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Theresa Brown, an oncology nurse, describes a situation in which an entire medical team on its morning rounds stands in a patient’s room, waiting for a test result. The patient, a friendly middle-aged guy, jokingly asked his doctor whom he should yell at. The doctor turned and pointed at the patients’ nurse and replied, “If you want to scream at anyone, scream at her.”

In this article on the New York Times’ Well blog, Brown notes that this bullying didn’t happen 30 years ago and it didn’t happen on a TV show like “House” — it happened to her, just a few months ago.

Brown later asked the doctor if she could quote him for the article, and he nonchalantly said “Sure, it’s a time-honored tradition — blame the nurse whenever anything goes wrong.”

While Brown was stunned and insulted, she also was concerned about the problems such attitudes pose to patient health. Nurses are the hospital’s front line, and such attitudes can create a hostile and even dangerous environment in a setting where “close cooperation can make the difference between life and death.” While many hospitals have anti-bullying policies, the seriousness of the issue is too rarely recognized.

While most doctors clearly respect their colleagues on the nursing staff, every nurse knows at least one, if not many, who don’t.

Indeed, every nurse has a story like mine, and most of us have several. A nurse I know, attempting to clarify an order, was told, “When you have ‘M.D.’ after your name, then you can talk to me.” A doctor dismissed another’s complaint by simply saying, “I’m important.”

When a doctor thoughtlessly dresses down a nurse in front of patients or their families, it’s not just a personal affront, it’s an incredible distraction, taking our minds away from our patients, focusing them instead on how powerless we are.

That said, the most damaging bullying is not flagrant and does not fit the stereotype of a surgeon having a tantrum in the operating room. It is passive, like not answering pages or phone calls, and tends toward the subtle: condescension rather than outright abuse, and aggressive or sarcastic remarks rather than straightforward insults.

And because doctors are at the top of the food chain, the bad behavior of even a few of them can set a corrosive tone for the whole organization. Nurses in turn bully other nurses, attending physicians bully doctors-in-training, and experienced nurses sometimes bully the newest doctors.

Such an uncomfortable workplace can have a chilling effect on communication among staff. A 2004 survey by the Institute for Safe Medication Practices found that workplace bullying posed a critical problem for patient safety: rather than bring their questions about medication orders to a difficult doctor, almost half the health care personnel surveyed said they would rather keep silent. Furthermore, 7 percent of the respondents said that in the past year they had been involved in a medication error in which intimidation was at least partly responsible.

The result, not surprisingly, is a rise in avoidable medical errors, the cause of perhaps 200,000 deaths a year.

Concerned about the role of bullying in medical errors, the Joint Commission, the primary accrediting body for American health care organizations, has warned of a distressing decline in trust among hospital employees and, with it, a decline in the quality of medical outcomes.

What can be done to counter hospital bullying? For one thing, hospitals should adopt standards of professional behavior and apply them uniformly, from the housekeepers to nurses to the president of the hospital. And nurses and other employees need to know they can report incidents confidentially.

Offending parties, whether doctors or nurses, would be required to undergo civility training, and particularly intransigent doctors might even have their hospital privileges — that is, their right to admit patients — revoked.

But to be truly effective, such change can’t be simply imposed bureaucratically. It has to start at the top. Because hospitals tend to be extremely hierarchical, even well-meaning doctors tend to respond much better to suggestions and criticisms from people they consider their equals or superiors. I’ve noticed that doctors otherwise prone to bullying will tend to become models of civility when other doctors are around.

In other words, alongside uniform, well-enforced rules, doctors themselves need to set a new tone in the hospital corridors, policing their colleagues and letting new doctors know what kind of behavior is expected of them.

This shouldn’t be hard: most doctors are kind, well-intentioned professionals, and I rarely have a problem talking openly with them. But unless we can change the overall tone of the workplace, doctors like the one who insulted me in front of my patient will continue to act with impunity.

I wish I could say otherwise, but after being publicly slapped down, I will think twice before speaking up around him again. Whether that was his intention, or whether he was just being thoughtlessly callous, it’s definitely not in my patients’ best interest.

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Nurses everywhere are celebrating National Nurses Week May 6th through 12th.

One such nurse, Renee DeRider, says that nursing has been one of the most rewarding experiences she’s ever had.

DeRider has over a decade of experience nursing. She graduated in 2001 and immediately started working in pediatrics, with a concentration in hematology, oncology, and surgery. Now she works in a hemophilia center where she coordinates patient care for both children and adults with bleeding disorders.

