According to a survey of 43,329 registered nurses working in adult acute care hospitals, 41% said they were dissatisfied with their present job. The survey results, published in Health Affairs on May 7, 2001, also indicate that one third of all nurses under the age of 30 plan to leave their jobs within the next year. The current average age for a registered nurse is 47 years. With retirement looming for many nurses in the next 15 years and very few nurses to replacement them, the environment of care in many facilities has become a sea of desperation.
Many nursing units are understaffed. Most managers are overextended, attempting to manage multiple units with responsibility for more than 100 staff members. The intense regulatory environment places tremendous burdens on each unit for training, safety and competency requirements. The continuous decrease in reimbursement for services has lead to minimal support staff and even fewer resources for education and skill development. Due to the 24 hour/ 7 day a week care requirements, there is never a time when all of the staff can come together in one room for a meeting or discussion of issues affecting the delivery of care. Communication becomes fragmented and rumors and myth replace facts. The healing environment becomes primed as a battleground and all of the elements for conflict ripen into horizontal violence between clinicians.
Physicians, social workers, therapists and support staff are under increased pressure to provide more services with fewer resources. Collaborative relationships are strained as competition increases for beds at the appropriate levels of care. Emergency departments in urban areas are routinely forced to divert patients due to a lack of critical care beds or appropriate staff. Transition through the health care system is complicated by poor information technology and complex admission/transfer and discharge processes. Flexibility and cooperative spirit among the health care team members is strained by a consistent stretching of the resources of time, space, and people.
On top of the internal strife affecting patient care, external pressures from worried families and patients adds fuel to the fire. Frequently, families feel the need to remain at the patient’s bedside to ensure that someone is there to help or to watch for one of the all too common errors so frequently reported in the media. The constant and rapid turnover of patients allows little time for conversation, education, and validation. In spite of the focus on error reduction and prevention, it becomes increasingly more difficult to manage the barriers within the system. Patients and families enter the hospital only after navigating the HMO and insurance approval process and are faced with limited hospital stays and fears of finding adequate resources to help them after their discharge home. Families are met by nursing staff who have limited time and a limited ability to cope with the complexity of competing needs. Physicians frequently have too little time to spend assessing and treating patients and the clinical relationship suffers. Both the clinicians and the families are faced with situations that make them feel compromised and a lack of trust drives apart the two strongest advocates a patient has.
In addition to resource constraints, difficulties arise around the conflicting interests and needs of the various stakeholders within the health care system. Stakeholders include physicians who have limited time and increasing pressure to adhere to financial profiles, patients with complex care needs including social support and financial assistance, families who need emotional support and information from a complex and often chaotic organization, and administrators who are concerned that financially the hospital may not make it through another year without profits. Each stakeholder competes to have their needs met in a constant give and get that casts a shadow over the clinical decisions taking place in the foreground.
Perhaps the most difficult of all are the values-based conflicts. Disagreements over the proper amount of care for a terminally ill person abound. The decisions of withdrawing life support, resuscitating aggressively, honoring an advanced directive, determining the wishes of the family, or determining the wishes of a patient who can no longer express his or her wishes are complex. The conflict in values between an administrator who has the responsibility for keeping the hospital viable and clinicians who have the responsibility for keeping the patient viable can drive many resource negotiations. Diverse cultural needs place additional demands on the system for translation services and flexible policies to enable integration of varying cultural beliefs. Difficult decisions are made through a complex series of negotiations occurring every hour of every day.
Added on top of the resource, interest, and values-based conflicts, exists a well-educated, highly experienced clinical workforce with little or no training in conflict management and communication techniques. The skills of negotiation and conciliation are learned on the job. In the best of circumstances, positive role models will exist to help guide those who seek a template for how to listen and seek agreement. In the worst of circumstances, competitive, power-based authoritarians and conflict avoiders abound creating situations which lead to escalation of disputes and unnecessary stress.
It is time for hope to return to healthcare. Hope that results from imagining what is possible. As health care providers, we have the opportunity to listen and to understand the interests and needs of our patients, their families and each other. We have the ability to show empathy and to treat each other with civility and respect. We have the choice to shift our perspective from one that focuses on the lack of resources to one that considers what we accomplish together to be the true miracle. We are not obligated to meet every need that society dumps at our doorstep, but we do owe it to ourselves to feel proud about the needs we can meet and the compassion that we show to those who need us most.
There is hope for making sense of the complexity and chaos surrounding health care. It takes an intentional movement toward appreciation of competing needs and an agreement to work together to achieve good outcomes. It takes seeking out ways to design policies that do not create conflict and creating systems that allow for dialogue between people rather than litigation between disputants. We can offer our skills of empathy and advocacy to each other. We can inject humor and creativity into our work. We can be present in the moment and find the joy that comes from being a part of a team working to solve a commonly defined problem.
All of us have the ability to generate hope through collaboration and mutuality. We have the creative capacity to solve the resource riddles and to envision a system that optimizes care and not just cure. We have control over our choices to communicate clearly, to resolve conflicts early and to apologize gracefully. We can restore hope by valuing the intangibles that are at the core of healing. As Vaclev Havel said, "We must try harder to understand rather than to explain." It is through our understanding that our health care system will shine again.