1. Forman, Harriet EdD, RN, CNAA

Article Content

I recently read Marie Manthey's guest editorial, AKA Primary Nursing [JONA. 2003;33(7/8):369-370] that describes a satisfying experience both Manthey and her friend had throughout a 30-hour hospitalization in a Minneapolis hospital. During this time, Manthey's friend received care from nursing staff on 5 units, was evaluated/treated by 4 physician/specialists, and had numerous diagnostic tests and an operative procedure. Manthey was with her friend through most of these experiences and was fortunate to see the "timeless values" of nursing being administered to her friend on each and every unit.


Unfortunately, this type of experience is too often not the case. I have frequently heard about or experienced impersonal, task-oriented, disjointed, or just plain bad care often enough that it caused me to go to my laptop muttering "let me tell you what's it's really like in too many of our hospitals." Sitting on my couch as a painful example was my 46-year-old son. His left hand was uselessly contracted; all 3 of the major nerves in his arm dead below the elbow, 2 of the tendons dead, and his brain so damaged that he now describes himself as having a brain like Swiss cheese-full of holes.


Had the physicians in the emergency room he was initially taken to more than a year and a half ago and the intensive care unit he was transferred to recognized his original condition as coma postseizure with compartment syndrome of the arm, he would still have a normal brain, hand, and arm. Had the MDs and RNs in the ICU he was transferred to recognized his hypotension or at least believed me when I reported seizures, perhaps he would not have suffered brain damage. The neurologist, an associate professor in the medical school of the world-class medical center to which I transferred my deeply obtunded son, told me that my son would not regain function, except perhaps to dress himself and maybe live alone. Had I accepted that prognosis, perhaps that might have been his fate.


Had nursing assigned the same nurse to care for him on a daily basis instead of assigning someone new every day, perhaps I would not have felt so abandoned day after day after day as my daughter and I vigilantly stood guard over him. We alerted the nurses of concentrated urine, lapsed IVs, and a persistently deflated air mattress. We turned him and worked his joints. We refused to allow the rest of his body to deteriorate or his mind to stay where it was.


Through the years of what I call distorted primary (relationship-based) nursing, when chief nursing officers (CNOs) took the concept beyond the intent and implemented all-RN units, I was a CNO. I did not see the point of having all-RN units. I believed deeply in relationship-based nursing. I believed that professional nurses could accomplish this better if they were unhampered by unskilled tasks that could be done by lesser paid support personnel available on their team.


I implemented team nursing, always assigning patient assessment, clinically complex care, patient and staff education, quality improvement, unit management, and discharge planning to RNs. I watched with horror as consultants placed the solution to reducing costs in the hands of desperate or greedy administrators. I watched as many of my colleagues, given orders to reduce staff, laid off RNs because they had no one else to lay off-an action with the domino effect of contributing to this latest and worst nursing shortage.


Now we pay the price of our shortsightedness; our patients and their families pay along with us-as mine did. The Minneapolis hospital at which Manthey's friend received care is a role model. Of course, there are many other good and caring organizations, but there also are too many that do not measure up. Persistent shortages and, yes, poor leadership and substandard management have resulted in labor strife, internal staffing problems, dissatisfied staff, and poor retention. Nurse administrators are forced to use staffing agencies, travelers, and excessive overtime. Some have so many tasks assigned to the few RNs they have on staff that RNs establish relationships with medication carts and IV pumps because that's all they have time for. In many of these situations, nurse aides, AKA nursing assistants, patient care technicians (PCTs), etc, work almost independently of the nurses.


In another major medical center, a comprehensive cancer center in which a friend's husband received care, including lung surgery, the RNs administered medications and treatments, while the PCTs did all pre-op, post-op and discharge care.


I implore nurse executive and nurse manager readers of JONA to spend time on your patient units observing care, watching, listening, and interacting with staff and patients on a daily basis. Nothing is more important. Unless you see the world through your staff nurse's eyes and your patients' eyes, you will never see what I saw and you will never know what I know. My son could be your son.


Although my son has recovered much of his intellect, he still faces extensive treatment. Each time I look at him, I remember the good nurses who during his 5-month inpatient stay locked their eyes to mine on entering his room, causing me to breathe a sigh of relief knowing I wasn't alone. Alas, those days were overshadowed by the days when I was the only RN in the room who understood the "timeless values" of relationship-based care.


Harriet Forman, EdD, RN, CNAA