This article on the Democrat and Chronicle website looks at DeRider’s experience and why she finds being a nurse so fulfilling.

DeRider said she loves her job as a nurse and her work environment due to the endless possibilities.

“As a nurse, there are numerous paths you can choose for your career,” DeRider said. “The choices are endless, and I think that’s what’s so attractive about becoming a nurse; there’s always a portion of the medical field that you can learn something about and there’s always your portion of the medical field that you become passionate about and an expert of.”

But with the love of work and numerous career paths within the field comes heartfelt stories that impact nurses.

DeRider said the most touching experience as a nurse came in 2004 and 2005 while caring for an 18-month-old girl with terminal cancer.

“To know that you’ve had the opportunity to support a family during their most difficult moments and be part of that experience is an honor,” DeRider said. “I know this sounds very awkward for some, but for a parent to allow a nurse — total stranger — in on your most intimate family moments; hold your hand, laugh with you, cry with and for you, and most importantly, love (their) baby as well … there’s no greater experience than that.”

And for her care, DeRider said she has been rewarded countless times by patients and their families with gifts like a simple thank-you card.

“I actually keep each and every one of them, including pictures colored by kids who, by now, are adults,” DeRider said. “I figure that if you’ve taken the time to say ‘thank you’ and what I meant to you, I can keep that to remember you by as well.”

For DeRider, the time spent being a nurse will never match her love and commitment to the job.

“Nobody goes in to nursing because they love the long hours, weekends, holidays and overnights. It’s not a fallback career and requires much dedication. It’s by far (not) a glamorous career, but we’re the thread that ties together the physician and the patient,” DeRider said.

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Nurses working in oncology care suffer from a high degree of burnout and compassion fatigue. The typical oncology nurse will develop a close relationship with patients and patients’ family members over the course of treatment, which can last months or even years.

In a study conducted by Memorial-Sloan Kettering Cancer Center, 153 participants (mostly nurses), responded to a wide variety of questions on their feelings of burnout and compassion fatigue. Forty-four percent of inpatient staff nurses felt they suffered some degree of burnout. Similar studies of oncology nurses found a high incidence of emotional exhaustion (37-44 percent), depersonalization (11-47 percent) and low personal accomplishment (20-55 percent).

In order to anticipate which nurses most likely to develop burnout and fatigue, the Kettering study identified a number of risk factors:

- Age. Nurses younger than 40 suffered a greater incidence of burnout, perhaps in correlation to their number of years of experience.

- Stage of worklife. Nurses with 6-10 years of oncology experience were more likely to suffer high-risk burnout and low compassion satisfaction than nurses with 11-20 years of experience. Nurses with a bachelor’s degree also experienced less burnout than nurses with a doctorate.

- Gender. Females suffered more burnout than men.

- Personality characteristics. A resilient attitude helped nurses cope with the stress of oncology nursing, and nurses who were equipped with a wide range of positive coping skills fared better than their coworkers who had fewer coping skills.

- Social support and spirituality. Not surprisingly, nurses with religious or social support experienced fewer dips in empathy, depersonalization and emotional exhaustion.

The study also identified signs and symptoms of burnout that nurses should monitor themselves for, which included boredom, depression, fatigue, frustration, gastrointestinal distress, frequent headaches, insomnia, low morale, weight loss, increased absences and deterioration in their relationships with physicians and patients.

Early detection was identified as key to preventing long-term effects of burnout and compassion fatigue. Simple alterations in lifestyle may best minimize the risk to oncology nurses and empower them to maintain balance in their work and personal lives as they are caring for vulnerable cancer patients. The Kettering study suggested the following lifestyle management tools:

- Monitoring and identifying early symptoms
- Good nutrition
- Spirituality, meditation and time in nature
- Grieving losses
- Reducing the amount of overtime worked
- Exercise or participation in sports
- Keeping a sense of humor
- Consulting with experts if symptoms increase
- Peer support, including discussion of coping strategies

Although originally developed as a coping mechanism for physicians, a technique of identifying and working with emotions may also prove beneficial to oncology nurses. This technique involves identifying the conditions under which the emotion arose, naming and accepting the emotion, identifying its source, stepping back to gain perspective in the situation, identifying behaviors that resulted from the emotion, considering implications and behaviors and then developing patient outcomes in response to different behaviors.

Organizations that expect perfection in nursing care also contribute to a higher degree of burnout, especially when standardized care and efficiency is expected. Institutions that empower the oncology nursing staff through educational interventions, emotional support and improved communication can reduce the burnout and compassion fatigue so common to caregivers of cancer patients and their families.

