Re: Blowing The Whistle On Deliberate Understaffing & Toxic Managerial Practices

Nurses Safety

Published

this question was sent to a patient advocacy group in the us and pertains to the deliberate understaffing issue that i was fired for revealing. it is posted here under the general nursing forum rather than the or forum since the core problem, the toxic managerial practice of deliberate understaffing and the consequences for those who speak out, is one that we are all facing hospital wide.

how long is too long for a member of the sterile team to remain continuously scrubbed into surgery?

although the public might not understand that medical professionals including the surgeon must leave the or briefly during lengthy surgery, most conscientious practitioners realize that this is a normal safety measure necessary to combat fatigue. i am trying to get a consensus of feedback from those who routinely face this dilemma in the or as to what time frame is universally accepted as the maximum period that any member of the sterile team can be expected to safely function while scrubbed into surgery without a break. although i am now in the “nifa” training program to become a first surgical assist, even as a surgical technologist, performing the “scrub” role, i had to concentrate on anticipating the surgeons needs during a case. after how long would you consider that scrub role jeopardized by fatigue to the point where i might have lost concentration and focus on the operation?

while a surgeon can, and should, demand that the person assisting him is relieved, nurses and technicians fall under the control of or management which leaves us vulnerable to the vagaries of inappropriate or coverage as determined by the hospital. as a consequence of hospital “downsizing” to cut costs redundancy of personnel has been severely limited to the point where during the off-shifts especially at night and on weekends there’s no free staff to break people out of surgery for even a brief run to the bathroom! calling in call team people to provide relief breaks is considered an unnecessary expense, despite the fact that there is a clearly established link between fatigue and medical errors. the sterile team scrubbed into surgery are trapped without food or water until they are relieved; this also represents an unacceptable deprivation strain on the body. however there are no safeguards within the existing us employment laws or ocha standards to insure that critical hospital workers, including those in the or, are not left for hours of continuous, and dangerous, practice without a break. “breaks are at the discretion of the employer.”

i was left stranded at the field without relief for 8, 10 and on the worst occasion 12 hours straight. these situations impacted my ability to concentrate as my blood sugar plummeted; each time i reported becoming sick, dizzy and faint to the point of nearly passing out. when i complained that my condition in response to this hardship presented a danger to my patients i was targeted for removal and then fired. incidents where any member of the or team is forced to remain on task for that long should be documented in an “incident report,” as an extreme of this magnitude presents an unacceptable danger to the patient. the geneva convention strictly prohibits such inhumane treatment of working pows! how many normal human beings are expected to go for 12 hours without water, food or urination?

this is an interesting reprint from a document that those who work under similar unreasonable, torturous or downright inhumane circumstances in the us should take careful note of:

43. hours of work are interspersed with one or more eating and rest periods of not less than half an hour. continuous work may not exceed five hours. the rest period in jobs which span two meal times ranges between one and four hours (labour act in force, art. 58).

unhcr is helping to legislate more humane working regulations in iraq than are afforded to us workers even in critical jobs like healthcare! the “labor act” is a un document, please visit this site: http://www.unhchr.ch/tbs/doc.nsf/(symbol)/e.1994.104.add.9.en?opendocument

there is a lot of talk about medical errors right now, but far less mention of the toxic work environment that now encourages mistakes. this situation is getting steadily worse. while “at will” employment laws silence those who dare to speak out, lack of a humane break policy condones driving hospital staff until they drop: is there any wonder that errors are on the increase? little wonder that a sponge or an instrument is inadvertently left inside the patient when the scrub is almost comatose after a 12hour ordeal in surgery. all the cross checking and safeguards are irrelevant if the hospital staff are trying to function while so severely fatigued, hypovolemic or hypoglycemic that they are at the point of either falling asleep or passing out. when will the various safety advocacy groups in the us finally address this very real problem and insist on proper protective legislation? there have been advances recently with limiting the residents working hours and trying to stop mandated overtime for nurses, but much more emphasis must be placed on eliminating unnecessary fatigue among all of our medical staff.

no one is more important than the patient unconscious on the or table. for my very prestigious maryland hospital the “nursing shortage” was a convenient excuse to justify unconscionable managerial abuse that seriously endangered my patient in the or. doctors and nurses face severe discipline when mistakes occur, but why isn’t a negligent hospital policy that condones drastic staffing cut backs ever recognized as the real culprit? in some cases administration even offers financial bonuses to encourage self-serving managers to implement inadequate staff coverage. then they fail to hold a repeatedly abusive manager accountable when they drive dedicated staff until they drop. this managerial excess is focused purely on saving money not saving lives; we need proper safeguards in place to cub this negligent profiteering strategy before patients are harmed. plus when staff are courageous enough to come forward and expose a pattern of ongoing negligent practices they must be protected from retaliation and taken seriously by accreditation agencies who’s duty is to protect the public. no medical institution no matter how iconic, prestigious or powerful should be immune to rigorous scrutiny, as this lack of oversight encourages bending the rules, ignoring regulations and cost cutting that is harmful to safe patient care.

