It was an intentionally simple question the clinical nurse in the examining room heard. “Lynn,” I said, “Have you ever been bullied?” There came a pause. Then, she responded with a torrent of emotions reflecting anger and disappointment that took her back to the start of her career 23 years ago. I posed the question as she prepped me for the ECG my doctor ordered.
After completing her nursing degree, Lynn went to work as a registered nurse in the emergency department at a suburban hospital in North Carolina. For the next two years, she was abused, intimidated, openly berated, and humiliated by staff nurses with more seniority and the nurse manager.
“What was that like?”
She said it was just how you were treated. “You were made to feel stupid when you sought clarification of a physician’s charted instructions, for example, or asked for input to correctly respond to a patient’s request. Eventually, I left.”
What happened to Lynn is not a rare occurrence among nurses, unfortunately. On July 9, 2008, The Joint Commission, which provides oversight to over 20,000 hospitals and other care facilities, issued a policy directive to its membership called a Sentinel Event Alert. Its instruction was to have procedures in place to deal with “behaviors that undermine a culture of safety” by January 1, 2009. It described “intimidating and disruptive behaviors” in great detail, which is the most widely accepted definition of bullying. Its rationale was clearly embedded within the body of the policy: “There is a history of tolerance and indifference to intimidating and disruptive behaviors in health care.”
With mounting evidence that bullying was surprisingly prevalent within the health care sector, the intended purpose of the Sentinel Event Alert was to amend its leadership standards. Accredited health care organizations would be required to create codes of conduct that define disruptive and inappropriate workplace behaviors as well as establish and implement procedures for managing such behaviors. Additionally, the institutions The Joint Commission accredits were expected to make their data available for review, according to Gerard M. Castro, PhD, The Joint Commission’s project director for patient safety initiatives.
Nursing’s Dirty Little Secret
“Nurses eat their young,” wrote Theresa Brown, a registered nurse, in an article in The New York Times in February 2010. “The expression is standard lore among nurses, and it means bullying, harassment, whatever you want to call it. It’s that harsh, sometimes abusive treatment of new nurses that is entrenched on some hospital floors and schools of nursing. It’s the dirty little secret of nursing.”
Her story is not exceptional, and it prompted me to contact Gina, a clinical nurse in Worcester, Massachusetts, with a master of science degree in nursing education and 35 years of experience—15 of which were on a nursing school’s faculty.
“There are nurses that I do not assign a new-to-nursing nurse to because of what I know would be their experience,” Gina tells me. Then, she describes her very recent experience where she accepted a per diem assignment in the operating room (OR) of a local hospital with which she is very familiar: “I almost never survived a month because of the bullying that went on. I had never seen anything like it and never experienced anything like it in my years in nursing.”
It seems that there had not been an assignment of someone new to the OR in 10 years, so Gina was treated as an outsider and not part of the clique. So targeted was the hostility that after three months of enduring the treatment, she says, “I began to feel myself spiraling down, losing my self-confidence. I endured badgering criticism; I couldn’t do anything right; there was an absence of kindness.”
Fortunately, there was a change of supervisor who observed the climate in the OR and stepped in to end the intimidation by referring the preceptor for retraining.
An Occupational Hazard
Scenarios similar to the one Gina describes must have been alarmingly common to have prompted The Joint Commission to issue a specific directive regarding workplace bullying, or lateral violence, as it is technically referenced. Diverse studies identify nursing as a risk group for workplace bullying; further, they confirm that the problem of hostility in the workplace is very common in the health care sector.
Indeed, health systems are aware of this hostility and responding to the Commission’s directive. Duke University and the University of North Carolina, for instance, have policies and procedures to deal with workplace behavior. Duke shies away from describing intimidating and disruptive behaviors as bullying per se—and perhaps may have tacitly not reinforced the implications that bullying is specific and disruptive conduct that impacts the delivery of care.
Carole Akerly, BSN, director of accreditation and regulatory affairs at Duke University Hospital, responded to my inquiry. “Duke,” she says, “has identified behaviors that are appropriate and has not specifically described intimidating and disruptive behaviors, and I don’t know whether we have identified it as that close.” But if bullying is as prevalent as the research and reports indicate—and there are many—it is unlikely that Duke and other health care providers have an incident pattern less than the norm.
The University of North Carolina Health Care System, on the other hand, provides a detailed description of intimidating and disruptive behavior and a very specific description of what constitutes appropriate behavior, so the employee has no room to allege ambiguity. The rationale for its disruptive and inappropriate behavior policy admits that disruptive behavior “intimidates others and affects morale or staff turnover [and] can be harmful to patient care and satisfaction as well as employee satisfaction and safety.” Further, the policy acknowledges the possible presence of such behavior: “While this kind of conduct is not pervasive in our facilities, no hospital or clinic is immune.”
Carol F. Rocker, PhD, RN, the lead investigator of a study of nurse-to-nurse bullying and its impact on retention in Canada, reported in OJIN: The Online Journal of Issues in Nursing in September 2008 that Canadian nurses are not alone when it comes to workplace bullying and emphasized that workplace bullying among nurses is now recognized as a major occupational health problem in the United Kingdom, Europe, and Australia. Why did The Joint Commission go to the trouble of defining bullying if it was not to delineate behaviors that threatened patient safety and care quality? The answer is embedded in what led the Commission to do this in the first place. It’s found in the promulgation of the Universal Protocol (UP).
