By Carol Taylor, PhD, RN and Sydney Howk, BSN, RN
Hypothetical CaseCarol Taylor, RN
Jenny Adamchak is a new nurse practitioner working in a busy inner-city emergency room, but questions the hospital’s commitment to achieving high patient engagement scores. She’s worked at the hospital for 18 years and loves its commitment to quality patient care. She attends a department meeting and learns that senior administration is not at all happy with the patient engagement scores coming from the emergency department. Administrators have alerted the medical director and chief nurse that the hospital stands to lose big money if patient engagement scores don’t improve. Since 2007, hospitals that fail to report required quality measures receive less money from the Centers for Medicare & Medicaid Services. The government’s value-based purchasing program bases only 70% of hospital performance scores on actual clinical care and a full 30% on the survey’s report of the patient experience of care. ED physicians and nurses express great frustration with patients and families who come to the ED insisting on tests and drugs because of information they have read online. If patient demands aren’t met promptly, patient satisfaction scores precipitously drop.
In a study of 155 physicians published in 2014 by Aleksandra Zgierska, David Rabago and Michael Miller, more than half reported pressure to overprescribe antibiotics and opioid medications and order unnecessary tests and procedures due to mounting pressure to obtain high satisfaction scores from patients. Of even more concern in the same study, 20% reported having their job threatened due to the outcomes of the scores, and almost 30% reported the pressure surrounding these scores made them consider finding employment elsewhere (Sibert, 2014).
Provision 5.4 of the ANA Code of Ethics for Nurses (2015) addresses the importance of the nurse’s integrity and recognizes the many threats to integrity in modern healthcare. When the integrity of nurses is compromised by patterns of institutional behavior or professional practice, thereby eroding the ethical environment and resulting in moral distress, nurses have an obligation to express their concerns or conscientious objections individually or collectively to the appropriate authority or committee. Nurse administrators must respond to concerns and work to resolve them in a way that preserves the integrity of the nurses. They must seek to change enduring activities or expectations in the practice setting that are morally objectionable (p. 20).
Adamchak adds her voice to the chorus of protests responding to the directive that everyone should work harder to satisfy every patient. After five months on the job, she already struggles with how best to respond to inappropriate requests for antibiotics, prescriptions for drugs like Vicodin and Oxycontin, and demands for X-rays. She laments the quick transition in her professional life where patients first became clients, then consumers and now customers, where the customer is always right. She also is painfully aware she has big tuition bills to pay and needs this job. She decides to work harder to educate patients who make inappropriate requests for medicines or tests, but the bottom line will be to send them away happy — even if this entails orders of which she is not proud. She comforts herself with the knowledge that many more experienced clinicians are bowing to the same pressures.
Adamchak takes seriously her Code of Ethics statement that the nurse’s primary commitment is to the patient. She worked hard to develop the expertise to collaboratively work with patients, their surrogates and colleagues to identify appropriate patient goals and treatment plans using shared decision-making strategies. She is unwilling to abdicate her role and authority to patients with unrealistic, misguided or even harmful preferences. She decides to see who among her colleagues shares her values and requests an appointment with the CNO. She is hopeful that at the very least she and her colleagues can reach some agreement about how best to respond to inappropriate requests. She remembers that one of the faculty from her nurse practitioner program was in a DNP program and working on the unintended problems related to Hospital Consumer Assessment of Healthcare Providers and Systems scores, and decides to contact her to learn what is happening at the national level.
Carol Taylor, PhD, RN, is a professor of nursing at Georgetown University School of Nursing and Health Studies, and senior scholar, Kennedy Institute of Ethics.
Sydney Howk, BSN, RN, is a graduate student at Georgetown University School of Nursing and Health Studies.