relentlessly abusive managers are a very valuable tool in facilitating staff downsizing without layoffs; i call this the spineless approach to cost cutting, but it makes our hospital working environment extremely dangerous for the patients. the current nursing crisis has come about through this dangerous downsizing and the creation of the toxic work environment that is driving nurses to leave their chosen profession because they refuse to take unnecessary risks. the us does not have a “nursing shortage” it has a “nursing exodus.” the us healthcare industry is still consistently expecting all of our medical professionals to take bigger risks by making do with unsafe staffing practices. this issue desperately needs to be addressed so please post comments,

kim.

ps: the issue of retaliation and unfair dismissal of whistleblowers has been further elaborated upon by myself and other affected nurses on another thread:

re: retaliation for voicing concern over unsafe practices. this thread was started by an icu nurse, but the problems i have seen discussed on this and other threads represent the growing concerns of many silenced patient advocate nurses. there are some valuable suggestions on exposing patient safety issues and combating retaliation on the above thread. i will be taking further action very soon by posting a petition calling for a compliance line investigation into my case. please visit this other thread to comment on the issue there too and consider the importance of making our voices heard, many thanks.

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Hey Kim, very thought provoking post, but why was it edited by Nurse Ratched as noted at the end? I am an RN and have extensive experience as a circ and understand the environment you describe. In reviewing many posters here it is evident that this cord of frustration and intimidation runs rampant within many environs of healthcare.

Those that speak out are effectively silenced and discredited as zealots who hold a grudge! How are things going for you now? I am still working registry but also venturing into Forensics since I also am passionate about the law and this job combines the 2 dynamics. How about a book about your insights and experiences? I predict a best seller!!! Keep up the good fight.

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Specializes in Geriatrics/Oncology/Psych/College Health.
but why was it edited by Nurse Ratched as noted at the end?

A link was removed per TOS - thanks :).

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You know guys...TsunamiKim.....is bringing up an important topic here. How long is "too long" to be asked to remain continously working without a break...with no relief...for lunch...for a bathroom break? I mean we are americans.....we all B****h and complain about human right violations when people in other countries are being made to work in conditions like that. People in the community...that come to hospitals.....and are outraged to find out that a "sponge" etc etc got left in.......and they suffer as a result. The HCF is looking to assign blame.....but yet they fire nurses like tsunamiKim...here who are saying that working 10 hours nonstop with no break is not humane...or safe. Not safe for the nurses....not safe for the patients.Period. Mistakes will be made.It is sad when nurses are effectively silenced for voicing issues that directly relate to being able to safely manage a patients hospital stay.I think thats what TsunaiKimis really saying.....:nono: :nono: :nono: ...and thats just not right. These are patients...people....who have families...lives......they are "someone" to "somebody". Their care...their hospital stay matters.In order to safely care for them we have to be able to take care of ourselves too...and 10-12 hours with no bathroom break ...or meal break...is wrong ...ya know.Arent there like labor laws that address this?

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hi tnnurse,

i have a tendency for my blood sugar to become quite low when i skip a meal, but everything is fine as long as i am sensible about what i eat and when. i would not describe it as a real medical problem that requires evaluation, as it is normal to need sustinance within a 12hour time frame. however, on one occasion when i bought the or abandonment issue to my manager, her responce was: "perhaps we should have you evaluated for a sugar problem." my nurse manager failed to comprehend that some, otherwise normal individuals, are more sensitive to skipping meals than others. i have become very cognisant of the indicators that my blood sugar is dropping. due to my acute sensitivity to these indicators i have learned to take note of what triggers or accelerates a more rapid drop in blood sugar and a major factor is stress. a particularly stressful case will bring on those tell tale signs that i have learned to recognize. going totally without anything for 12hours during a stressful case taxes me to the max and i worry about my concentration as i struggle to focus on the surgery.

i sometimes think that those around me who are less attuned to noting the more subtle signs often allow themselves to run on empty. if the physical signs are missed or ignored the mental signs can still continue to have disastrous effects without any clearly percieved warnings. my nutrition wasn't great as a child and my mind would go completely blank when my blood sugar dropped. this problem severely compromised my schoolwork while so many teachers believed i was just lazy or acting out. the physical signs were not picked up i had no idea how to cope with this until much later in life when i learned to pay more attention to regular eating habits. one moment my mind is blank; the next i drink orange juice and it is like someone flipped a switch and turned the power on. i used to take small cartons of oj to work with me to facilitate fast recoveries after periods of or abandonment, but this should not have been necessary. we all deserve to be treated with common decency and humanity.

how many us health care workers these days are subsisting on coffee, sugary doe bombs and stress. the skip meals when no one bothers to relieve them and stretch their physical resources to work a few more hours when they are completely exhausted? are they too busy and too besieged to notice that their blood sugar is critically low and they are trying to function while their mind is completly blank. how do you calculate a dassage when your mind is blank? is this safe? no. i believe the problem of low blood sugar is plauging many medical professionals during their stressfull schedules with no backup and mandated overtime. this further compounds the problem of fatigue and heps contribute to the alarming medical errors commited while the mind is blank due to low blood sugar. until we recognize these dangers and stop driving staff to run on empty we will continue to risk making dangerous mistakes.

