BY: FR. MICHAEL D. PLACE, STD
Fr. Place is president and chief executive officer, Catholic Health
Association, St. Louis.
In the two years before I joined CHA, I had several surgeries because of problems
with disks. (They seem to have been "made for walking.") While the lower back
surgery was not complicated, it did involve a period of convalescence and rehabilitation.
The cervical fusion, which obviously was more complicated, involved an extended
hospitalization, longer convalescence, and more extensive rehabilitation. Unfortunately,
the first fusion did not work and the entire process had to be repeated, with
all its components being even more complex than the first time.
Though I had no idea at that time that I would be joining CHA, I was very
involved in health care issues and in the health care ministry. As a result,
I was probably more knowledgeable than most patients about delivery issues.
(This was the era of strong HMOs and the rapid expansion of investor-owned hospitals.)
Consequently, I went through the surgeries as an observer as well as a patient.
One of my most vivid memories of that time is awakening from the second cervical
surgery on a ventilator with my hands and arms restrained. (I knew that I was
to be on it during surgery, but had been assured I would be off it long before
I awoke.) It is hard to describe the panic and fear that ran through me as I
struggled to emerge from the haze of the anesthesia. My first thought was that
I must have had a cardiac event or a stroke during the surgery.
After finding that I could move my hands and feet and doing an "internal scan"
that detected no gross deficits, I relaxed a bit—but returned to full panic
when my best friend suddenly entered the room. My friend, who had accompanied
me to the hospital for the surgery, had planned to return to his parish after
it. The fact that he was there in my room frightened me. Even worse was the
look on his face when he saw me on the ventilator. It was then that I learned
how hard it is to cry when you are on a ventilator.
"Enter Heroine from Stage Right"
It was at this moment that the ICU nursing director entered the room. She explained
that the anesthesiologist, over the objection of the surgeon, had left me on
the ventilator because my heartbeat was too slow. All other vital signs were
normal, however, and she assured me I would be extubated shortly.
Unfortunately, that did not happen. Instead, a drama began to unfold. The
details would fill pages, but the story line was simple: The ICU nursing director
started battling with an arrogant physician. This meant that, at one and the
same time, she and her nurse colleagues provided me with needed postoperative
nursing care; tended to my fragile psyche; related well with my worried and
increasingly frustrated friend; consulted with the surgeon; and, in the end,
became my advocate within a web of bureaucracy that seemed determined to leave
me on the ventilator for what appeared to be no good medical reason.
Later in the morning, after another of what seemed endless blood oxygen level
checks proved normal, the nurse's professional patience began to wane. She returned
to the room and said, "I am not going off shift until we get you off the ventilator
and out of ICU. Let's start from the top." She then worked her way through my
medical history, trying to explain conflicting evidence. She needed "proof"
to verify her clinical intuition. After what seemed like endless questions,
she set down her chart and said to my friend, "What haven't I asked?" Perplexed,
he said, "What do you mean?" She glanced out the window and then said, "Does
Father exercise regularly?" The reply was: "Until these surgeries, he swam a
half to three-quarters of a mile four to five days a week."
While her next words cannot be repeated in polite company, she had found the
"smoking gun." Though it took another two hours and the serious botching by
an anesthesiologist of the extubation (which added another complication to recovery),
long after her shift was over, the ICU nursing director walked along beside
me as I was moved, bed and all, to the orthopedic floor. As she said goodbye,
my "guardian angel" bent over my bed, squeezed my now-liberated hand, and in
a confessional-like voice said, "Forgive us, Father. I am sorry we could not
have done better for you. This is not what health care is supposed to be all
about." With tears in her eyes, she squeezed my hand again and walked away.
The Way It's Supposed to Be
I have not forgotten those words. "This is not what health care is supposed
to be all about." While she was correct in part, she also was quite wrong because,
during this process, she had incarnated what a critical component of health
care, the profession of nursing, is all about. She had provided human
touch, medical treatment, delivery coordination, and patient advocacy with a
determined, albeit strained, professionalism. Though the drama inherent in the
situation brought these elements into bold relief, they really were not that
extraordinary. Rather, they were the ordinary "stuff" of her calling, as they
were for the other women and men nurses who cared for me during a hospital stay
that seemed determined to be a showcase of "worst-case practices in a world-class
hospital."
In time, I was liberated (otherwise known as discharged) to a home setting,
where another remarkable cadre—this time of home health nurses and nursing aides—continued
to provide care. (At another time, I may reflect on home health and rehabilitative
services from the patient's perspective.) It was in that more relaxed setting
that I asked one of the home care RNs what had drawn her to home health. (It
certainly was not the money.)
Her reply was instant and almost guttural. "So I could be a nurse again,"
she said. She was a former nurse supervisor who had left a secure hospital position
because the environment was, as she put it, "toxic." No need here to chronicle
the dimensions of the "toxicity." We are all too aware of them. Though paid
less, this nurse described herself as quite content in the home health setting.
The Nurse Shortage Crisis
Why do I share all of this? Obviously one reason is the fact that this issue
of Health Progress is about nursing. The issue topic and the column,
however, have not happened accidentally. Both reflect a growing concern within
health care, within the ministry and within CHA's board of trustees about nursing.
Several years ago, I was privileged to serve on the University of Illinois'
Nursing Institute Commission on the Future of the Health Care Labor Force in
a Graying Society. The commission, which was chaired by former Secretary of
Labor Lynn Martin, issued a study that was one of the first to highlight the
crisis now facing U.S. health care delivery: the shortage of nurses. That study
(and others like it) prompted CHA, the American Hospital Association, and other
organizations to support passage of last summer's Nurse Reinvestment Act and
to work for its full funding.
