Healthy respect

Nasty doctors? Testy nurses? Some hospitals are saying enough.
By Julie Salamon
June 18, 2008
When I set out to observe life inside a major urban hospital for a year, I expected to find heartbreaking, inspirational and possibly alarming medical stories. I anticipated insurance entanglements, technological marvels and cultural conundrums.

I didn't expect, however, to find classes to correct bad behavior. The classes -- at Brooklyn's Maimonides Medical Center in New York -- were designed to enforce the hospital's Code of Mutual Respect, and part of a national trend to help people in the medical field rediscover the value of that old-fashioned virtue called common courtesy.

Among the provisions that these doctors and nurses needed to be reminded of were not to use racial or ethnic slurs, or language that was profane or sexually explicit. Also, to refrain from intimidating behavior, "including but not limited to using foul language or shouting, physical throwing of objects."

Slurs? Throwing things? Was this a hospital or a reform school, I asked one physician, a department chief. He shrugged and told me that such behavior was far more common than I might imagine.

"I've worked in lots of hospitals where surgeons have thrown instruments; they get scissors that don't cut, they fling it across the room," he said. "I was at a hospital where the resident accused the attending surgeon of breaking her wrist."

Broken wrists may be extreme, but the way hospital workers treat one another sets the tone for how they treat patients and their families, who are often frightened and fragile. The simplest form of human communication -- a harsh or caring tone, abrupt or attentive behavior -- can be healing or destructive. So in the past few years, hospitals around the country have begun writing codes similar to the one at Maimonides, to promote respectful behavior all around.

During my year at the hospital, real cases illustrated the relationship between respect and result. In one case I heard about, a patient had been prepped for a knee operation. The operating team had followed the universal protocol called "preventing wrong site, wrong procedure and wrong person surgery." Yet just before the procedure began, someone asked, "How come the knee being prepped isn't marked with a 'yes?' "

Who had dared to speak? It was a medical student, the lowest-ranking person in the room, who had noticed the "yes" was on the other knee.

A physician who was there said, "There has to be enough respect so a medical student can raise his hand and say, 'You're operating on the wrong knee.' "

More often than not, catastrophe isn't in the balance, but rather the opportunity to make a difficult situation easier or more stressful.

Another small but all-too-familiar example I witnessed: A terrified family member followed the medical team into a restricted area where the patient was waiting for surgery. A nurse snapped at him to move and shut the door in his face. The man erupted in fury, until another nurse apologized and explained the restrictions were meant to stop the spread of infection. The anger and helplessness on his face quickly turned to understanding and then gratitude.

At Maimonides, the hospital president, Pamela Brier, became Miss Manners on overdrive because she believes disrespect can result in harm to patients. "Bad behavior ruins communication, and communication problems are what cause mishaps that can harm patients," she told me. "I mean communications between doctor and nurse, nurse and clerk, housekeeper to nurse or doctor, everybody."

The craving for respect is a palpable part of hospital life. Nurses and technicians feel underappreciated and underpaid. "I have nursing attendants who make $28,000 a year working elbow to elbow with these attending doctors who come into work in Jaguars," a senior nurse told me. "I think what beats them down is the hierarchy, the respect they're given or not given. Everyone beats down on the one below."

And patients can feel the reverberations of these wounded feelings.

Things can get better, though. For every act of rudeness, I encountered many, many more examples of compassion and kindness. From housekeepers to department heads, most people were doing what they could to improve care in an over-stressed and inequitable system. They did it by recognizing that the healthcare system, after all, isn't abstract or anonymous; it is the sum of individual human successes and failures, in which small gestures can and do make a difference.

Like minding your manners.

Julie Salamon is the author of "Hospital: Man, Woman, Birth, Death, Infinity, Plus Red Tape, Bad Behavior, Money, God, and Diversity on Steroids."

Doctor offers to treat dying Winnipeg man after colleagues refuse

A doctor in Winnipeg has agreed to treat a dying 84-year-old man amid a legal and medical row between his family and physicians who say keeping him alive is unethical, a published report said Wednesday.

Three doctors at the city's Grace Hospital have refused to continue providing care to the elderly patient, Samuel Golubchuk, who they say has no brain function and should not be kept physically alive on a ventilator.

But another, unnamed doctor has come forward and agreed to be Golubchuk's physician of record, according to a report in the Winnipeg Sun that quotes a spokeswoman for the city's regional health authority.

That will enable routine care to be provided to Golubchuk and his life support to be maintained, medical officials said.

Golubchuk and his family are Orthodox Jews who believe it is immoral to hasten death.

"When a person is born, it's written down when they're gonna die," Golubchuk's daughter, Miriam Geller, told CBC news. "So it's God that decides this, not the doctors."

