Why is meeting the "minimum standard of care" good enough?

barefootlady, ADN, RN · Feb 5, 2004

"DO UNTO OTHERS AS YOU WOULD HAVE DONE UNTO You",

Minimum is only acceptable when something extreme is going on.

Like 2 nurses and 1 cna for 25/30 patients and electricity is on generator.

I have heard statements like those GLDGRL expressed made by 2 HN, 1 CNO, and 1 CEO. All of these people were fired not to long after this became common knowledge in the community. Wonder who told? Shame on those pesky nurses.

I have been written up for taking the time to chart specific notes on patients' the doctor neglected to monitor. When the case was settled I was specifically told my notes saved me from being named in a lawsuit.

"Remember customer service is important to us." If you allow patients to come to expect only the barest minimum of care then they will generally accept that type of treatment. Seen it, been there, and left.

Each nurse must decide how she will care for the patients she is assigned. Hopefully, we can do and will do our patient care to the best of our ability, not just the minimum level to get by.

donmurray · Feb 6, 2004

Apart from a personal motivation to give more than the minimum to what I do, in the event of some serious incident, the Coroner's Court would expect me to carry out my work to at least the same standard as that of my peers. The mythical "average" nurse, of equivalent education and experience, is the lowest legal standard which I must daily attain. Being average does not appear that difficult, till you remember that by definition, half the profession is below average! :eek:

stevierae · Feb 8, 2004

I just don't understand why, legally, experienced RNs are not held accountable to higher standards of care than those with less experience are.

Why should it be acceptable to perform at the same level you did as a new grad--yet, legally, it is.

We all have to perform to that "minimum standard--" whether new grad or after 25 years in the trenches. I wonder if it is this way in other professions? I'll bet it is not so in police detective work--can you share with us your view from that perspective, BarbPick?

Gldngrl · Feb 9, 2004

Stevierae-I'm not qualified to answer your question on behalf of all other professions, but I will share what little I've learned in law school and during my internship with my state bar. Passing a bar exam establishes minimal competency to practice, but there is a requirement to attain CLEs (continuing legal education) including ethics requirements. There is in many states, but not all, a requirement to take and pass the MPRE (Multi-State Professional Responsibility Examination) as well. Attorneys must practice according to their state disciplinary rules and failure to do so may be cause for discipline. Generally speaking, there is no difference between a new attorney vs. an experienced attorney regarding minimal standards of performance, so one will find great attorneys, average attorneys, and bad attorneys in the mix. The state bar however, will only take action against those attorneys with whom the evidence shows to have violated a disciplinary rule(s). The fact that an attorney may be relatively inexperienced, didn't get much of an orientation or supervision, may be he/she is in solo practice and is overwhelmed, etc. may be taken as mitigating factors in deciding sanctions.

Minimum standards are those decided upon by the powers that be that establish bare bones competency...it may not be what you or I would like them to be, but it's simply what is. I will tell you that I once had a manager who had high expectations of everyone, including herself and I believe that empowered the staff and benefitted the overall unit and patients.

tiliimnrn · Feb 16, 2004

Hi, this is my first reply to something, and I've been reading quite a few of these letters/notes. I'm totally suprised that most of the mail on here is about how we can give more, and how we can do better....what about the hospitals.........I'm beginning to feel that the "Gods that be" in the hospitals are sitting around, spending money and trying to come up with more paperwork, more for us to do at work,etc. I feel like we don't get enough time to do some of the nicities:crying2: I wish I had the time. Please don't tell me I need a break, that's not the answer, we need to get involved....try to get something going that will give us time to do these things. I feel that the big companies, don't care anymore about the patients wellbeing, they just worry whether you've crossed you t's and dotted your i's. :angryfire I got into nursing because I love people, and I want to take care of them, but not the way the companies want me to take care of them. I've been a nurse for 13 years, a hospital nurse, and it's always been stressful, but lately it's getting dangerous. Why is it that we nurses (as a group) won't help ourselves? We'll die trying to help others, but when it comes to taking care of ourselves we fail...............I don't mean to drag anyone down, I just don't understand why most of the messages on here aren't about the shortage, the danger, the abuse we get, and how we can help each other........tilii stands for "tells it like it is". :confused:

