Health Communication in Practice

A Case Study Approach

Eileen Berlin Ray

• Publisher: Routledge
• Year: 2005
• eBook ISBN: 9781135619022
• Topic: Medicine
• Subtopic: Communication Studies

Health Communication in Practice: A Case Study Approach offers a comprehensive examination of the complex nature of health-related communication. This text contains detailed case studies that demonstrate in-depth applications of communication theory in real-life situations.

With chapters written by medical practitioners as well as communication scholars, the cases included herein cover a variety of topics, populations, contexts and issues in health communication, including:

*provider-recipient communication and its importance to subsequent diagnosis and treatment;
*decision-making;
*social identity, particularly how people redefine and renegotiate their social identity;
*communication dynamics within families and with health care providers through unexpected health situations;
*delivery of health care; and
*health campaigns designed to disseminate health-related information and change behaviors.

Reflecting the changes in health communication scholarship and education over the past decade, chapters also explore current topics such as delivering bad news, genetic testing, intercultural communication, grieving families, and international health campaigns. A list of relevant concepts and definitions is included at the end of each case to help students make connections between the scenario and the communication theories it reflects.

With its breadth of coverage and applied, practical approach, this timely and insightful text will serve as required reading in courses addressing the application of communication theory in a health-related context.

V: Issues in Health Care Delivery

20: Role Negotiation, Stress, and Burnout: A Day in the Life of “Supernurse”

Julie Apker

Western Michigan University

Across the United States, spiraling health care costs, advancements in medical technology, and aging patient populations have transformed hospital health care delivery. Managed care- a system that strives to efficiently manage health care services and reduce medical costs-has driven many hospital changes. To remain competitive, more and more hospitals have been forced to do things differently through strategies such as reducing or limiting medical services, implementing shorter patient stays, downsizing staff, and restructuring employee roles. These changes have impacted the working conditions and professional practices of most hospital health care workers and, ultimately, have affected patient care.

Registered nurses (RNs) who work in hospitals often find themselves on the front lines of changes in their work roles, job responsibilities, and professional relationships. Today's nursing roles not only include traditional responsibilities, such as providing bedside care, but also new duties, such as team leading, administration, and supervising assistant personnel. Moreover, many RNs are taking on the tasks once done by allied health personnel and medical support staff. These role additions come at a time when nurses are pressured to “do more in less time” but without additional training, higher wages, or institutional support. Thus, nursing work is characterized by role overload, increased job complexity, and a lack of organizational resources. These workplace stressors can result in negative outcomes (e.g., physical illness, relationship conflict, and poor job performance). In some cases, role stress may actually cause nurses to burn out and leave their hospital positions for other jobs or even other professions.

THE HOSPITAL

City Hospital is a 900-bed, full-service teaching hospital located in a major midwestern city. As the flagship hospital of a large integrated health care system, this institution employs more than 1,000 physicians, nurses, allied health personnel, and support staff. Like many other urban health care facilities in the United States, City Hospital relies heavily on Medicare and Medicaid funding to pay for patient health care costs. Consequently, the hospital experienced a severe financial setback with the passage of the 1997 Balanced Budget Act-federal legislation that included substantial cuts in health care funding for elderly, poor, and indigent patients. In addition, managed care organizations continue to exert heavy pressure on the hospital to keep health care costs and insurance premiums down.

To curb multi-million dollar losses, City Hospital implemented a number of dramatic changes that directly affect the nursing staff and their patient care. First, the hospital eliminated hundreds of support personnel (e.g., respiratory therapists, phlebotomists, and patient educators) and assigned many of their duties to staff nurses. Second, RNs were given more patients to care for at the same time the hospital mandated shorter length-of-stay requirements. Third, nurses were required to supervise unlicensed personnel (nursing aides, housekeeping, and patient transport). In addition to these past changes, City Hospital has continued to experience a nursing shortage, and many of its medical services consistently run short of qualified nursing personnel. Nurses have felt the impact of many vacant RN positions firsthand which, in some cases, involves mandatory overtime. The combination of these factors has created a stressful work environment and negatively affected nurse morale.

THE NURSING UNIT

Three East-one of City Hospital's 26 inpatient units-is a 30-bed, general medicine unit made up of middle-age or elderly patients, usually with pulmonary-related diseases, such pneumonia, asthma, chronic obstructive pulmonary disease, and bronchitis. Three East employs about 50 full-time employees, of which 18 are RNs. Like all other inpatient nursing units in City Hospital, Three East functions 24 hours a day with three shifts of nursing staff, six nurses on each shift. The day shift runs from 7 a.m. to 3 p.m., the afternoon shift is staffed between 3 p.m. and 11 p.m., and the night shift is staffed between 11 p.m. and 7 a.m.