Last month, in a letter to the Winnipeg health authority, Golubchuk's original attending physician, Anand Kumar, said he would no longer work in Grace Hospital's critical care unit because it meant providing medical services to his former patient that were "grotesque."

Golubchuk had developed bedsores, Anand wrote, and doctors were having to trim infected flesh from his body to prevent infections from spreading.

"To inflict this kind of assault on him without a reasonable hope of benefit is an abomination," Anand's letter said. "I can't do it."

Do no harm: ethicist

Anand advised the family to remove Golubchuk's ventilator and feeding tube, but they went to court instead and obtained a temporary order to continue treatment until the case can be heard fully in September.

Earlier this week, two doctors who had been maintaining Golubchuk's life support treatment also withdrew from the case.

Arthur Shafer, a medical ethicist at the University of Manitoba, said the physicians were correct to follow their conscience once they'd formed a professional opinion on Golubchuk's case.

"They did morally the right thing," Shafer said. "As every first year medical student learns, the basic principal of medical ethics is 'do no harm.' "

But Percy Golubchuk, the elderly patient's son, said it's all about being able to trust that a medical team will provide the care that's needed to preserve life.

A person, he said, "should not be afraid when you go into a hospital that you might not come out because a doctor thinks your life is not worth living."

Golubchuk's father was put on life support late last year when he was being treated in hospital for injuries suffered in a fall.

Nurses to be rated on compassion

Nurses are to be rated according to the levels of care and empathy they give to patients under government plans.

Health Secretary Alan Johnson told the Guardian newspaper that he wants the performance of every nursing team in England to be scored.

He said he believes compassionate care was as crucial to the recovery of patients as the skills of surgeons.

Nurse leaders welcomed the move and said they would work with ministers on developing the system.

Mr Johnson said plans were to be outlined in the forthcoming review of the NHS by health minister Lord Darzi.

Nurses work tirelessly to ensure that patients are treated with dignity, compassion and sensitivity
Peter Carter, of the Royal College of Nursing

Wales, Northern Ireland and Scotland are not planning to introduce a similar scheme, although nurse performance is already monitored through patient surveys and core standards.

Mr Johnson suggested the results, compiled by regulators using patient surveys, could be displayed on an official website.

But he ruled out rating individual nurses and also said it would not affect pay.

Standards of nutritional care, minimisation of pain, hand-washing, and safety on the wards could also be measured, he added.

Mr Johnson said he hoped to encourage friendly rivalry between wards over which nursing team could achieve the best ratings.

The scheme will be piloted and the first results are likely to emerge next year.


Mr Johnson said: "What nurses tell us is that you can have the best surgeon in the world, who carries out the most terrific operation on you, but your stay in hospital won't be satisfactory if you don't get a high level of compassion and care.

"If your experience involves nurses looking grumpy, or someone being rude, or not getting people there when you need them, then it ruins the whole experience."

Peter Carter, general secretary of the Royal College of Nursing, said the union would work with government on the scheme.

"These new standards are groundbreaking in that they will directly recognise nurses for the kind of care that patients really value.

"Nurses work tirelessly to ensure that patients are treated with dignity, compassion and sensitivity, aspects of care which are so important but rarely measured."

But Steve Barnett, acting chief executive of the NHS Confederation, which represents health managers, warned: "It will be very difficult to measure and benchmark compassion - particularly at the level of the ward."

  • Meanwhile, 12 leading health unions representing nurses, midwives, paramedics and a range on non-medical health staff have agreed to sign off the government's three-year pay deal worth 8%.

    But the unions have warned if inflation continues to rise they will activate a clause compelling the governments of the UK to enter talks to renegotiate the deal.

    It comes after the majority of the unions had already indicated they would agree to the deal after balloting members.

  • Story from BBC NEWS:

    Published: 2008/06/18 09:08:49 GMT

    The making of "Dr. Nurse"

    The doctor of nursing practice degree is a two-year program open only to those who hold a master's degree in advanced-practice nursing. New York's Columbia University School of Nursing, one of the schools offering this degree, has a 40-credit-hour curriculum that includes a year-long residency.

    1. Support core courses (19 credit hours):

    • Translation and synthesis of evidence for optimal outcomes
    • Quantitative research methods
    • Legal and ethical issues
    • Clinical genomics advanced seminar
    • Practice management
    • Informatics

    2. Clinical core courses (11 credit hours):

    • Doctor of nursing practice I and IIv
    • Didacting and clinical
    • Chronic illness management.
    • Doctor of nursing practice I and II
    • Didactic and clinical
    • Chronic illness management

    3. Residency/seminar (10 credit hours)

    Source: Columbia University School of Nursing

    Medical testing board to introduce doctor of nursing certification

    Physicians are concerned that the move will lead to scope-of-practice expansions.