In addressing the need to create a climate of safety related to wrong site, wrong patient, and wrong procedure within a health care facility, the Commission became aware that one of the contributing factors was the failure to speak up. What stops a clinician from speaking up? Oftentimes, it’s the deference to the physician and other clinicians.
“We have heard of abusive behavior by physicians when clinicians in the operating room, for example, have corrected the physician. Not speaking up is the result of deference to the physician,” says Castro. The UP team became aware at that time that this harmful behavior within care facilities was a safety issue.
A 2003 survey on workplace intimidation conducted by the Institute for Safe Medication Practices found that 40% of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator. Elaborating on this issue, the Commission’s Sentinel Event Alert cites several reasons why disruptive behaviors go unreported, such as fear of retaliation, the stigma associated with “blowing the whistle” on a colleague, and leniency towards physicians who generate high amounts of revenue.
But, so serious is the epidemic of workplace bullying—with particular emphasis on the nursing sector—that 26 state legislatures have proposed legislation to address this concern, beginning with California in 2003. The model, the Healthy Workplace Bill, provides very specific employee and employer remedies, protections, and sanctions. There is clearly a movement to expand safety in the workplace from the purely physical aspect to the equally important emotional and psychological aspects.
When Nurses Hurt Nurses
Kathleen Bartholomew, RN, MN, renowned for nursing consulting and training, cites episodes of nurse bullying that astonishes: a nurse hides a surgeon’s favorite instrument when a substitute fills in as the scrub; a circulator, a nurse who makes preparations for an operation and continually monitors the patient and staff during the surgery, doesn’t tell a new nurse who is scrubbed that she knows the shunt the surgeon selected has fallen on the floor; a newly hired RN who was previously a scrub technician is shunned by both camps. These episodes, Bartholomew says, pose the question whether this is what life is like in the OR.
When the administration at Indiana University Ball Memorial Hospital studied the issue of bullying, it was clear that the problem existed beyond nursing units. “It starts with physician to physician and then trickles down the chain of command,” says Renee Twibell, PhD, the lead investigator and an associate professor of nursing at Ball State University. “If the doctor kicks the nurse, that nurse turns around and kicks the new nurse or the CNA.”
The consequences of adult bullying have led investigators to name it as a significant occupational stressor in the workplace. Moreover, the Center for American Nurses labels workplace bullying a serious issue affecting the nursing profession in particular, and defines it as any type of repetitive abuse in which the victim suffers verbal abuse, threats, humiliating or intimidating behaviors, or behaviors that interfere with the victim’s job performance and are meant to place the health and safety of the victim at risk.
Are all nursing sectors equally at risk? Specifically, I was curious to know whether military nurses have a similar experience. Having spoken with Lieutenant Colonel Angelo D. Moore, PhD, the deputy chief for the Center for Nursing Science and Clinical Inquiry at Fort Bragg Womack Army Medical Center for a previous story, I remembered what he had said. Moore turned my inquiry around and wondered whether gender issues might be at work in some bullying episodes. The ratio of male to female nurses in the military is thrice that of the nonmilitary nursing sector and, according to Moore, the combination of having been to war and the culture of the military contributes to very few incidents where bullying was alleged.
Still, bullying is a complex phenomenon. Although bullies are responsible for their behaviors, investigators have analyzed several potential factors that prime the workplace for bully behaviors, which include organizational leadership and culture, the social system, character traits of the victim, and character traits of the bully. Bullying clearly qualifies as hostile workplace behavior, and if the target can claim protected class status, it becomes a major legal issue for hospitals and care centers. A 2011 study of student nurses by the American Nursing Association reported that 53% of study participants had been “put down” by a staff nurse, and 52% had been threatened or experienced verbal violence at work.
Cheryl Dellasega, PhD, faculty member at the Penn State University College of Medicine and author of When Nurses Hurt Nurses: Recognizing and Overcoming the Cycle of Bullying, provides significant research that led her to state that there are cases where the nurse manager or charge nurse—often a highly competent, valuable nurse that the administration does not want to lose—may act as a bully, playing favorites when it comes to assignments or time off. “If they are role modeling this stuff, it will be worse among the staff,” Dellasega told NurseZone.com. “If they get the message that it’s OK to treat people like this, everybody will.”
So, what’s the remedy? Bullying in the workplace is both an awareness and a leadership issue. Moreover, as is so often the case in workplace practices, the leadership should be careful not to be caught being party to making case law by a complainant seeking to link hostile workplace to bullying as a protected class member. Hospital management might address the presence or prevalence of bullying behavior by examining how it is factored into their training in root-cause analysis, as well as what their whistleblowing protection policy provides.
Nurse leaders must establish clear guidelines about what behaviors will not be tolerated and what is unacceptable, Dellasega believes. She also recommends creating a suggestion system so nurses can anonymously report things that happen on the unit, and asking for feedback about what would make the work environment better.
