’t only on patients. It’s on nurses themselves.

Nurses who work such long hours have more back, neck and shoulder injuries, suffer from more depression and are also at risk for other health problems. A 2007 study has documented that lack of adequate sleep puts people at twice the risk for cardiovascular problems and early death.

And now we have this new study that tells us that people who don’t get enough sleep suffer from greater brain aging. If you don’t get your seven or eight hours, you can suffer as much as a four to seven year increase in age. Even before this study came out, Geiger Brown and her colleagues asked the question, “Is It Time to Pull the Plug on 12-Hour Shifts?”

My recommendation? Before the month is over, nurses should take a visit to an exhibit at the American Textile History Museum in Lowell, Massachusetts. The museum is a monument to American fabrics and to the workers whose sometimes backbreaking labor produced them. One glass case exhibits a letter written to a mill official in 1867 and signed by dozens of mill workers. It reads as follows:

To the treasurer of the Appleton Corporation. We, the undersigned operatives in your employ, believing that 11 hours a day is inimical to our best moral & physical interests, would most earnestly request you to reduce the term of labor from 11 to 10 hours per day & your petitioners as in duty bound will ever pray.”

When you read this and combine it with all the documentary evidence, the answer to Geiger-Brown’s question — “Is It Time to Pull the Plug on 12-Hour Shifts?” — ought to be an enthusiastic “yes.”

Suzanne Gordon is editor of the Culture and Politics of Health Care Work series at Cornell University Press and co-editor of a forthcoming book on patient safety.

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2. New York Times Article on Changes in Resident Hours
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Walk into a hospital in the United Kingdom, Ireland, the Netherlands and much of Scandanavia and take a good look around. What don’t you see? No male physicians wear ties. No one is wearing a lab coat. No one — male or female — is wearing rings, not even a lone wedding band. No watches adorn wrists – people pull them out of their pockets when they want to check vital signs. No stethoscopes dangle around the neck of either doctors or nurses. There is instead a stethoscope in each patient’s room.

Now consider the United States or Canada. White coats remain the symbol of status for physicians and some elite nurses, like nurse practitioners. Women and men wear rings galore, and it’s hard to find anyone without a wrist watch. Ties — mostly traditional long ones — are de rigeur for docs. And stethoscopes are draped casually around the neck as if the latest fashion accessory.

Why the difference in medical equipment and attire? Health systems in the UK and Europe have acted on studies that document the fact that pieces of standard medical equipment and attire pose the risk of harboring and transmitting a host of dangerous organisms to patients. Ties can dangle into wounds as a doctor is examining a patient; it isn’t therefore surprising that ties have been shown to be colonized with hospital superbugs. Rings can shelter untold dangerous organisms underneath the band, inside an intricate setting, or even in the tiny spaces etched out by a loving inscription. It is impossible to keep many germ free, even if medical staff members take off their rings and washed them everytime they cleaned their hands. Watches and bracelets carry the same infection control hazards. As for stethoscopes, it should come as no surprise that these can be laden with lethal organisms yet are rarely cleaned between patients.

As for lab coats, their long sleeves are constantly touching patients and transporting germs from one to another. They are never changed or washed between patients and rarely laundered everyday, as are hospital scrubs. With scrubs, which leave the arm below the elbow bare, it’s much easier to clean the entire arm that might have inadvertently brushed a patient, a bedsheet, or an open wound.

While numerous studies have documented these dangers, many in healthcare will argue that with the exception of artificial nails, there is no smoking gun that directly links pathogens on a ring, tie, watch etc. with a bad patient outcome. In a culture that worships randomized controlled trials, lack of such “grade A” evidence allows the system to maintain the status quo until further research comes along. One can only imagine how long it will take to run study where patients are rubbed with a contaminated tie or lab coat versus a placebo…

That’s why the Europeans have acted on available evidence rather than wait for the impossible to happen. For them, removing such obvious sources of possible contamination is just common sense much like wearing a helmet while snowboarding. In the United States and Canada, despite more than a decade of intense concern about patient safety and the increasing number of hospital borne infections and “superbugs” there has been little serious action taken on the tie/ring/lab coat etc front. In fact, many prominent patient safety advocates seem to dismiss these things with a kind of “what can we do about it?” shrug. Inactivity speaks volumes: are we really serious about these issues or are people more wedded to the trappings of status and power, or fashion, which not only provide infection risks to patients but also perpetuate the kind of silos and hierarchies that are rife in modern medicine and that are also risks to patient safety. On a recent trip to Sweden where doctors wore short sleeve scrubs and had forgone jewelry, they looked and acted like they were part of the team. Doing away with these medical accessories costs little or nothing. Plus it may help health professionals act their way into a new way of thinking about patient safety.

