To my later regret, I didn’t keep a diary of what I’ve been describing here. All I have are vivid memories of certain events that contains clues as to their dating. I almost always remember the patient’s room and a sense of the season. Hem-Onc could get chilly in the winter, and the sun rose much earlier in the summer. That helps. The nurse I was working with offers another clue. One experience often informed another, so that establishes their order. Most helpful of all is feeling the surrounds an event. My last months on Hem-Onc were accompanied by a haunting fear that the war between nurses created risks for our kids. That colored every event.
That’s how I know the incident with a mysterious visitor came early, perhaps during my first month on Hem-Onc. What I was doing was so new, a nurse that I’d not seen before did not strike me as unusual. Later, I would have been more curious about who she was.
She was about forty and thus older than most. The hospital liked to hire young, so the typical floor nurse was in her twenties, while most specialty nurses were in their thirties. She may have worked in an out-patient clinic. Since she had had come to Hem-Onc in the wee hours of the night to check on something, it was probably the one for leukemia. Checking on me—the new guy on nights—may have even been one of her reasons. She did go out of her way to talk with me.
She also did more than chat. She confided something surprising. The hospital, she said, had a history of going off on a tangent about every five years. The last time was about three years earlier when its specialists decided their colleagues out in the community didn’t need to be kept informed about patients they’d referred.
It’s easy to understand why that might happen. These specialists were busy. Establishing phone contact with the referring physicians was a hassle. They felt it was better to stay focused on patient care.
On the other hand, the referring physicians knew those children remained their patients and, when discharged, they’d again have to provide care. They didn’t like feeling that when a child was admitted a door slammed in their face with an implied “you’re not needed anymore.”
The result, my mysterious visitor went on, was a boycott. Whenever possible, doctors sent their sick children elsewhere. The patient count fell so low, she said, some units had to be shut down. It was grim.
I had no reason to doubt her, and a few months later I received confirmation. Rummaging in a nursing-station drawer I came across a motivational lapel pin whose slogan was along the lines of “Have You Talked to the Referring?” The hospital had learned a lesson.
During my last, troubled months at work, I recalled that mysterious visitor. Three years before, she had said, and now it was roughly two years later. Her prediction was proving disturbingly accurate.
Another thought troubled me. On Hem-Onc, I had tried to explain the tensions between nurses as a result of the envy that older and talentless nurses (and a head nurse) had for younger and more capable nurses. That made me feel less uncomfortable than the possibility that the nasty, critical attitude originated higher up. That wasn’t true on the teen unit. All its nurses were capable and got along well. Instead, the problems only began when the permanent head nurse returned. As she attempted to set nurse against nurse, morale plummeted. Then I had to face the fact that these head nurses might be responding to signals from higher up.
At this point, some disclaimers are appropriate. First, when I started at the hospital I saw nothing, apart from the poor orientations given to me and the nurses hired a few months after me, that indicated trouble lay ahead. All seemed well. In fact, I saw the opposite. I was impressed by the responsibilities the hospital was willing to assign to me. I was soon teaching CPR and trained to monitor peritoneal dialysis.
The later was with a machine that was incredibly primitive. Since Seattle hospitals pioneered kidney dialysis, the nurses joked that it was “pediatric peritoneal dialysis machine serial number one.” Perhaps that was true. Online, I found a picture of one that looked similar. It had been hand-built at a nearby hospital in 1964. The nursing administration must have trusted me because, other than my vigilance, that crude collection of large glass bottles, industrial timers, rubber hoses, and valves had no safety features. The machine had lingered on well beyond its time for one reason. When a child had a peritoneal tube surgically implanted, it provided their first overnight test of whether dialysis could be tolerated. That’s what I was doing.
My second disclaimer is to stress that not all the hospital units were affected by this slowly spreading madness. I’ve already mentioned that the teen unit was fine when I transferred there. That was thanks to a sweet nurse filling in temporarily. No amount of pressure from above could make her mean-spirited. I was also impressed with the spirit of the nurses when I floated to Babyland, the unit that cared for most children under one. The joy its nurses displayed about their work was so delightful, I envied them. I was so impressed by what I saw of their head nurse, that she’s one role model for a senior nurse mentor. She motivated and taught rather than blamed and criticized.
My final disclaimer concerns that five-year cycle. I have no reason to believe that the pattern continue beyond the nursing troubles that immediately followed my departure. The high turnover that came just after my departure meant that, even when I ran into a nurse I’d worked with, she wasn’t working there anymore.