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In honor of National Nurses’s week, Sherry R. Siegel, R.N., M.S.N., C.H.P.N, is featured in an article on GoErie.com, relaying her story of being a nurse over the past twenty years.

Her story begins more than 20 years ago when she was a single mother with two children and lots of bills to pay. She was a waitress at the time and actually enjoyed that job, but the pay was not enough to give her family financial security (or health insurance). So she contacted a nearby college and asked the admissions counselor there what agree would be most likely to actually assure her a job. As a waitress she knew many people with college degrees who were nonetheless unable to find jobs in the area they had studied.

The admissions counselor told her, “Be a nurse. You’ll always have a job.” She took that advice, and enrolled in the college, graduating two years later with an associate degree in nursing.

She quickly found a job as a nurse, with a steady paycheck and health insurance, and then also discovered that she loved being a nurse.

My first nursing job was in cardiology and then I moved to home care. After a few years I became a hospice nurse, which was where I needed to be. I loved being a hospice nurse and became passionate about a good end-of-life experience for everyone. I believe in the hospice philosophy of living as well as you can for as long as you can. Isn’t this what everyone wants?

After 10 great years, I left hospice to become the palliative care coordinator at The Regional Cancer Center. I had learned so much during my time as a hospice nurse and hoped that I could use my skills and knowledge to help cancer patients maintain their quality of life while facing a life-threatening disease. While working with cancer patients and caregivers can be challenging and emotionally draining, it can also be rewarding. Cancer is a heartbreaking word and a life changing event for patients, their families and caregivers. Much can be done to address pain and suffering throughout the cancer journey if we take the time to listen.

As a palliative care nurse I provide symptom management and extra support to patients and caregivers. Patients who have their needs met have fewer psychosocial issues, such as depression, stress and worry, and are more likely to complete their cancer treatments. This allows patients with a life-threatening disease to live as well as they can for as long as possible.

Twenty years ago when I decided to be a nurse I never dreamed where this journey would take me. I have since received bachelor’s and master’s degrees in nursing and became certified in hospice and palliative care.

I love being a nurse and knowing that the little things I do to improve quality of life makes a difference. Nurses are members of the largest health care profession and the ones who have the most contact with patients and their families. This makes us, as nurses, the front line for advocating for patients and families in a very complex health care system. Every day we have an opportunity to make a difference. Let’s recognize these opportunities, and then use our skills and knowledge to make a difference.

Happy Nurses Week to all fellow nurses. Go out and do what we do best: Care!

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An RN named Kelly Jantz loves being a nurse, and loves making people laugh.

Once a week, she shows up at her hospital in a vintage nursing uniform, wheeling her cart full of supplies. No hypodermic needles here — it’s all the likes of stuffed animals, comic DVDs, and clown noses. These supplies are used for laugh therapy with staff members, patients, and their families.

She’s dubbed her program Positive Hopeful Individuals Laughing, or PHIL. In this article on the KC Community News website, Jantz says, “Humor is so important… It can change your whole day.”

Jantz started being interested in integrating laughter therapy into nursing after attending a conference where she was exposed to the healing properties of laughter during a yoga session. She researched laughter therapy further and then contacted the vice president of nursing at North Kansas City Hospital about starting a program there. After getting the green light, she did more research and then launched PHIL last fall.

Like Mary Shlapkohl, another nurse who has harnessed the power of laughter to help her patients and their families, Jantz appreciates being able to make a hospital stay more comfortable.

Jantz now dedicates her entire Wednesday shift to PHIL. She spends 10 minutes with each patient and family members. Sometimes patients know of her arrival in advance and sometimes they are surprised, she said. She wheels the PHIL cart into patient rooms, outpatient waiting rooms or meets with staff members to tell jokes, present riddles or perform magic tricks. A cackling monkey sends children and adults into fits of laughter every time, she said.

“Everyone laughs at the monkey,” she said.

Jantz’s photograph and pager number are posted in units throughout the hospital. Jantz responds to nurses, managers, charge nurses, transporters, technicians and doctors who recommend their patients. She said the laughter therapy is three-fold. She lightens stressed-out staff members and signals a lighter mood to patients and their families. Research shows that a good guffaw has similar benefits to a cardiovascular work-out, she said.

“It increases heart rate and blood pressure,” Jantz said.