the abandonment of the abusive evening/off shift or nurse manager at my former hospital was relentlessly inflicted on numerous employees for years and lost the hospital dozens of really good nurses as no one could tolerate the abuse. her treatment towards me as a tech demonstrated her complete disgust for lower forms of life i.e. non-nurses and it is somewhat beyond excusing in the simplistic way in which it was handled. i wrote incident report, they were ignored or thrust back in my face as times where i had "caused a scene in the patient care area," by protesting the abuse. despite the fact that these volatile exchanges were untrue they were used to supress the real issue and make me look like a loud, rude, uncooperative employee; they ended up in my file as strikes against me! when i went to the assistant director of surgery to voice my concern over a schedule change that placed this most abusive manager working as charge and me working virtualy alone under her supervision i got an equaly complacent reply. i said i felt that my working conditions under this nurse had reached a "toxic level of dangerous;" but the deputy director just said "she probably will not do that again." to this day i do not believe she has ever been disciplined.

there is a little know quirk of ada regarding "threat to self." that i would like to link to, but have a copy for you here. it does not bode well for the nursing profession if a precident is set by cases like the following example and they are used by hospitals to shield themselves from liability in not providing necessary breaks. this was what i copied from one legal website: 5. chevron v. echazabal a. summary

in echazabal, 536 u.s. 73 (2002), plaintiff was offered a job contingent on passing a medical examination. the examination revealed elevated liver enzymes and he was eventually diagnosed as having asymptomatic chronic active hepatitis c. accordingly, his employer rescinded the employment offer on the basis that plaintiff would pose a direct threat to his own health and safety. issue was whether the defense of direct threat was limited to "threat to others" as set forth in the ada or if it also included "threat to self" as defined in the eeoc's regulations. the supreme court held that direct threat included "threat to self" and thus, the employer's actions were deemed valid under the ada. the court emphasized that under the ada's direct threat analysis, employers will have to rely upon objective medical knowledge and conduct an individualized assessment of the employee's present ability to safely perform the essential functions of the job instead of relying on stereotypes or paternalistic perspectives. following the supreme court's decision, the case was remanded to the 9th circuit to apply this new standard. despite the supreme court's ruling on direct threat, the 9th circuit still found that there were material issues of fact as to whether chevron successfully raised the direct threat defense. among other factors, the court focused on the lack of credentials of chevron's doctors to adequately assess the potential impact on echazabal's liver. [ see, echazabal v. chevron, 336 f.3d 1023 (9th cir. 2003)] the case will now proceed to trial.

b. impact

to date, only a handful of lower courts have applied echazabal. advocates, however, fear that the decision will be used in the lower courts as a justification for paternalistic and discriminatory employment decisions. this fear has been realized in at least one recent case: in orr v. wal-mart stores, 297 f.3d 720 (8th cir. 2002) the eighth circuit ruled that the plaintiff, a pharmacist with diabetes, was not a person with a disability as defined by the ada. in dicta, however, the court suggested that even if the pharmacist had established a prima facie case of actual disability under the ada, wal-mart could have successfully raised the "threat to self" defense. the pharmacist had argued that because of his diabetes, he needed to eat on a regular schedule, and that failure to do so could result in his experiencing symptoms of hypoglycemia. as a reasonable accommodation, he asked that he be allowed to routinely close the pharmacy for thirty minutes at the noon hour in order to eat an uninterrupted lunch. citing echazabal, the eighth circuit ignored plaintiff's request for a reasonable accommodation and instead suggested that wal-mart was justified in not continuing the plaintiff's employment. the court relied on the fact that working in a single pharmacist pharmacy that did not provide for uninterrupted meal breaks posed a direct threat to the plaintiff's health. [color=#333333]

[color=#333333] this ruling is very troubling with regard to health care professionals and we must insure that safeguards are put in place to insure that profit driven hospitals do not try to normalize intolerable standards of deprivation as a required "condition of employment." the above rulling is a slippery slope that could force health care workers to accept skipped meal breaks not just in an emergency situation, but as a regular necessity brought about by deliberate understaffing. the big danger is that we do not make cookies; we take care of criticaly ill patients! our patients will suffer if and when we make mistakes caused by this abandonment. it is not about our abandonment of a patient to run to the bathroom; it is a deliberate hospital policy of dangerous understaffing to maximize profits. we must demand humane treatment with proper protective measures put in place immediatly.

[color=#333333] the or abandonment issue looked even worse as documented by the arbitrator in his final ruling against me issued one year after my botched arbitration hearing. if i were to expose his final ruling to the media the public would be horrified. it actually says i was left for 16hours scrubbed into surgery without a break, to most people that will constitute torture! why? because i didn't beg to be treated like a human being. i "didn't ask for a break" and "the er was busy." i didn't even cover the er, i was in the or, but all defence was irrelevant against the word of or managers at the "best hospital in america." i think exposing these details will possibly force my former hospital to act responsibly. they cannot bear to accept that they are the sole transgressors, so my instincts tell me they will try to institute industry wide changes in an effort to recover from the damage of this embarrassing episode. this is a very good thing and it is why i am working so hard to make it happen. still no comment on how long is safe to work without a break......