Gabriela Cora, MD, takes a harder stand, saying hospital administrators should have zero tolerance for bullying behavior. “Lay a plan for improvement,” Cora adds. “Reward them when they improve their behavior and be ready to fire them if they continue the bullying behavior. Second, avoid praising or rewarding nurses for their work performance if they are bullies. Instead, respectful treatment of patients and positive interactions with colleagues should be rewarded.”
Ultimately, it’s all about modeling positive behaviors and holding employees accountable. If the policy is zero tolerance for bullying, it should mean just that—zero tolerance.
The month of May is probably the most celebrated month of the year. The list, reflecting a very busy calendar, includes Memorial Day, Mother’s Day, Armed Forces Day, the Kentucky Derby on the first Saturday in May —this might be more than a day’s celebration—and Cinco de Mayo. That’s not all. Starting on May 6th through the 12th, as you swab your wounds from the disappointing performance of your favorite steed at Churchill Downs, celebrating our 3.1 million nurses should also be on the list.
In 1982, the US Congress designated the 6th of May as National Nurses Day, but it actually goes back to an October 1954 week-long celebration to mark the 100th anniversary of the queen of nurses, Florence Nightingale, for her service during the Crimean War. Yes, the same Crimea Russia just annexed. Nightingale, accompanied by 38 volunteer nurses, was put in charge of caring for British soldiers in Turkey during the War. Her efforts to formalize nursing education begun during the war, which led her to establish in 1860 the first scientifically based nursing school—the Nightingale School of Nursing, at St. Thomas’ Hospital after her return to London. International Nurses Day, observed annually on May 12, commemorates her birth and celebrates the important role of nurses in health care.
Understanding her connection to Crimea begins with an understanding of the reason for the war. In October 1853 the Turkish Ottoman Empire declared war on Russia following a series of disputes over holy places in Jerusalem and Russian demands to exercise protection over the Orthodox subjects of the Ottoman sultan. The British and the French, allies of Turkey, sought to curb Russian expansion. The majority of the Crimean War was fought on the Crimean Peninsula. However, the British troop base and hospitals for the care of the sick and wounded soldiers were primarily established in Scutari, a suburb of Istanbul, Turkey.
The care of the wounded soldiers had been reported to the London Times by the first modern war correspondent, British journalist William Howard Russell, who described the medical treatment provided by the establishment as incompetent and ineffective. The most basic care supplies were either unavailable or inadequate. Between June and August, 20% of the British troops were infected with cholera, diarrhea, and dysentery, and about 1,000 died before a shot was fired. This triggered an enormous public outcry in Britain and a demand that the situation be drastically improved. Nightingale arrived in Turkey on October 21, 1854, but received a hostile reception from medical officers at Scutari hospital and barracks.
She described the conditions she found as unsanitary, supplies inadequate, staff uncooperative, and overcrowding severe. Cholera was raging and the nurses were not allowed to visit the hospital wards. So she set about recruiting soldiers’ wives to assist with the laundry and cleaning the wards. Nightingale eventually established standards of care, requiring such necessities as bathing, clean clothing, and dressings, and adequate food, which the nurses carried out. She wandered the wards at night, providing support to the patients; this earned her the title of “Lady with the Lamp.” Two years into the war, Nightingale began the first of several excursions to Crimea, but they were cut short because she fell ill with “Crimean fever,” believed to be brucellosis, and it is believed she probably contracted from drinking contaminated milk. She returned home on August 7, 1856, as a reluctant heroine.
While Florence Nightingale was going about the business of establishing the procedures for scientific nursing in Britain, the US was moving ever so inexorably towards Civil War over slavery, and Harriett Tubman, a slave who engineered the Underground Railroad that afforded freedom for hundreds of slaves, would emerge a distinguished nurse and military tactician on the side of the Union Army Forces.
In 1863, when a decision was made to use black troops, Tubman was motivated to become a nurse for a regiment. When the famous Fifty-fourth Massachusetts Volunteer Infantry, one of the first official “colored” units in the Civil War, marched away from Boston, she followed a few days later with a commission in her pocket from Governor John A. Andrew, a popular abolitionist. In July of that year, she led troops under the command of Colonel James Montgomery in the Combahee River expedition, disrupting Southern supply lines by destroying bridges and railroads. The mission also freed more than 750 slaves.
Tubman is credited not only with significant leadership responsibilities for the mission itself, but was also able to calm the slaves and keep the situation under control. It was reported that General Rufus Saxton reported the raid to Secretary of War Edwin Stanton saying that to the best of his knowledge the success of the mission represented the only military command in American history where a woman irrespective of race led, originated, and conducted the raid. Tubman used her nursing skills and her knowledge of herbs to bring relief to the soldiers suffering from dysentery, a condition that also confronted Nightingale. Tubman learned this remedy during her years living as a slave in Maryland.
Tubman’s experience was in sharp contrast to the experience of Florence Nightingale who, as a nurse to British soldiers fighting to defend the powerful Ottoman Empire, was actually helping to maintain a slave society in that part of Europe and Asia – society that existed into the early 20th century. The Crimean Khanate within the Ottoman Empire had become a major slave exporting region. It raided the surrounding neighbors of Eastern Europeans, Ukrainians, Poles, and Caucasians among others, exporting them throughout the Empire. Black slaves imported from Egypt were forced to become eunuchs to serve their owners’ families.
