Patient Safety / Quality

Good intentions eclipsed

Cindy Johanson, RN*, a 47-year-old married mother of two college-age children, held a demanding job on a busy medical-surgical unit. She left her house by 5:10 am for 40-minute commute to the hospital. Her 12-hour shifts were filled with patient assignments (usually 6 to 8 patients), meetings, procedures, and exacting—sometimes life-saving—work. By the end of her shifts, she was exhausted, and yet still faced a 40-minute commute. Cindy was not unhappy with her compensation, which allowed her to hire in-home workers to clean the house, grocery shop, and even prepare meals. The rest went to pay college tuition for the children. Nonetheless, she often did not get home until after 7:30 pm—and on some nights when she was forced to work mandatory overtime, she did not get home before midnight. Moreover, she had been forced to work “doubles,” which ended up becoming three 12-hour shifts in a row or 36 hours on duty several times.

After several years at this exhausting pace, Cindy found that she was becoming edgy with patients, impatient with her children, and alienated from her husband. She went to her supervisor and asked to be relieved from mandatory overtime. The answer was an unequivocal (though certainly not cold) “no.” The supervisor explained that with the many lay-offs of the last 5 years coupled with an increased census and continuing cost-containment restraints—not to mention a growing shortage of experienced nurses—the hospital had no choice but to implement a “no exceptions” mandatory overtime policy. So Cindy went home and talked things over with her husband. They carefully went over their finances and looked at options, and they eventually included their children in the discussion. Subsequently, the two young adults applied for student loans and Cindy gave notice to the hospital. They sold their large home and moved to a smaller one in the same city, and Cindy went to work part-time for another hospital. Although their dual income is now less than half of what it used to be, Cindy’s life is far more manageable and enjoyable, her children are working hard and borrowing the money to finish college, and her marriage is better than it has been for years. Cindy and her husband will not be able to take expensive vacations, and they will have to scale back their expectations for retirement income—but they have more balance and more fun in their lives.

The hospital system, however, lost a valuable and experienced nurse, making its staffing even more difficult; agency nurses had to be brought in to maintain minimal staffing levels. In January 2009, an agency nurse accidentally switched off a quadriplegic patient’s respirator. As she left the patient’s bedside, he tried to raise the alarm by clicking his tongue as he lay trapped in his bed, all too aware of what was happening. The nurse heard him, and called for help from a care assistant, who can be heard** asking, “What’ve you done?” When she is told, the assistant says, “We’ll get this quickly, quickly,” and hands the nurse a hand-held resuscitation device (“Ambu bag”). But the nurse was unable to attach the Ambu bag to the patient’s trach. The care assistant called the charge nurse who successfully re-attached the respirator. The charge nurse asked the first nurse, “You haven’t had any training on it?” to which she said, “No.” The patient was brain-damaged after being without oxygen for 21 minutes. The patient’s family filed suit against the hospital.

What can one say?

Next to this disaster, it seems almost ridiculous to mention the fact that the costs of recruiting another nurse for Cindy’s position were considerable. In fact, the position was not filled for a year, and then only with a far less experienced nurse who, moreover, had to be oriented and credentialed to bring her competencies up to par.

What could have been done to produce a more satisfactory outcome for patients, employees, and hospital? To answer this question, we have to ask another: What do we, as members of the healthcare community value most? It is important to note that this question is rarely asked, no less answered. Cindy did this for herself. It takes radical courage to reformat our lives to become centered on our values, but she did it. Good for her!

Obviously, the patient deserved and should have received safe care. The nurse assigned to his care should, minimally, have been competent to deal with respirator patients. There is no adequate “excuse” morally, legally, or clinically for this patient to have suffered brain damage from lack of oxygen. To say anything more would require a root cause analysis, which I am sure was done. I am sure that no one at any level in the organization is anything other than appalled by what happened to this patient. No one chooses to work in health care to do harm. Their intentions at least are good. But the pragmatic problems of managing in today’s environment often obscure them.