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TsunamiKim,

See...I mean there are always 2 ways of looking at things.You...shouldnt be expected to work 12 hours non stop with no break in ANY hospital....and likewise.....people with severe health problems that are not stable shouldnt be placed in a high acquity environment.What I consider "stable" is someone who with one break every 6 hours plus a 20 min break for a quick lunch every 12 hours can make it thru a 12 hour shift and function in a safe and competent manner.When nurses function.,..with no breaks for 12 hours it is unreal to expect them to perform at high levels with no mistakes.I mean....we have addressed this as unacceptable I believe in the USA.And this is in any area...not just ICU's or OR's.

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Specializes in Nursing assistant.

I agree this is crazy crazy crazy

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I am having trouble posting as the site keeps inserting icons? Will try later,

Tsunami Kim.

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Nurses need to start practicing "defensive employment", and learn to cover your you now what. Start a paper trail that can be followed to allow a complaint of "retaliation". Start right from the beginning, and it will be easier than trying to back track and find evidence. Keep a notepad in your pocket, note times, events, personnel, result, etc. Make copies of everything that you turn in, even incidence reports. Make copies of internal memos. Report violations of labor laws to the Feds and State, and involve an employment attorney, and get advice from him/her. You have to be proactive instead of reactive. JMHO.

Lindarn, RN, BSN, CCRN

Spokane, Washington

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I am still having problems with my posts to this site. Why are all my posts being blocked by junk?

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Specializes in ICU.
I am still having problems with my posts to this site. Why are all my posts being blocked by junk?

Suggest you download some spyware cleaner for your computer adware is good as is spybot

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thank you for following up by responding to my question as i often feel like one lonely voice in the wilderness. i believe when, if, and how often medical staff require relief should be predicated by the need to ensure that everyone involved in patient care is physically in a fit condition to focus their attention fully on the needs of their patients. due to their training nurses are exceptionally well attuned to judging their own fitness capabilities and should not be forced to deny the obvious: fatigue and inadequate sustenance foster conditions where serious mistakes can harm patients.

my initial medical background placed a strong emphasis on core elements of survival and the importance of teamwork. my first medical training was self taught as a necessity of being adequately prepared for my job at sea: i used to deliver sailing yachts on lengthy ocean passages like trans-atlantic crossings between the americas, europe and africa. i soon found my limited medical knowledge was barely adequate considering the length and remoteness of some of my voyages. the new zealand navy generously allowed me to train for a few weeks with their cadet medics during a brief stop over after functioning as the medic aboard a racing boat on a southern ocean leg, uruguay to australia, of the whitbread round the world race. i was given my first experience in the or and from then on i was hooked on increasing my medical knowledge. after returning to the us i took wilderness emt training at the solo school of wilderness and emergency medicine in new hampshire. this training was heavily focused on survival and the need to pay strict attention to the basics of staying fit and alert in order to be well prepared to treat others. this small school in nh provides practical hands on training for some of the finest rescue teams in the country.

after this wilderness training and obtaining national registry emt my first real medical assignment was as a volunteer after hurricane andrew where i teamed up with the medics of the 82nd airborne and remained camped out on site for six weeks. the us armed services, indeed military personnel in general, place a much stronger value on teamwork and keeping members of the team healthy too; a lesson that hospitals should take to heart. this volunteer experience also changed my life as i was now totally dedicated to becoming an overseas medical volunteer; all of my training since has worked towards this one main goal. i spent the next 3years working in the 2nd busiest er in the country at jackson memorial in miami dade; i also helped man jackson's stand alone trauma center: ryder trauma. i was one of the founding members of the south florida dmat team. once again during our training exercises i couldn't help but notice the powerful emphasis placed on teamwork and supporting one another to remain at peak preparedness to face disaster casualty needs. i have just returned from six months as a medical volunteer out in aceh province, indonesia following the tsunami. i was pleased and reassured to find that ngo personnel stationed in disaster zones are also encouraged to share this valuable, team safety is patient safety, priority in carrying out their responsibilities. this vital component is absent or ignored in staff scheduling and medical training for us hospitals.

before entering conventional medical institutions i was especially well attuned and sensitivity to the problems of fatigue; i was at sea for over twenty years delivering yachts offshore. as a us coast guard licensed captain i was responsible for the welfare of my crew while at sea; ensuring that they did not become sick, exhausted and fatigued was a top priority. as a captain it is necessary to watch your crew like a hawk to spot tell tale signs of any potential medical situation long before they come to you for assistance. mid-ocean evacuation by helicopter is expensive, dangerous and sometimes impossible; it was my job to make sure those on board stayed fit. a captain can choose who is qualified to sail with them, who is fit and rested enough to stand a night watch and how many people it takes to man the vessel. in the majority of cases this level of control is denied to nurses even when they are assigned as the charge nurse. we trust nurses to recognize critical trends in their patients, but we deny their instincts with regard to their own basic needs and fitness for duty. this is disrespectful and, all too frequently, downright dangerous; nurses know when the need to, eat, drink and rest. however, if a mistake is caused by under staffing, untrained assistive personnel or fatigue, will the hospital managers who created this appalling situation be held accountable? i doubt it.