When entering Three East, a visitor immediately sees a small reception area with a comfortable visitor lounge instead of a large, central nursing station. Two glassed-in counseling areas located on either side of the lounge are used for private conversations between medical staff, patients, and their families. A small pharmacy is located behind the reception area, and social workers assigned to the unit have an office adjacent to the reception desk. Two wings branch off of the reception area. Each wing consists of a long hallway that houses patient rooms and two nursing ministations (also called pods). Each pod is “owned” by a particular health care team for the day, afternoon, and night shifts-the same RN and nursing aide cover the same six to eight beds every day. Each pod contains computer terminals, equipment, and supplies needed by the nursing and medical staff.

Communication is central to work life on Three East. In addition to wearing pagers, all nurses carry portable cellular phones-enabling constant, immediate communication on the floor among members of the health care team. Each pod has its own phone, which rings constantly, as other employees and individuals working outside the hospital contact nurses and doctors for patient care information. Further, medical and nursing staff communicate via multidisciplinary report sheets and patient documentation forms that are located in wall alcove chart stations. Nurses and doctors use these communication tools constantly to update each other on patients. In addition, they engage in dozens of face-to-face interactions during each shift in settings such as rounds, team meetings, and private consultations. Moreover, Three East nurses and physicians are consistently communicating with patients and their families as they perform their daily work activities.

THE NURSE

Rob Carter is a 35-year-old RN who holds a bachelor's degree in public health education and gerontology. Twelve years ago, he earned a diploma in nursing from City Hospital's School of Nursing. He has worked on Three East for his entire nursing career, including his two years of nurse training, making him one of the most senior staff nurses on the unit. Like many nurses, Rob describes his career as a calling:

I always wanted to be a doctor as a kid, so I knew I wanted to be in the medical field. I found a job at a nursing home. I saw what the nurses did there, and I liked their focus on patient care. I didn't go into nursing for the paycheck. I went into nursing for myself, my own joy, to care for patients.

Rob supervises and coordinates the nursing care of six to eight patients that are assigned to Pod One. Rob works at the patient bedside and manages a nursing aide, Belinda, unit support personnel (e.g., patient transport and housekeeping), and senior nursing students, who are called externs. He describes his responsibilities:

I lead the health care team to help our patients. I am someone who answers questions and directs other people to do their jobs effectively and efficiently. I pass meds to patients, document nursing activities, develop care plans, conduct patient assessment, and perform nursing interventions like dressing changes and drawing blood.

Rob takes his nursing role seriously, often working well beyond his regularly scheduled hours and skipping lunch to give “100%” to his patients. Below, he comments on his professional dedication:

I have to know everything that's going on with my patients. If someone is going out the door, I better know about it. Don't take the patient off the floor before making me aware of it. It will mess up my whole day. I'm responsible. I have to be kept in the know. I like knowing that there's something I've done that's made an impact on my patients' well- being and their progress to optimum health.

Rob's comments typify the views of many care providers, professionals who see their jobs as a chance to make a difference in people's lives. Certainly, Rob's devotion to his patients should be valued, but there are significant human costs to his high levels of caring and commitment. As Rob suggests in the following quote, stressors such as workload, role conflict, and role ambiguity impact his nursing practice:

I'm the king of stress. I can't handle a lot of stress…everything and everyone at once. When the does are all just pulling at me. It's ‘Rob, Rob, Rob. Do this, do that, get this.’ It just keeps eating at the stress level a little more. The docs push me too far. A lot of work falls on me to arrange at the last minute. Don't they know I have my own work to do? I can't be at their beck and call all the time. That causes me stress, and I'm not the best at coping with stress. I don't verbalize my stress. I keep it in. Some days, the stress makes me question whether I should work here. I wonder if I should just leave nursing entirely.

LIFE ON DAY SHIFT

During one eight-hour shift, Rob interacts with dozens of people (e.g., doctors, nursing aides, allied health personnel, patients, family members, etc.) on a wide variety of issues related to patient care. Although each of Rob's workdays is unique because of a varying patient mix, Rob's day always includes morning report, initial patient assessment, rounds, postround follow-up (which lasts several hours), and afternoon report.

7 a.m.-Morning Report

Report is a half-hour time period for the nurses to provide information from the previous shift about each patient's physical, emotional, and mental health. A typical day for Rob begins with him receiving morning report from Shirley, the Pod One nurse who works the night shift. Shirley and Rob review patient charts and visit patients so Rob can visually assess their conditions.