Laughter is also good for the immune and respiratory systems, enhances mental functions, reduces pain, increases endorphins and leaves you thinking more clearly, Jantz said. Jantz’s program includes DVDs of vintage sitcoms such as “I Love Lucy,” “I Dream of Jeannie,” “Kids Say the Darnedest Things” and “Candid Camera.” The comedy shows spark memories among patients and their families, she said, taking their minds off pain and worries. Conversations flow and blood pressures drop, she said.

“Everybody should be laughing,” Jantz said.

The spirit is contagious, too, Jantz said. She once passed a clown nose to a patient in radiology, who then wore it the rest of the day, tripping staff and family members into fits of giggles. Jantz always leaves them laughing, she said. She leaves patients with clown noses, oversized sunglasses or giant combs among her silly exit gifts.

“It reminds them of their laughter moment,” she said. “It brings up conversation with other people. It’s going to bring back that positive moment.”

Jantz said she is naturally humorous and hails from a family of jokesters. She said she always has approached nursing with smiles and a light touch.

“I love to laugh,” Jantz said. “I love talking to people and joking around.”

Jantz said she wants to grow the PHIL program. She is already at work creating online laughter websites for staff members and thinking of ways to spread the program more effectively throughout the hospital. She documents each visit, and results are reviewed for the program’s impact.

“She shows up, she’s just a hoot,” Kathy Riddle, RN and staff nurse in the oncology department at North Kansas City Hospital said. “Everybody’s mood changes.”

Riddle said she is a jokester as well and connected with Jantz’s program.
“I love humor. Patch Adams was my hero,” she said. “This is perfect. I am quite a joker. We just meshed.”

Riddle chooses appropriate patients for Jantz to visit, depending on their stage of cancer and where they sit emotionally. She said her patients love the singing stuffed animals and humorous gifts she leaves behind.

“It takes their mind off what’s going on,” Riddle said. “They can still have fun and laugh. They have a different perspective on life after she leaves.”

Patients talk about Jantz after they leave, Riddle said. They tell their family members about her, keep her photo on the wall and write favorable comment cards, she said.

“She is a blessing,” Jantz said. “She is like a breath of fresh air. She just has a great personality. She is always like that.”

Sarah Fields, vice president of nursing at North Kansas City Hospital, said when staff members are having a bad day, Jantz can make them laugh and relieve their stress. One of the games on Jantz’s cart is a guessing game involving physicians.

“It’s fun watching them gathered around Kelly’s cart looking at the pictures of the doctors dressed up in disguises and trying to guess who’s who,” Fields said.
Fields said the hospital frequently receives WOW comment cards about Jantz. Patients and their families write that Jantz brought joy and smiles to their day.

“Her passion and dream have become a reality that ultimately benefits our patients,” Fields said.

Image of the Texas State Capitol courtesy of adpal3180 via Flickr

One of Tim Flynn’s first duties as the first full-time nurse for the Texas State Capitol was to give then-Governor Ann Richards a flu shot. He was nervous enough that he forgot to bring a band-aid, which led Gov. Richards to warn him that he better not let any blood sully her $300 silk blouse!

He did his job carefully and well and her blouse was safe. His job was safe too evidently, because he’s been the Capitol nurse for the two decades since then, according to this profile of Mr. Flynn in the New York Times.

Through the administrations of Ms. Richards, George W. Bush and Rick Perry, Mr. Flynn has been at the Capitol to dispense flu shots, treat sinus infections, and provide patient education to lawmakers.

Everyone in the Capitol knows him and trusts him. Representative Rick Hardcastle says, “He knows I have bad allergies because he’s seen me before. It’s like going to see your family doctor.”

Even though he loved his job, he did get frustrated that he wasn’t able to write prescriptions or diagnose illnesses. So he decided to go back to school and become a nurse practitioner, graduating from the University of Texas in 2002.

As a state employee, Mr. Flynn does not charge patients. His Capitol clinic operates on a first-come, first-served basis. When children on school trips fall down, they go to him. State employees drop by when they have headaches.

“I love my job,” he said. “After being here 20 years, I know most of the folks that work here. I know their medical histories, their idiosyncrasies. This is my community. That’s why I call it my Capitol.”

In emergencies, Mr. Flynn is one of the first on the scene, providing life support until paramedics arrive. In 1999, when a Capitol parking guard was found slumped over his desk and suffering from gastrointestinal bleeding, Mr. Flynn treated him for shock before paramedics arrived and saved the man’s life.

