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T H E V O I C E O F N AT I O N A L N U R S E S U N I T E D

NURSE

National

OCTOBER 2010

Washington, D.C. RNs Join NNU

ENOUGH IS ENOUGH

CAPITAL IDEA

RNs on Strike in California

PATIENT CARE

DUMMIES? How hospitals are using

rounding and scripting programs to control nursing practice

FOR

Letter from the Council of Presidents

kudos to all of you who vote nurses' values and encourage your family, friends, neighbors, and coworkers to do the same. But we're here to tell you that the hard work of building a national nurses movement extends well past Election Day. Who keeps our elected officials accountable after they take office? That's right. We do. By calling and writing them, by getting involved with our union's legislative and political advocacy program, and by hitting the streets, whether it's a picket line, vigil, or a rally, to let them know where nurses stand and that we're watching them closely. Across the country, employers are using the down economy as an excuse to lay off needed nurses, restructure the workplace, skirt regulations, and go after unions. Some lawmakers are proposing gutting safety, environmental, and labor protections in the name of "job creation." In this issue's news section, you can read too many examples of the many battles we're fighting. We had RNs at two California hospitals, Children's in Oakland and Watsonville Community Hospital, go out on strike in October. Nurses in Maine are considering doing the same to defend patients and RN standards. Nurses at Tufts Medical Center in Boston are beating back a dangerous floating plan. And facing incredibly tough contract negotiations this year with a recalcitrant employer, the nurses at Washington Hospital Center in Washington, D.C. recently voted overwhelmingly to join National Nurses United. Management is proposing outlandish takeaways, and now the nurses are ready to fight-- with the strength of more than 150,000 RNs backing them. We are so excited to welcome them into NNU. So keep your walking shoes handy, because you'll need them for all the activity this fall. Also in this issue is an article and continuing education home study on an inane, marketing-driven phenomenon that many of us are fighting at our hospitals: hourly rounding and scripting. Hourly rounding and scripting are programs that management implements to improve patient satisfaction survey scores by creating the illusion that patients are receiving lots of personal attention. Most of them involve requiring nurses to recite certain pat lines (hence the idea of "scripts"), such as "Is there anything else I can do for you? Because I have the time." These programs are not only insulting by telling RNs how they should talk to their patients, but actually interfere with nursing practice and judgment. Guess what? Patient (and nurse) satisfaction naturally rises when units have safe staffing ratios! If your workplace has not instituted such programs, consider yourself lucky--but perhaps not for long, because federal reimbursements are becoming increasingly tied to patient satisfaction scores. Read these important pieces to learn about this troubling trend so that you can either be prepared to challenge management when it arrives at your hospital, or band together with coworkers to oust these programs entirely. We're registered nurses, not actors. Deborah Burger, RN | Karen Higgins, RN | Jean Ross, RN National Nurses United Council of Presidents

NATIONAL NURSE,TM (ISSN 2153-0386 print/ISSN 2153-0394 online) The Voice of National Nurses United, October 2010 Volume 106/8 is published by National Nurses United, 2000 Franklin Street, Oakland, CA 94612-2908. It provides news of organizational activities and reports on developments of concern to all registered nurses across the nation. It also carries general coverage and commentary on matters of nursing practice, community and public health, and healthcare policy. It is published monthly except for

combined issues in January and February, and July and August. Periodicals postage paid at Oakland, California. POSTMASTER: send address changes to National Nurse, 2000 TM Franklin Street, Oakland, CA 94612-2908. To send a media release or announcement, fax (510) 663-0629. National NurseTM is carried on the NNU website at www.nationalnursesunited.org. For permission to reprint articles, write to Editorial Office. To subscribe, send $40 ($45 foreign) to Subscription Department.

Please contact us with your story ideas

They can be about practice or management trends you've observed, or simply something new you've encountered in the profession. They can be about one nurse, unit, or hospital, or about the wider landscape of healthcare policy from an RN's perspective. They can be humorous, or a matter of life and death. If you're a writer and would like to contribute an article, please let us know. You can reach us at [email protected]

EXECUTIVE EDITOR

Rose Ann DeMoro Lucia Hwang

GRAPHIC DESIGN EDITOR

Jonathan Wieder Charles Idelson

COMMUNICATIONS DIRECTOR CONTRIBUTORS

Gerard Brogan, RN, Hedy Dumpel, RN, JD, Jan Rabbers, Donna Smith, David Schildmeier, Ann Kettering Sincox Jaclyn Higgs, Tad Keyes, Lauren Reid

PHOTOGRAPHY

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Contents

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News Briefs

Washington, D.C. nurses join NNU 5 | Children's Hospital RNs Strike Over Health Takeaways 6 | UMass nurses win new contract 7 | Tufts RNs protest floating plan 8 | Watsonville RNs go out on strike 9 | Michigan nurses hold convention and unveil new logo 10 | Florida RNs expand metro committees; Maine RNs settle contract while others consider strike; Texas bargaining leadership report

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20 Losing Our Voice

Across the country, hospitals are forcing RNs to adopt hourly rounding routines and scripts in efforts to boost their patient satisfaction scores. RNs say this focus on the appearance of care is jeopardizing patients and the nursing profession.

By Heather Boerner and Lucia Hwang

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An Open Letter to Nicky Diaz

By Rose Ann DeMoro

Scripting and Rounding: Impact of the Corporate Care Model on RN Autonomy and Patient Advocacy, Part I

Earn CE credits by learning about the real purpose and consequences of rounding and scripting programs. Submitted by the Joint Nursing

Practice Commission, DeAnn McEwen, RN, and Hedy Dumpel, RN, JD

CE HOME STUDY

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The Economic Deceit Few Discuss

Making the rich richer doesn't help the economy.

When the Going Gets Tough

Washington, D.C. RN Sandy Falwell has always fought for her patients and other nurses, even through week-long blizzards and union-busting campaigns. By Lucia Hwang

LOOK TS FOR POBER NOVEMION ELECT GE IN A COVERNEXT THE E! ISSU

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honor [those differentials]," said Jean Keppler, an ER nurse and shop steward who has worked at Washington Hospital Center for 34 years. Keppler said if the hospital does away with differentials, her salary could drop by almost 25 percent. "This is a direct attack on the senior nurses." Second, nurses want to give real input and help make decisions about patient care and safety issues. The acuity of patients at Washington Hospital is very high, report the RNs, but managers don't seem to consider acuity when deciding staffing levels. "When we ask for more staff, they say, `I can't give you what I don't have. You have to go with what you've got,'" said Marlowe. "But we are the professionals. If we say we need an extra nurse, we need an extra nurse! We are questioned and judged because of the budget."

Washington, D.C. RNs Join NNU

early 1,600 registered nurses at Washington Hospital Center, the largest hospital in the nation's capital, have joined National Nurses United after a landslide 1121-66 vote which took place Oct. 3-5. RNs, who had previously been unionized through an independent union, said they sought power in greater numbers by banding with NNU's 150,000 members, particularly as they face difficult contract negotiations and deteriorating working conditions under MedStar Health, the corporation that owns Washington Hospital Center. The facility is a Level One trauma center with a top-level neonatal intensive care unit and attracts patients from regions far outside of northwestern Washington, D.C., including West Virginia and Virginia, Pennsylvania, and Maryland. "We did this for the future of the bedside nurses here," said Lori Marlowe, a cardiac RN, shop steward, and negotiating team member who works in a heart failure unit at Washington Hospital Center. "The hospital is making corporate decisions that have disrespected the nurses and patient care. We 4

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strongly felt that our voices were not being heard." For example, last year nurses learned that flu vaccinations were mandatory for all employees, even though they had previously been voluntary. When we questioned the directive, we were told "this is a MedStar decision," said Marlowe. First on Washington Hospital Center RNs' plates after the vote is negotiating a fair contract. The nurses' previous contract had expired in April and been extended several times, but they have been working without a contract since June 19. Management greatly antagonized the nurses when it unilaterally implemented its last and final offer--a proposal nurses say is unacceptable--just a few days before the vote. The RNs are forming their facility bargaining council and electing their negotiating committee, but report that several issues top their list of bargaining priorities. First is defeating the many takeaways the hospital has proposed. These include inferior healthcare benefit and pension plans, a cap on paid time off when nurses already have a hard time getting approval for vacations, discontinuing paid educational leave, and eliminating many of the pay differential incentives that RNs who work permanent nights or other shifts receive. "To me, it's a big slap in the face to not

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Marlowe said that RN-to-patient staffing ratios have steadily worsened. Several years ago, nurses on her unit typically cared for four patients, and the resource nurse had no assignments. Then the load increased to five patients on nights. Then gradually on other cardiac-like units some day shift RNs were assigned five patients. At first this happened only on a monthly basis, but then became a weekly occurrence. "Then five became the norm," said Marlowe. "Guess what? Now we see six on the other cardiac-like units and resource can have anywhere from one to five patients." To address these issues, RNs are eager to form a professional practice committee, an elected group of RNs who meet regularly to investigate patient care problems and work on solutions with management. At many facilities, the PPC is a powerful group of leaders who organize the RNs in creative ways to put pressure on administrators to fix patient safety issues. Since the vote, RNs say that coworkers are more enthusiastic about getting involved, whether it's volunteering to be a shop steward or attending the next meeting. "The excitement is kind of infectious," said Keppler. "I'm also excited that we're now part of a union that's not just a union, it's a national movement."--Staff report

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Children's Hospital RNs Strike Over Healthcare Takeaways

egistered nurse Angela Guevarra's baby daughter can't talk yet, but her message came through loud and clear. "Mommy's healthcare is my healthcare too!" read Kennedy's homemade pink and white bib as Guevarra walked her along the picket lines where she and nearly 800 of her coworkers at Children's Hospital of Oakland protested while on a three-day strike Oct. 12 to 14. The deal breaker issue for the nurses during contract negotiations was healthcare benefit takeaways that for many would mean family insurance premium increases of up to $300 a month and loss of choice in provider that would prevent them from having their own children treated at the hospital where they work. Management is citing the recession for proposing that RNs on the PPO plan start paying, for the first time, 15 percent of the insurance premium. RN negotiators believe that the hospital is using economic woes as an excuse for opening the door to the ultimate goal of shifting more and more healthcare costs onto employees. They also point out that this plan would put Children's RNs

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far below community benefit standards for RNs in the San Francisco Bay Area, making it harder for the hospital to retain and recruit experienced and talented nurses. As an alternative, the RNs offered to forgo wage increases this year, but the hospital continues to insist that they also accept the cuts in healthcare benefits. "We work in healthcare, we deserve healthcare," said Aina Gagui, a medicalsurgical RN at Children's who was dressed in a bright red Hello Kitty scrub top. While Gagui would not be immediately affected by the takeaway proposal since she is on the other Kaiser Permanente HMO plan, she said her cousin, who also works at the hospital, and her family would struggle with the additional costs. "For a family it would be $300 a month extra," she said. "It's really hard to afford that. And there's no telling if they do this, what they will go after next." The RNs are resolute about not accepting takeaways on health insurance just because workers in other industries have had takeaways forced upon them. While the nurses have been criticized in the media for being unwilling to pay part of the premiums like many other workers do, they point out that they are fighting for better healthcare for everyone--their communities, patients, as

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well as themselves--by taking such a stand. Furthermore, other area nurses are closely watching what happens with the Children's RNs' healthcare package because employers will follow suit when their contracts are up for renegotiation. "Our position is that we shouldn't lower our standards, but that we should be bringing those standards up," said Heather Brister, a surgical RN. One of the results of the healthcare takeaway nurses found most ironic was that they would no longer be able to bring their own children to the hospital for care without paying a portion out of pocket. "I'm about to start a family, and the way Children's is trying to herd us all into the Kaiser plan is just wrong," said Anna Smith, an ER nurse and a member of the negotiating committee. "I wouldn't be able to bring my own children here." Smith explained that nurses who can't afford the 15 percent premium payment would switch to the Kaiser HMO plan, but that care could then only be delivered at Kaiser. As an ER nurse, she often sees parents with Kaiser insurance who bring injured kids to Children's because of its reputation in pediatrics. But as soon as the kids are "technically stable, they put them in an ambulance and ship them off in the middle of their care. And that's almost never the best thing to do," Smith said. RNs said they were upset that Children's Hospital wanted its nurses to pay for poor management decisions it made over the years. The hospital spent almost $9 million in compensation in 1998 for its top 26 administrators, including social club memberships and $560 million in severance packages for two short-term executives. The hospital also spent about $4 million on a failed and ill-conceived ballot measure from 2007 to 2008. In contrast, the hospital would save only about $1 million under the health benefit takeaway proposal. And nurses were disappointed that the hospital let contract negotiations escalate to a strike, further wasting resources on hiring replacement nurses and security personnel. The October strike was their first ever for many of the nurses marching outside the hospital. "The best thing about the strike is feeling like the community really supports us and how passionate all our coworkers are," said Gagui. "The worst is worrying about our patients, knowing that the temp nurses in there are not as experienced as us." --Staff report