rns are saddled with the full accountability associated with working under their license, but without sufficient authority to insure that the patient environment is genuinely safe. responsibility without appropriate control is the real downfall of the nursing profession today; as a yacht captain offshore it was my license, my responsibility, but under my command. for this reason i have never elected to become a nurse, but believe me it's no disrespect to this noble profession, far from it. i also believe that us nurses are greatly undervalued and appallingly misused; their talents are frequently squandered and they are forced to tolerate serious disrespect on a daily basis. assistive personnel should have taken over some of the more mundane routine tasks, thus freeing up experienced nurses to concentrate on more important patient care issues. instead they are assigned another mindless drudgery task, filling out excessive paperwork! emts and paramedics have reduced paperwork with well designed forms. hospitals should be revamping their nursing forms and placing more emphasis on computerized data entry. we did this out of necessity at ryder trauma because we just could not afford to tie up valued nurses during life and death emergencies.

the false "nursing shortage" crisis situation is being repeated all over the us and elsewhere. one good look at the actual number of rn licenses being issued right now reveals the real picture: nurses ready to work, but not ready to compromise patient care by working unsafe hours with too many patients and too few staff. nurses are leaving our hospitals in droves and the us is scavenging nurses from overseas who will be more compliant with the abusive demands of for profit hospitals. this not only harms the foreign countries who are now being deprived of medical staff that they desperately need; it helps support the continuation of dangerous practices and negligent understaffing. we are driving away not only potential new nursing recruits who are dissuaded by the pitfalls of responsibility without control, we are also loosing tenure nurses as they simply burn out. we need to rethink our strategies, to encourage experienced nurses to stay working in our hospitals, by creating a less toxic, more respectful working environment where they feel valued, appreciated and are capable of making decisions important to the care of their patients.

in over 150,000 miles of ocean sailing i did numerous lengthy ocean passages crossing the north and south atlantic 13 times under sail. towards the end of my career at sea i did many of my delivery passages sailing double handed. learning to pace myself to stay alert was critical when sailing with only one other person aboard the boat. i have never needed an alarm clock or a wake up call to rouse me and i believe this is an important indicator of getting enough rest. looking out for each other is even more critical in a team of two than it was in a crew of fourteen on the whitbread. this goes for hospital staff too. that small skeleton crew covering saturday night must be proactive in supporting one another in the best interests of being well prepared to face the stresses of a full-blown emergency situation. after directing my career focus towards the or i believed i would see a stronger commitment to team work in a surgical setting; however or staff are being neglected and abandoned by recent trends in staff reductions.

in one article i was directed to entitled: "an exhausted workforce increases the risk of errors" some very important points were made and i would highly recommend reading this piece. i was glad to see an endorsement of "power napping" and the suggestion about creating a quiet space for staff to rest while on duty. unfortunately, in reality this will take a complete reversal of conventional hospital thinking, since currently employees are often penalized for taking a brief nap even during their break period! instead a charge nurse should be empowered to order staff to take a nap if the need is perceived. while this is tolerated better among busy interns on duty for hours at a time, there is very little emphasis on ensuring that there is a quiet place for them to snooze undisturbed. in addition, while it is assumed that they will rest at some point during a 30hour stint, the practicality of this is becoming more complex. for one thing patients who remain in hospital are sicker now. with serious cut backs in nursing and supportive staff our interns are often left to transport patients and do numerous other tasks that do not require their medical skills: this is yet another dangerous consequence of understaffing. all of this is so counter productive, exhausting and frustrating, not to mention promoting unsafe levels of fatigue that cause medical errors. the single most important need is for all of the medical team to cooperate and give their total focus to the patients needs when called upon to do so.

at sea we consider rest while off watch an obligation that must be taken very seriously by all crew members with everyone cognizant of their duty to maintain the safe operation of the vessel by watching out for the wellbeing of one another. in reality the very hardest thing to do in a dire emergency at sea is go below and rest, but that is your solemn duty to your fellow crew, your most important responsibility so that you do not let them down by being unprepared to stand your watch. try sleeping after your forty foot yacht has just sustained serious damage following a full capsize hundreds of miles offshore, but sleep you must. when i faced this crisis i had sustained a head injury in the rollover, but that first night was long and terrifying for everyone on board. with the engine thrown from its mounts and useless to us, gapping cracks in the deck and a frigid north atlantic gale blowing, it took the three of us another four grueling days to bring pearson 424, "red barron," safely into bermuda under sail. despite injury, discomfort and paralyzing fear we all had a duty to ourselves and to one another to try to sleep and stay fit enough to function as a unified crew.

there is a good reason why on the airlines you are instructed to don your our own oxygen mask first before attending to the needs of someone else. however, in our hospitals we are taught that the obligation to our patient must preempt even the most basic self preservation necessities. we are encouraged to feel guilty about abandoning the patient to take a rest break or get something to eat, when instead we should be more concerned that in neglecting ourselves, we will seriously compromise the care of others. the zero redundancy of medical personnel, therefore no one to cover breaks, therefore just go without, situation is happening in all areas of numerous for profit hospitals throughout the united states. it is all about the money, as our conscience is being unfairly manipulated to enable big corporations to bleed healthcare dry. in contrast the commitment to be concerned about those we work alongside is very strong at sea as mistakes can have tragic consequences for those who quickly become close friends. i watched my best friend on the whitbread race tossed overboard into the freezing southern ocean at 50degrees south. while many of us shared feelings of guilt over not watching out for him by insuring that his harness was clipped on, it was teamwork that got him back onboard the boat alive. the crew members on board a yacht live in extremely close quarters, but there is much to be learned from the bonding of teamwork that dictates our cooperation while out at sea.