Responding to emergencies is the smallest part of his job, Mr. Flynn said. He spends most of his time on procedures like treating strep throat, saving patients a trip to their primary care providers.

His job takes on added importance during the biennial legislative sessions, when lawmakers convene for 140 days at the Capitol.

“When it’s crunch time, I don’t have to call a doctor; I can go down to Tim’s office,” Mr. Hardcastle said. “When you have the flu during the night and you’re working on legislation, you need treatment. His job is vital to what we do.”

Image courtesy of AMagill via Flickr

Debt collection agencies have been embedding debt collectors as employees who run interference in emergency rooms and visit patients’ bedsides to demand payment, among other aggressive tactics.

The Minnesota attorney general, Lori Swanson, revealed that Accretive Health, one of the nation’s largest collectors of medical debts, has been engaging in these tactics. The New York Times notes that this raises concerns that “such practices have become common at hospitals across the country.”

Hospitals are increasingly desperate to recoup payments as their unpaid debts mount. To patients, the debt collectors can blend right in with hospital employees, yet these staff members focus on demanding that patients pay outstanding bills and may even discourage them from seeking emergency care at all. For example, they will sometimes purposely “stall” a visitor to the emergency room in an attempt to get payment before the patient receives any treatment. Their focus is on getting money, not the patient’s health.

Additionally, these workers (who are not actually medical staff) sometimes have access to health information, possibly in violation of Hipaa (the Health Insurance Portability and Accountability Act). Accretive employees may also have broken the law by not clearly stating that they were debt collectors.

As hospitals struggle under a glut of unpaid bills, they are reaching out to companies like Accretive that specialize in collecting medical bills.

Hospitals have long hired outside collection agencies to pursue patients after they have left hospital facilities. But financial pressures are altering the collection landscape so that they are now letting collection firms in the front door, according to Don May, the policy adviser for the American Hospital Association, a trade group.

To achieve promised savings, hospitals turn over the management of their front-line staffing — like patient registration and scheduling — and their back-office collection activities.

Concerns are mounting that the cozy working relationships will undercut patient care and threaten privacy, said Anthony Wright, executive director of Health Access California, a consumer advocacy coalition. “The mission of these companies is in direct opposition to the supposed mission of these hospitals.”

Still, hospitals are in a bind. The more than 5,000 community hospitals in the United States provided $39.3 billion in uncompensated care — predominately unpaid patient debts or charity care — in 2010, up 16 percent from 2007, the hospital association estimated.

Accretive is one of the few companies specializing in hospital debt collection that is publicly traded. Last year, it reported $29.2 million in profit, up 130 percent from a year earlier.

Late last month, Fairview Health Services, a Minnesota hospital group that Accretive provided services to, announced it was canceling its contract with Accretive for back-office debt collection. After Accretive informed investors, its stock plunged 19 percent in a day. On Tuesday, the company’s shares closed at $18.49, down 2.7 percent.

Accretive says that it trains its staff to focus on getting payment through “revenue cycle operations.” Accretive fostered a pressurized collection environment that included mandatory daily meetings at the hospitals in Minnesota, according to employees and the newly released documents. Employees with high collection tallies were rewarded with gift cards. Those who fell behind were threatened with termination.

“We’ve started firing people that aren’t getting with the program,” a member of Accretive’s staff wrote in an e-mail to his bosses in September 2010.

Collection activities extended from obstetrics to the emergency room. In July 2010, an Accretive manager told staff members at Fairview that they should “get cracking on labor and delivery,” since there is a “good chunk to be collected there,” according to company e-mails.

Employees were told to stall patients entering the emergency room until they had agreed to pay a previous balance, according to the documents. Employees in the emergency room, for example, were told to ask incoming patients first for a credit card payment. If that failed, employees were told to say, “If you have your checkbook in your car I will be happy to wait for you,” internal documents show.

Employees at Accretive’s client hospitals ask patients to make “point of service” payments before they receive treatment. Until she went to Fairview for her son Maxx’s ear tube surgery in November, Marcia Newton, a stay-at-home mother in Corcoran, Minn., said she had never been asked to pay for care before receiving it. “They were really aggressive about getting that money upfront,” she said in an interview.

Ms. Newton was shocked to learn that the employees were debt collectors. “You really feel hoodwinked,” she said.

While hospital collections at Fairview increased, patient care suffered, the employees said. “Patients are harassed mercilessly,” a hospital employee told Ms. Swanson.