As important as this and other efforts will be in increasing the size of the
pool of nurses, everyone involved knows that, in the end, the nursing environment
must be transformed if we are to recruit and retain nurses in the acute care
and long-term careýsettings. In fact, our board at its November 2002 meeting
explicitly engaged the topic of nurse retention/recruitment as part of a larger
discussion of workforce issues. That discussion was greatly assisted by the
observations of board member Sr. Rosemary Donley, SC, PhD (a professor in and
former dean of the School of Nursing at The Catholic University of America,
Washington, DC), and Julie Trocchio, RN (CHA's senior director of continuum
of care services), both of whom served on our association's Catholic Health
Ministry Workforce Initiative.
Sr. Rosemary reported that in order to determine a role for the ministry in
attracting a more stable nursing workforce, the CHA Health Ministry Workforce
Initiative Committee asked nurses for ideas. "We issued a 'Call for Innovative
Ideas,'" she said, "and offered $10,000 for the winning idea." That idea, Sr.
Rosemary continued, would:
- Involve collaboration among Catholic health and other ministries
- Draw on the strengths of the ministry's tradition and experience
- Have a potential for improving the quality of nursing care
Nearly 350 entries were received from nurses throughout the country: from
acute care long-term care, parishes, and schools of nursing; from staff nurses,
supervisors, directors of nursing, student nurses, and faculty. Some of the
ideas were exciting but not practical (tax breaks for nurses and their families);
others broke my heart ("Know my children's names"); one made me laugh (more
pizza at staff meetings). Although only 50 words were requested, some entrants
gave multiple pages. One nurse sent her resume. A great many thanked us for
asking their opinions.
The winning entry came from Elaine Hlopick, RN, MSN, emergency department
case manager at Saint Vincent Health Center in Erie, PA. (The hospital is not
part of a large health care system.) She is from St. Philip parish in the rural
town of Crossingsville, PA. She earned her nursing and graduate degrees in Catholic
colleges. (See p. 43 for an interview with Ms. Hlopick.)
Ms. Hlopick suggested that CHA establish an office of nursing advocacy to
promote the image of nursing as compassionate and essential to the outcome of
patient care. Catholic health care facilities would also be encouraged to have
a nurse advocacy program to promote nurses' accomplishments and identify and
deal with problems.
Sr. Rosemary noted that, in following up on the award-winning proposal, the
Award Committee discussed establishing a distinct nursing presence within CHA,
although not necessarily a separately staffed function. CHA could make an effort
to consider the viewpoints and interests of nurses in our strategic directions
in our focus areas. We could seek opportunities to include nurses from the ministry
on committees and in other member engagement activities. In the spirit of New
Covenant, we could build relationships with Catholic-sponsored schools of nursing
nationally and locally.
Two Themes
Sr. Rosemary and Julie also shared two themes the committee had learned from
the process: First, there is a strong feeling that nursing is tied to spirituality
and the mission of the church. Second, there is profound unhappiness among many
nurses in our facilities.
We found an untapped element of spirituality in nursing. One nurse wrote
that nursing is a "calling that embodies compassion, spirituality, and human
touch." Another suggested that we tell students about the "pastoral joy" that
being a nurse can provide. To many, nursing is a vocation and patient care
is sacred work.
On the other hand, we heard loud and clear that nursing is hard, frustrating,
and often unpleasant. There is a high level of disillusionment and disappointment.
Being underappreciated and insufficiently respected were recurring themes.
A nurse from acute care wrote: "A naturally hard and strenuous job is made
more difficult by the lack of respect nurses receive from doctors, patients,
and the institutions we work for. The only way to attract people into the
profession is to prove to them that nurses are respected and valued."
It is disturbing that between our first and second meetings, the two nurses
from our committee who work in clinical areas of hospitals resigned their
positions to assume what they hope will be less demanding jobs. One was a
young assistant head nurse who said that whenever she wasn't working, she
was on call. The other had been director of a coronary care program for over
20 years. She said that to take care of her patients and supervise her staff
properly she had to work more than 55 hours every week. Both nurses said the
long hours were no longer tolerable and they needed time with their families
and for themselves.
The committee discussed problems in our institutions that they fear are
approaching dangerous levels. Staffing shortages are leading to new graduates
being given responsibilities they are not prepared to take and to nurses being
made supervisors without getting needed supervisory skill training.
In light of these reflections, CHA's staff and board will work in the near
term to respond to what we have learned. Certainly, the area of the spirituality
of nursing is a "natural" for CHA to address. The soul, however, is united to
a body, and we also must attend to the body of health care delivery if we are
to effectively address nursing and other staffing issues. These other issues
were cogently summarized in an op-ed column that appeared in the Boston Globe
of December 15, 2002. The piece was coauthored by Michael Collins, MD, a
former chair and current board member of CHA, and Richard M. Freeland, president
of Northeastern University. They wrote:
But much more needs to be done. We need to finance health care at a level
that enables hospitals to increase caregiver time and lower patient-to-staff
ratios, thus reducing burnout among workers. That means changes in Medicaid,
Medicare, and the private payer system so reimbursements come closer to covering
the actual costs of providing care. We also need to expand retraining for
existing staff and provide opportunities for career advancement tied to skill
enhancement, through both formal classroom instruction and clinical learning—especially
critical given rapid technological changes.
Reasonable workloads, employment stability, decent pay and benefits, and
a chance for upward mobility are important, but attracting and retaining more
health care professionals requires something more. We must organize the delivery
of patient services in a way that honors the values that have motivated so
many dedicated staff to the service of those in need of care. For it is that
motivation and dedication upon which the future health of our Commonwealth
depends.
The test of whether we are successful will be quite simple: Will my "guardian
angel" nurse feel at home in Catholic health care?