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the pact meets the nurses' call for parity in pay and benefits with their colleagues who work at the UMass University campus. The agreement will provide a 1 percent pay raise in 2010, 1.5 percent in 2011, and the addition of four new 3.5 percent steps to the top of the nurses' stepped salary scale. At the end of the agreement, nurses at the top of the salary scale will be earning $58.68 per hour. "It's unfortunate that my colleagues and I have had to take our issues to the streets, but our employer has left us no choice," said Lynne Starbard, RN, a nurse at the hospital and chair of the MNA local bargaining unit. "As registered nurses, it is our duty to advocate for our patients. This hospital system, which has realized profits in excess of $90 million in the last 15 months, has announced the closure of a medical-surgical unit at the start of flu and pneumonia season and when the hospital routinely declares bed shortages." The demonstration underscores the growing unrest between the state's nurses and a healthcare industry that seems intent on exploiting the current economic climate as an excuse to cut services, demand concessions from nurses, and gut patient safety standards. "Your fight is our fight, your struggle is the struggle of every nurse in this state and

UMass Nurses Defeat Concessions to Win Contract

he power of the Massachusetts Nurses Association and NNU was felt in Worcester, Mass. last month in a struggle for a new contract by the 1,000 registered nurses from the UMass Memorial, Hahnemann, Home Health, and Hospice campus of UMass Memorial Health Care. UMass nurses staged a highly successful and wellpublicized picket and rally outside their hospital, which was attended by several hundred nurses from across the Commonwealth, as well as members of NNU who were attending the MNA's annual conven6

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tion being held that day in the same city. The nurses planned the event as part of a campaign to beat back a number of concessions demanded by their employer, as well as to call attention to their concerns about poor staffing conditions and the recent closure of a medical surgical floor. The demonstration was the lead story on local radio and television broadcasts and was front-page news the next day. A week later, the nurses and management reached a tentative agreement on a new two-year contract. The pact was reached after the hospital agreed to remove all its demands for concessions by the nurses, including its plan to cut home health and hospice nurses' pay by 10 percent. Instead,

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the nation, who is fighting to protect their patients in an increasingly dangerous work environment," said Donna Kelly-Williams, president of MNA. "From Cape Cod to North Adams, from Massachusetts to California, nurses are rising up and speaking out about efforts by hospital administrators to use the specter of health reform to make dramatic changes, the likes of which we have not seen since the advent of managed care and healthcare deregulation in the 1990s. We are here today to let your administrators, along with administrators across the state, know that we are united in our opposition to their practices and we will do whatever it takes to stop them from harming our patients and our communities."

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The nurses used the event to take issue with UMass administration's touting of factory-modeled "lean production" methods as a justification for its cuts and concessionary demands. The nurses answered in the media with a powerful response. "We're not factory workers," said Colleen Wolfe, an invasive radiology nurse and a member of the UMass Memorial negotiating team. "And our patients are not widgets on an assembly line." "When you have an accident at a factory, you do a recall," added Lisa Cargill, vice chair of the UMass committee. "When you have an accident at a hospital, you have a funeral." In addition to nurses, the event drew broad support from the labor community, including Massachusetts AFL-CIO President, Bobby Haynes, as well as local public officials. "They can find the money. If they have $90 million in profits, some of it ought to go where it should go ­ to the people that made those profits, the nurses, and other workers in these facilities," Haynes told the crowd. "We need to get the message out. We need to fight. We need to secure justice and honor and dignity for working people and we're tired of backing up; we're tired of giving in, we need some respect in this community, and we're going to get it from these people. You deserve a good contract!" "The days of profiting off patients' sickness, off of the backs of nurses are over. Hang together and know we have your backs," said Jeff Breslin, RN, an NNU member and president of the Michigan Nurses Association, who spoke at the rally on behalf of NNU. --David Schildmeier

Tufts RNs Protest Floating Plan

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n response to a recently announced plan to implement a policy that would allow nearly all nurses at Tufts Medical Center to float to cover for chronic staffing shortages on other units, the Massachusetts Nurses Association local bargaining unit in early October staged a silent protest in the highly trafficked lobby of the medical center, which was attended by more than 100 nurses dressed in black scrubs, affixed with stickers that read "Reject Forced Floating" and "Safe Staffing Now." The protest occurred just prior to an open forum for hospital staff by the hospital's Chief Nursing Officer Nancy ShendellFalik. As part of the protest, a dozen star-shaped black balloons were delivered to Shendell-Falik at the forum. The card with the balloons read, "Mourning the death of safe patient care at TMC." Nurses were outraged to learn of the plan, introduced to the nurses' MNA negotiating committee, which would essentially allow the hospital to ask any nurse to float to another unit at any time, which not only is in direct violation of the nurses' union contract, but also compromises nurses' ability to provide safe nursing practice. The nurses immediately began to raise concerns

Statement of Ownership, Management, and Circulation

Publication title: National Nurse. Publication number: USPS 0807-560, ISSN 2153-0386. Filing date: 9-28-2010. Issue frequency: Monthly except for combined issues in January-February and July-August. Number of issues published annually: 10. Annual subscription price: $40. Complete mailing address of known office of publication: 2000 Franklin St., Oakland, Alameda County, California, 94612-2908. Contact person: Lucia Hwang. Telephone: (510) 273-2200. Complete mailing addresses of headquarters or general business office of publisher: Same as above. Publisher: California Nurses Association/National Nurses United, 2000 Franklin St., Oakland, California, 94612. Editor: Lucia Hwang. Managing editor: None. Owner: California Nurses Association/National Nurses United, 2000 Franklin St., Oakland, California, 94612. Known bondholders, mortgagees, and other security holders owning or holding 1 percent or more of total amount: none. Tax status: Has not changed during preceding 12 months. Publication title: National Nurse. Issue date for circulation data below: July-August 2010. Extent and nature of circulation: Registered nurse members of CNA/NNU and subscribers. For the following, the first number represents the average number of copies of each issue during preceding 12 months and the second number represents the number of copies of the single issue published nearest to filing date. Total number of copies (net press run): 124,412; 148,500. Mailed outside-county paid subscriptions stated on PS Form 3541: 117,464; 141,165. Mailed in-county paid subscriptions stated on PS Form 3541: 0; 0. Paid distribution outside the mails including sales through dealers and carriers, street vendors, counter sales, and other paid distribution outside USPS: 0; 0. Paid distribution by other classes of mail through the USPS: 72, 81. Total paid distribution: 117,536; 141,246. Free or nominal rate outside-county copies included on PS Form 3541: 50; 50. Free or nominal rate in-county copies included on PS Form 3541: 0; 0. Free or nominal rate copies mailed at other classes through the USPS: 5; 37. Free or nominal rate distribution outside the mail: 4,800; 4,800. Total free or nominal rate distribution: 4,855; 4,887. Total distribution: 122,391; 146,133. Copies not distributed: 2,021; 2,367. Total: 124,412; 148,500. Percent paid: 94.5%; 96.7%. Information in this statement will be published in the October 2010 issue of this publication.

about the plan, and a flyer was circulated by the union detailing the nurse's concerns. The union told management that the appropriate place to raise this issue is at upcoming union contract negotiations, where the parties would have the obligation to negotiate the policy, and nurses would have the right to strike if they didn't agree with it. Whatever the hospital's decision on the plan, the MNA will address the issue during its negotiations, along with a host of other concerns related to poor staffing conditions and deplorable working conditions at the hospital. Shendell-Falik's misplaced floating plan is just the latest in a series of decisions the hospital has made that have angered the nursing community, including the decision a year ago to institute a new "model of care" at the hospital, which consisted of increasing nurses' patient assignments on most floors, while failing to provide necessary support staff. Last February, several hundred nurses picketed outside the facility to protest the staffing cuts. What was once one of the better-staffed hospitals in Boston, if not the state, is now one of the worst-staffed hospitals. In fact, over the 12-month period since the staffing cuts were implemented, nurses at the hospital had filed 328 official reports of unsafe staffing conditions that threatened the nurses' ability to deliver quality patient care. The hospital neglected to post its new staffing plan on the hospital association's "Patients First" website, so the public couldn't compare its staffing plan to other hospitals in the area. "We are saddened and appalled at the hospital's total lack of regard for nursing practice and the quality of care our patients receive," said Barbara Tiller, RN, chair of the nurses' bargaining unit. "Since management refuses to listen to us, we are taking all necessary steps to make sure our voice is heard. We feel we have exhausted every means of resolving the unacceptable changes the hospital administration has implemented. We are being forced to take these measures, because our patients and our licenses are on the line." ­ David Schildmeier

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Watsonville RNs On Strike

egistered nurse Roxanne Heisinger can't help but start to cry when she thinks about the care that patients at Watsonville Community Hospital, where she works, are not getting. Her telemetry unit is so short staffed that patients are not getting fed and changed promptly. Others are falling and hurting themselves. "Nobody should have to vomit on themselves and lay there without having that cleaned up right away," said Heisinger. "I have little old ladies who are confused and falling. We don't have enough people watching them. They've cut our support staff and they're not taking acuity into account." Despite attempts by Heisinger and her coworkers to solve staffing issues at the bargaining table over the past nine months, the hospital has barely acknowledged their concerns. So Watsonville Community Hospital's 300 RNs staged a one-day strike on Oct. 26 to show administrators that they mean business. The hospital, which used to be a community facility but in 1999 was purchased by corporate hospital chain Community 8

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Health Systems (CHS) in Tennessee, responded by putting the emergency room on diversion five days before the strike, and then locking out the nurses for two additional days. Nurses at the facility, many of whom have worked there for decades, said they were extremely upset that patient care has deteriorated under CHS' ownership and that the company has retaliated against them for simply wanting to take better care of patients. They are more determined than ever to reverse this trend. "Does anyone remember when we used to routinely give back rubs to patients?" asked Tim Thomas, an operating room RN, of a large crowd of coworkers during a spirited noon rally on the strike lines outside the hospital. "We don't do that anymore. We are slipping away from the care we used to give 20 years ago. [Management] needs to know we have deep concerns about the care we give and our relationship with the hospital." RNs at Watsonville Community Hospital report that understaffing, staffing not based on acuity, and lack of meal-and-break-relief RNs is jeopardizing the safety and care of patients. Heisinger estimates that for 98 percent of her shifts, the hospital's acuity software says her four patients on average require

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three hours of care each. That's 12 hours of care. Yet her shift in telemetry is eight hours. "With the bad economy, people are waiting longer and longer to come to the hospital. They are so much sicker," she said. Many RNs criticized the hospital for not factoring acuity into staffing decisions. "We need an acuity system that works," said Mary Kelly, a medical-surgical charge nurse at WCH. "Ratios say those numbers are the minimums. But to them, a 5 is a 5 is a 5." The nurses' contract expired in July, and Thomas, who is chief nurse representative and also a member of the negotiating committee, said the hospital has refused to bargain in earnest with the RNs by constantly postponing and rescheduling meetings, and by simply saying no to every proposal. Carmen Attanasio, a surgical ICU RN at Wilkes-Barre General Hospital in Pennsylvania, knows what that feels like. He and his coworkers have also been trying to bargain a contract with Community Health Systems since last summer. "I am sick of it. I'm sick of how CHS treats hospitals all around the country," said Attanasio, who had traveled to the Watsonville strike in support of the RNs. "We just want you to know that your fight is our fight."--Staff report

