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Rounds+Scripts_FNL with art 11/6/10 2:07 PM Page 24 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. 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." "This is like Stepford nurses. It really takes away from the independent practice of the nurse. Patient care should be based on outcomes, period." W 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 N AT I O N A L N U R S E Heather Boerner is a freelance health and medical writer based in San Francisco. Lucia Hwang is editor of National Nurse. 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 O C TO B E R 2 01 0