Suzanne Gordon’s latest book is “Beyond the Checklist: What Else Health Care Can Learn from Aviation Safety and Teamwork.” Dr. Michael Gardam is medical director of Infection Prevention and Control at University Health Network and Women’s College Hospital in Toronto.

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The School has long been doing wonderful work and continues to pioneer in patient safety and in assuring that patients receive the highest quality care from the highest quality practitioners.

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One barrier is, of course, workload and fatigue.  Whether it is in the hospital or any other workplace, like primary care, people who are too tired, who have not eaten, and who have too much work tend to be irritable and have trouble attending to others.  In healthcare settings, professionals and other staff are constantly expected to act in a professional manner when, as Lucian Leape and his colleagues argue, their institutions do not treat them respectfully and ask them to work too hard and too long.  It is totally clear – and the evidence backs this up – that HCPs of every sort are taking care of too many patients (see my book Safety in Numbers on the issue of nurse staffing ratios and patient care) and, at least in North America, working hours that are way too long.  Health care professionals may also disrespect themselves and their patients when they choose  (see Trinkoff and Geiger Brown in First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety)to work long hours for any of a variety of reasons (they want to earn more or prefer to lessen their commuting time by working three days rather than five in a row).  And here, I am not talking about the single mother who has to work two or three jobs to make ends meet  or someone who lives in a rural area and has no option but to drive long distancs to work.

Both the institutions they work in and the professionals themselves need to act on the scientific evidence that has now documented that the human brain does not function “professionally” when fatigued, famished, or when constantly interrupted and asked to multi-task.  This means we will have to figure out ways to apportion our healthcare dollars in a way that allocates financial resources to care rather than profit, marketing, and administration.

Clearly, workload and fatigue are major barriers to caring for patients who have legitimate needs without stigmatizing them.  I believe there is also, another reason why some HCPs may so easily view  patients who are not abusive as “difficult.” This has to do with what I think of as the paradox of expertise or experience.

I think the fundamental problem with the patient-centered- care, putting- the patient- first philosophy is that it ignores or fails to acknowledge the intrinsic paradox in the caregiving professions. This paradox stems from the fact that, over their careers,  nurses, doctors and others in healthcare (I absolutely refuse to use the term “allied health professionals”) will care for thousands of patients.  What is unique to each patient, who is an N of one,  is, all too often routine to the professional who has seen this problem over and over again.  What we, as patients, complain about, or consider so terrible, may appear to be far less significant to the caregiver who is taking care of a total train wreck lying in the bed several rooms down the hall. As patients, we may even wander by that room and see that train wreck lying in the bed surrounded by machines and sprouting a literal field of tubes and lines.  While we may intellectually recognize that that person is far worse off than we are, when we return to our rooms and deal with our pain and fear, we are mired in our own reality and comparisons provide little relief.  What we need is acknowledgment – as in “that must be really hard.”  We don’t necessarily need tears (although that is sometimes appropriate) or hugs, (ditto), we need someone to legitimate our concerns rather than blow them off.

Patients may also put unfair burdens on HCPs.  We may want them both to have “all the answers” and fix the problem and to be kind and caring and attentive not only to the physical issue but to our emotional needs.  We want the kind of expertise that goes way beyond the N of one but we also want to be treated as utterly unique.

But it may not be easy for caregivers to do that when they are overworked, exhausted.  It may also be difficult because HCPs with experience have a different perspective on their patients’ problems than novices.  New graduates of health professional schools are often very kind and caring (and very critical of their “callous” and battle scarred teachers and mentors) precisely because they do not have much expertise and tend to view patients as an N of one.  Their concern may be helpful to the patient but they don’t have the expertise needed to manage all the dimensions of patient care.  Trouble is, when they do have that expertise, will their ability not to think of patients as “difficult” be compromised.  This is why any discussion of patient engagement, patient centered care, or caring must include a discussion of this paradox of expertise.

Related posts:

1. The “Difficult Patient”
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3. My Husband Burned the Pot and Patient Safety

Nurses, in particular, are adamant that they are members of THE Caring Profession and that their fundamental role is to be THE patient advocate. (This formulation does nothing enhance teamwork since it drives physicians, PTS, OTs and other non- RNs crazy. “What does that make me?” they may retort, “The patient’s enemy?”) Patient-centeredness, and the sanctity of the patient/clinician relationship is  the talk everyone is talking.