That said, I’ll explain the answer I developed to the chaplain’s question about the cause of those administration versus nurses troubles while I was studying in the University of Washington’s medical school, focusing on ethics, history, law and politics. All play a role in what I was studying—medical ethics.
I’ve already mentioning meeting the hospital’s head of nursing but once in an interview was scheduled for three months after I started. She told me that my EMT training had gotten me the Hem-Onc position and I got the impression that she was happy with that decision, which was reassuring because she struck me as a rather stern disciplinarian.
Strange as it sounds for someone working in nursing, I had more contact with the hospital’s CEO than with her. Every so often, the team that taught CPR would meet at 8 a.m. in one of the small conference rooms next to the cafeteria to discuss assignments. Since I wrapped up my Hem-Onc work by 7:30, the person in charge asked me to show up early for one meeting to make sure the room was properly set up.
The conference rooms were scheduled by the hour and the previous user was supposed to leave ten minutes before the hour. I showed up about five minutes before 8 a.m. and found the room still occupied by none other than the CEO and a couple of other people. The result was not happy.
Yes, I probably should have been apologetic with the guy who was ultimate boss, but I’m not someone who is inclined to be deferential to authority figures just became of their titles. Also, like most people who worked nights, I attached a high value to the sleep I was now missing thanks to this meeting. I also felt that by interrupting my sleep to teach CPR, I was doing the hospital a favor. Besides, I was in the right. By the rules, he should have already left. For all my willingness to cheat on the rules for a patient’s benefit, when the mood struck me I could be quite a stickler for rules.
We exchanged a few words that avoided the real issue—that he should have been gone already and that I had a right to the room. Later, when I thought about it, I concluded that nothing bad would happen to me as a result of our exchange. He was so many levels above me that he’d look silly trying to get even.
I didn’t need to worry anyway. I ran into him in a hallway near the cafeteria a few weeks later and he obvious remembered me and seem eager to be friendly. I concluded that, while anyone in his position would have to be quite good at bureaucratic gamesmanship, he was someone who could be trusted to play by the rules.
Unfortunately, those contacts, brief as they were, don’t offer me any explanation for why the relationship between the administration and nurses would turn so sour. Of course, neither struck me as having the sort of warm, emphatic personalities that might have prevented the problems from developing. But both did seem capable and neither seemed to display the mean-spirited, blame-placing attitude I saw coming those two head nurses.
Instead, I concluded that much like the pressures I faced at my job forced me to make some choices is disliked, they were under pressures that may have distracted them from seeing the importance of nursing moral.
In particular, while I was doing that graduate work I became aware of two changes in hospital care at that time which placed both of them between the proverbial ‘rock and a hard place.’
The rock was a change in how the federal government was reimbursing medical costs that had begun under the Carter administration. It was called Diagnostic Related Groups (DRGs). Instead of paying all the costs associated with a particular patient, the government would pay based on a patient’s diagnosis. For acute appendicitis, for instance, there’d be a fixed payment. A hospital that handled such a patient well and discharged them early might come out with a modest profit. If complications such as an infection developed, though, the hospital would a have to absorb the added costs itself. Policy makers saw DRGs as a way to force hospitals to control costs rather than pass them on to others. At the time, DRGs were not being applied to pediatric care, but hospital administrators had good reason to believe that it would come to all areas of medicine.
The other was an extremely rapid increase in medical malpractice payments that was taking place at the same time. I forget the precise figures, but over the space of about seven or eight years, the amount of money that hospitals had to pay for malpractice insurance coverage increased about 600 percent. That was most unsettling for hospital administrators. How were they going to keep from plunging deeply into the red?
Worst of all, these two changes worked against one another. DRGs pressured hospitals to take shortcuts to reduce costs. Lawsuits pressured hospitals to practice defense medicine, running more tests and doing more procedures to reduce risks and look better in court.
Remember what I’ve written about stress causing people to narrow their loyalties and limit their focus? That’s what I suspect was happening here. The hospital was committed to offering care to all children, irrespective of their ability to pay. At the same time it had earn enough income those rising costs. Who lost out?
The nurses did. They were a major cost for the hospital. Many of its lawsuits could be blamed, rightly or wrongly, on nursing errors. They were a ready target.
MORE TO BE WRITTEN