after a humiliating experience of being screamed at during surgery, i tried explaining to my surgeons that when at sea; "i tried to avoid alienating those with whom i might be forced to share a life raft!" the critical point being that cooperation, trust, and respect for others is the best preparation for facing an emergency in order to function swiftly and effectively together as a team for the best patient outcome. i wrote about this in a letter that went from me as a rookie or tech to the dean of my former hospital. he took it seriously and i was impressed by the positive outcome as we organized six multidisciplinary committees to address problems and frustrations with a view to creating a "perfect day in the or." between us we produced a one inch thick book of positive suggestions. this ambitious initiative culminated with an or retreat at the inner harbor with well over a hundred employees from all levels of or service in attendance. then the director of surgical nursing left our hospital. when she was replaced the situation deteriorated rapidly; we didn't even see her replacement in the or once in the first 8months after she was hired! all of our hard work was ignored as the priorities changed to support more "downsizing" for profit. the problems that had been raised were all swept under the rug leaving staff feeling used, cynical and jaded. the "perfect day in the or" became an elaborate wall exhibit in deceiving jcaho during one of their perfectly choreographed scheduled visits.

i tried to submit a follow up to my initially successful effort by proposing a computerized format for employee input with reward incentives and multidisciplinary "think tanks" rather than standard committees. it would have required real decision making power. i called the proposal the "kaleidoscope of innovative momentum," but it was never even considered; once the or climate changed all discussion was futile. the dean who once placed a glowing letter of commendation in my file began ignoring the disquieting realities that might negatively impact patient care. i was now perceived as a threat to the new management and a potential troublemaker. if i acted as a patient advocate by alerting management to a problem in a written memo i got a terse reply falsely accusing me of causing a scene in the patient care area. lulled into a false sense of security by my early success i was too naïve to recognize the dangers of being so outspoken; they were steadily building a case against me with slanderous false statements. i was asked to revamp the general surgery instrument trays, but after months of work during my personal time this too was shelved.

although i was not myself a nurse i was alarmed by the near exodus of experienced or nurses as the work environment became more toxic. i tried making suggestions for nurse retention, but was told "this just happens ever once in a while." this was just happening all over the us as the for profit hospitals promoted cutting benefits and making the nurses job less and less desirable. as nurses left the burdens of forced overtime and excessive call commitments made those left behind want to leave too and the situation spiraled out of control. obviously this had happened before, culling of tenure nurses was a well proven strategy for boosting profits. hospitals created this so called "nursing crisis" using manipulation and greed. the concept of staff input, teamwork and genuine patient safety is being seriously eroded in us hospitals as regular nursing staff are cut to a bare minimum, few long-term dedicated staff are left behind and many of those on duty are providing temporary agency coverage. under these dangerous circumstances fewer staff are genuinely invested in their job and no one is really knowledgeable about their place of work, the location of critical items of equipment or the reliability and experience of their coworkers.

add to this toxic mix the stressful job these severely overworked, overstretched colleagues endure and the hostility of those who feel used, abused and manipulated by their hospital purely to maximize financial gain. this badly balanced "pack of cards" will collapse on occasion, but it is only the unnecessary harm of a "sentinel event" that has any hope of forcing a hospital to make changes. even when a perfectly preventable tragedy occurs the hospital will target nurses as their scapegoat sighting their incompetence when the real culprit is fatigue, too many really sick patients and too few qualified staff. even as these incidents are on the rise due to bad hospital policies they hope to minimize the financial damage with tort reform. tort reform will just help to make unconscionable profit driven dangerous understaffing more financially feasible and more patient will be seriously harmed.

i used to give lectures on maritime safety issues and i was in the habit of warning my audience that almost all of the mishaps that occur at sea came down to one of three causes: panic, fatigue or complacency panic was usually the result of insufficient training and inadequate preparation. this has now started to become a bigger factor in us hospitals with the deliberate shift from tenure nurses to cheaper less experienced nurse grads and assistive staff. these personnel in training should have been introduced to spread the workload for better coverage and create entry level roles in a fulfilling career progression. instead minimally trained workers are outright replacing the experienced nursing staff to cut cost regardless of the risk to patients. complacency is generally demonstrated when shortcuts are made by people who's greater experience has lead them to become lackadaisical about important details. while this is less obvious in hospitals; when it does occur it's generally less likely to be motivated by plain arrogance, but is most often the result of unreasonable time constraints on chronically overstretched staff. fatigue is far worse in the medical profession as it is not taken seriously at all and it is having appalling consequences in terms of medical errors.