When you start actually probing and physicians and nurses (as well as others in health care) describe the real life patient (rather than the patient as abstraction), things start to get a bit more complicated. It’s amazing how quickly so many of these patients – who were absolutely revered a few minutes earlier — suddenly become “difficult,” when clinicians start discussing actual patient encounters.

A couple of months ago, I was talking to a nurse at a major American teaching hospital. She began to describe a “difficult” patient and the patient’s even more “difficult” family.  The patient was a young woman who was engaged to be married when she had developed a serious health problem.  She had to have surgery and now found herself in the hospital, in pain, constipated, her life plans on hold. She was, according to the nurse, “not responding well” and her family was equally problematic – calling the nurse manager, complaining about everything. When the nurse manager gave her her patient assignment, she was warned that she would be dealing with a very “difficult” patient and family. The RN gritted her teeth and went in to assess the young woman. The woman was upset because she had to have an enema, which she’d never had to have in her life. The patient was distraught about her condition, when, in fact, the RN said, the patient was so much better off than almost any other patient on the floor.  The RN expressed her irritation about how “difficult” the patient was (her words not mine).

Nonetheless, she exercised professional discipline and tried to reassure the young woman about the enema, her recovery, and her future. By the end of the day, the family was reassured and had ceased complaining and everyone – including the manager – complimented the nurse on the good care she had given.

What surprised me about this discussion was how little sympathy the nurse expressed toward the patient and how easily the manager and then the nurse had categorized her as “difficult.” Since I could totally relate to the young woman’s anxiety and dismay, I actually found it a bit scary to think about the reaction her plight elicited.

This happens very often when I talk to nurses, doctors, and other health care professionals. I was recently talking to a young Canadian who’s just gotten a nursing job after graduation. Once again, the nurse lamented the fact that so many patients are so “difficult.” “You cannot imagine what these patients are like,” the nurse said,” always on the bell, always demanding. They just expect you to be there to take care of their every need.” This nurse is not a callous human being. Yet, it only took a few months post graduation for the RN to develop a definition of “the difficult patient” that goes way beyond what non-healthcare professionals would expect it to be.

I talk to ER docs, or surgeons, or even internists and get the same thing. “You see a patient whose chart is the size of a dictionary, and you run in the other direction,” one internist told me recently.  (I cringed when I heard this. What happens when I’m 80 and my medical chart is as thick as my wrinkles are deeply etched?) Another ER doc (like so many ER nurses) complained about all the “frequent flyers” coming to his institution. (A “frequent flyer” is what you get called if you have mental or a chronic illness and have repeat visits to the ER). Among themselves, nurses, doctors, social workers – you name it – speak in very derogatory tones about patients who have mental or so-called psychosomatic illnesses. This in spite of the fact that many, when talking about patients publicly, acknowledge that every illness has a mental, pscyho-social component. The mentally ill come in for particular derision, even though people are talking about patients who have an “Illness” or “disease,” and who are not deliberately play-acting.

Most non HCPs (healthcare professionals) would heartily agree that screaming, shouting, punching, constantly complaining when there is, really, not much to complain about constitutes being “difficult.” The descriptor “difficult,” however, is not attached only to this kind of patient but to anyone who mpves out of the narrow bandwidth of what seems to be “the good patient.”

To me and many other patients or would be patients, it’s pretty frightening to learn how quickly HCPS can go from loving us in the abstract to describing us as the medical equivalent of cop-show “perps” or “unsubs.”  It doesn’t seem to take much to become a “difficult patient.” All you seem to have to do is be anxious, upset, frightened, worried, terrified at being in an alien land – i.e. a hospital – and not keep it to yourself.  Ask a few questions when the nurse or doc is busy. Ring the call bell more than once because illness has reduced you to the status of an infant who can’t do anything for herself. Express a slight doubt about treatment. Have a question. Doubt a treatment recommendation. Come into the office, ER or hospital frequently because you have a chronic illness and pouf, you have become “difficult.”

Reading this, many HCPs might respond that they describe patients as “difficult” because they are tired and overworked and, after eight or ten hours on the job –totally fried. Many insist that, in spite of this, they don’t let their innermost thoughts show and are outwardly caring and sympathetic to their patients – even the ones who kick and scream and punch. I am sure that is true.