stevierae · Feb 16, 2004

Hi, this is my first reply to something, and I've been reading quite a few of these letters/notes. I'm totally suprised that most of the mail on here is about how we can give more, and how we can do better....what about the hospitals.........I'm beginning to feel that the "Gods that be" in the hospitals are sitting around, spending money and trying to come up with more paperwork, more for us to do at work,etc. I feel like we don't get enough time to do some of the nicities:crying2: I wish I had the time. Please don't tell me I need a break, that's not the answer, we need to get involved....try to get something going that will give us time to do these things. I feel that the big companies, don't care anymore about the patients wellbeing, they just worry whether you've crossed you t's and dotted your i's. :angryfire I got into nursing because I love people, and I want to take care of them, but not the way the companies want me to take care of them. I've been a nurse for 13 years, a hospital nurse, and it's always been stressful, but lately it's getting dangerous. Why is it that we nurses (as a group) won't help ourselves? We'll die trying to help others, but when it comes to taking care of ourselves we fail...............I don't mean to drag anyone down, I just don't understand why most of the messages on here aren't about the shortage, the danger, the abuse we get, and how we can help each other........tilii stands for "tells it like it is".

Actually, I HAVE gotten involved, and I encourage all nurses to do the same. I wrote an article entitled "How Can Nurses Advocate for Patients, When We Can't Even Advocate for Themselves?" addressing how nurses--and patients, as consumers--can be more proactive in holding the powers that be--hospitals and their various levels of management--accountable for situations that lead to unacceptable treatment of nurses and unacceptable patient care. I have sent it to various nursing and consumer watchdog groups. It appears below. All comments welcomed.

Fellow RNs: This is an op-ed article I submitted to our local newspaper and to various journals and consumer advocate magazinnes in response to various other articles addressing the nursing shortage.

I have suggested some ways that both nurses AND CONSUMERS can, and must, empower themselves to confront this national crisis head on, and demand accountability from those who caused and perpetuate it.

Consumers are all potential patients who have the right to demand an excellent product in return for their investment--in this case, the product is nursing care. Why should they settle for am mediocre product, simply because some manager or insurance company is trying to cut costs? Would that administrator or insurance company executive settle for less than a quality product if he or his family member were on the receiving end? He absolutely would not!

I encourage all nurses to write similar articles or letters and send them to your local newspapers and magazines such as AARP, Family Circle, Working Mother --any publication that will be read by non-nursing consumers and get them thinking about how they can advocate for nurses, as well as for themselves and their family members. We MUST get the word out about how our adverse working conditions affect the quality of patient care we deliver.

When potential patients add their voices to ours, safe staffing levels will become law everywhere, and we can deliver the level of nursing care we are currently being prevented from delivering--the quality of nursing care that we would want for ourselves and our own families--excellent care by which standards are set. Less than that is simply not good enough. We are dealing with human lives.

Subject: "How Can Nurses Advocate for Patients, When They Can't Even Advocate for Themselves?"

Nurses need to assert their right to "just say no" to mandatory overtime. What is so difficult about simply saying "No, I cannot stay overtime?" No apologies or excuses are needed. By accepting it, they are delaying what needs to be done: the passage of a staffing law, that will hold managers accountable; this will ensure a safe ratio of nurses to patients, rather than compromising patient care.

This is the real reason for the nursing shortage: nurses are tired of being forced by management to deliver substandard and, at times, downright dangerous patient care. They see too many incident and occurrence reports documenting mistakes, and witness plenty of "near misses" that weren't documented. Every nurse has witnessed an error made by a colleague who was either overtired or was denied the proper resources to carry out a job safely, due to understaffing, and has had the same thought: "There, but for the grace of God, go I."

"Mandatory overtime" is a contradiction in terms. It is an unfair labor practice, and is illegal. Management knows this; the nursing unions know this. Too many nurses, even union nurses, however, are afraid to "make waves," or be thought of as troublemakers, so the practice continues.

