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In healthcare, those who call the shots, determine who is pleased…

September 8, 2009


Nurses Tethered to Donkeys

by Kellyann Curnayn

As in any industry, the current state of health care is determined largely by who is calling the shots, which boils down to a series of questions: Who does the Nurse want to please? Who does the Nurse Manger want to please? Who does the Chief Nursing Officer want to please? Who does the Chief Executive Officer want to please? Unfortunately, all of these people are forced to please the current medical and regulative bureaucracy, instead of pleasing patients. We have lost perspective on whose interests we ought to be serving.

An example may elucidate this loss: Cowboys had their hands full when trying to win the west, and the horse became a critical means of revenue, transportation, and everyday life. One technique used to tame the “wild” bronco was to tie it to a donkey and send it out into the plains. The two animals would return within a few days, and after being tied to the donkey the horse appeared much calmer. I would suggest that America’s nurses, like the broncos of the wild west, are often tethered to donkeys of bureaucratic distraction and obligation that provide no added benefit to the patient. Since there seems to be no hope of changing the situation, many nurses, like the bronco, have given up.

One such donkey is charting—a bureaucratically-driven and time-consuming distraction with little bearing on quality patient care. I believe every charting process that hasn’t demonstrated its value to the patient needs to be challenged. Questions should be asked everyday: Who wants this charted and why? Has this charting process produced a measured improvement in care? Is the effectiveness of this process measurable at all? But no one asks these questions anymore because we have been tied to the donkeys for far too long. Questioning mandates from on-high is considered heresy in a world accustomed to appeasing the person with the greatest perceived power.

These are just a few of the overbearing charting processes:

Insulin administration – A nurse must have another nurse readily available at all times to verify the original order, verify the bottle, verify the dose, and last but not least document that all this verification was done.

Restraint documentation – Nurses are required to get the attending physician to renew the order every 24 hours. On top of that, the nurses must fill out a specific task form every two hours indicating that the patient was taken care of.

PCA (patient controlled analgesics) administration – Nurses have administered narcotics for years, but charting processes have now been put in place which make the practice nearly impossible. A narcotic medication error is very serious, yet the action being taken to prevent errors is further burdening the already stressed-out nurse. This extent of this extra burden will only lead to poorer patient care in other areas.

Documenting a plan of care – Unfortunately, this kind of charting cannot prevent bad care since the forms are not reviewed. Furthermore, nurses do not have the time to fulfill all of these charting policies on the best of days. The sole purpose of these policies is to appease the ever-watchful eye of the accreditors.

The various charting forms (including Morse Falls Scale, Braden Scale for skin assessment, and a new form used to evaluate the potential for Deep Vein Thrombosis) don’t change the plan of care a nurse would give; the forms simply give them more paper or computer work to fill out, reducing the amount of time they can spend actually caring for patients. In order to prevent falls, skin breakdown, and blood clots, a nurse must be present at the bedside, turning a patient and facilitating such activities as sitting in a chair. But there aren’t enough nurse-hours to provide a patient with this level of care when nurses are torn between the patient and the mandatory charting.

If there is a policy on the books that prevents the health care provider from spending quality time caring for the patient, then the policymakers need to reevaluate. As hospitals struggle to find people willing to go into nursing because nurses are often overworked, and as medical errors continue to run rampant through the system, maybe administrators should stop and reevaluate their mandatory procedures.

Checks and safeguards are a good thing, if used effectively, but unnecessary paperwork will only lead to poorer patient care. If the procedures in place are preventing good basic patient care, something needs to change. After all, the patients are the people we should be pleasing.

Kellyann Curnayn is a Registered Nurse and author of the book A Good Day in Hell: The Flatlining of Nurses in America.

About the Center for a Just Society

The CJS Forum seeks to promote an open exchange of ideas about the relationship between faith, culture, law and public policy. While all the articles are original and written especially for the CJS Forum, they do not necessarily reflect the views of the Center for a Just Society.


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