Both Florence Nightingale and Harriett Tubman travelled very different roads in service to mankind and both have left a legacy worthy of celebration as we consider the contributions of our modern-day nurses.
James Z. Daniels, MPA, MSc, is a consultant and writer who lives in Durham, NC.
It’s the experience of a lifetime. After you’ve cleared security to enter Fort Bragg in North Carolina and your vehicle has been searched, you are instantaneously awed by the enormity of this army military post. I am on my way to engage two ranking officers—nurses—in conversation regarding health care in the military. The drive takes you on the four-lane All American Expressway with vehicles whizzing by between 55 and 60 miles per hour. As I slow down to take in this sprawling city, I am reminded that I am no longer in the city of Fayetteville that abuts the post.
But the pièce de résistance was the emotional tremor I felt when the Womack Army Medical Center loomed up at the end of a long entrance way to affirm that this was iconic America. This complex, 1.1-million-square-foot (this is not an error) care facility is not just impressive by its bricks and mortar, but is a care facility providing world-class health care across a compendium of general and specialized medical disciplines to our service men and women, veterans, and the families of those who serve on active military duty. To visually take it all in requires a significant swivel of my head.
The purpose of my visit is to gain some measure of understanding and appreciation of this reputable institution and to tell the story to those who will not have the opportunity I had to visit and see for myself. My host is Lieutenant Colonel Angelo D. Moore, Deputy Chief, Center for Nursing Science and Clinical Inquiry, a native of Queens, New York, and graduate of Goldsboro High School in Goldsboro, North Carolina. Moore holds a PhD from UNC Chapel Hill and was the university’s first African American male awarded a doctorate from the School of Nursing. A scholar, clinician, and practitioner with a passion for attacking health care disparities, Moore knows his way around scholarly journals but is just as comfortable applying a Band-Aid to a 5-year-old with a splinter in his thumb. He leads the effort at Fort Bragg to integrate evidence-based practice (EBP) into all aspects of nursing care.
Moore chose Winston-Salem State University for his undergraduate degree because of the seven-to-one ratio of women to men among the student body—a decision he candidly admits worked out for him because that was where he met his wife, Lee Antoinette, a civilian nurse now on the faculty at Fayetteville Technical Community College. He was posted to Fort Bragg last July from Honolulu, where he had been stationed for six months having initiated and led the EBP process.
For the better part of a day, Moore allowed me to engage him in an in-depth conversation on what happens within the walls of this facility that necessitates a tour by a skilled guide to truly appreciate the delivery of military health care services. I was taken through the “miles” of passageways and corridors, to the service malls and the various departments, as well as the skilled nurses training center to witness the nurses being tested on their competencies on a variety of medical and dispensing procedures; the cafeteria to sample military fare; and, eventually, one of the deputy commanders of the medical center, Colonel Kendra Whyatt, who on this day was in charge.
Too often there is a perception that connects questionable treatment of our military service personnel to the assumption that the health care delivered is similarly questionable. Nothing could be further from the truth. In my conversation with Colonel Whyatt, she very carefully called my attention to the signature difference between a military nurse and a civilian nurse that is invaluable in understanding the dynamism of military health care.
“Military nurses,” Whyatt says, “wear inseparably and simultaneously the role of the soldier and the role of the nurse, and they are expected to provide care for their fellow soldiers and protection for them if necessary, and certainly for themselves at the same level of competence.”
It is this dichotomy—the syringe and the gun—that guides my desire to understand how care is delivered by our nurse soldiers to a military population of 57,000 at Fort Bragg, of which 45,000 are active duty members.
What we know today as Fort Bragg came into effect in September 1922, but its history is attached to a Confederate general, Braxton Bragg, a native of North Carolina. The post occupies 127,000 acres; its population makes it the largest US Army base; and it is the home of the Airborne—the 82nd Airborne Division, referred to as “All-American” because its members represent 48 states. It is also the home of the distinguished Special Operations Force. Among its many amenities are its schools—preschool through high school for nearly 5,000 students, the children of soldiers on active duty.
Womack Army Medical Center opened its doors on March 9, 2000. The center is named for Private First Class Bryant H. Womack, a North Carolina native who was posthumously awarded the Medal of Honor for conspicuous gallantry during the Korean conflict. The center’s mission is succinctly stated: Provide the highest quality care, maximize the medical deployability of the force, ensure the readiness of Womack personnel, and sustain exceptional education and training programs.
The center is 1,020,359 square feet, encompassing six-floor towers and other buildings. It sits on a 163-acre site, has a 153-bed inpatient capacity, and serves the more than 225,000 eligible beneficiaries in the region. It is the largest beneficiary population in the Army.
The building has a state-of-the-art design: The inpatient tower floors have an interstitial space between each floor that allows computers, as well as other technical components, to be repaired without interrupting patient care. The complex is designed to transform many of the administrative areas into service areas providing care if necessary, which would double their inpatient treatment capacity.
Four patient-centered medical homes are located on Fort Bragg, and two community center medical homes are located in the surrounding military community where their beneficiaries live and work. The Womack Army Medical Center was among the first health care providers in the country to seize on the benefits, design, and purpose of the medical home in 2004. The military’s ability to make the medical home work for their patients rests on their enormous electronic records capacity, making it easier for them to implement the benefits from the Electronic Health Records (EHR) system that gives providers worldwide access to comprehensive and timely patient histories. The $1.2 billion medical records system began deployment that year across the entire force and was fully operational by 2007, just as the benefits and necessity of the EHR were dawning on the civilian medical community.