Today, Shirley tells Rob that Mr. Riordan, an elderly patient with chronic heart problems and pneumonia, has been particularly difficult to deal with during the night.

“Mr. Riordan keeps pulling out his feeding tubes and IV lines,” said Shirley. “I was constantly in his room either checking on him so he wouldn't do it or putting the tubes and IVs back in when he did take them out. He's driving me crazy!”

“This is the guy who has depression, right? He has no friends or family who visit,” replied Rob. “Maybe he's just trying to get someone to talk to him.”

Shirley added, “You're probably right, but I just didn't have time to sit with him. It was a zoo last night.”

“By the way, we still can't find a qualified nurse to work nights yet. The temps the nursing agency sends don't know what's going on. I don't have time to teach them, either, so they don't come back for a second night. I wish Mr. Riordan would leave well enough alone!”

“I'll talk with Mr. Riordan and ask Dr. Ryan to order a consult from psychiatry. About the temps…that's a tough one. We need their help, but we don't have time to train them. It's a no-win situation,” sighed Rob. “What else is going on with our patients?”

Shirley sighed, “Well, they're the same group as yesterday. Their health status is unchanged, as you see in their charts.”

“On a side note, I had difficulty stocking our supplies last night because of the staffing problem, so I couldn't get to it. To add to it, the computers are crashing again. We had to reboot them four times last night. That was fun-it takes even longer to document patient information! I've called tech support twice, and they say they'll be here as soon as possible, but I doubt it. You can't count on that department ever since the hospital downsized half of their technicians. Same goes for the supply department. It's ridiculous that we have to stock our own supplies!”

“Ever since the hospital got into debt, we've had to do more with less,” said Rob. “Take the housekeeping situation. Last week, I had to leave the floor to go get clean towels because housekeeping couldn't spare anyone to deliver them to the unit! Last time I looked, delivering laundry was not a part of my job description! Next thing you know, they'll make washing laundry a part of our jobs. Unbelievable!”

“Well, all I know is that I have at least an hour of charting to do before I go because I didn't have time last night,” Shirley responded. “The patients are all yours. I hope your day goes better for you than it did for me, Rob.”

“Thanks, Shirley. I'll see you tomorrow,” Rob said.

Rob asked Belinda to stock the pod before she starts her regularly assigned tasks. “Please look for the cell phone while you're at it,” Rob told Belinda. “I think it was lost on afternoon or night shift.”

“Rob, I keep telling you, you're not responsible for everything that goes on in Pod One,” Belinda replied. “They lost the cell phone, not us.”

“I know, but our unit can't afford to replace the phone again,” Rob said. “They told us at the last staff meeting that if a cell phone is lost or stolen, we have to do without. I tried to tell the nurse manager that using the cell phones is the best way for the docs to reach us on the unit, but it doesn't matter. Administration doesn't understand that it makes our jobs more difficult when we can't communicate with each other. They just don't get it.”

“I'll look for the phone. It probably was misplaced in the supply closet again,” said Belinda. “After that, I'll start checking vital signs.”

“Okay, in the meantime, I'll do our assessments and see what needs to be brought to the docs' attention during rounds. Mr. Riordan was giving Shirley some problems last night, so I'm going to spend some time with him to find out what's the matter.”

7:30 a.m. to 9 a.m.-Patient Assessment

Today, Rob hurries through his assessments so he can spend time with Mr. Riordan. Rob enters Mr. Riordan's cramped room, which is filled with medical equipment and smells of disinfectant, and sits down next to the bed.

“How are you feeling today, Mr. Riordan?”

“Not good. These damn doctors won't give me a straight answer! They just keep running tests. One day, Dr. Andre tells me I need surgery. Then, the next day, she says no. Which is it? I've got so many tubes running in and out of me that I can't sleep and that stupid night nurse won't give me enough medication for the pain. A dog would get better care at a vet's office! That's how I'm feeling!”

“Mr. Riordan, it won't do either of us any good if you yell. Maybe I can help,” responded Rob calmly. “I looked at your chart, and you're scheduled for surgery tomorrow. Dr. Andre will tell you more about it when she comes by at 9 o'clock for rounds. I'll be there too, and we can talk after the doctors leave in case you want more information about the procedure. The doctors have a lot of patients to visit in a short amount of time, but I'm here all day.”

Mr. Riordan grumbled, “Well.okay. But what about the other nurs...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Introduction
• List of Contributors
• I: Issues in Provider-Recipient Communication
• II: Issues in Decision Making
• III: Issues in Social Identity
• IV: Issues in Family Dynamics
• V: Issues in Health Care Delivery
• VI: Issues in Information Dissemination