    Starting this fall, doctor of nursing practice graduates will be able to take a certification test that proponents say will set a national standard for DNPs and add to the profession's credibility.

    The voluntary test, being created by the National Board of Medical Examiners, is based on the medical licensing exam. It will be offered at a time of growing momentum in the DNP movement: About 200 nursing schools are expected to offer the two-year DNP degree by 2015 -- more than double the programs available today.

    Test proponents said the DNPs, called "doctor nurses" by some in the nursing profession, are comparable with primary care physicians in their diagnostic and disease-management skills.

    But physicians expressed concerns that DNPs will use the test as leverage to seek scope-of-practice expansions that cross into medical practice.

    "Why would they get a DNP unless they want to do things that are currently not in the nursing scope of practice in most states?" asked AMA Board of Trustees Secretary William A. Hazel Jr., MD. "It makes sense they will want to change their scope."

    The AMA and the American Academy of Family Physicians said they support advances in nursing education but emphasized that nurses should operate as part of a health care team under physician supervision. Dr. Hazel said there are important distinctions between DNPs and physicians that the public should understand.

    "I do not want to be construed as attacking nurses, but there are concerns," Dr. Hazel said. "There's a difference in training that should not be overlooked."

    In April, the nonprofit Council for the Advancement of Comprehensive Care contracted with the NBME to create the exam, which is expected to be offered in November.

    Mary Mundinger, DrPH, speaking for the council, said the goal is for a national standard that distinguishes DNPs who have an advanced clinical knowledge from those who have an emphasis in research, administration or systems management.

    "While a primary care physician went to medical school and did residency, a nurse practitioner with a DNP has achieved many of the same competencies but through nursing education," said Mundinger, who also is dean of Columbia University School of Nursing in New York City. "They have the same skills in identifying a disease state and treating it, but it's a different hybrid of care."

    Using a similar test

    Richard Hawkins, MD, NBME vice president for assessment programs, said the test will be based on Step 3 of the U.S. Medical Licensing Exam, the last level in the test series.

    "We're a testing organization, and this fit our mission," said Dr. Hawkins. The NMBE develops assessments for health care professionals in general, not just for physicians.

    Mundinger said about 75 graduates qualify to take the DNP certification test. Once nursing schools finish their program expansions, she expects there will be at least 2,000 DNPs graduating each year. Candidates must first complete a master's-level nurse practitioner degree before they begin a DNP program.

    Though DNPs have a year of residency as part of their two-year program, Dr. Hazel said, it is important to recognize the difference between physicians' and nurses' residencies.

    Residency, DNP style

    DNPs' residency year entails 1,000 hours, Dr. Hazel said. Medical residents work 80 hours a week, racking up about 4,000 hours their first year and approximately 12,000 hours over three years, he added. In addition, patients could easily confuse these nurses with a licensed physician.

    "Let's make sure they make the distinction between a doctor of nursing and medical doctor," Dr. Hazel said.

    At press time in early June, the AMA House of Delegates was expected to consider a resolution to endorse policy that the title "doctor" be used only by licensed physicians, dentists and podiatrists in a medical setting. The resolution also sought to have the title "resident" apply only to individuals enrolled in a medical, dental or podiatry training program.

    Another resolution sought to oppose the NBME's development of the certification test and to urge the Association to adopt policy that DNPs practice under physician supervision.

    AAFP President James King, MD, said that although these nurses pass a test similar to the one for medical school graduates, that does not make them physicians.

    "I don't think they can replace family physicians," Dr. King said.

    "If they are sincere in saying they are going to contribute to easing the physician work force shortage, they'll work as part of a team, not leading that team," he said.

    Mundinger said the nursing degree and test do not alter existing scope-of-practice rules, but as DNPs demonstrate their expertise, she expects that scope to change.

    "The more nurses prove they can do certain things, the more likely it is legislation will follow, but there is no direct link between certification and what nurses [legally] can do," Mundinger said.

    Working with physicians

    Richard Mulder, MD, is a family physician in Ivanhoe, Minn., who has worked with Dawn Bucher, DNP, since she was a registered nurse and then a nurse practitioner. He said her level of expertise as a DNP has eased his workload.

    On days she works, he feels free to do hospital rounds or take a coveted day off.

    He is confident that patients will be well taken care of by Bucher. He and his partner set her prescribing formulary and have given her unrestricted prescribing authority.

    Bucher said the biggest impact her DNP degree has had is how she thinks about patient care. She looks for ways to better meet patients' needs and coordinate their care.

    "We're all about patient care," she said.

    Bucher does not introduce herself as doctor. When the voluntary DNP certification test is available, she plans to take it.