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empty Alligators in the hospital: Part II : Medical Staff Leader
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Alligators in the hospital: Part II

My last two posts have dealt with the analogy between hospitalist program managers and civil engineers who find that they cannot drain the swamp as contracted because they are occupied with fighting off alligators. I want to discuss now the most prevalent type of alligators in hospitals—the nurses. Doctor-nurse relationships run deep and may well be the prime determinant between hospitals that fail and those that succeed. The nurse was historically a handmaiden to the physician and maintained extreme deference. Advances in nursing education have prepared nurses for a professional role that is still subordinate to the physician, but the relationship between the two varies from cooperative to antagonistic.

What makes a nurse into an alligator? Nurses are expected to carry out a daily care plan for a group of patients that may number from one (in the ICU) to 30 or more (typically on a night shift). They are expected to respond promptly to call buttons, answer calls from doctors and families, send patients off to scheduled tests and procedures, administer complex medication regimens correctly, and document their activities thoroughly. There is a lot to do in the course of a day and not quite enough time to do it. Years ago, all of a nurse’s patients might be in a single room and she (no male nurses back then) could see them all and shift attention quickly to those that needed it. Today’s nurse may have each patient in a different room and the rooms may be at opposite ends of the floor.

You may wonder why nurses put up with this. A lot of them do not, and seek employment in nonhospital settings that pay less but offer less stress. The average age of a hospital nurse is over 40 and rising. Burnout is a major problem in hospital nursing, and may be defined broadly as a desire to get through the workday without concern for the effect upon others. The February 2011 issue of Health Affairs contains an article by McHugh, Kutney-Lee, Cimiotti, Sloane, and Aiken describing a study of over 95,000 nurses. One out of three nurses providing direct patient care in hospitals gave responses indicative of emotional exhaustion (i.e., burnout), though only one in four explicitly cited job dissatisfaction.

How does a burned-out nurse make it through the day? Often, it is by blasting anyone who is perceived as an obstacle to finishing tasks quickly. The favorite weapon is the incident report, as it allows burned-out nurses to feel that they are advocates for patient care, when they really don’t give a damn. Pity the poor hospitalist who fails to dance to the nurse’s tune, as he or she will be described to hospital management in pages of purple prose.

A comprehensive solution to the problem of nursing burnout is beyond my capability and that of most hospitalists, but there are things that we can do (and must do) to help the situation. We need to develop partnerships with nurses. It involves bidirectional trust and respect for the capabilities of each partner. It requires constant, honest, and respectful communication with a concern for providing each partner with the information they need when it is needed. We need to move toward unit-based hospitalist staffing. In the open wards of the past, the nurse was there all day and so was the intern. Don’t expect a lot of help from hospital management on this. Senior hospital leaders have dealt with waxing and waning nursing shortages throughout their careers but have generally not had to deal with physician shortage except in rural areas and certain subspecialties. Their attention is focused on keeping nurses happy and satisfying the specialists that perform lucrative procedures, while hospitalists are generally seen as a necessary evil. I’ll talk more in my next post about how to develop high-performance partnerships.

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Error: Unable to create directory uploads. Is its parent directory writable by the server? About the Author: Richard Rohr MD, MMM, FACP, started one of the first hospitalist programs in Connecticut in 1996 and is a charter member of the Society of Hospital Medicine. He is a graduate of Columbia University, New York Medical College, and received the Master of Medical Management degree from Tulane University. Dr. Rohr is certified in internal medicine and pulmonary disease. He began his career practicing pulmonary and internal medicine for two staff-model HMOs in MA and CT, and then directed a long-term care facility specializing in medically complex patients before joining Milford Hospital to establish the hospitalist program. Dr. Rohr spent a year as vice president for medical affairs at a small hospital in upstate New York before assuming his current position directing hospitalist programs for the Guthrie Healthcare System in Sayre, PA.

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  1. I came to this most interesting site via the big to-do over at the NYT about the “dressing down” by a doctor to a nurse–or, if you will, a doctor’s attempt at humor which offended a nurse. What a great resource, thank you. Now: how does a nurse become an alligator? 1). Expecting a doctor to dance to her tune. Unacceptable 2). Decreased sense of humor, increased sense of importance. 3). Misuse of incident reports, which should be patient centered, and preferably about clinical topics. Purple prose for the purpose of complaining, also unacceptable. This is why God made lounges. 4). An unwillingness to assist the doctor in a collaborative fashion to both locate and noose pesky alligators. He or she could at least call Animal Control.

    New thought: Nurses suffering from the catch-all burnout, in addition to being emotionally exhausted, are often also afflicted with clinical depression, for which they may or may not be being treated. Sorry I don’t have a citation, pure tiredness on my part. But thanks again for a very jam packed site full of interesting content. And thanks for your sincere efforts toward collaboration. Next: How to get nurses to meet you at least halfway, further if needed, since it is clear that you are willing to return the courtesy.

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