We now know a lot about the phenomenon of framing– how we think about things and interpret them – and how framing affects our behavior. Research on how the brain works also tells us that we are notoriously poor judges of ourselves and our own behavior. Read Daniel Kahneman’s book Thinking Fast and Slow (about how the brain works) and you’ll discover that a stranger on the street is sometimes a better judge of how we come off than we are ourselves. Well-intentioned as they may be, many health care professionals convey what their feelings about “difficult” patients to those patients.

Whether they intend to do it or not, they are “framing” the patient to themselves and others they work with in a way that colors how others view and then treat that patient. (Just say the word “difficult patient” to yourself and imagine how you would respond to that person. See how your stomach clenches, your blood pressure rises, and your minds races to the most negative images). It’s because how we frame things is so important to how we behave that this issue is so important.  Many HCPS, it has been documented, clearly convey their negative feelings about the “difficult patient” in the broader culture as well as to patients, which is why Dominck Frosch’s recent study in Health Affairs documented that so many patients are terrified of even asking a single question to the doctors and nurses.  They are afraid to participate in – or question – decisions about their care for fear of being labeled “ a difficult patient.” (Read Chloe Atkins book My Imaginary Illness, to learn more about the consequences of this labeling).

What can be done about this? Well many people smarter than I am have been thinking about this problem and making recommendations.  The Gordon and Betty Moore Foundation, for example, has just engaged Frosch as a fellow who will help advance their efforts to encourage patient and family engagement and he has lots of ideas about how to help patients navigate this negative framing.

That said, I want, in this and future blog posts to offer some ideas and suggestions of my own. The other day, for example, I was talking with my friend Sioban Nelson, Dean of the Faculty of Nursing at the University of Toronto. We were discussing the problem of “the difficult” patient, and Sioban mentioned what it is like to take care of patients with whom you have difficulties. Wow, I thought, that is a very interesting reframing of the problem. Rather than the patient being “difficult” why not think of the problem in terms of “difficulties” that one has, as a professional, with the patient (as in, I am have difficulties dealing with this particular patient). This reframing changes everything.  Instead of making the patient the problem, the issue is one’s own difficulty dealing with the patient. This makes it possible to search for options, alternatives, and solutions to those “difficulties.” Conceptualizing the patient as difficult, on the other hand, tends to make it very hard to imagine options, alternatives, and solutions, since the problem becomes turning a “difficult” person into an easy one.

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The process of planning, team decision-making, and vocalizing.” (TeamSTEPPS 06.1 Situation Monitoring, p17.)

This is, of course, totally true.  But another thing that a shared mental model depends on is experience.  No expert can share the whole universe of consequences and implications that they envision and have gathered from years of mistake/success making.  This is why it is so important to have the right blend of experts and novices at the bedside.  Of course, it’s also important for the expert to explain as much as possible to the novice so that he or she can do the job correctly.  I probably could have explained things to my husband in a way that helped him understand what was at stake.  What one constantly has to be aware of is the fact of inexperience — or experience — and how that affects what the information that we need to share in order to create the shared mental model upon which high reliability depends.

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When he complained that he did what he was told and I thought, with great frustration– and probably said — but “use your commonsense — couldn’t you smell something burning?”  And then thought, “what’s wrong with you, don’t you have any common sense?”(which, thankfully, I didn’t say).  But think it I did, which of course,  To utterly neglected the fact that common sense is not something you are born with but actually something you acquire through experience.

This kind of scenario happens all the time in the domestic setting, where it results in constant wrangles and probably more than one divorce.  It also happens constantly in healthcare, where the consequences may be far more dire.  Indeed, many contemporary attempts to save money in a system with escalating costs depend on laying off experienced and educated staff with less expensive, experienced and educated replacements (the healthcare equivalent of replacing me with my husband in the kitchen.)  Many of those in leadership positions in our healthcare system seem to be unmindful of the kinds of problems people have when they lack on-the-job experience.  Instruction manuals, clearly delineated protocols, and well articulated scripts are no substitute for what people learn in a well thought out program of education, which is supplemented by recurrent on the job training and learning.  These replacements may seem to be cheaper and effective in the short term, but like my husband, with the best intentions in the world, they may burn the pot, destroy the dinner — and in healthcare, do irrepairable damage to the patient.

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The Podium

The Cheesecake Factory isn’t health care’s answer

By Suzanne Gordon

|  September 11, 2012

 

 

Globe File

A Cheesecake Factory at the North Shore Mall in Peabody.