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Michigan Nurses Hold Convention, Unveil New Logo

he michigan Nurses Association unveiled its new logo with a rousing video on Sept. 24 at the kickoff of its state convention. The logo ties MNA closer to its national union, National Nurses United. "MNA-NNU is building on the bedrock of the strength and power of Michigan nurses while standing in solidarity with our national union," said John Karebian, MNA's executive director. "Our new logo reflects these successes, signaling a new era in which RNs flex their muscles to transform the healthcare system, not just within individual hospital chains, but nationwide." "From now on, when people see our logo on signs, on our clothing, and on our letterhead, they will know that the strength of Michigan has joined a national nurses union boasting over 155,000 members," said Jeff

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Breslin, RN, MNA president in his address to the House of Delegates. "Since its inception in 2009, NNU has rallied for safe patient care in Washington, California, and Minnesota, organized nurses throughout the United States, and answered the call for nurses to help with the Haiti earthquake relief effort. MNA has been there at every NNU event as a valuable and respected partner." As attendees entered the hall for the convention, they were greeted by large panels describing MNA's five areas of concentration: organizing, nursing practice, collective bargaining, public policy, and politics. MNA's new logo was evident everywhere, from large banners on the walls depicting "MNA at Work" to the attendees' bags, to new black jackets for everyone. Over the two day period, attendees were exposed to the effect of health information technology and for-profit medicine on nursing practice, RNRN's work in Haiti and other locations, and labor initiatives around the

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nation. The annual MNA awards banquet honored nine outstanding healthcare professionals and featured Sen. Debbie Stabenow as a special guest speaker. The MNA-PAC, in a special challenge held on Saturday morning, raised more than $11,000 in contributions, and attendees heard from Michigan candidates David Leyton (for attorney general), Jocelyn Benson (for secretary of state) and Mark Schauer (Congressman, D-7). An integral part of the two-day conference was the MNA House of Delegates, which elected new leaders, approved resolutions, and heard various reports on the business of the association. Compliments flowed from members after the convention. Nurses spoke of their newfound desire to be involved and showed their resolve by paying the fee and reserving a spot on the team heading for Washington, D.C. next spring for the NNU Staff Nurse Assembly. It was a full 48 hours of nurse activism at its best. --Ann Kettering Sincox

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Florida

florida nurses in September expanded into four new areas by starting metropolitan committees in Gainesville, Daytona Beach, Palm Beach County, and Jacksonville. These groups build on the original three established in Tampa/St. Pete, Orlando, and Ft. Lauderdale/Miami. "This is an exciting time for nurses in Florida," said RN Angel Stewart, who attended the meeting in Gainesville. "We hope to win ratios but we also hope to be part of forming an organization of nurses so that we can work together to support each other in our efforts to advocate for our patients." Nurses from each of these geographic areas were represented on a leadership council selected by their colleagues at an Oct. 23 statewide strategy group meeting held in Orlando. This group plans the ratios and rights campaign for NNOCFlorida/NNU and provides leadership and overall direction for the organization.

on hospitals maintaining minimum RN-topatient staffing," said Liane Koch, an RN in labor and delivery. "Safe staffing provisions are also critical to our ability to retain and recruit experienced registered nurses who can deliver that care." The emergency department won extra staffing, including a charge nurse who will not have patient assignments during peak periods. The hospital also agreed to better staffing by acuity for the critical care services unit. RNs were also able to hold the line on employer contributions to their healthcare benefit, and win safe patient handling language. Elsewhere in the state, at Eastern Maine Medical Center in Bangor, RNs in early November scheduled a strike authorization vote to put pressure on management, which so far had failed to agree to safe staffing language in their contract negotiations.

Maine

rns at The Aroostook Medical Center in Presque Isle approved in October a new twoyear contract that includes many new safety provisions, a key issue for nurses during recent negotiations. "Our ability to provide quality and safe care to our patients depends 10

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Texas

texas nurses at their September bargaining leadership council enjoyed visits from out-of-state nurses, giving them an opportunity to trade stories and share strategies for building the RN movement. Three Hospital Corporation of America nurses from Research Memorial Medical Center in

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Kansas City attended to report on their major union victory on Sept. 14. The Texas nurses passed a motion pledging solidarity and support of their Kansas City colleagues working in three NNU-represented HCA hospitals there. A delegation of NNOC-Florida nurses also travelled to Texas to report on the RN movement they are building in that state. Texas nurses will soon return the favor by traveling to Tampa in November. RNs spent much of the meeting reporting and discussing contract negotiations with HCA, as well as progress toward building strong nurse organizations in all facilities. NNOC nurses from the metro committees met with HCA nurses to plan the Rights and Ratios campaign work for October through December. Each NNOC city now has a RN Rights and Ratios Committee and a work plan for the month of October. The afternoon session was devoted to discussion of the national political situation and how NNOC nurses can translate nurses' values into positive social change for nurses, patients, and the public. --Staff report

Texas RNs rally for state minimum safe staffing ratios at a bargaining leadership conference in September.

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Rose Ann DeMoro

Executive Director, National Nurses United

An Open Letter to Nicky Diaz

person, there is sadness in his heart. When a nia, the sixth largest economy in the world. ear nicky, Meg Whitman and those like her see a Had it not been for you, that could have This letter comes to you homeless person, they are annoyed because been Meg Whitman. on behalf of nurses that person is in their visual sight. I know Governor-elect Brown quite well. throughout the country to Unknown thousands of people could And what I know mostly about him is that thank you for your courage have become deeply harmed by a Whitman he has tremendous compassion. in taking a difficult stand Governing California, or anywhere in Amer- administration. These people, with advocathat undoubtedly changed history. cy coming from the nurses, will hopefully ica, is no easy task. But in great part because of As Meg Whitman's hardworking housefind California a place where they have you, we will now be able to develop a model for keeper for nine years, Whitman obviously healthcare, where they have jobs, and the rest of the country to follow, a model where had respect for the quality of your work. But where they can live a secure life with their people are respected for their humanity. like the rest of us, you would have been Unlike under a Whitman administration, family. collateral damage to her political ambitions. If every state in this nation had a Nicky where people would have been viewed as When you stood up, while visibly shakDiaz, this country could truly ing, to one of the wealthiest become the home of the brave women in the world, you stood When a Jerry Brown sees a homeless and the free. And people who up for all people who are not a person, there is sadness in his heart. put themselves at risk, as you part of the corporate elite. You When a Meg Whitman and those did, to speak out for others stood up for humanity. like her see a homeless person, they would be viewed as heroes. As you said, "I'm doing are annoyed because that person From the bottom of my this because I know there are is in their visual sight. heart, thank you, Nicky. The a lot of Megs out there who are nurses in California will be mistreating the Nickys who work honoring you at their convention next expendable commodities if they were not so hard for them." year. We sincerely hope that you and your Whitman and most in her corporate class serving up greater profits for corporations. family may find California a safe and As Brown said in the second debate with see all of our lives as expendable for money. loving place for you for the rest of your Whitman, to be used, to "do our dirty work, We were all you, Nicky. lives. and then we're finished with you, like an Your bravery has been noted throughout orange [that has been squeezed]. You just the world. throw it away ... That's not right." Largely because of your honesty, Jerry Rose Ann DeMoro is executive director of National When a Jerry Brown sees a homeless Brown will now become governor of CaliforNurses United.

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icandra (Nicky) Diaz Santillan, an undocumented immigrant from Mexico, was employed by Meg Whitman and her husband, Dr. Griffith Harsh IV, for nine years as a housekeeper. In a Sept. 29 press conference, Diaz recounted how, after Whitman began her campaign for governor, Nicky went to the billionaire CEO and asked for help to find an immigration attorney to seek legalization. The response from Whitman, who later told press she viewed Nicky as a "member of her extended family," was to fire Diaz and tell her, "Don't say anything to my children, I will tell them you already have a new job and that you want to go to school and from now on, you don't know me and I don't know you. You never

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have seen me, and I have never seen you. Do you understand me?" Whitman's actions highlighted her double standard on immigration policy (a hard line for other employers, a different standard for herself). It also reinforced doubts about Whitman's character and credibility ­ she denied knowing Diaz's immigration status though it was revealed that Dr. Harsh had written a note on a letter from the federal government indicating that her name and Social Security number did not match, a clear indication that they were aware of her legal status and a refutation of Whitman's insistence they had seen no documents about her status. The Los Angeles Times later called the Sept. 29 press conference a "turning point" in the California governor's race.

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CE Home Study Course

Scripting and Rounding

Impact of the Corporate Care Model on RN Autonomy and Patient Advocacy

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This home study CE is part one of a two-part series. Look for the second installment and the CE quiz to appear in the next issue of National Nurse.

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Description

his home study course examines the impact of scripting and rounding on the autonomous practice of registered nurses that interferes with their critical role as patient advocates. Scripting and rounding schemes are being aggressively marketed, incentivized, and implemented in a variety of acute-care and outpatient settings using deceptively reassuring terms on embracing change, transforming care at the bedside, and increasing customer satisfaction designed to create and influence the public's "perception" of quality. It describes a new restructuring model for nursing, which is aimed at deskilling and automating RN interactions with patients. Under these new schemes, patient outcomes are secondary to patient satisfaction scores based on customer service and hospitality as practiced by companies such as Disney and five-star hotels. These schemes are being mandated by hospital policy over the objections of direct-care RNs despite the fact that there is a dearth of evidence linking patient satisfaction to positive clinical healthcare outcomes.

Objectives upon completion of this home study RNs will be able to: Articulate their major advocacy role in the delivery of safe, therapeutic, and effective patient care where the patients' individual healthcare needs, interests, and wishes are respected and protected. Explain the potential of protocols and patient interaction scripts for replacing individualized human interaction in the delivery of A total decrease of 14.2 percent in the ratio of licensed nursing healthcare. staff to acuity-adjusted patient days of care because of the increase Describe how rounding, scripts, and rigid protocols can supplant in patient acuity. critical thinking and override the independent professional clinical The skill mix of nursing staff shifted, and as a result, RNs were judgment of registered nurses. forced to take on additional supervisory responsibilities that took them State why safe staffing with specific, numerical RNaway from the bedside at a time when their patients to-patient ratios, and the requirement that hospitals needed more nursing care. staff up from the minimum based on individual patient Concerns that have arisen from increased patient Submitted by the Joint acuity, is an evidence-based practice that improves acuity and increased workload appear to be directly Nursing Practice patient outcomes, results in cost-savings, and increases related to job dissatisfaction expressed by nurses in a Commission, DeAnn both patient and nurse satisfaction that allows directvariety of research studies. McEwen, RN, and care RNs to be in control of the nursing process. These reports were developed and written by outHedy Dumpel, RN, JD side research and academic organizations designatProvider Approved Background ed as Evidence-based Practice Centers, and are by the California based on rigorous, comprehensive reviews of relein 1996 the institute of medicine (iom) issued Board of Registered vant, peer-reviewed scientific literature. The a report that recognized the importance of deterNursing, Provider AHRQ's goal in sponsoring these reports was to promining appropriate nurse-to-patient ratios. The #00754 for 2.0 contact hours (cehs). vide the scientific foundation that public and private IOM's analysis of staffing and quality of care in Recognized by all organizations can use to improve the quality and hospitals concluded by calling for "a systematic states with the excepdelivery of healthcare services. effort" (on a national level) to collect and analyze tion of Arkansas, Although inadequate staffing places a heavy relevant data for the purposes of informing and Delaware, Massachuburden on nurses and adverse events are painful for developing public policy. setts, Minnesota, Montana, North Carolina, patients, there is a considerable financial burden According to research funded by the Agency for and South Carolina. as well. Another AHRQ study found that all adverse Healthcare Research and Quality (AHRQ) hospitals events (pneumonia, pressure ulcer, UTI, wound with low nurse staffing levels tend to have higher

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rates of poor patient outcomes. Numerous other studies have found that patients in short-staffed hospital units are more likely to have higher rates of hospital-acquired illnesses and adverse outcomes, such as pneumonia, upper gastrointestinal bleeding, urinary tract infections, shock, longer hospital stays, and failure to rescue. "Failure to rescue" is defined as the death of a patient with a life-threatening complication for which early identification by nurses and medical and nursing interventions can influence the risk of death. As of March 2004, the largest of these studies on nurse staffing, ( jointly funded by AHRQ, the Health Resources and Services Administration, the Centers for Medicare and Medicaid Services and the National Institute of Nursing Research) found the following: In hospitals with high RN staffing, medical patients had lower rates of five adverse event outcomes. Major surgery patients in hospitals with high RN staffing had lower rates of UTIs and failure to rescue. Higher rates of RN staffing were associated with a 3 to 12 percent reduction in adverse outcomes. Higher staffing at all levels of nursing was associated with a 2 to 25 percent reduction in adverse outcomes, depending on the outcome. Three AHRQ-funded studies found a significant correlation between lower nurse staffing levels and higher rates of pneumonia. Another study, funded jointly by AHRQ and the National Sciences Foundation, examined the relationship between nurse staffing and hospital patient acuity (the average severity of illness of the inpatient population). Acuity determines how much care a patient needs: the higher the acuity, the more care is required. This study found: A 21 percent increase in hospital patient acuity between 1991 and 1996.