The medical home is best described as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the simplest to the most complex medical conditions.
But there is also the Soldier Centered Medical Home (SCMH). This is a care process with an exclusive and unique focus: the soldier. It includes behavioral health, physical health, and nutrition services; these are significant to soldiers who may be displaying the symptoms of Post-Traumatic Stress Disorder (PTSD). Everyone is screened using a predetermined questionnaire and an initial evaluation that determines whether the soldier is a prime candidate for treatment or follow-up. The Army’s official position is that “80% of all soldier complaints at sick-call are muscular-skeletal,” according to physician Colonel Dallas Homas, the former commander of the Madigan Army Medical Center in Tacoma, Washington, and the originator of the SCMH that became operational in November 2011. The concept grew out of an incident where an exceptional noncommissioned officer lost his knee unnecessarily, according to Homas.
Diagnosis and treatment of PTSD, however, continues to be a contentious issue within the military sector and might have led to Homas’s reassignment from Madigan Army Medical Center. Colonel Ramona Fiorey, a nurse, assumed command of Madigan on August 9, 2013. The Department of Veterans Affairs (VA) has reported that for the last two years PTSD diagnoses are just shy of 30% of the 800,000-plus Iraq and Afghanistan War veterans treated at VA hospitals and clinics.
It is during my conversation with Moore that a picture emerges of how the soldier-nurse threads her way through the system to attain the highest heights of a nursing career. One thing they do have is the role models to motivate them to succeed. You see, the Surgeon General of the US Army is also the Commanding General of the US Army Medical Command. Currently, that person is Lieutenant General Patricia Horoho. She is a nurse. Whyatt, one of Womack’s deputy commanders, is also a nurse. Nurses provide the leadership at the highest level and at base level. This is without precedent, and the profession does take notice.
Horoho has already made significant changes regarding military health care by her emphasis on what she calls, “life space.” She wants providers to address those periods when military personnel are away from a care facility with emphasis on ensuring they are engaged in healthy behavior.
Horoho’s leadership centers around the Army Nurse Corps’ five-point strategy, known as the Patient CaringTouch System or—with the military’s characteristic use of acronyms—PCTS. It has five components: enhanced communication, capability building, evidence-based practices, healthy work environments, and patient advocacy. The PCTS is a patient-centered model for nursing care that was developed to reduce clinical quality variance by adopting a set of internally and externally validated best practices. Additionally, it is an enabler of Army medicine’s culture of trust initiative and the transition from a health care system to a system of health. The plan is elaborately laid out in a campaign document intended to guide the care leadership through 2020, with emphasis on evidence-based decisions, metrics, and best practices that cannot be overemphasized.
As you might expect, the Army takes the issue of leadership very seriously. Army nursing is guided by an Army Nursing Leader Capabilities Map that encompasses a thirty-year journey, and Moore is a good example of how the process has guided his own career. A nurse’s development has three segments, and the progression is tied to seven performance criteria. The three segments are tactical skills, operational and organizational skills, and strategic thinking and execution. The nurse can move along a career path in what is called “duty positions,” beginning as a staff or charge nurse and rising in rank to a section or department chief and then deputy commander for nursing.
During this progression, the Army nurse develops competency in such areas as change and people management, succession planning, and foundation thinking, where he or she is expected to demonstrate unit-level, evidence-based decision making. At this level, “the PhD or the DNP enables and equips a nurse to engage in visionary and strategic thinking,” explains Moore. “After ten years in the military, nurses overwhelmingly have acquired the master’s degree, and this is a distinguishing factor in military nursing culture.”
Lieutenant Colonel Moore (never addressed as “Dr. Moore” but exclusively by his rank, as is the pattern within the military regardless of credentials) actually wanted to be a dentist, but financing that career seemed to be out of reach. He heard about the Army College Fund, so he enlisted in 1989. He was placed in the communications section, but had a strong desire to transfer to the medical field. He was working to complete his associate’s degree at night and heard from a friend about the Army’s Green to Gold program in which, if selected, he could progress over time from an enlistee to an officer. He completed the degree and applied, was accepted, and enrolled in the nursing degree program at Winston-Salem State University, graduating with the BSN in 1995.
As an active duty nurse, Moore’s assignment took him to the Eisenhower Army Medical Center in Georgia as a medical/surgical nurse; later, he chose to be certified as a critical care nurse upon completion of a four-month training program. Moore tells me that this is the normal developmental pattern allowing nurses to be associated with a particular specialty of their choosing.
As a male nurse in the 1990s, Moore was not an oddity because the requirements of war had always allowed the Army to attract males to the military nursing profession. Medics were trained to provide treatment to fellow soldiers on the battlefield, so the transition to formal training to administer generalized or specialized care was natural for many. Today, males’ 30% representation in Army nursing is six times higher than in the civilian nursing population.
“Male nurses,” Moore says, “are usually more prevalent in the areas that are ‘action-packed,’ such as trauma, or the highly technical areas where elaborate technical components are integrated into the patient’s care and in emergency room nursing.”