In their drive to cut costs and produce better patient outcomes, American health care policy makers and administrators are embracing a variety of work re-organization schemes borrowed from other industries. Some boast of their “Toyota lean” approach to health care delivery. Others have looked to Disney World for new ideas. The newest business model being touted is the chain restaurant The Cheesecake Factory.

Earlier this month, Boston’s own Atul Gawande, a well-known surgeon and writer about health care, surprised many readers of The New Yorker by praising The Cheesecake Factory for demonstrating how the US health care system could provide more standardized, high-quality patient care.

According to Gawande, the “delicious” fare served by over 180,000 employees in its more than 2000 restaurants represents just the kind of reliable, innovative product that would better fit the budgets of cost-conscious health care providers — and meet the needs of their “customers” — in the competitive new world of US medicine.

He admits, in passing, that “the front-line worker” at the Cheesecake Factory and similar chains “now generates unprecedented value but receives little of the wealth he is creating.” But because firms like these “have learned to increase the capabilities and efficiency of the human beings who work for them,” the Cheesecake Factory model of food preparation and service “represents our best prospect for change” in health care, he argues. Although standardization is long overdue in health care, it is questionable if this particular model of standardization addresses the needs and complexities of health care.

In the labor intensive world of health care delivery, as physician and patient safety advocate Lucian Leape, of the Harvard School of Public Health has pointed out, quality patient care (and thus customer satisfaction) depends on whether health care employers treat their staff respectfully. While the Cheesecake Factory may have developed a highly efficient and thus profitable business model, it seems to be one based on punitive labor practices. In California, Cheesecake Factory workers won a $4.5 million settlement with the chain for its widespread wage and hour law violations. It appears that the chain has not learned its lesson: A law firm in Tennesee is pursuing litigation on behalf of current and former servers at the chain. The complaint alleges that all across the country Cheesecake Factory servers have worked hours for which they have not been compensated or for which they have been paid “at rates less than one-and-one-half times their normal hourly rates, and/or for which they were paid below the minimum wage.”

Because of its continuing deficiencies in this area, the Restaurant Opportunities Centers (ROC), a nationwide restaurant workers group, gave the chain a very low rating in its 2012 “Diners’ Guide” to ethical eating. The guide named the Cheesecake Factory as one of the worst employers in the industry. At a restaurant worker protest in Baltimore in May, ex-Cheesecake Factory worker Raquel Rojas spoke for many when she told a local reporter that a her former employer “treated us like machines — like we didn’t have any emotions or needs.”

It is hard to consider the Cheesecake Factory’s record of process innovation while divorcing it from its product. Dr. Gawande, who has written about the costs of obesity-linked cardiac problems in some of his other writings, does acknowledge that the food at the Cheesecake Factory, ” was sweeter, fatter and bigger than it had to be.” At the same time, he lauds the chain for providing “goods and services of greater variety, better quality, and lower cost than would otherwise be available.”

It is troubling to learn that a respected patient safety advocate like Gawande — someone who has long written about enhancing patient safety and reducing health care costs — would assert that The Cheesecake Factory produces a quality product. Just last year, The Center for Science and the Public Interest gave the chain one of its “Extreme Eating” awards for its Farmhouse Cheeseburger, which weighs in at 1,530 calories, 36 grams of saturated fat and 3,210 milligrams of sodium. As Bonnie Liebman of the Center put it, chains like the Cheesecake Factory seem intent on “targeting the remaining one out of three Americans who are still normal weight in order to boost their risk of obesity, diabetes, heart attacks, and cancer.”

In “The End of Overeating: Taking Control of the Insatiable American Appetite,” Dr. David Kessler, former head of the Food and Drug Administration, addresses the obesity crisis that is costing the US over $147 million annually . He singles out The Cheesecake Factory for manipulating the fat and sugar content of its food to encourage over-consumption. Even some business analysts in favor of standardization health care argue that a restaurant chain that has contributed so heavily to obesity can hardly be considered our “best prospect for change.”

As we search for ways to control health care costs while still providing quality care, there are some high reliability industries, like aviation, that do provide promising models for change. The Cheesecake Factory — with its history of violations of basic worker rights and almost anti-lean cuisine — just isn’t one of them.

. Suzanne Gordon is a health care journalist and coeditor of “First Do Less Harm: Confronting the Inconvenient Problems of Patient Safety.’’

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