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infection, sepsis, patient fall/injury, and med/drug events) were associated with increased costs. For example, the cost of care for patients who developed pneumonia while in the hospital rose by 84 percent. The length of stay increased by 5.1-5.4 days, and the probability of death rose 4.67-5.5 percent (Cho, Ketefian, Barkauskas, et. al, 2003). Hospitals have pursued a number of strategies to limit costs and increase revenue by reducing their RN staff and replacing them with unlicensed assistive personnel. McCue, Mark, and Harless conducted a study published in 2003 that examined the relationship between nurse staffing, quality of care, and hospital financial performance. The researchers found a statistically significant increase in operating costs when hospitals increased their staffing of RNs, but no statistically significant decrease in hospital profit, suggesting that the cost-benefit of reduced complications and length of stay offsets the additional cost incurred by increasing the ratio of the RN staff. The Institute of Medicine: From Safety to Quality. How did we get here from there? in 1999 the iom committee on Quality of Healthcare in America published its landmark report, "To Err is Human." The IOM reframed medical error as a chronic threat to public health. One of the report's main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group ­ this is not a "bad apple" problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. For example, stocking patient-care units in hospitals with certain full-strength drugs, even though they are toxic unless diluted, has resulted in deadly mistakes. Thus, mistakes can best be prevented by designing the health system at all levels to make it safer ­ to make it harder for people to do something wrong and easier for them to do it right. Of course, this does not mean that individuals can be careless. People still must be vigilant and held responsible for their actions. But when an error occurs, blaming an individual does little to make the system safer and prevent someone else from committing the same error. The IOM committee followed its initial report 18 months later in 2001 with a second report titled, "Crossing the Quality Chasm." The Quality Chasm report broadly implied that patient safety is only part of a larger picture. Indeed, in a theoretical opinion article titled, "A User's Manual for the IOM's `Quality Chasm' Report," Dr. Donald Berwick stated the second report was "even more important because it deals with the entire terrain of concerns about healthcare quality." He further opined that "to the serious student of healthcare quality and the serious leader of needed change, it signals the possible dawning of a new and persistent sense that the U.S. healthcare system's performance in many dimensions, not just safety, is unacceptably far from what it should be." In bold print under the title of the article, Berwick asserts, "Patients' experiences should be the fundamental source of the definition of quality." How reliable is a check list? in 2002, the centers for Medicare and Medicaid Services (CMS) formed a partnership with the AHRQ to develop, test, and seek endorsement of a nationally standardized survey tool and methodology for such data collection that would allow "valid" and credible 14

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practical comparisons to be made among hospitals locally, regionally, and nationally. Over the years many hospitals have collected information on patient satisfaction for their own proprietary use for quality control, marketing, and advertising purposes. Although many hospitals administered their own surveys or were already working with survey vendors to design and administer a patient satisfaction survey as part of their own internal quality improvement efforts, the questions and methodologies were customized and did not allow comparison across hospitals. AHRQ published a Federal Register notice on July 24, 2002, soliciting the submission of existing instruments measuring patients' perspectives on care. The notice of request for measures closed on September 23, 2002. The seven submissions received were reviewed rigorously by the Consumer Assessment of Healthcare Providers and Systems (CAHPS) II Grantees (AIR, Rand, and Harvard). Three criteria were considered in reviewing the submissions: 1) Does the instrument capture the patients' perspectives on care in acute-care and/or hospital settings?; 2) Does the instrument demonstrate a high degree of reliability and validity?; and 3) Has the instrument been widely used, not just in one or two research studies or local hospital settings? In January 2003, AHRQ submitted to CMS a draft HCAHPS instrument that consisted of 66 questions. AHRQ drew upon the seven surveys submitted by vendors, a comprehensive literature review, and earlier CAHPS work to develop the HCAHPS instrument. Most reviewed studies of hospital patient satisfaction used institution-specific measures rather than a standard instrument. The instruments reviewed included the HCA Patient Judgments System Questionnaire/Nashville Consulting Group Survey; the Comprehensive Assessment of Satisfaction with Care Instrument; the SERVQUAL; the Press Ganey Survey, and several privately prepared instruments. In instances when AHRQ drew upon items in existing surveys from vendors, it made material changes, modifying wording and changing the response sets. The instrument that was developed to meet the need for publicly reporting patient perspectives on care information is called Hospital CAHPS, or HCAHPS. In 2003, CAHPS II investigators and the Agency for Healthcare Research and Quality (AHRQ) performed an empirical analysis of the HCAHPS pilot data of hospital patients' perspectives of care to evaluate the degree to which these experiences corresponded with the Institute of Medicine's (IOM's) nine domains of care: respect for patient's values; preferences and expressed needs; coordination and integration of care; information, communication, and education; physical comfort; emotional support; involvement of family and friends; transition and continuity; and access to care. While some of the survey items correlated strongly with this hypothesized domain or composite in pilot studies, it became clear that the general hypothesized structure was inconsistent with the observed data. Based on analyses of the data and stakeholder suggestions, a revised HCAHPS survey was produced that consists of questions assessing seven internally developed domains of care: (1) nurse communication; (2) nursing services; (3) doctor communication; (4) physical environment; (5) pain control; (6) communication about medicines; and, (7) discharge information. The revised survey also includes global rating items for nursing

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care, doctor care, and hospital care. A single item is also included that assesses whether or not the patient would recommend the hospital to family and friends. The seven composites had a median internal consistency reliability of 0.69 and a median hospital-level reliability of 0.74 in the pilot study. In addition, these reporting composites were significantly associated with global ratings of the hospital and willingness of patients to recommend the hospital to family and friends. In May 2005, the final 27-item HCAHPS survey was endorsed by the National Quality Forum (NQF), a national organization that purportedly represents the interests of consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. In December 2005 the federal Office of Budget and Management gave final approval for the national implementation of HCAHPS for public reporting purposes. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) the hcahps is a standardized, publicly reported nationwide survey of patients' perceptions of their hospital experience that was intended to produce data that allows "objective and meaningful" comparisons of hospitals on topics that are important to consumers. The three broad goals of the HCAHPS survey are: to produce data about patients' perspectives of care. to encourage new incentives for hospitals to improve quality of care through public reporting of the results. to enhance accountability in healthcare by increasing transparency, (through public reporting of consumer satisfaction perceptions), of the quality of hospital care provided in return for public investment. Hospitals implement HCAHPS under the auspices of the Hospital Quality Alliance (HQA), a private/public partnership that reportedly includes major hospital and medical associations, measurement and accrediting bodies, government, consumer, and other stakeholders with an interest in improving hospital quality. The survey, its methodology, and the results it produces are in the public domain. The enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute-care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions ("subsection (d) hospitals") must collect and submit HCAHPS data in order to receive their full IPPS annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS survey, may receive an annual payment update that is reduced by 2.0 percentage points. Non-IPPS hospitals, such as Critical Access Hospitals, may voluntarily participate in HCAHPS. The recently enacted Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) includes HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program, beginning with discharges in October 2012. The HCAHPS survey asks discharged patients about their recent hospital stay. The survey contains 18 core questions about the socalled "critical" aspects of their hospital experiences, (communications with doctors and nurses, responsiveness of hospital staff, cleanliness and quietness of the hospital environment/patient

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rooms, pain management, communication about medicines, discharge information, overall rating of the hospital, and would they recommend the hospital to family and friends). The HCAHPS survey is not restricted to Medicare beneficiaries, and is administered to a random sample of adult patients across medical conditions between 48 hours and six weeks after discharge. Hospitals may use an approved survey vendor, or collect their own HCAHPS data (if approved by CMS to do so). To accommodate hospitals' preferences, HCAHPS can be implemented by a choice of survey modes: mail, telephone, mail with telephone follow-up, or active interactive voice recognition (IVR). If you're happy and you know it, clap your hands? although the stated aim of the HCAHPS is to produce valid and reliable objective data for hospital comparison, many credible researchers are of the opinion that the number of confounding variables poses a substantial threat to the validity of the data. Experienced medical and nursing researchers know that patients' perceptions and the subjective interpretation of their experiences can be limited and of little value as a consistent and reliable indicator of quality, due to several uncontrollable variables such as differing levels of cognitive ability, impairment due to illness, injury, clinical condition, and the side effects of therapeutic interventions and medications that may render their responses useless as empirical evidence and for making meaningful comparisons. And what about the patients who died? It's a small leap to consider the fact that since those "customers" won't be coming back, their satisfaction, or lack thereof, with the care they received, is of little concern to the proprietors of hospitality industry schemes. It stands to reason, because what they're looking for is repeat "business" and customer loyalty based on "satisfaction." The exception of course, would be the "perception" of the family and friends. Professionals understand that loss and grief is a process that can involve many stages, from shock and numbness, shame and doubt, to anger and frustration. If families are not "happy" or "satisfied" with the outcome of their loved one's hospitalization, chances are they might be inclined to go looking for someone to blame; chances are they might even consider filing a lawsuit against the hospital; chances are that a good consumer advocate attorney might lift the lid on the smiles and satisfaction marketing schemes and uncover the fact that the hospital's RN-to-patient ratios were unsafe, and that subtle signs and symptoms of deterioration were missed due to deliberate short-staffing. The point being that as nurses, we're educated, licensed, and experienced to assess whether or not the care we're able to provide is safe, therapeutic, and effective, and whether or not there are barriers to our ability to apply the nursing process for the exclusive benefit of our patients. Patients and their families are generally not qualified or sophisticated enough to make that determination with regard to true "quality" of care indicators, i.e., whether or not there were sufficient numbers of competent RNs employed and on duty to meet their needs and reduce their risks of suffering preventable complications of their illness, injury, or treatment. Ignoring the evidence: Collaboration with industry for profit and control over the past several years, many hospitals have cut costs by reducing their licensed nursing staff in response to declining manN AT I O N A L N U R S E

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aged care reimbursement contracts. Other hospitals have cut spending for support personnel, thereby increasing the workload of RNs. One reason for changing nursing processes and systems is to strongly embed management control to ensure the development of behaviors and skills that reflect the institutional business strategy. Key elements of the restructuring of the hospital environment from a nursing process model to a corporate care model are driven by the economic incentives of institutional providers and the commercial mandates of the healthcare industry. Along with shared governance schemes and new technologies, many hospitals are now introducing scripted "rounding" schemes. These schemes require RN loyalty to the business enterprise. This is hostile to the fiduciary responsibility of the RN to provide care in the exclusive interests of their patients. For example, the Studer Group, a proprietary proponent of these schemes, published a newsletter/press release article titled "Rounding for Outcomes: How to Increase Employee Retention and Drive Higher Patient Satisfaction." It's written by a nurse who is identified as a "Studer Group Coach." The author states, "While many organizations struggle with issues related to pain management, response to call lights, attention to personal needs, and increasing their sensitivity to patient's inconvenience, rounding is a powerful way to shape the experience for patients and increase patient perception of care." From an evidence-based standpoint, this author has a vested and biased interest in promoting the program. The references for the article used to support her claims are Studer Group press releases, promotional materials, and Press-Ganey opinion surveys from 2000 and 2003. Other so-called "studies" and articles reviewed on rounding reveal a similar lack of rigorous scholarly study and empirical scientific evidence to support what appear to be preconceived and purported claims of satisfaction and quality outcomes. There are serious concerns about the validity and reliability of rounding/scripting studies due to oversimplification of the conceptual design and inaccurate correlation of questionable "nursing sensitive" indicators to quality patient outcomes, including the use of voluntary, proprietary, and confidential data. There is a critical lack of systematic and ongoing monitoring and evaluation of the effects of organizational redesign and staffing reconfiguration on patient outcomes. There has been drastic clinical restructuring of nursing processes, and the acuity of patients has been rising steadily for years. Patient care is more complex, causing an increase in nurses' workloads, especially with the imposition of additional burdens of data collection that is unrelated to initial and ongoing patient assessments, documentation of the actual care provided to the patient, and the evaluation of patient's response to the treatment, patient education, and nursing advocacy activities. Research designs can lead to meaningless "findings" if care is not taken in the selection of variables and in avoiding the temptation to assume that because a variable is associated with a particular outcome, that it is therefore a cause of that outcome. The results of several rounding and patient satisfaction "studies" are highly suspect as measures of quality. It's important to note that the National Quality Forum (NQF) lists 15 voluntary consensus standards for nursing-sensitive care (standards based on patient outcomes, nursing interventions and system level measures) and consensus-based performance measures 16