After several years of praying “Please, Lord, do not let any of my ICU patients die on my shift,” Moore wanted a change out of critical care and chose to work in primary care to reduce the prospect of patients needing critical care in the first place. He applied to the Army’s long-term education and training program and was accepted into the master’s program to become a nurse practitioner.
His next assignment was his appointment in 2007 as a recruiting commander stationed in Brooklyn, New York, with centers in Albany, New York, and New Jersey. Moore and his team of recruiters focused on enticing doctors, dentists, and nurses into the Army as officers by being visible at medical conferences and health forums where these professionals were present. The recruiters championed the experience, benefits, and research engagements that a recent MD graduate, for example, would never get in a hospital or private practice in his or her civilian role. They also targeted students considering careers in the medical profession.
Moore responds to my question regarding minority recruitment within the Army by explaining that there is no program designed to recruit minorities into the health care ranks as a targeted group.
“To the best of my knowledge, we do not look at race in our recruiting efforts,” says Moore. “We make appealing what the Army has to offer and allow the prospect to decide. Because of the culture of the Army, we encourage the prospective recruit to consider carefully the choice of military service.”
There is a well-known, generalized concern, however, about the low minority representation among the officer ranks in the military, which has attracted the attention of the top brass. So it came as no surprise when in March 2011 the Military Leadership Diversity Commission issued a report that included the state of diversity among the leadership ranks of the military.
“The disparity between the numbers of racial and ethnic minorities in the military and their leaders will become starkly obvious without the successful recruitment, promotion, and retention of racial/ethnic minorities among the enlisted force,” the report states. “Without sustained attention, this problem will only become more acute as the … makeup of the United States continues to change.” It’s similar to the state of private sector organizations.
Whether the Army does or does not have a minority recruitment strategy, the fact is that officer and leader representation will not improve unless there is a deliberate pipeline strategy leading from enlistee to officer. However, as I walked the hallways and visited the patient treatment locations at Womack, those at work and those receiving care looked very much like America.
With Moore accompanying me as I toured the facility past the many labs, the enormous back-office function, work stations, administrative functions, physical therapy service areas, and clinical specialties of every description along the long and seemingly interminable walkways, he added to my attempt to grasp the magnitude of what takes place at Womack as a matter of routine, by citing some impressive statistics. While doing so, he emphasized that the active military and the Veterans Healthcare Services are decidedly not affected by the provisions of the Affordable Care Act (ACA).
“There is one provision, however, where we see eye-to-eye with the ACA, and that is in the aspect of prevention as opposed to curative or disease care, because a healthy lifestyle is central to mission readiness,” explains Moore. “The three streams that drive mission readiness within the healthy life space triad are activity, nutrition, and sleep—and we are confident there will be a pay-off down the road.”
In fiscal year 2013, the Womack Army Medical Center had over 12,000 admissions with a 62% average daily bed occupancy rate and average length of stay of 2.6 days, over 3,000 live births, and over one million outpatient appointments. On a daily average, the associated clinics provided over 3,400 outpatient visits, approximately 6,000 outpatient prescriptions, almost 1,000 radiological exams, over 4,000 pathological tests, almost 200 Emergency Department visits, almost 40 surgeries, and at least eight live births. There are two medical residencies (family practice and obstetrics), and 14 other physician or Allied Health educational and training programs. Moore points out that no prosthetic service is provided to the injured soldiers at this facility. He reminds me that the health care staff consists of active duty members, Department of Defense civilians, and contractors who include civilian physicians and nurses. It is easy to identify the civilian medical staff because they are listed on appointment boards by their medical credentials; whereas, the active duty medical staff are listed by their rank, often on the same appointment boards.
Moore guides me along a walkway with photographs of distinguished service members and towards the skilled nursing center where competency tests are taking place. This is a biannual event where nurses are tested and certified to perform certain medical procedures. Womack nurses are required to expose themselves to this process if they are to be allowed to perform certain procedures. It is proctored by senior nurses and other technical staff. My visit to the center as this event was taking place was purely coincidental.
In a room deep inside the complex, nurses were examined on performing catheterizations on a mannequin (part of the infusion therapy procedure) and on their ability to know the difference when it is a pediatric patient compared to an adult; reading and interpreting the ECG tape—a necessary step before referring it to a cardiologist; identifying mental health behavioral issues such as PTSD; and using newly introduced, technologically sophisticated equipment. There are charts and poster boards everywhere. The atmosphere is intensely business-like, presided over by a nurse with the rank of major and dressed in fatigues. Even the test mannequin appears to be aware of the buzz over the event’s significance.
Next, Moore takes me to the pharmacy services mall, which is where the patients have their prescriptions filled. Every aspect of this procedure is very clearly understood as between 25 and 30 patients wait for either a consultation with a pharmacist or watch to see that their prescription is ready. The first served are those requiring immediate and preferential attention: the active duty soldiers. He or she registers as they all do, and the patient’s name lights up on a marquee pallet as an indication that the prescription is ready. The active duty member’s name will supersede all others.