Cindy’s supervisor was caught in a dilemma. She was dealing with a tight budget and a hiring freeze. Administration implemented mandatory overtime to keep things running, but given the costs of overtime, it is somewhat counterproductive. In fact, given the various Centers for Medicare & Medicaid Services (CMS) “incentives,” such as Value Based Purchasing and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) initiative, added to the data emerging from studies correlating human error and overtime, mandatory overtime is a Pyrrhic policy at best.

The rule of thumb, in ethics at least, is, “People come first (this would be patients and personnel) and things come second.” I could stop here, but perhaps the time, talent, and treasure framework should also be applied to the organization and its values. The nursing supervisor and hospital no doubt regret losing Cindy. Undoubtedly she was considered a valuable “human asset.” Moreover, the pool of talent in nursing is drying up as nurses are pulled to outpatient care, advanced practice, clinics, home care, and so forth.

However, a fair guess is that most hospitals and nursing supervisors collectively sigh and shrug regretfully, and then get back to solving the crises at hand—perhaps even one caused by short staffing. But what if, like Cindy, hospital and nursing leaders took a hard look at their priorities and developed a practical action plan to put patients and caregivers back at the top of the priority list? What might happen if the bottom-line wasn’t king? If leadership developed ways to conserve clinical talent by developing flexible human resource policies that accommodate an aging—and diversifying—workforce? Changes that fortify the healthcare workforce through encouraging and honoring diverse staffing patterns? Changes to human resources that help us live out what we say is important—patient care and employee well-being? In other words, what might happen if the healthcare industry “walked its talk?” In this crazy, rapidly shifting field of health care, we might find the stability we need by modeling the values we proclaim.

*Name changed to protect privacy.

**At the request of the patient, his family had installed a secret video camera in his room. Discussion regarding this part of the situation is beyond the scope of this article.

Leah Curtin, RN, ScD(h), FAAN, is Executive Editor, Professional Outreach for American Nurse Today.

Related Articles:

6 thoughts on “Good intentions eclipsed”

  1. Rose says:

    This was painful to read on so many levels. There have been many restrictions placed upon the working hours allowed from residents, but none on nurses. As the largest group of employees, why is the nursing staff taken advantage of? This can be applied to many on-call areas as well, where nurses have no supplemental staff and no mealtime breaks for over 12 hours. Sleeping or inattentive driving often carries the same regulation as being intoxicated. These situations result from poor leadership.

  2. Leah Curtin says:

    The major point I thought I was making in this article is that federal and state regulatory initiatives and financial incentives are aligning with nursing research on safe staffing levels. However, I do agree with RN who says some CEOs are greedy, and with JLMS that some nurses are exploited and with both RN and Mari’s points.

  3. JMLS says:

    NURSES ARE ABUSED BY THIS SYSTEM. THE HOSPITALS HAVE ONLY ONE THING TO SELL & THAT’S SERVICE. WHY THEN CUT THE THING THAT PROVIDES THEIR PRODUCT?

  4. SJS-RN says:

    I am not so sure that hospital CEOs, CFOs — in fact, the whole C-Suite — have good intentions!

  5. RN says:

    Good intentions for who? The hospitals bottom line at the expense of the very people who depend on us for everything. Why most facilities are so unwilling to have nurses job share is beyond me. I worked 3 on, 3 off, 10 hr. shifts for many years, and when I left that hospital, other nurses had adopted the same schedule. Patient care was consistent and nurse’s were rested. Many new grads have no knowledge of procedures and equipment, which reflects badly on their schooling.

  6. Mari says:

    Losing someone like Cindy is a tragedy. I am glad she was able to opt out with integrity. But many good nurses have no such option, and when they are tired and burned out, everyone suffers. Patients lives can be altered forever – and nurses careers ruined.

Leave a Reply

You have to agree to the comment policy.

 

Newsletter Subscribe

  • This field is for validation purposes and should be left unchanged.

Test Your Nursing Knowledge

Answer this interactive quiz to be entered to win a gift card.

  • This field is for validation purposes and should be left unchanged.

Insights Blog

Today’s News in Nursing

Shares