Patients with outstanding balances were closely tracked by Accretive staff members, who listed them on “stop lists,” internal documents show. In March 2011, doctors at Fairview complained that such strong-arm tactics were discouraging patients from seeking lifesaving treatments, but Accretive officials dismissed the complaints as “country club talk,” the documents show.

Ms. Swanson said that the hounding of patients violated the Emergency Medical Treatment and Active Labor Act, a federal law requiring hospitals to provide emergency health care regardless of citizenship, legal status or ability to pay.

In the January lawsuit, Ms. Swanson said that by giving its collectors access to health records, Accretive violated the Health Insurance Portability and Accountability Act, known as Hipaa (pronounced HIP-ah). For example, an Accretive collection employee had access to records that showed a patient had bipolar disorder, Parkinson’s disease and a host of other conditions.

In addition, she said, the company broke state collections laws by failing to identify themselves as debt collectors when dealing with patients.

Late Tuesday afternoon, Accretive announced it won a contract to provide “revenue cycle operations” for Catholic Health East, which has hospitals in 11 states.

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Most nurses can expect to face at least one instance where legal representation becomes necessary in the course of their career. Although most healthcare institutions carry malpractice insurance for nurses and will provide their own in-house counsel or insurance counsel, there may be times when nurses feel they need their own private lawyer to protect their interests.

Generally, the amount of malpractice insurance an institution carries will suffice for protecting a nurse from personal financial loss, but in high liability areas of nursing practice, such as nurse midwifery and surgery, nurses should carry an additional policy. Several companies offer professional liability insurance and the Nursing Service Organization offers several types of insurance policies that are tailor-made for the nursing profession.

Two key instances where a nurse should always seek outside counsel are: 1) any time a complaint has been made with the state Board of Nursing, which includes notice of investigation by the Board of Nursing and, 2) any time a nurse has been given notice of being a named party in a lawsuit.

Patients and family members, upon filing a lawsuit, will name every person that has come into contact with the patient as a party to the action. Parties are discharged as the investigation uncovers which healthcare providers are most likely to have caused the alleged harm to the patient. The process can be upsetting and affect a nurse’s practice, but the investigation is a necessary element in the process of resolving the matter.

Nurses may also wish to retain counsel in matters concerning their employers. This can range from a simple review of a contract before hire, to more serious instances involving action taken by employers, supervisors and physicians. Situations in which a nurse should hire outside representation aren’t always clear however. Consider the following situations and advice from Medscape’s “Ask an Expert” before seeking your own legal counsel:

Forced overtime. Several states prohibit employers from requiring nurses to work overtime, but employers mandate the overtime just the same. Employers may threaten a nurse with patient abandonment, which can cause loss of the nursing license. A nurse should consult an attorney in this situation.

Inadequate staffing. Short staffing can lead to dangerous outcomes for patients, but in this situation, a nurse should first work up through the chain of command and bring the situation to the attention of supervisors and the director of nursing. It’s also good to do some background investigation of state laws for minimum staffing levels, which can add credence to the nurse’s case for proper staffing levels. If the facility is a Magnet hospital, it may also be in violation of the requirements to keep Magnet status.

Derogatory or critical supervisor. Derogatory statements can be actionable if they involve discrimination or harassment. A critical supervisor may focus comments more on the nurse’s job performance; these comments are more disparaging than discriminatory or harassing. In this case, the nurse must first examine the reason for the remarks. Is the nurse performing the job as outlined in the job description? If so, the nurse may wish to seek legal counsel who will determine if a cause of action exists.

Termination of employment. Getting fired is usually an emotional situation, but if a nurse believes that he or she was wrongfully terminated, then consulting legal counsel may help recoup financial loss.

Before hiring an attorney, nurses should investigate whether the attorney has experience in handling employment or malpractice issues. It can also help a lot to do some investigation of the applicable laws and regulations before contacting a lawyer — you may discover that the matter can be handled without legal representation, thereby saving hundreds and maybe thousands of dollars.

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Dr. Otis Brawley is concerned how health care is currently consumed. He’s written a book called “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America” that examines and explains these concerns.

Tara Parker Pope of the NYT’s Well blog spoke to him about his book and how broken he considers the United States health care system to be. He states that “failure is in the system” — that no horror stories (and he has some doozies, like a woman with untreated breast cancer who brings in her breast for re-attachment after it falls off) should be dismissed as an aberration.

He doesn’t just blame hospitals, health care workers, or insurance companies though. He also thinks that patients demand overtreatment, and that this contributes to the bloat and inefficiency of the current health care system.