not only is rest considered a luxury and a privilege, food is trivialized as an inconvenience. the ability to eat a decent meal at regular intervals is entirely discounted by hospital scheduling policies, especially during the off-shifts and at night. in some hospitals there is no cafeteria service at night and few food outlets exist in the almost deserted, dangerous downtown areas where these facilities are located. when medical personnel experience a particularly stressful emergency their blood sugar is likely to drop even more quickly in response to the challenge. there may be no inclination to eat, "i can't think about food at a time like this," but sustenance is doubly important at such times. we must look out for one another to insure that all of our coworkers remain focused and at their best. in the wilderness and in disaster areas we consciously remind one another to get rest, food and drink plenty of water. we are taught to notice tell tale signs of environmental stress, exhaustion and deprivation in fellow rescuers as well as those being rescued. in a hospital supervisors question your ability to withstand deprivation as if it was a tangible health defect. when i complained that i had become sick, dizzy and faint after 12hours continuously stranded at the sterile field during a lengthy transplant case my manager suggested that i should be "evaluated for a sugar problem."

one landmark court case, echazabal v. chevron, 336 f.3d 1023 (9th cir. 2003), has altered the situation for the worse, although to date, only a handful of lower courts have applied echazabal. advocates, however, fear that the decision will be used in the lower courts as a justification for paternalistic and discriminatory employment decisions. this fear has been realized in at least one recent case: in orr v. wal-mart stores, 297 f.3d 720 (8th cir. 2002). this now threatens to normalize the deprivation routinely inflicted upon us medical staff. when "threat to self" was used to deny a diabetic pharmacist the right to an uninterrupted lunch break it signaled the way forward for negligent hospital policies. wal-mart has gained the reputation of being one of the most notorious employee abusers in the us and i don't doubt that their pharmacists are frequently expected to go without food altogether. but, do you want them filling out your prescription when their mind is completely blank from dangerously low blood sugar?

while ada chose to focus on wal-mart's right to sustain their unacceptable work environment as a "normal" job requirement the unhealthy degree of deprivation tolerated by us employers just got much worse. this will set an intolerable precedent that hospitals will defiantly take advantage of as the conditions being normalized became more toxic and dangerous to the general public. we, the public, should consider the implications of encouraging anyone to become hypoglycemic while their job of work is filling out prescription drug orders, many of them for strong and highly sensitive medications. this man wasn't making cookies; medication errors can cause serious harm or death! you do not have to be diabetic to need regular nutrition and perfectly healthy people can suffer from the affects of low blood sugar after a skipped meal. so what happens when a wal-mart pharmacist is rushed off his feet, stressed out, misses lunch and then makes a tragic error with a drug order due to becoming dangerously disoriented by critically low blood sugar? simple, the pharmacist will be found negligent and it will probably mark the end of that person's career not to mention a lifetime of torment over the guilt of having harmed a customer. what would be the consequences for the wal-mart store: bad publicity and the lowest compensation payment they can get away with by using their aggressive attack dog lawyers to trivialize the damage?

i learned in my back country training that not feeling hungry or thirsty was not a reliable indicator of the body's basic needs. in the or that empty feeling of nausea, the telltale headache, becoming light headed and shaky, diaphoretic under the heat of those stifling or lights; i knew when my ability to concentrate was flagging. however, i was expected to remain absolutely focused on the case, anticipate the needs of my surgical team and pass sutures as fine as a human hair. why are we trusted to make medical decisions about others when we know full well we are unfit to continue functioning? why do we have to plead and beg to justify the need for even the most minimal rest break, food or water. i should have been relieved and ordered to break scrub; if not for my personal comfort purely for the safety of my patient. how can managers get away with denying our basic body functions in a way that would be unacceptable in a third would sweetshop? how can us regulatory agencies endorse conditions that do not meet geneva convention standards for working prisoners of war?

it is not healthy to wear a tampon for 12hours straight due to the risk of toxic shock! should that disqualify all scrubbed medical personnel from permission to use tampons or can we reasonably expect to be given permission to break scrub to attend to this need? but, the patient cannot be abandoned, so we are at the mercy of managers. does the ada, eeoc, jcaho etc expect hospital staff to wear diapers while at work? another required read is the book "void where prohibited." on one occasion when i asked for a brief run to the bathroom the charge nurse said jokingly that she could insert a "foley catheter," but there was no chance i could break scrub to leave the or. although i bled through my underwear that night i didn't complain as we had 7 ors running in the middle of the night and i considered it a real emergency. but we are being conned into thinking abuse and cruelty is not only ok in an emergency it is expected of us all the time. in hindsight i latter learned that the nurse manager on call had not been called in to help out with staffing the or that night.

