A physician’s lament is nursing’s, too.
By Maureen Shawn Kennedy, AJN editor-in-chief
By Alan Cleaver/via Flickr
Last week, the New York Times Well blog published “The Importance of Sitting With Patients” by Dhruv Khullar, a Harvard medical resident. Khullar expressed regret over not spending more time with a patient who was near death, and then discussed how little time residents actually spend with patients—eight minutes, according to a Journal of General Internal Medicine study (2013) that analyzed the time of 29 interns over a month. (The study found that only 12% of the residents’ time was spent on direct patient care; 40% of their time was spent on computers.)
Khullar detailed the various activities that take him away from direct patient contact and noted as well that the shorter working hours mandated for residents had the unintended consequence of reducing time with patients. He wondered:
By squeezing the same clinical and administrative work into fewer hours, do we inadvertently encourage completion of activities essential in the operational sense at the expense of activities essential in the human sense?
The second part of the question seemed especially pertinent for nurses. Hospital nurses have long lamented that paperwork, insufficient staffing, and nonnursing tasks keep them from the bedside. The promise of computers to reduce documentation time has yet to be realized, as first-generation documentation systems are not necessarily designed from a nursing perspective and often lack the specificity and flexibility to truly capture nursing activities.
The same might be said for some medication delivery systems. And we know from Beatrice Kalisch’s research on missed nursing care that it’s not just a matter of missed opportunities for empathy—the lack of adequate time for direct care also has negative consequences for patient outcomes.
Khullar talks about the trade-off of empathy for efficiency:
We hide behind buzzwords like ‘patient-centeredness’ and ‘shared decision-making’ without being able to offer the time that gives these terms true weight. Ultimately, reconciling this tension may mean reconceptualizing ‘efficiency’ to include the tremendous value that exists in having more time to spend with our patients.
This, too, is the challenge for nursing. As hospitals tout patient-focused care, are they investing in resources to make it more than a marketing slogan? What is your hospital doing to make it easier for you to provide nursing care?
My hospital is not making it easier to provide nursing care. I work for a “VIP” unit, which prides themselves as having excellent care and personalized attention. However, the unit is also a telemetry floor and a normal day for us is seven patients to one nurse. With such a high ratio there is barely any time to care for patients. Nurses on my floor also find themselves overwhelmed with patient care duties. They barely have time to spend with patients and really do not have time to show empathy. As you pointed out, multiple studies have shown that this breeds a culture where mistakes and errors lead to detrimental patient outcomes. The price for the appearance of efficiency is too high. However, none of this will ever change until nurses unite together and advocate for a change in the prevailing culture of healthcare.
I also agree with your point regarding electronic charting. Even though hospital administrators claim that electronic charting speeds up charting, most of the nurses on our floor find that it still takes a substantial amount of time to chart and any time it potentially saves is taken by additional patient assignments. As was mentioned in the blog post, many of the electronic charting systems are not designed from a nurse’s perspective and as a result nurses find themselves having to write many notes. Even so, there are many nursing actions that are performed but not documented. Although these systems are an improvement compared to the days of manual documenting, there is still much work to be done.
Though I no longer work in a hospital setting, the same issues plague home care and community nursing; meeting productivity standards; electronic charting (unfortunately this has not been the boon we anticipated) and too much to do in too little time. What is true for most of the nurses I have worked with over the years: the most satisfying part of our jobs continues to be connecting with patient’s and families and knowing our expertise helped ease them in a very difficult time. A nurse’s caring presence is one of the greatest gifts we bring, and we can still give this even if it means taking an extra few moments to stay, and listen, and be fully present at the bedside.
Hospitals strive more and more for efficiency in staffing and patient care, but as human beings there is a limit for nurses and perhaps we have gone past that limit. Unfortunately, nurses are seen as commodities not professionals each with a unique skill set.
I totally agree with you that the system doesn’t often doesn’t seem to allow time for “empathy.” All too often, nurses feel like automatons, mere machines providing inputs to other machines. But then, you see a nurse who has transcended the system to provide exquisite empathic care. While system changes are critical, we also need to learn from these nurses who have not been so overwhelmed that they cannot provide the care our patients deserve.
The problem with non patient care activities is what is affecting patient safety and sending patient satisfaction downhill. It is not nursing anymore, it is just pleasing administration. They don’t get it, which is why the majority of nurses are so frustrated and leaving as soon as they get a chance!