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for nursing care. A reduction in the patient's use of call lights is NOT one of them! Undaunted, a number of misguided champions of change have embraced scripting and rounding initiatives and other transforming-care-at-the-bedside initiatives. In the race to "publish or perish," several clever and even amusing titles have washed up along the periphery of our nursing literature shoreline like so much debris that's cast off from the sea of serious and credible research. These papers all but ignore the results of more rigorous scientific studies on the relationship between the significance of increased nurse-to-patient ratios with staffing that is flexed up from the minimums based on patient acuity, and their well-documented impact on improved patient safety, nurse and patient satisfaction, and therapeutic outcomes that address the NQF standards in a more comprehensive and meaningful way. Most of the published results of rounding and scripting schemes are as substantive as sea foam due to their lack of identification of critical problems such as deliberate short-staffing and its relation to preventable complications and patient deaths, and the implementation of effective solutions, such as increasing the number of direct-care RNs at the patient's bedside. Below is a selected listing of article titles: Ring for the Nurse! Improving Call Light Management Hourly Rounding for Positive Patient and Staff Outcomes: Fairy Tale or Success Story? Rounding for Outcomes Using Scripts Call Light Study: A Summary Abstract from the Studer Group You Called? Hourly Rounding Cuts Call Lights Rounding for Outcomes: A Practical Tool to Increase Patient and Staff Satisfaction Effects of Nursing Rounds on Patient Call Light Use, Satisfaction, and Safety How to Increase Employee Retention and Drive Higher Patient Satisfaction Hourly Rounding: How One Nurse Reduced Call Lights to Almost Zero Patient Rounding: A Prescription for Satisfaction Critical thinking and analysis: Food for thought some of the authors of these articles on rounding are refreshingly upfront about the weaknesses and limitations of their findings. Common threads and concerns begin to emerge, and the prudent nurse should be apprised of them in order to more critically and properly evaluate the lofty claims made by proponents and authors with undisclosed biases that are often unsubstantiated. According to one such article by Kocis and Miksch (2007), "A search for written evidence revealed a paucity of literature regarding the direct use of rounding as a strategy." Yet another commentary, by Melnyk (2007), with regard to a study titled, "Nursing Rounds and Patient Safety" (Meade, Bursell, and Ketelsen, 2006) is instructive. Melnyk describes a rating system for evaluating the hierarchy of research evidence (Melnyk and Fineout-Overholt, 2005). She encourages clinicians to evaluate the strength of the evidence presented in a study before initiating a change in practice. A Level I study presents "evidence from a systematic review or meta-analysis of all relevant randomized controlled trials (RCTs), or evidence-based clinical practice guidelines based on systematic reviews of RCTs." Randomized controlled trials are the strongest

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design for testing cause and effect relationships. Quantitative study is ideal for testing hypothesis and for hard sciences trying to answer specific questions. On the other hand, the lowest level on the study design totem pole of hierarchical and qualitative research is a Level VII study, which cites "evidence from the opinion" of the authors or reports of "expert" committees. Qualitative study is a much more subjective form of research in which researchers often allow themselves to introduce their own bias to help form a "more complete" picture. Qualitative research may yield stories or descriptions of feelings and emotions, and the interpretations of research subjects are given weight; there is no attempt to limit their bias. Scripting, rounding, and patient satisfaction researchers have an apparent preference and attachment to the "less-than-rigorous" form of qualitative study, so their own bias often plays heavily into the results. While qualitative studies have their place, the researchers must have the integrity to disclose their biases, and be forthcoming about the weaknesses and limitations of their study when reporting their findings and making recommendations. A cursory review of the literature demonstrates that many of the recommendations to implement scripting and rounding schemes are not supported by the so-called "evidence" presented by the author(s). For example, the findings in the 2006 study by Meade, et. al, were listed as follows: "Of the 46 units in 22 hospitals that participated in the (Rounds/Patient Safety) study, data from 19 units in 8 hospitals were excluded from the analysis because of poor reliability and validity of data collection." Melnyk's commentary, (with implications for action in clinical practice and future research), regarding the study by Meade and associates, includes the following statements:

"When assessing whether findings from an intervention study are valid (i.e., as close to the truth as possible), it is important to answer some key questions, including whether: (1) random assignment to study groups was used, (2) the study groups were equal at baseline on key demographic and clinical variables, and (3) all of the subjects were accounted for at the end of the study. This research used a quasiexperimental design that did not randomly assign hospital units to one of the three intervention groups, which resulted in non-equivalent groups at the beginning of the experiment (e.g., patient satisfaction and falls were not equal among the three groups at the beginning of the study). In addition, there was a high attrition rate in this research, (i.e. data from several units were excluded from the analysis), which also threatens the internal validity of this study."

Melnyk generously rates this study as a Level III in terms of strength of design. The question remains as to whether or not it measures what it intends to measure in terms of a relationship between safety and satisfaction. HCAHPS is purposely misread and misapplied by the industry the hcahps survey is a standardized tool that asks discharged patients about their recent hospital stay for purposes of measuring customer satisfaction. However, it is but one of the indicators currently used by CMS that purportedly allows the public to compare hospital quality. The prestigious Institute of Medicine reports have recommended a healthcare culture "that is transparent, open, safe, and honest about its defects and its performance." And, the IOM

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warns against "toxic financing schemes" and has recommended that CMS establish service area experiments of payment reform as a way to encourage improvement. Although a greater focus on patient safety has been a trend since the Institute of Medicine's landmark report in 1999 estimating that 44,000 to 98,000 people die yearly as a result of medical errors, several recent studies have turned the spotlight on nursing as a safety net. When nurses' workloads are too heavy, safety can too easily become compromised. Can we expect nurses caring for too many patients or working too many hours, and burdened with tasks and data collection schemes, to continue to catch 86 percent of the medication errors made by physicians and pharmacists that they usually intercept before such errors reach the patient? It has become apparent to many of the critical thinkers among direct-care RNs that some of the presumably well-intended "change agents" out there, in their rush to win their employer's coveted "early adopter" and "champion of change" badges, are guilty of not using well-constructed pre- and post-implementation studies of therapeutic outcomes to determine whether or not a change in practice and care model delivery is even justified in the first place. According to Dr. Berwick, "the overall strengths of the IOM'S `Quality Chasm' report lies foremost in its systems view. Rooted in the experiences of patients as the fundamental source of the definition of quality, the report shows clearly that we should judge the quality of professional work, delivery systems, organizations, and policies, first and only by the cascade of effects back to the individual patient and to the relief of suffering, the reduction of disability, and the maintenance of health." As the principal caregivers in any healthcare system, nurses are critical to the quality of care patients receive, a fact that is well-documented in multiple well-designed studies. The research on patient morbidity and mortality in relation to RN-to-patient staffing has been published in respected peer-reviewed scientific journals over the course of many years. The evidence is clear and convincing that safe staffing saves lives, but the bottom-line, profit-seeking mentality leads most healthcare employers to ignore the preponderance of evidence. Nurses are fed up while their employers waste time and money on unproven tactics and rounding schemes that nibble around the edge of the problem, while patients' lives hang in the balance and the careers of direct-care nurses are threatened. National Quality Foundation (NQF) patient-centered outcome measures include: death among surgical patients with treatable serious complications (failure to rescue); central line catheter-associated blood stream infections and rate of septicemia; ventilator-associated pneumonia for ICU and high-risk nursery patients; urinary catheter-associated urinary tract infections; hospital-acquired pressure ulcers; and falls associated with serious injury. NQF system-centered outcome measures include skill mix and percentage of RNs, LVNs, and number of nurse staffing hours, staffing and resource adequacy, voluntary turnover of staff, and collegiality of nurse-physician relations. Basic rounding and satisfaction study designs usually tout the success of their programs by casually addressing only one outcome goal, a reduction in the number of reported falls, but results so far are spotty and inconclusive. Because of a failure in the researchers' ability to address or control for significant confounding variables, the results are not applicable or generalizable. It's scientifically

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invalid to assume that these two measures alone, reduction in falls and increased patient satisfaction scores, could or should serve as a proxy for measuring patient safety and quality-of-care indicators. Any study that boils down quality care to two or three variables that are measurable is highly suspect. The nursing care process is a highly complex and interdependent process involving many participants and variables. Any meaningful measure of quality should take this into account. A more holistic and scientific study of patient care which takes into account whether or not the care provided is safe, therapeutic, effective, and beneficial to the patient in terms of measurable physiologic and functional outcomes is clearly a more academic approach to research for determining reliable, valid, useful, replicable, and generalizable findings.

What is scripting and rounding and where does it come from? one of the expensive consultants hired by hospital administrators is called the Studer Group. Its founder and CEO, Quinton "Quint" Studer is described by business news interviewers and in company profiles as a former teacher with a master's degree in special education. Studer started his career in healthcare as a community relations liaison at a substance abuse hospital in Janesville, Illinois. From there he worked his way up the corporate ladder in a variety of hospital administrative positions to eventually become president of Baptist Hospital, Inc., in Pensacola, Florida. Studer evidently took his leadership cue from contacts at Southwest Airlines, who told him to "focus on the employees, not the

References

Agency for Healthcare Research and Quality (AHRQ). (2008). The CAHPS hospital survey (H-CAHPS). (2008). Retrieved September 8, 2010, from http://www.cahps.ahrq.gov/content/products/HOSP/PROD_HOSP_Intro.asp Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H., (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association, 288: 1987-93. Aiken, L. H., Sloane, D. M., Cimiotti, J. P., Clarke, S. P., Flynn, L., Seago, J. A. , Spetz, J. , & Smith, H. L., (2010). Implications of the California nurse staffing mandate for other states. Health Services Research, 45 (4). 904-21. Berwick, D.M. (2002). A User's Manual for the IOM's `Quality Chasm' Report. Health Affairs, 21 (3): 80 ­ 90. Dall, T. M., Chen, Y. J., Seifurt, R. F., Maddox, P. J., & Hogan, P. F. (2009). The economic value of professional nursing. Medical Care, 47 (1), 97-104. Dumpel, H. (2010). Hospital magnet status: Impact on RN autonomy and patient advocacy. National Nurse. pp. 22-27. Eastabrooks, C. A., Midodzi, W. K., Cummings, G. C., Tickler, K. L., & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30 day mortality. Nursing Research 54 (2); 74-84. Ford, B. (2010). Hourly Rounding: A Strategy to Improve Patient Satisfaction Scores. Med/Surg Nursing, 19 (3). 188-191. Guadagnino, C. (2003). Role of patient satisfaction. Physician's News Digest; pp 1-12. Retrieved on July 25, 2010, from http://www.physicansnews.com/cover/1203.html HCAHPS: Hospital Care Quality Information from the Consumer Perspective. Centers for Medicare and Medicaid Services, Baltimore, MD. Website accessed on September 10, 2010, from http://www.hcahpsonline Institute of Medicine (IOM). (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. Jha, A. K. , Orav, E. J. , Zheng, J. , & Epstein, A. M., (2008). Patients' perception of hospital care in the United States. New England Journal of Medicine, 359:1921-31.