Finally, our walk heads towards the command center where Moore has arranged for me to visit with Colonel Whyatt, Deputy Commander for Nursing and Patient Services, who is acting commander today because Commander Colonel Steven J. Brewster is off the post. This is Whyatt’s first assignment to Fort Bragg. After being cleared to enter the command center, I am seated in what is quite easily comparable to an executive suite in any corporate headquarters. The offices are bright and cheerfully wood-paneled, with each executive officer’s support staff seated within earshot of their work stations. One is dressed in fatigues, as is Colonel Whyatt. She is tall, relaxed, and with a distinctive military bearing that suggests a calm, in-control demeanor. She is a native of Greenwood, Mississippi, and was previously stationed at a military facility in Germany.
With my discussion about minority recruiting still turning over in my mind, I wanted to know her opinion regarding mentoring and coaching. But first she has to be reassured by Moore that I have been cleared to have this conversation with her.
I first want to know what makes for a successful and responsive military health system. “It’s the combination of the military, civilians, and contractors working together,” Whyatt responds.
“What are the two top concerns that occupy your attention?”
Whyatt responds succinctly: “[To stay in mission readiness], I have to recruit staff, retain and train staff, and we are facing challenges in this area; in particular, in the recruiting and retention of staff. Most everyone knows that certain funding is at a standstill.”
“Do you mean the sequester?”
But a majority of hospital executives believe there is a shortage of physicians and nurses in the US, according to a new survey from American Mobile Nurses Healthcare, a staffing company that recently published its 2013 Clinical Workforce Survey. It found that 78% of hospital execs think there is a shortage of physicians; 66% say there is a shortage of nurses; and 50% report there is a shortage of advanced practitioners. The survey also found that the vacancy rate for physicians in hospitals is nearly 18%, compared to 10.7% in 2009, and nearly 17% for nurses, up from only 5.5% in 2009. The vacancy rate also rose for allied professions, from 4.6% in 2009 to 13.3% in 2013. But Womack is currently under a staff freeze, and the civilian workforce is expected to be reduced sometime during 2014.
Colonel Whyatt owes her military career to her mother. At the end of Whyatt’s sophomore year at Prairie View A & M University, her mother strongly suggested that instead of coming home and looking for a summer job, she visit with the ROTC office on campus and see what they could do for her. Whyatt visited the office, enlisted, and went on to complete her undergraduate degree in nursing with a scholarship from the Army. Her career has taken her to three tours of duty to Germany and several Army posts within the US.
“Are you mentoring and coaching any on active duty at this time?” I ask.
“That is an expectation of this position. Yes, I am,” she responds.
Huge changes are sweeping the health care landscape; electronic medical records (EMR), the resurgence of clinics as the point of care delivery, the medical home, care disparities, cost and financing issues, the Affordable Care Act, and the market-driven nature of medical care. But their significance, however, is not matched by one that is passionately mentioned in that list. It’s the primacy of the patient and their satisfaction.
Several months ago I spent several days in Duke Regional Hospital in Durham, NC. It was memorable for the care I received but the experience persuaded me to reexamine the use of the word patient. Upon being admitted, among the first questions asked of me was whether I was, “under the care of a family physician.” As the examination proceeded, I was eventually told that depending on what was uncovered, a decision would be made on admitting me for further tests and observation. It sounded as if I was excluded from any role in that decision.
Before being installed in my room on the fifth floor, a doctor in a white coat came to see me and in a tone that communicated confidence told me that he would be “taking care of me.” After several days in the hospital, I received calls from family and friends who said, they heard I am “suffering from” (and they named the illness). I was exposed to language that was so powerful in assigning me a place relative to others that on one occasion when a nurse came in to just check on my progress, I remarked that I was a “victim” of (and I named the illness).
The origin and use of the term, “the patient” is an intriguing one. A patient is a person who seeks and receives treatment for an injury or an illness from a clinician. Original research has established that the word “patient” made its first appearance in English in the 14th century. Its meaning, among others, was a person bearing difficulties without complaint. From this early definition, it morphed in the 18th century to signify a person with an injury or illness and became exclusively associated with medical treatment. Before that its medical and non-medical meanings coexisted. But as physicians appropriated and narrowed the meaning of patient, the word’s reference to someone suffering in any other sense than the medical, disappeared. In the 19th century, it became firmly attached to hospitals as places to go for medical services. Hospitals, however, have been in existence from antiquity.
The dominant connotation of the word, patient, is that of an individual who is appreciative of medical attention and to convey this, such expressions as, “under the care of a physician” or “being cared for in the hospital” became common phrases. From its earliest use, however, there was more than a hint that there was a distinct imbalance of power in the interaction between the clinician and patient. It went beyond gratitude to an implication that patients were subservient to and entrusting of whatever the clinician conveyed as the solution to their health concern. Ignoring a physician’s directives was considered more than very risky; it was worthy of opprobrium.
This power imbalance is at the center of a major shift in how health care is delivered. The patient has emerged as a subscriber and the evolution of what the patient becomes continues as resources are trained on the delivery mechanisms and channels of care.
Before this attention on the patient, clinicians reinforced their power-position in the medical language they used to affirm both the illness and the recommended therapy. For the patient, it often was so incomprehensible it must be the right thing to do. The patient was very motivated to comply with the clinician’s instructions, especially so if coming from a physician, because they were impressed by the language and the demeanor reinforcing the therapeutic directives. It was a reflection of how medical encounters, in spite of the fact that the interactions could involve two or more persons, were virtually clinician centered. Compliance was de rigueur of the interaction.