He says he decided to write the book after listening to the debate over the Affordable Care Act. He says, “The talk should not be about rationing health care but about rational health care. So much of what we do in health care is irrational.” When asked to describe an example of irrational health care, he says:

A.
There was a man with colon cancer who went to a wonderful hospital with a wonderful reputation. He got surgery and was referred to a medical oncologist who has a wonderful reputation as a doctor to the rich and famous in Atlanta. That medical oncologist started giving him chemotherapy and two other expensive drugs. When this man lost his insurance, the oncologist basically dropped him, and the guy ended up being seen by me at the county hospital. A doctor who is training with me to be an oncologist immediately realizes that this guy is getting a chemotherapy regimen for colon cancer that we stopped using about 15 years ago. His medical oncologist was practicing the best medicine of the late 1980s, but we were in 2006. The other drugs he was being prescribed were totally unnecessary. But the doctor could get a substantial markup and make a substantial amount of money by selling them. The oncologist had known just enough to be greedy and prescribe drugs he can make money off of, but he didn’t know enough to prescribe the chemotherapy that would have given the patient a much better chance of surviving his cancer.

I’ve seen that so many times, where doctors really have failed to evolve and failed to learn as the profession and the scientific evidence have changed over time.

Q.
But in reading the book, you don’t just blame doctors for being greedy. You blame patients for being gluttonous. Can you explain?

A.
Another patient of mine had early colon cancer. Three doctors had told her she should not get chemotherapy. She decided she wanted it, and she went doctor-shopping until she found a doctor who would give it to her. Her insurance had no way to object to her getting this inappropriate chemotherapy because privacy laws prevent disclosing the stage of the disease to the insurance company. She was referred to me by a relative who was concerned about what she was doing. She readily admitted that she had three different medical opinions that said she should not get chemotherapy, but she wanted chemotherapy. So a doctor made $10,000 off that six months of chemotherapy, and she got an increased risk of leukemia for the rest of her life, not to mention losing her hair and everything else, with no scientific evidence that the treatment reduced her risk of the colon cancer coming back.

I blame patients, I blame doctors, I blame hospitals, I blame drug companies, I blame insurance companies. Our health care system is messed up because the system is designed to fail, and everybody is responsible for health care failing as it is now.

Q.
The story about the woman whose breast fell off was horrible. What were you trying to tell us with that example?

A.
We so frequently talk about breast cancer almost as if it’s a boutique disease or trendy. I feel some people have forgotten how terrible this disease can be. This lady – I saw a lot of things in her background that were lessons for society about what we need to do if we want to defeat breast cancer. When she realized she had something growing in her breast, she had insurance, but logistics having to do with her job and child care and a little bit of denial kept her from going to the doctor and getting this thing diagnosed and treated when it was likely curable. Later on, when she wanted to see a doctor, she couldn’t because her insurance had gotten so expensive that she had to drop it. If she had come in when she first found this thing 9 or 10 years earlier, I probably could have cured it, and it would have cost about a tenth of what we spent when she was uninsured and receiving free care from the hospital. She lived for about two years after I met her. That’s a failure of medicine to educate people.

Q.
In the book, you talk about a conversation with a hospital marketing executive who talks about drumming up business with free prostate cancer screenings at a mall health fair. How did that affect you?

A.
That was the beginning of Otis Brawley becoming a loudmouth in the prostate cancer screening debate. We’re making promises to patients and making them think we know things we don’t know and making money off of them. There is a subtle little corruption in medicine. We’re selling chemo to people who don’t need it, giving prostate screening when it might save lives, but we make them think it definitely does, and then I see a lady whose breast is falling off who couldn’t afford to see a doctor when she wanted to see one.

Q.
Is there any hope that things might improve someday?

A.
I am trying to get folks, through this book, to talk a little more about rational use of health care and realize that we are actually hurting people with overtreatment. Health care needs to be consumed in a wiser way that is much more concerned about allegiance to the science. We need to be more concerned about the welfare of our patients. There was a recent report, the 45 tests we do too much, that I was thrilled to see. People are starting to realize that we need to be a little wiser in our use of health care.

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A Minneapolis-based hospital group will require that their employes wear matching uniforms distinguished by colors starting in May, one color per job category. Think Star Trek, but in a more Earth-bound (and medical) setting.

Nurses get navy scrubs. Licensed practical nurses will wear eggplant. Respiratory therapists get olive green.