Kohn LT, Corrigan JM, Donaldson MS. (1999). Committee on Quality of Healthcare in America. Institute of Medicine of the National Academies. To err is human: building a safer health system. Washington, DC: National Academy Press. McCue, M., Mark, B.A., & Harless, D. W. (2003). Nurse staffing, quality, and financial performance. Journal of Healthcare Finance, 29, 54-76. McGillis-Hall, L., Doran, D., & Pink, G. (2004). Nurse staffing, care delivery model, and patient care quality. Journal of Nursing Care Quarterly, 19 (1), 27-33. Meade, C. M., Bursell, A. L., & Ketelsen, L. (2006). Effects of nursing rounds: On patient call light use, satisfaction, and safety. American Journal of Nursing, 106 (9), 58-70. Melnyk, B. M., (2007). The latest evidence on hourly rounding and rapid response teams in decreasing adverse events in hospitals. World Views on Evidence-Based Nursing: Evidence Digest, (Fourth Quarter) . 220-223. Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse staffing and the quality of care in hospitals. New England Journal of Medicine, 346; 1715-22. Needleman, J, Buerhaus, P. I., Stewart, M., Zlevinsky K., & Mattke, S. (2006). Nurse staffing in hospitals: Is there a business case for quality? Health Affairs, 25 (1); 204-211. Outzen, R. (2005). Quint Studer: The story of a fire starter. Fire Starter, 5(27). Accessed September 8, 2010 from http://www.inweekly.net/article.asp?artID=1624 Stanton M.W. & Rutherford M. K. , (2004). Hospital nurse staffing and quality of care. Rockville (MD): Agency for Healthcare Research and Quality; Research in Action Issue 14. AHRQ Pub. No. 04-0029. Studor Group (2010). The Nurse Leader Handbook: The Art and Science of Nurse Leadership. Gulf Breeze, Florida: Firestarter Publishing. Tourangeau, A. E., Cranley, L. A., & Jeffs, L. (2006). Impact of nursing on hospital patient mortality: A focused review and related policy implications. Quality and Safety in Healthcare, 15 (1); 4-8. Vahey, D.C., Aiken, L.H., Sloane, D.M., Clarke, S.P., & Vargas, D. (2004). Nurse burnout and patient satisfaction. Medical Care, 42 (2)11-57, 11-66.

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patients," after he was given a project to improve patient satisfaction while employed at Holy Cross Hospital. He made a determination that "nurses needed certain requirements to do their jobs properly," according to one article. For his first performance improvement and customer satisfaction project, Studer turned to the consultants at Press Ganey. According to the Press Ganey website, "Press Ganey questionnaires are the healthcare industry's method of choice for collecting patient, employee, and physician perspectives." The Studer Group currently markets and sells manuals, scripts, books, and interactive video training courses on the subject of influencing customer satisfaction. The Studer Group's latest book, The Nurse Leader Handbook: The Art and Science of Nurse Leadership (2010) reads like a Carnegie text on "how to win friends and influence people." Most, if not all, direct-care nurses would be hard pressed to glean any "art and science" of nursing from its pages. The ego hook for nurse managers comes in the introduction with a flattering sales pitch for his program presented in the book's forward: "As a nurse leader, you know the ultimate goal is to make sure that every patient has a great experience." (Emphasis added) Direct-care nurses know that acute-care hospitals are not vacation destinations where patients go for an "E-ticket" ride to Fantasyland and a thrill-seeking experience! Patients needing medical care in hospitals are at risk of significant complications or death. Patients require sufficient numbers of registered nurses with substantial scientific knowledge, experience, and sophisticated technical skills to meet their needs and to prevent complications of their illness or injury. Patients require RNs to provide, monitor, assess, document, and evaluate the safe, therapeutic, effective administration of care and the patient's response to treatment. In terms of "evidence-based science", the Studer Group book and method appears to fall short. In the introduction he writes, "We know what is in here works. Studer Group doesn't publish anything on theory, based on hypothesis, or based on thought (as in "We think this is true"). The book is basically the result of being out in the field, watching these tools being implemented, and observing and documenting the outcomes." Instead of scientific research to test a hypothesis, and controlling for variables using unbiased research observers for data collection, analysis, and interpretation, the book apparently presents self-fulfilling and biased opinion surveys and perceptions as "research" rather than empirical evidence. This research omits a critical IOM recommendation: taking into account organizational variables. Current research on scripting, rounding, and patient satisfaction schemes employs the most simplistic design; holding everything else constant, change one variable and then see what happens. This may be appropriate in a lab setting where everything else can be held constant. The problem is "holding everything else constant" in the real world of applying the nursing process and providing the art and science of nursing care to patients who are uniquely different. It is impossible because the patient's characteristics, work and practice environments, organizational financial priorities, and emphasis on technology are constantly changing. The most desired outcome for the Studer Group is not helping the patient achieve his or her optimal level of health and wellness. The goal is apparently about reducing the number of times patients use their call lights. The major problem with patient call lights is that they constitute a significant (according to Studer's proponents)

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source of interruptions in workflow, which leads to a high rate of medical errors. Indeed, frequent interruptions of nurses are, according to the Institute of Medicine (2003) study, a contributing factor in errors, but patient call lights are not identified or documented as the most significant source of errors attributable to interruptions. Low nurseto-patient ratios and worker fatigue due to forced overtime and lack of rest and nourishment breaks are, however, highly correlated with an increased risk of patient complications according to several published research studies. The apparent goal of the Studer scheme is to single out nurses, routinize their communications with patients, and provide unscrupulous employers a means for selectively evaluating (through surveillance) employees' compliance and competence in implementing the employer's behavior standards with regards to rounding and customer satisfaction schemes. Such surveillance is an example of the use of technology in restructuring initiatives that override the independent professional judgment of RNs and restrict their RN duty and right to advocate. Rounding and scripting is skill degrading and it is purposely designed to maintain a healthcare industry driven by private interest and to assert paternalistic dominance and control of RN autonomy and ability to individualize the nursing care plan based on the individual healthcare needs of the patient. Managers are instructed to observe and monitor individual nurses, follow up with patients to validate performance expectations, and, as necessary, have "Critical Conversations" with "HighMiddleLow Performers" (sic) and reward their success or punish their failure in using the "Key Words at Key Times (AIDET *sm)" scripts and "Service Recovery" tasks. Such tasks might include writing an "I'm sorry" note, and/or giving gift certificates for a free meal, free parking, or a massage if the patient or family member is upset and complains that there's been a perceived delay in staff responsiveness. Management surveillance, discipline and punishment of directcare nursing staff for failure to fully comply with the additional burden of the hospital's imposition of these customer service initiatives and schemes may be construed as a form of harassment which is incongruent with promoting a culture of respect for the nursing process and the intellectual knowledge work of nursing. CNA/NNOC/NNU nurses who've been mandated by their employers to attend the Studer Group's A.I.D.E.T training have reported that they feel disrespected, insulted, and annoyed at the suggestion that their interactions with patients and families should be scripted. They report the "rounding for outcomes" initiative interferes with their ability to plan, prioritize, and individualize their patients' care, in accordance with the nursing process. Many nurses are reporting they are being subjected to intimidating, offensive scrutiny and disciplined for not following "the script" or completing the additional survey paperwork in a "timely" manner. According to the Institute for Safe Medication Practices (ISMP), intimidating and disruptive behavior on the part of management can interfere with nursing care and undermine the culture of safety, leading to increased medication errors. According to The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the presence of "intimidating and disruptive behaviors" in an organization erodes professional behavior and creates an unhealthy and/or hostile work environment that can lead to a reduction in patient safety. End of Part 1

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Losing Our Voice

In their quest to boost patient satisfaction scores to maximize revenue, hospitals are forcing RNs to act like waiters and hotel staff. Nurses say this obsession with the appearance of care, not actual clinical outcomes, is jeopardizing patients and the nursing profession.

By Heather Boerner and Lucia Hwang

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fren garza has been a registered nurse for 23 years. He checks armbands, doublechecks medication prescriptions and dosages, and constantly monitors his adult psychiatric patients for signs of psychosis, depression, or that they might hurt themselves or others. He spends time talking to them about their self-destructive urges and comes up with treatment plans that help them recover from trauma. But if Garza were to follow the orders of his managers to the letter, he'd spend his shifts running from one room to the next, checking instead on whether his patients have water or need to go to the restroom, always ending his hourly rounds with, "Is there anything else you need? I have the time." "I feel like a butler or a concierge," said Garza, who works at Alta Bates Summit Medical Center in Oakland, Calif. "It's the same thing a waiter or someone in the service industry would do. It has nothing to do with my clinical skills." Garza's story may sound all too familiar. In nursing stations from Massachusetts to California, nurses are facing two disturbing trends. First, the federal government is tying patient satisfaction scores to Medicare and Medicaid reimbursements,

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ILLUSTRATION BY CHOPPY OSHIRO

essentially requiring hospitals to participate in programs which purport to measure patient satisfaction or risk losing funding. Second, hospital marketing departments are rolling out programs designed to elicit more positive responses on patient satisfaction surveys, whether it's forcing RNs to make hourly check-ins with patients for appearance's sake or literally putting words in nurses' mouths with pat scripts crafted to promote their workplaces. Nurses everywhere are protesting this hospitality and service model for their profession. They say it's not only insulting and demoralizing to be told how to talk to their patients, but that these programs override their ability to plan and implement care based on their patients' unique needs, that they interfere with their real work, threaten their autonomy and nursing judgment, and raise concerns about their job security. Most importantly, scripting and rounding programs are not an acceptable substitute for safe staffing levels. As patient advocates, say nurse leaders, nurses should not just accept these changes. By banding together and with the help of their union, they can fight back to protect both their patients and their profession. "When people come into a hospital, they're there because they need sophisticated nursing care ­ not because they need room service," said DeAnn McEwen, a critical care RN at Long Beach Memorial Medical Center in Southern California. McEwen is also a co-president of the California Nurses Association, chair of its Professional Practice Committee, and a nurse representative. "These practices deskill and dumb down nursing care and they're an attempt to override the independent professional clinical judgment of the direct-care registered nurse."

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f course, it's all about the money. For years, medical centers have relied on patient perception and feedback to improve care and attract patients. But starting in 2006, caring about patient opinions became a near mandate when federal reimbursements became linked to participation in satisfaction surveys. In that year, the Centers for Medicare and Medicaid Services (CMS) implemented a rigorous national feedback system for quality and perception of care at American hospitals called the Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS. Developed since 2002, the federal Office of Management and Budget approved the use of HCAHPS for public reporting purposes in 2005, and CMS rolled it out the following year. The first statistics were available in 2008. While participation is not mandatory, CMS began in 2007 docking annual payment increases by 2 percent from hospitals that don't submit data. And starting in October 2012, HCAHPS scores will be among the measures used to calculate incentive payments to hospitals under one of the new healthcare reform laws passed by Congress in March. HCAHPS scores are now available online at the CMS website and on websites like HospitalCompare.hhs.gov. The HCAHPS survey contains 27 questions that judge a hospital's quality, including mortality, effectiveness of treatment, pain management, and discharge information. But it also contains subjective questions: What did you think of the hospital's cleanliness and quietness? What did you think of the responsiveness of hospital staff? Would you return to this hospital? Would you recommend it to others? 22

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These questions reflect the healthcare industry's treatment of patients as customers, as consumers of a product, and of beliefs in studies dating back to 1988 that claim to find a correlation between customer satisfaction and measurable quality of clinical care. A 1995 study found that health outcomes could be improved by so-called "psychosocial interventions" -- such as politeness, friendliness, and gentleness on the parts of nurses and doctors. In an influential 1999 study, Pensacola, Fla.-based Baptist Hospital saw both its clinical scores and its income increase when it instituted patient satisfaction techniques that included asking staff to be friendlier to patients. (Not coincidentally, the administrator for Baptist Hospital at the time, Quint Studer, went on to found the Studer Group, a consulting firm that is a leading seller of rounding and scripting programs.) And as recently as 2004, researcher Kelly Worthington announced that people who enter a hospital for medical care are part patient and part customer, adding, "acknowledgment that the person is also a customer affirms that person's right to personalized service that meets all their expectations." But other studies are more skeptical about any direct link between patient satisfaction and clinical outcomes. In a 1991 paper by Hannu Vuori, chief of epidemiology statistics and research for the World Health Organization, Vuori says that there is no evidence in the literature that measurement of patient satisfaction has improved quality of care. Researchers can find little literature on the topic, and even physician administrators have commented that patient perception data are not objective measurement tools. Despite the tenuous connection, hospitals are embracing the idea of catering to patients as if they were pampered guests. Hospitals are moving beyond marketing themselves based on medical excellence and compassion. Many are now following the hospitality model, reinventing themselves as upscale hotels, with marble lobbies and cascading waterfalls.