how does any manager earning call pay to answer the occasional inquiry from dangerously overworked, overstressed staff justify remaining at home while the or complex copes with 7 surgical cases, 7 fully engaged surgical teams, no spare staff, one charge nurse and the hospital was still not on bypass! we didn't believe in going on bypass, bad for the reputation and avoided at all costs. during the entire time i was at my former hospital i never heard of a manager being called in from home. i think they would have sat out a mass casualty without reprimand or a change in policy! is the priority: safe staffing for appropriate patient care or continuing the guaranteed comfort of managers who are permitted to ignore an emergency by remaining in the comfort of their home? i only ever complained about being abandoned in surgery if i was left continuously scrubbed for a time period in excess of 8hours for no legitimate reason. incidents like this are not a pleasant experience, but we are increasingly forced to tolerate such circumstances. those engaged in surgery conscientiously remain scrubbed until they are relieved while hospital management abuse this dedication to make dangerous staffing cuts that deny breaks. in my case several public agencies that were contacted all wholeheartedly supported this policy without question; it was portrayed as a perfectly acceptable consequence of the "nursing shortage." when these hospitals are not held responsible for deliberately downsizing the staff, medical errors will be made.

a few of the less conscientious nurse managers are of the opinion that no one needs to eat at night which is patently ridiculous. while such nurse managers are more inclined to take care of fellow nurses, in some cases the disrespect shown to scrub techs who are not nurses extends to not bothering to break them out of surgery to go get something to eat or even to use the bathroom. the hospitals breed this adversarial attitude towards assistive personnel by demonstrating a callous policy of replacing tenure nurses with cheaper, less experienced staff. instead of more affordable staff making it possible to provide better coverage as we all work together, this good initiative has been hijacked to skim off bigger profits with fewer experienced staff. it has bred resentment from tenure nurses who recognize that their careers are being threatened.

we cannot do without these nurses and attempts to decrease their numbers are seriously misplaced. due to the increasing age of our population and the acuity necessary to remain in a hospital bed our patients generally need even more vigilant care and monitoring than they did just ten years ago. it is sickening to watch this immoral process of deliberately downsizing the most experienced and better trained staff to save money at the expense of safety. on nursing bloggs on the internet hospital staff are reporting the issue of being torn between abandoning a patient to get food or even run to the bathroom; rest is out of the question due to the lack of coverage. it is happening in many of the critical care areas of the hospital and negatively impacting patient care. i used to take cartons of orange juice to work with me for a speedy recovery after periods of being stranded in surgery. i also kept spare underwear at work!

while these measures helped me to cope with a sometimes intolerably abusive situation this was not some third world sweatshop or imprisoned in a sordid foreign jail, why was it considered acceptable at the "best hospital in america!"

this latest aggressive purging of staff that now fails to provide for break coverage, as if rest and food were an unnecessary job perk, is just one more dangerous trend on the road to disaster. hospital management must start taking responsibility for the crisis they created in the name of big profits and start putting patients first. the downsizing needs to target top-heavy management to recover purely superfluous personnel expenses. safe care is not possible without adequate, sufficiently trained and experienced regular nursing staff supported by assistive help working under their experienced supervision. this shift in gears will take nation wide legislation as the american for profit hospitals have proven in the past to be incapable of acting with integrity. the healthcare advocacy groups, the unions and the nursing association must push for legislation to close the cost cutting loopholes that have become increasingly abusive to staff while compromising the safety of hospital care. the real culprits in the criminal abandonment of patients are the hospital administrators who are striving for greater profits with chronically few well trained staff while unscrupulous management help to facilitate this process. there are even cash bonus incentives given to help these corrupt managers overlook any momentary pangs of conscience.

the most experienced nurses recognize the risks that understaffing is forcing them to take with the care of their patients, but what are their alternatives? refuse to participate or endorse these dangerous profiteering strategies: leave the hospital and the staff mix you leave behind is even less equipped to care for patients. this actually benefits the hospital's bottom line as the less experienced are lower paid and the staff mix is relying on far fewer and less experienced nursing personnel all the time. this is at the very core of the "nursing exodus;" experienced nurses who are no longer in nursing practice because of the dangerous compromises and the toxic work environment.

a conscientious nurse might try to lodge a formal complaint about the unsafe practices of understaffing, but they commit career suicide in doing so. not only are they swiftly removed to silence their protests, but the painful, humiliating and damaging firing process is used to destroy their professional credibility as a warning to others who might consider following their brave example. once fired it is harder for them to report negligence, abuse or even the retaliation used to silence them to outside agencies. they are systematically ignored, ridiculed and persecuted for speaking their mind; they are now portrayed as a "disgruntled former employee with an axe to grind." the more prestigious the institution, the more futile any attempt to raise public agency concern over the dangerously negligent understaffing policies at a former hospital and with elimination from the workforce you no longer have any say in their internal affairs. despite the appalling personal costs this courageous stand will accomplish absolutely nothing as the hospital will undoubtedly refuse to change policies that maximize their profits and the agencies are condoning this negligence. we need to recognize deliberate understaffing for what it really is: criminal fraud!

i want to get this important message out there loud and clear so that we do not have to realize our mistakes though more harmful errors and loss of life. i had a rather unconventional start to my career after many years at sea, but my time at sea has given me an unusual perspective on the importance of teamwork and working together to stay fit and able to care for patients. i am eager to continue doing the job i love and this has made it extremely important to clear my name and restore my former reputation as a conscientious healthcare worker. the damage to my credibility is still a major obstacle even as i apply for jobs overseas as an unpaid medical volunteer. sorry about the length of this "soap box" piece, but the consequences of my own situation has just made me even more determined to reveal the truth.

tsunami kim.

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