The idea is to make it easier for patients and family members to identify their care team by the color of their uniform. However, unionized nurses are not happy that the change has been imposed from on high, without any negotiation. Many of them also disagree with the new uniform plan. This article in St. Paul Pioneer Press quotes oncology nurse Cristin Betzold of Blaine as saying that her patients appreciate the variety of bright colors she wears. “I have many patients comment on how at least they see a little bit of color in what they see during the day from my uniform,” she said.

They also question whether the color-coding would actually help patients.

So, amidst the discord, the Minnesota Nurses Association has filed a grievance over the uniform policy. The uniform policy will still go into effect on schedule but may roll back later depending on result of the arbitration process.

A survey of hospitals across the Twin Cities finds that there’s no uniform position on color-coded outfits.

There’s no requirement for matching scrubs at St. Joseph’s Hospital in St. Paul, Methodist Hospital in St. Louis Park or medical centers in the Minneapolis-based Fairview system.

To address concerns that hospital patients sometimes struggle to recognize who’s caring for them, Fairview workers get pointers on introducing themselves. Workers at St. Joseph’s, meanwhile, wear super-sized name tags called “badge buddies” that clearly identify their skill set.

But other medical centers have switched to standardized uniforms.

About five years ago, Woodwinds Health Campus in Woodbury started requiring navy blue scrubs for its RNs. Nurses selected the color in a vote after hearing from an advisory committee that matching outfits would be helpful to patients, said Cindy Bultena, the chief nursing officer at Woodwinds.

Regions Hospital in St. Paul has required workers in the same job category to wear the same color for at least a decade and is in the process of again affirming the policy. Over the past few years, workers have started wearing patterned scrubs within their given color, but solids will be required as of Jan. 1, said Jon Henkel, a hospital official.

At the Mayo Clinic in Rochester, Minn., uniforms are color-coded within work units but not across all clinical areas. That means, for example, that not all nurses wear the same color, but all workers in obstetrics wear teal green scrubs.

“The dress code is always under review and we are currently entertaining administering a patient study which will help identify their needs specific to dress,” said Kelley Luckstein, a clinic representative, in an email.

Allina officials say their hospital in Buffalo first experimented in 2010 with what’s now been dubbed the “uniform initiative.” The medical center saw its patient satisfaction scores improve following the change to standardized uniforms.

The health system started talking with employees last year about the switch, which will apply at the system’s 11 hospitals. In December, about 5,500 employees cast ballots for their favorite colors.

“Some employees networked across the entire Allina system to say, ‘Let’s pick these as the top three choices,’ ” said Sorbel, the United Hospital official. “The larger groups got the colors they wanted.”

Even so, the change has proven divisive.

Patients respond to variety, especially pediatric patients, said Bernadine Engeldorf, a nurse at United who also is first vice president of the Minnesota Nurses Association. She added that nurses like the freedom of being able to choose their outfits.

In contrast to the cheery colors some nurses currently wear, navy blue seems “somewhat muted, dark,” she said.

“People take a lot of pride in what they wear to work,” said Betzold, the nurse from Blaine. “I think people don’t agree (with the change), but obviously nobody wants to be terminated because they chose not to wear navy blue.”

The change is being felt in the pocketbook, too, although there are different estimates of the magnitude.

The average uniform costs $80 to $100, said John Nemo, spokesman for the Minnesota Nurses Association. Full time nurses need five to 10 sets of uniforms, he said, because they can only be worn one day before washing. Replacement occurs every six to 12 months, Nemo added, depending on the quality of garments.

Allina officials, however, quote a range of $20 to $50 for scrubs, adding they have negotiated special discounts for workers who purchase from a preferred vendor. The health system is providing up to $80 in vouchers to workers to help defray costs.

“We do recognize that in making a change, there is a financial burden to our employees,” said Tracy Kirby, the director of nursing at Abbott Northwestern.

As the labor dispute plays out, some wonder why navy seems to have become the new color of nursing.

Sure, it’s a color that doesn’t show spots or evoke strong emotions, said Helen Strike, the chief nursing officer at St. Joseph’s Hospital. But there was a time when all nurses wore uniforms, Strike said, and the color always was white.

“Even today, kids who are 3 or 4 years old have this idea that a nurse wears white,” she said. “There’s something very positive about that historical perspective, and I wonder why we don’t utilize that more in nursing.”

White also has been linked with doctors through their historic use of white coats. The new Allina policy, however, won’t apply to physicians, since many aren’t directly employed by the health system.

Kirby, the nursing director at Abbott Northwestern, added: “Patients tend to really know who their doctors are.”