hether or not it should, the trend is shifting toward basing more of a hospital's Medicare and Medicaid compensation on patient satisfaction marks. To cater to hospitals' pursuit of better scores, there's now a booming business underway to develop and sell programs not only to increase patient satisfaction marks, but conduct the actual surveys. For just $1,495, your hospital can buy a training DVD developed by the consulting firm Studer Group explaining the "recommended behaviors and actions" of hourly rounding, the program that Garza's workplace instituted. Studer Group, based in Florida, also sells another popular program that hospitals adopt called AIDET, which is intended to reprogram how nurses talk to patients so that they have "a better patient experience." AIDET stands for "acknowledge, introduce, duration, explanation, and thank you" ­ five things RNs are supposed to do every time they come into contact with a patient. The AIDET training DVD is yours for $2,150, according to Studer Group's online store. An extra $60 gets you 25 participant guides and pocket cards for your nurses. In-person trainings by Studer Group "coaches" are more expensive, of course. Press Ganey, based in Indiana, is another major healthcare consulting firm that advises hospital clients how to implement rounding programs and other methods of improving patient satisfaction

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scores. It is also a major vendor of patient satisfaction surveys; according to its website, more than 40 percent of the nation's hospitals partner with Press Ganey for "service quality measurement and improvement." And for $279, your hospital can buy a webinar titled "Rx for Patient Communication: Using scripts to provide consistent, effective communication with patients." Giving RNs scripts, lines, or keywords to say is not required by the HCAHPS. But just as preparatory programs and products for the Scholastic Aptitude Test proliferated when colleges started requiring prospective students to score well on these tests, so have programs, products, and consulting services geared toward raising patient satisfaction scores. "I don't want to use the phrase `teaching to the test,'" said Donna Hartman, vice president of clinical quality and patient safety at Long Beach Memorial. "But we do know that one of the measures on the HCAHPS is patient safety. Patients will be asked whether they felt their safety was important to the staff. So when a nurse checks the patient's armband, she makes sure to mention that she's doing it to keep him safe. When the survey comes in the mail and it asks `Did you feel your safety was important?' he'll remember, `Gee, that nurse kept mentioning to me that they were doing all these things to keep me safe.' It's that kind of triggering." Many hospitals, however, have taken scripting to extremes. Almost every nurse interviewed for this article had been given a laminated card detailing exactly what she was supposed to say to a patient at the start of each shift, even if she had cared for the patient just the day before. It goes something like this: "Hi Mrs. _______, my name is ______ and I'll be your registered nurse today. I want to let you know you are in very good hands. I've been a nurse in this department for 20 years. Working with me is Betsy and she's been a nurse for 30 years. Your physician is an expert in this procedure and has 15 years experience doing the kind of work you're here for. The director of medicine has 30 years of clinical experience. Thank you so much for choosing our hospital for your care." "This is the same malarkey I'd expect from a waiter in a restaurant," said Gail Jehl, an RN at Sparrow Hospital in Lansing, Mich. "You're not allowed to greet the patient the way you want. You're not allowed to use your own words. It's nuts." In some hospitals, nurses are required to do follow-up phone calls with patients ­ not to find out how patients are healing or if they have any questions about disease management, but to ask if they received excellent care and would recommend the hospital to their friends. Those conversations are scripted, too, and nurses report that they are told not to deviate from their lines, even when patients want to start a real discussion about a problem they encountered at the hospital. Besides being told how to talk to patients and sounding fake, RNs also object to scripts for other reasons. For instance, Sandy Reding not only feels uncomfortable "boasting" about herself, but she knew it would cause patients to unfairly compare nurses. "Our patients are separated by a curtain," said the operating room RN, who works at Bakersfield Memorial Hospital in California and is a CNA/NNU board member. "I did my spiel: `Hi, I'm Sandy

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"I feel like a butler or a concierge. It's the same thing a waiter or someone in the service industry would do. It has

nothing to do with my clinical skills."

Reding, I'll be your OR nurse today. I want to let you know that you're in really good hands. I have 20 years of experience. I'm certified in the operating room, certified in pediatrics.' I did the whole thing and was disgusted. But then I heard the patient in the next bed say, `I want that nurse.' The nurse he had had only one year experience. I find it really distasteful to have to do it." On a practical level, rounding and scripting adds more busy work onto nurses' already hectic shifts, and makes nurses choose between following management directives or attending to the clinical needs of their patients. Ironically, nurses have been making rounds on their patients since time immemorial to conduct patient assessments and familiarize themselves with their assignments. But RNs say this new type of rounding that management wants them to do is more about creating the illusion for patients that they're receiving a lot of attention by focusing on superficial comforts ­ such as whether the patient would like his pillow fluffed or her trashcan moved closer to the bed ­ rather than letting RNs prioritize for themselves the care they know they must deliver to keep patients safe and to heal better. Most nurses are asked to round every hour, always ending the conversation with the line, "Is there anything else I can do for you? I have the time." Many RNs particularly bristle at this closing sentence, because it's simply not true and makes it more difficult focusing on their real clinical nursing work. Some nurses are finding that the scripting and rounding orders can actually worsen relationships with patients and their families. Some patients have complained that nurses sound fake. And on one nurse's pediatric floor, she and her fellow RNs were instructed to hand off care at the end of their shifts in person ­ even waking patients if need be. At morning shift change, parents who had just gotten crying babies to sleep were furious when their newborns woke up and started screaming again after nurses entered the room and started reciting their scripts. The way rounding and scripting interfere with the nursing process and supersede nursing judgment is probably the most frustrating and enraging consequence of these programs. "This is like Stepford nurses," said Jehl. "It really takes away from the independent practice of the nurse. Patient care should be based on outcomes, period." Nurses are finding that if they don't comply with these programs, regardless of staffing, they could be counseled, reprimanded, or even worse. At Jehl's hospital, managers stand right next to the RN or outside the door to make sure that RNs are completing all five parts of the "AIDET" program. Recently, Garza learned that all the mental health RNs will receive only 2.5 out of a possible 4 points on the patient satisfaction component of their performance evaluations "until their Press Ganey scores are above 50 percent." He was incredulous that the hospital would unilaterally judge him and his RN coworkers based on how patients felt about their stay at the hospital. "We have schizophrenic and psychotic patients," said Garza. "Some are involuntarily placed there and held against their will. And you're asking them to score you? It's just ridiculous."

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Besides just being insulting and a waste of nurses' time, McEwen is afraid that rounding and scripting programs are providing a smokescreen for the real problem: that hospitals are often dangerously understaffed. "It's unethical and immoral to divert money away from providing the care patients need by making nurses attend these customer service trainings," said McEwen. "This market-driven focus on enhancing patients' perceptions is just being used to help the employers hide a really disgusting, grim reality." In an ideal world, hospitals would schedule enough registered nurses to provide the clinical care patients need and the small niceties they deserve. But they don't. Or they would hire enough assistive staff to help take patients to the bathroom or make sure their water pitchers were filled. But instead, they have laid off LVNs and nurses' aides left and right. No matter how many scripts management comes up with, say RNs, they can't substitute for putting money into staffing and lower nurse-to-patient ratios. "If they followed the laws with no mandatory overtime, with appropriate staffing, breaks and lunch times offered to nurses, they'd end up with naturally high patient satisfaction rates instead of trying these tactics to force the issue," said Reding. The research backs up Reding's perspective. A study in a 2004 issue of the journal Medical Care found that improvements in nurse work environments could increase patient satisfaction all on its own. Articles in the New England Journal of Medicine have pointed out that patients are generally more satisfied with hospital stays at facilities with higher ratios of nurses to patients. Even in the 1999 Baptist Hospital study, part of the overall improvement in patient satisfaction was an improvement in nurse satisfaction and reduced turnover.

It really takes away from the independent practice of the nurse. Patient care should be based on outcomes, period."

"This is like Stepford nurses.

hile rns say they certainly do care about whether patients and their families feel they are getting the attention they deserve, patients often do not see the big, complex picture of what's happening on their nurse's shift or on the unit. For example, McEwen recalled a nurse who had been assigned a patient just in from surgery. But that RN was also around the corner, gowned and gloved, taking care of her other patient who was in isolation. The family came in and, ignorant of the staffing situation, became worried when alarms started going off in the patient's room. "The manager talked to this nurse, called her in a couple days later and said, `The patient's family is upset and they've complained that no one was watching and paying attention. Where were you, what were you doing? What can you do to prevent this from happening next time?'" recalled McEwen. "As a nurse rep, I said, how we make it better is by assigning enough nurses to meet the needs of the patients. A fresh post-op should be assigned oneon-one with a nurse so the nurse can provide ongoing assessments to prevent complications. By putting that nurse in with another patient around the corner, that nurse can't provide continuous and direct observation." McEwen proposed to the nurse that she document the assignment as unsafe because the hospital refused 24

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to provide adequate secretarial, technical, and nursing assistant staff to help. "In our experience as nurses, when patients and their families perceive that there has been inattention to their concerns in the hospital ­ delays in answering a call, put on hold too long, delay in being allowed to visit, delay or cancellation of awaited procedures, alarms and red lights flashing at the bedside without immediate response by a nurse -- this perception is valid," said McEwen. But it's a mistake to believe that the reason is because nurses need to be better trained in customer service. "It is most often a result of short staffing, which is a systemic problem." When new clinical restructuring initiatives are introduced that interfere with the nursing process, RNs have a duty to protect their practice by fighting back as patient advocates. When the hospital where Deirdre Tremblay works, Merrimack Valley Hospital in Haverhill, Mass., instituted "Studer rounds" and "Studer scripts" during patient handoffs, the medical-surgical RN and her coworkers protested en masse. At first, when the RNs questioned and challenged the programs, hospital management told them, "Listen, this is the way it's going to be and if you don't like it, you can find a job somewhere else," remembered Tremblay, who is also her unit's nurse rep. With the help of the Massachusetts Nurses Association, the RNs filed a group grievance. While they were not able to eliminate the programs entirely, management did agree that the programs would not lead to any punitive actions, such as discipline, threats of termination, or negative performance evaluations. While the RNs do try to check hourly on their patients, all the RNs have basically boycotted the script. "The Studer program is designed as if you work at a hotel," said Tremblay. "They are more concerned with the cosmetic things than why the patient is actually there, which is for medical treatment." At Mercy General Hospital in Sacramento, Calif., where float RN Kathy Dennis works, the nurses several years ago successfully refused to participate in rounding and scripting. "I wouldn't do it," said Dennis, who then started encouraging coworkers throughout the hospital to stop filling out the hourly rounding record sheets. When nurses learned that not everyone was participating, they naturally quit, too. The program fizzled away after six months. "I told my managers that I check on my patients as appropriate according to my professional nursing judgment," said Dennis. "Checking a box does not make my patient safe." Tremblay added that nurses at Merrimack felt it was important, like it is with the disease process, to "nip these programs in the bud" before they escalated or spread. It's solid advice for nurses at hospitals across the country, too. "They want to restructure the way nurses act," said Tremblay. "They want us to be more like puppets than nurses. If nurses do not stand up and squash this now, I think it's going to get worse."

Heather Boerner is a freelance health and medical writer based in San Francisco. Lucia Hwang is editor of National Nurse.