Indeed, why should the nurses themselves HAVE to make waves? This is what they pay union dues for, so that they can concentrate on patient care, and rest secure in the knowledge that their union is protecting them from unfair labor practices. Why are the unions falling short? Staffing is a management dilemma. Management may like to use a lot of guilt inducing catch phrases to try to force nurses to stay overtime; these phrases include "Health care is changing everywhere. We all have to pull together to work with less resources; it's the same all over the country," (Untrue!) or "How can you leave? How would you feel if that was YOUR mother in there?" or, my personal favorite, "If you don't stay over, you will be disciplined for patient abandonment!"

Mandatory overtime is a ploy used by management as a way to avoid hiring and benefiting the proper number of employees to do a job. There are other options available to ensure safe levels of staffing, such as using traveling or registry nurses to augment hospital staff, but some nursing managers simply refuse to use them.

Nurses need to learn to advocate for themselves. If they can't, how can a patient trust them to advocate for him or her? No hospitalized patient should have to advocate for himself or herself. That is a role traditionally played by nurses, who have those skills. Potential patients or family members can learn some self-advocacy skills before they even enter a hospital. Health care is a commodity for which they pay handsomely; they have every right to demand the best care, and to hold people involved in that care accountable.

I suggest every patient, or designated family member, ask the following questions of his nurse when he is hospitalized, and any others that might help ensure quality care and his peace of mind:

 Are you my primary nurse?

 What is your name?

 Who will be in charge of my care when you are on breaks or at meals?

 Will you actually be making rounds on me at intervals, or just talking to me via intercom when I ring my call bell?

 What is the reason you have to stay at the desk, rather than making rounds? Does it have to do with understaffing? --Is there a safe nurse to patient staffing ratio on this floor today?

 Will there be unlicensed personnel doing procedures on me that, in your opinion, should be done by a Registered Nurse?

 Are you forced to be here today on mandatory overtime?

 To your knowledge, are there policies and procedures on this floor that were implemented after an incident report was generated that documented a mistake that occurred because of unsafe staffing levels? (If your nurse seems uncomfortable answering that last question, ask to speak to the nurse manager, and direct the same question to her. In fact, move right on up the chain of command--nursing administration, medical administration, hospital administration--put THOSE powers that be "on the spot.")

 To whom can I address a letter of complaint regarding the unsafe patient care and adverse working conditions I noticed while I was a patient here?

 To whom can I address my immediate verbal concerns?

Let's hope it doesn't take a death or tragedy to force Oregon (and other states) to implement a safe nursing staffing law. Assertive RNs and proactive potential patients can pull a lot of weight when it comes to enacting a safe staffing law. I know; I saw it happen in California, where I still choose to practice hospital nursing, even though I live here. Even before California had a safe staffing law in place, I can honestly say that every manager I ever worked for there did her utmost to ensure that we had all the resources we needed to ensure outstanding patient care.

If someone called in sick, she was replaced by registry; if staff were out on vacation, travelers were contracted to take their place in the interim. Overtime was something you were ASKED to do, and for it, you were compensated generously, and thanked.

If you could not do it, you did not need to fumble for excuses as to why you could not and you were not made to feel guilty. Management had too much respect for our intelligence to try to implement unfair labor practices; plus, we had, and still have, an incredible union. God bless CNA!

By the way, physicians are under some of the same pressures we are: to get more done, in less time, with fewer resources, particularly in HMO affiliated and teaching hospitals. There are many questions patients or designated advocates can and should be asking their physicians, as well, as a way of being pro-active in their own treatment plans. That, however, is the subject for another op-ed article or letter!

Dagwood · Feb 20, 2004

Helloooo?? Since when is doing what you are paid to do--and doing it the way it should have been being done in the first place--something to complain about?
So sad--I wonder how patients would feel, or families of those patients would feel, knowing that they will be the recipient of "minimal standard of care?"