Over the past seven years, the monumental changes regarding how health care is delivered have shifted the encounter away from the physician-centered model to the patient-centered one and enormous resources now propel it to the center of a new health care delivery emphasis. This sea change in the relationship, now enshrined in the phrase, “patient-centered care,” elevates and emphasizes the person receiving care and is at the center of the competition for patients and how medical care is marketed. Because of this, we are now able to release “the patient” in the medical interaction and welcome the “subscriber” to health care. It will be unsettling for some to embrace this change but it will happen. It is probably a transitional expression.
The emergence of the subscriber as the recipient of health care services is attributable to several powerful forces that have coalesced to place the patient at the center of health care delivery or at the very least to equalize the relationship with the clinician. Today, medicine’s transformation as the most segmented profession is dominated by market-driven forces and this is virtually responsible for the power shift in the clinician – patient relationship. It is not yet comparable to selling computers, tires or even refrigerators, but it is close.
For example, advertising by American hospitals, clinics, and medical centers rose 20.4% over 2010 to one billion dollars for 2011, according to the Kantar Media unit of WPP Group that tracks these expenditures. Expenditures like these in other sectors of the economy would have to be reconciled against, “satisfied customers and market share growth.” In health care, it’s “satisfied patients and market share growth.”
Simultaneous with the market-driven phenomenon was the rise in the demand for personal responsibility. In health care, self-management and the emergence of a vigorous wellness movement began to chip away at the power differential between clinician and patient. Together they propose that if a healthy lifestyle is followed inclusive of exercising, maintaining a healthy weight, not smoking, and adhering to a healthy diet, then visits with a clinician will be less frequent. Advocates, including clinicians, encouraged patients to access the mountain of wellness and prevention information that’s only a Google click away. This became a display of individual freedom and patients’ autonomy. Visits with a physician were a deliberate and conscious choice but no less a shared responsibility. Clinicians were swept up in its advocacy.
Patient-centered approach to the delivery of care is increasingly being considered a paradigm for high-quality interpersonal care, according to research findings reported by Drs. Klea D. Bertakis and Rahman Azari. Although their findings do not support the linkage of patient-centered care to improved patient outcomes, they do say that there is evidence to suggest that when the patient is actively involved in decision making regarding their own health, significantly lower primary care charges result. “Moreover, there is emerging evidence,” they say, “for an association between patient-centered communication and the utilization of medical resources.” They further add, “It has been found that patients who perceived their visit as having been patient-centered received fewer diagnostic tests and referrals and corresponding lower expenses for diagnostic testing.” These would most certainly be visits where shared decision making (SDM) was practiced.
A solid patient-clinician relationship can potentially help reduce the incidence of tort claims. Studies reported in the Journal of General Internal Medicine have shown that most cases of iatrogenic complications and adverse outcomes never enter the tort system. One reason is that patients will be much less likely to sue when they have feelings of well-being and goodwill and are satisfied and respected.
As hospitals in particular and the medical community generally embarked on service differentiation because of competition for patients, and with increasing choice options available to patients, those receiving care began to be seen as “customers” within the medical services community. The highly segmented medical services sector encouraged the exercise of significant selectivity. This pattern mimicked what takes place in the generalized market place. The delivery of medical services shifted deliberately to one of service niches.
Patients were now being wooed to subscribe to services that were more identifiable with their pattern of purchases. One provider was marketed as specializing in cancer treatment, another with having facilities that made child birth a very pleasurable experience, another with specialization targeting athletes — that’s sports medicine, and even another with capabilities in integrative medicine where the patient’s cultural perspectives on wellness resonated with their clinical staff. The conclusion was that the provider’s brand had become paramount.
However, the least empowered are those whose wellness diversity is often times discounted by clinicians who often times say with amazing irony that they treat all patients alike. An empowered patient sector persuades providers to listen and communicate with them within the context of their wellness paradigm. Health diversity is linked to care delivery when it is viewed as a public health issue precisely because of the association of disease with certain demographic entities. It’s in this context that inclusion serves to elevate disparity to the forefront of what needs focused attention and correction in our health care system.
The implications for the health care system are that clinicians now accommodate a new paradigm and have had to restructure how care services are delivered to attract and maintain subscriber patronage because of emphasis on shared decision making, regulation, access to health information, and market competition. These changes have had a profound impact on redesigning the power dynamics in the patient-clinical encounter.
The compelling question that’s posed in view of this shift is this: Is the patient-centered approach and the corresponding power-shift a good thing or not, and will it deliver improved health care outcomes? This much is certain from the research, patient-centered care has been associated with decreased utilization of health care services and lower total annual charges.
Reduced annual medical care charges may be an important outcome of medical visits that are patient-centered and power-balanced. There will be no going back to the clinician as medical oracle. The patient has been liberated; if not to the role of customer most assuredly to that of subscriber. But so has the clinician as truth teller.
James Daniels, MS, MPA, is the principal consultant for J Z Daniels Co. Ltd., a cultural health care competency practice.