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The Economic Deceit Few Discuss

Annual Change in Inflation-Adjusted Gross Domestic Product for Each Dollar Reduction in Federal Tax Revenue or Increase in Federal Spending

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o listen to the campaign rhetoric that stained much of the 2010 campaign season, you'd think the biggest problems facing our nation are excessive government spending, workers' pensions, and inadequate tax breaks for corporations and wealthy Americans. The few who can break through the conventional wisdom are quickly attacked as advocating class war by the corporate elites, as if there was not an alarming erosion of living standards and shocking growth in income disparity that has undermined the promise of the American dream for so many. Consider two stats from the November 2010 Harper's Index, published by Harper's Magazine. Net domestic profits earned by U.S. corporations since the fourth quarter of 2008--$609 billion. Net decrease in the amount these companies spent on wages and benefits--minus $171 billion. Or as David Cay Johnston reported in a column on tax.com in late October, average wages, median wages, and total wages all declined in 2009--except for those at the very top of the income bracket whose income increased five fold in that time. Over the past quarter century, the richest 1 percent more than doubled their share of total U.S. income from 10 percent to 23 percent, and the average CEO who was paid $27 for every dollar earned by an employee now gets a ratio of about $275 to $1. Healthcare was once considered relatively protected from the deep chill affecting other working people. But no longer. That's evident in these messages sent by RNs to NNU via our website in recent weeks: Saratoga Springs, NY--"We are part of a six-county hospice under the umbrella of a large hospital which is soon to join two other facilities to become the largest healthcare providers in upstate New York. Our hospice nurses are paid `salary' which once conferred some benefits over hourly pay. Those benefits have been completely stripped so that now we are required to work 10 to 20 hours a week

Federal Spending on Food Stamp Benefits Has the Biggest "Bang for the Buck"

$2.00 $1.80 $1.60 $1.41 $1.40 $1.22 $1.20 $1.01 $1.00 $0.80 $0.60 $0.40 $0.22 $0.20 $0.00

Extend Net Enact Cut Operating Accelerated Corporate Loss Depreciation Tax Rate Carryback Make Make Permanent Permanent Bush Dividend & IncomeCapital Tax Cuts Gains Tax Cuts Provide Housing Tax Credit Provide NonRefundable Lump-Sum Tax Rebate Provide AcrosstheBoard Tax Cut Provide Provide a Refundable Payroll Lump-Sum Tax Tax Rebate Holiday

$1.57

$1.61

$1.24

$1.02

$0.90

$0.25

$0.32

$0.32

$0.37

Provide Increase Extend Temporarily Temporarily Federal Infra- Unemployment Provide Increase Aid to structure Insurance Federal Food Stamp State Spending Benefits Financing Benefits Governments for WorkShare Programs

beyond the 37.5 hours for which we are paid. We have had an increasing workload with decreasing compensation." Baltimore, MD--"Our hospital has laid off the whole Department of Vascular Therapy team. All those girls without a job!" Raleigh, NC--"Instead of cutting management positions, they have hired a consulting firm and forked out millions of dollars to learn how to save money ... Their response, `We are going to learn if we are market competitive,' meaning they are no longer going to offer benefits that result in excellent staff. They have also introduced a `work matrix' that causes understaffing and constantly decreases patient safety." Felton, CA--"My experience is not one of being laid off, but not hired at all. Currently, the situation on the Central Coast is that new graduate nurses have very few jobs to go to, and as a result, many are returning to previous careers after nursing school, or leaving the state. I was able to locate my first job out of state ... Upon returning to Santa Cruz this May, I have filled out close to 70 applications, and no local hospital has called me for an interview despite an excellent resume, and references. "This short-sighted policy will eventually lead to another crisis nursing shortage. In addition, these hiring practices send a clear message to new nurses that we are not of any value, and not worth training. My nursing school has cut back enrollment, and I fear for the next few graduating classes. Where will these nurses go? I feel that this local situation will lead eventually to worsening

patient care as we miss the golden opportunity to benefit from the life experience of our long-term nurses who must retire someday soon." But, when the next Congress convenes, the "solutions" to the continuing economic crisis we are likely to hear are not expanding real economic or health security. Instead expect the newly elected legislators to push proposals to privatize or sharply reduce Social Security protections, and new cuts in safety-net programs while even more wealth is shifted to the have-mores who need it least of all. As MSNBC's Rachel Maddow reported in October, Bank of America, CitiBank, and General Electric were three major corporations, among many, that paid exactly nothing in corporate taxes last year, "and you can tell from our politics that politicians are counting on us not understanding that." An analysis by the California Budget Project using Moody's business data clearly identifies what creates economic growth and what doesn't. Contrary to the myths peddled by so many on the right, the federal spending that has the least impact on economic growth, and by implication, jobs is corporate tax cuts, eliminating capital gains taxes, and extending the Bush administration tax cuts for the wealthy. What does promote economic growth, according to the data? Increased infrastructure spending, and funding for unemployment benefits and food stamps--putting money in the pockets of people who will actually spend it, instead of those with enormous wealth who are unlikely to buy their 45th pair of shoes. Or, as CNA/NNU documented in the landmark study done by our research arm, the Institute for Health and Socio Economic Policy last year, guaranteed healthcare for everyone, by expanding Medicare to cover all Americans, which would create 2.6 million new jobs, and a healthier nation. --Staff report

$1.69 $1.74

CHART BY CALIFORNIA BUDGET PROJECT. SOURCE: MOODY'S ECONOMY.COM

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Neither blizzards, unjustified discipline, nor union-busting managers can stop RN Sandy Falwell from advocating for nurses and patients.

By Lucia Hwang

When the Going Gets Tough

R

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egistered nurse sandy falwell will never forget the blizzards of 1996. The January snow piled up so high in Washington, D.C. where she worked at Children's National Medical Center that she and her coworkers were stuck in the facility for five days. Nobody could get to or from the hospital, so Falwell and her fellow neonatal intensive care unit nurses came up with their own emergency strategy for staffing: half the nurses worked past their shifts so that the other half could get some sleep. Then they'd switch. When nurses finally started to be able to return home, Falwell was so committed to her tiny patients and the other staff that she gave up her slot to a pregnant coworker. She did not go home until she was sure everything was settled and that her unit didn't need her. So imagine her surprise when the hospital days later accused her of abandoning her assignment and suspended her for three weeks. She believes that the hospital was targeting senior nurses and union supporters, since the RNs had been trying to organize. Without a formal grievance procedure, all Falwell could do was protest and appeal to higher administrators. Luckily, the human resources department

finally cleared her of the false accusations and Falwell went back to work, but now with a different perspective and purpose. "What they made out of me was a rabid union supporter," said Falwell. "I remember walking into a meeting by myself with eight hospital administrators sitting there and thinking, `If I can help it, I'm not going to let any other nurse feel that alone by themselves with no support.'" Falwell's false discipline story became a cause célèbre among the nurses at the hospital and elsewhere, helping the Children's RNs score an election victory that summer despite intense union busting by the hospital. "It was beautiful," she remembered about hearing of the successful vote. Contract negotiations, said Falwell, were "brutal" and consisted mainly of night shift nurses like her working all night and negotiating during the day, since they didn't yet have paid leave to conduct bargaining. They finally settled a first contract, and Falwell became the chief shop steward at Children's. "I was the only one who had fought back and won," laughed Falwell. "Somehow that makes you the chief shop steward." Her activism never stopped, and today Falwell is a veteran RN leader, not only still president of the bargaining unit at her facility, but also sitting on the executive council of National Nurses United

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used to be an arm of the American Nurses Association. Over the years, activist, staff nurses like Falwell grew tired of their organizations paying significant dues to the ANA, which was dominated by nursing executives, in return for no representation and basically no say in the group's work. Falwell, as one of the few staff nurse presidents, supported the eventual parting of ways in 2008 between ANA and UAN. And when the chance to join forces with a dynamic allstaff nurse organization like NNU came along in 2009, Falwell was more than on board. Since NNU formed, she said she has been impressed by how much more power RNs have in gaining audiences with legislators and in better news coverage of nursing, citing nurses as experts. "I see nurses "I remember walking into a meeting by myself with more as the voice of reason about healtheight hospital administrators sitting there and thinking, care," she said. "That's good, because we `If I can help it, I'm not going to let any other nurse are the ones doing the work. Staff nurses feel that alone by themselves with no support.'" are starting to be aware that they have strength. This is huge because it had never been before." At age 62 and with more than 35 years of nursing under her belt, or seventh grade that she wanted to be a nurse. After graduating Falwell is concerned with the future of the profession and in encourfrom the Harrisburg Hospital School of Nursing in Pennsylvania, aging younger generations of RNs to get active. "I think the biggest Falwell moved to Washington, D.C. to be close to her mother, who challenge for us as nurses is to understand what NNU can do for us," worked as a mediator for the U.S. Department of Justice. She found a job at Washington Hospital Center in the operating room and soon said Falwell. "It's easier to go along in your little world, and everything's fine as long as you're happy. You're usually not getting involved became the evening charge nurse. unless your back is against the wall. I'm a classic example!" Her career took a new path, however, after she gave birth in 1975 to her son, who was six weeks premature. Though he turned out healthy and never had any problems, Falwell became fascinated by Lucia Hwang is editor of National Nurse. preemies. "At first he was very small and I was worried he wasn't going to grow," she said. "I just thought I would really like to learn everything I could about these kinds of kids." An RN friend convinced her to get hired at Children's, and soon she was working in the NICU and then as part of the elite neonatal transfer team that flew out to other hospitals to bring back critically ill premature infants. "I just felt like I was at home," remembered Falwell. "Everything about the NICU just appealed to me." To continue her education and Name: Sandy Falwell, RN, NP ensure she was prepared to deal with all kinds of transfer situations, Facility: Children's National she also earned an advanced practice license as a nurse practitioner. Medical Center In the 1990s, Falwell had a brief stint as the clinical manager of the Unit: NICU NICU, where she got a taste of hospital management that she did not Nursing for: 35 years like. She learned that administrators thought nothing of making nursSign: Scorpio es work unreasonable schedules and about the games they played in Pet nursing peeve: When nurses don't cutting nurses' salaries. "That's where I discovered the things they were support one another and turn on each doing to the nursing staff that wasn't right," said Falwell. When she other. Also messy work spaces. spoke up in defense of the staff nurses, she said, the other managers Favorite work snack: Grapes made her life difficult and assigned her projects she could not possibly Latest work accomplishment: A decent working relationship complete. So when a new management team took over in 1995 and she with management at her hospital had an opportunity to return to bedside nursing, she jumped at it. Color of favorite scrubs: "Burgundy and gold. Yes, I do have The year after was the big blizzard and the Children's RNs' unionizWashington Redskins scrubs." ing victory. Many contracts later, Falwell said she is very proud of havHobbies: Snorkeling and cruising ing helped take the Children's nurses from one of the worst Favorite movie: Imitation of Life compensated to best compensated RNs in the Washington, D.C. area. Favorite books: The Harry Potter series Falwell also reports that they have excellent staffing ratios in the majoriSecret talent unrelated to nursing: She performed a few ty of the hospital, though she would like to see actual ratio language in times as a background singer and dancer with Sly and the contract. And she would like to end floating completely. But they the Family Stone. "I called it fluff. I mostly just shook have come such a long way from that first contract. my tambourine and my behind." Because of her leadership role, Falwell inevitably grew involved with the District of Columbia Nurses Association and UAN, which and on the board and cabinet of the District of Columbia Nurses Association, of which she also served as president from 2000 to 2004. As a past board member of United American Nurses, Falwell has been instrumental in shepherding DCNA and other UAN nursing organizations through the formation of NNU in 2009. "NNU has been and will be a conduit to doing bigger and better things," said Falwell. "We have to show other nurses the power of nursing." A native of Chicago, Falwell said that she's known since the sixth

Profile

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N AT I O N A L N U R S E

27

Want to learn about healthcare trends that you won't hear explained anywhere else?

Sign up today for one of National Nurses United's continuing education courses! Free for direct-care and staff registered nurses!

For more information and to register, please visit www.calnurses.org/ nursing-practice/continued-education

Need CE Credits?

The Impact of Technology on Professional RN Practice and Safe Staffing Standards

Kansas City, Missouri | Dec. 9, 2010

This course examines the effects of technology-driven patient care--which includes the integration of Computerized Physician-Order Entries (CPOE) and computerized care plan and charting systems for financial/billing purposes--on professional RN practice and safe staffing standards.

Faculty: Hedy Dumpel, RN, JD, National Chief Director of Nursing Practice and Patient Advocacy and Gerard Brogan, RN

The End of Work? Electronic Patient Data Mining in a Crisis Economy

California | Offered from January through March 2011 in cities throughout California.

Recent technological developments affecting healthcare distribution vividly reflect trends leading to the ongoing U.S. economic crisis. This class will look at these trends, at the history of paid labor in the U.S., and its relation to the growth of the financial sector. How is the productive work of patient care valued in this economic context? And how is health information technology (HIT) being used to increase hospital and insurance company profit margins by rationing that care? In particular, the class will address technologies such as medical credit screening that are used to mine patient data. Outcomes and comparative effectiveness research, key aspects of evidencebased medicine, will be examined. Prior CNA classes about HIT focused on technologies that surveil, deskill, and displace caregivers. This class supplements that analysis by focusing on patient data mining technologies that limit patient care. Those who attended prior classes will find most of this material to be new, but prior classes are not prerequisites.

Faculty: Linette Davis, Educator and Research Analyst

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