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CE 2_Nov REV 12/10/10 8:16 AM Page 23 Hospital Association's annual survey which provided information about nurse staffing levels, profit status, number of beds, teaching status, and rural or urban location. According to their study the , biggest satisfaction differences between hospitals with higher versus lower nurse-to-patient ratios showed up in the specific areas related to nursing services: discharge instructions, communication with nurses, and communication about medications. Of interest, researchers also found that patients in nonprofit hospitals ranked their satisfaction higher than patients in proprietary hospitals; something the authors suspected might be related to patient expectations. There was no difference in satisfaction between teaching and non-teaching hospitals. Patient satisfaction was associated with quality of clinical care on indicators for the conditions assessed: acute myocardial infarction, congestive heart failure, pneumonia, and surgery. Rounding and other similar patient satisfaction schemes do nothing to improve actual therapeutic patient outcomes. They are short sighted and are aimed at manipulating the perception among patients and visitors that staffing is adequate. These "creative" management schemes depersonalize the relationship between RNs and patients. Ultimately they interfere with the Nursing Process, the RN's professional judgment and control of their ability to prioritize, assess, plan, individualize, implement, and evaluate the care they provide. Such interference leads to nurse dissatisfaction and burnout, poor patient outcomes, and lower patient satisfaction. Rounding schemes are not required by CMS for the purpose of obtaining increased reimbursement incentives. These schemes never discuss the ratio of RNs to patients even though the CMS guideline states: "The nursing service must ensure that patient needs are met by ongoing assessments of patients' needs and provides nursing staff to meet those needs. There must be sufficient numbers, types and qualifications of supervisory and staff nursing personnel to respond to the appropriate nursing needs and care of the patient population of each department or nursing unit. There must be a RN physically present on the premises and on duty at all times. Every inpatient unit/department/location within the hospital-wide nursing service must have adequate numbers of RNs physically present at each location to ensure the immediate availability of a RN for the bedside care of any patient." By tying reimbursement to patient satisfaction using rounding schemes, CMS would be in violation of its own guidelines. Rounding schemes appear to come from the same philosophical place as computerized charting, charting by exception, overuse of technologies, speed up and fragmentation – all driven by the depersonalization of healthcare. Rather than stress individual care, the new paradigm is population-based care, i.e. fitting patients into a statistical mean. This also corresponds with attempts to deskill the health professions to both save on labor costs and eliminate the voice of professional advocacy. Experienced bedside RNs are reacting to the introduction of these scripts in their facilities. Here are just a few of the comments made about such scripts: "Most nurses are 'people persons,' and we know instinctively that we can save ourselves a lot of time and give the best care by anticipating our patients' needs. It's so much easier to invest a few minutes of time at the beginning of the shift to learn who your patients are and what they need, and assure them that you will do your best NOVEMBER 2010 to meet those needs. No one has to tell us how to do this; it comes naturally." "It's the idea of the 'script' that sticks in my craw. Nurses are professionals; it's insulting to all concerned to demand that we utter a canned, pat phrase like 'Is-there-anything-else-I-can-do-for-you-Ihave-the-time.' It sounds insincere and forced, and most patients know it." "If hourly rounding and scripting is supposed to be so fundamental in a customer service focus, but if everyone is doing this latest management craze then I don't see how it will help these institutions stand out. And now the big trend for managers is being taught the lean, mean 'Toyota Way' or the 'Disney Way'; and they have another new thing called a 'Power Minute' where a manager comes along and tells you something new, then you have to sign and say you agree with it or you learned it. I'm about to go ballistic! Who are these people and why should we listen to them? It's like, they're not even nurses." "Our hourly rounding logs hanging on the patient doors say at the bottom, 'Always remember to ask: Is there anything else I can do for you, I have time?' Sure, I have time as my hospital-issued cell phone is ringing off the hook, and the pager connected to my patient's monitor is beeping. Instead of calling in more staff to answer the call lights, they want us to fill out another form and they write us up if we have to stay overtime to finish our charting." "We have the same exact script at our hospital. In critical care you almost never leave the patient's room anyway, but to be told what to say and to have to initial and check a piece of paper to show I was in the room is insulting. If the patient's in a coma they want us to have the family bring in a picture and dialogue with the patient about their picture." "Why don't they just look at my charting and read it if they want to know what I've done for my patients? The initialed rounding log isn't part of the patient record anyway; it's for our boss. If you don't fill it out you get counseled and if you get more than three counselings, you are suspended and they threaten to terminate you. I didn't know that R.N. stood for Robot Nurse." "At my hospital we formed an informational picket to alert the public about our employer's failure to correct several safety issues brought forward by the staff nurses. We developed our own acronyms and a rather colorful chant about the phony 'AIDET' scripts our boss was pushing: A is for Asinine, Abhorrent, and ' Abominable; I is for Insulting, Intrusive, and Idiotic; D is for Demoralizing, Deskilling, and Dumb; E is for Egregious, Erroneous, and Excrement; T is for Thoughtless, Terrifying, and Trespassing on our rights as nurses." Compare and Contrast: Nursing Practice and Patient Advocacy Standards vs. Commercial Interests and Corporate Profits the cna/nnoc/nnu professional practice and patient advocacy model definition of "quality" in nursing practice is as follows: Competent, safe, therapeutic, and effective care provided in the exclusive interest of the patient. This model ensures that the RN always acts in the patient's best interests. This is not only the moral obligation of the nurse, inherent within the social contract between the public and the profession of nursing, but it is also a duty and a right. As direct-care nurses, we have a vested interest, on behalf of our patients and our profession, W W W. N A T I O N A L N U R S E S U N I T E D . O R G N AT I O N A L N U R S E 23