I personally have been on the recieving end of the "minimal" if you can even call it that standard of care. I was 19 years old and had to have an ACL repair--while strapped into bed (CPM) at 0300 the next morning, call light out of reach, terrible pain and had to pee, I was miserable. I had not seen a nurse since about 2100 and I hadn't been to sleep yet--yup! I finally had to yell out for help, when the first nurse came in, she said she would be right back with something for pain and ran out of the room, I heard her complaining all the way down the hall!!! :angryfire Finally the only CNA on that night came down the hall, helped me to the bathroom, and brushed my hair for me. Thank you to all of the nurses and other ancillary staff who go above and beyond for their patients!!! I knew I wanted to be an excellent nurse before that incident, but it drove it home even more. It comes down to integrity--own it and take pride in all you do.

jeanine622 · Feb 24, 2004

This is a topic that I am most passionate about. It is indeed disheartening to work with nurses who clearly will only give the bare minimum of themselves. At the bedside there is something intangible that occurs between you the nurse and the patient. This is especially felt in patients who cannot speak there is a look sometiimes that surpasses all understanding where you know within your self that that patient truly knows that you care about them and their well being.

it makes you want to do your best for them. It gives you the courage to move forward even in the face of your critics. At the end of my day when I have hung

up my stethescope, and I have reviewed my day in my mind I am assured that I can sleep peacefully because I know I have done my best. This is what counts most to me. Amazingly however, if any of the nay-sayers or their families became patients They would expect the maximum care effort. instead of hearing

so often "that is not my patient". They would become EVERYBODY'S patient.

Tiki_Torch · Feb 24, 2004

It feels soooo good to have found kindred spirits here posting to this thread!!!!!!

I've been nursing since 1990 and have found in my experience that the above-and-beyond nurses are few and far between. I will be forever thankful that my initial preceptors and mentors were high-quality-care nurses. I've always been one to strive to do my best and have been ridiculed by co-workers for not sitting around and gossiping with them, etc. I also have never made the popularity-contest list because of spending my time with my patients instead of my co-workers. Sometimes I feel that they don't enjoy having me around because my high-quality care subconsciously reminds them that they are giving minimum-standard care. I just go quietly about my work and seem to always be busy... too busy to read magazines or sit around and gossip. Sigh.

No matter! I'll keep plugging along doing my best, going the extra mile, charting like I should, etc. and will always be able to fall asleep knowing I did my best for my patients each day. And when I'm at the end of my life looking back over all I've done, I'll have Integrity rather than the Despair Erikson speaks of.

I digress...

Anyway, it's soooooo great to have found a bunch of kindred spirits here. I'd love to learn of ways I can help to encourage others to want to do their best too. I suppose it's an innate personality trait or something though. I've always figured setting an example in a kind and non-threatening way is a very good way for instigating change. I also try to be the same type of preceptor/mentor for new nurses who I help precept or work with... Fighting management/corporations seems futile to me.

Tiki

jeanine622 · Mar 1, 2004

Tiki, i would have thought that i wrote your reply myself. trying to go your very best very

often does not win popularity contests. however i find that i can let it all roll off my back

as long as i am giving my patients what they need. And indeed i never really thought about it the way you described. that it pricks the conscience of those who provide less than excellent care. but guess what, they will need a tourniquet because i won't stop striving to provide just that. Sleep well!!

barb4575 · Mar 5, 2004

Having them...does not make one popular as it does tend to make others look bad...been there many times over and for many years; trying to figure out how they can assess and document on six acutely ill Med-Surg patients and be at the desk again within one hour or less. The aspect of all of this that makes me angry is that while I am running nonstop, they are sitting at the desk complaining about being overworked. In fact, it makes me want to stay busier to avoid the nurses' station. I have been teaching and am appalled at the low standards that are deemed acceptable. When I worked agency over the summer and the patient had been there for a week without a toothbrush, I just cannot understand why the patients tolerate it. I guess they feel they have to...I am returning to practice along with my educator role and know that I will be frustrated, but hopefully, I will be able to ignore them once again. I do find it comical when they attempt to get me to sit down with them...it is the last thing on my mind and I prefer to keep busy...there is always something to do on a Med-Surg floor. I enjoy spending time with the patients and improving their quality of care and life. A few weeks ago, I was in the hall and a patient's wife approached me with four staff nurses at my side and administration watching....she thanked me for the patient advocacy and teaching that I had done. Her husband had been there for two weeks, yet my one six hour rotation with them and my students... touched them. I didn't see the staff nurses nor the administration smiling. Sad, indeed. It is my hope that the students have learned that it is more satisfying to deliver the utmost quality of care, but I am not so sure they all agree with that theory. Students, like nurses, have changed over time...

Barbara

amh · Mar 18, 2004

does anyone have any views on caring verses curing