Lower Turnover with Respect from Authority

One of the areas in healthcare I find interesting is leadership. While I am not personally interested in a formal leadership role, I am specifically interested in the behavior of leadership and how it affects patient outcomes. Cancer care often requires nurses to provide extra attention to patient needs at a levels that some other areas of nursing don't, particularly with regard to psychosocial issues, discharge arrangements, and family/caregiver needs.

These days, as healthcare is grinding away at a furious pace, fueled by a fetish for data collection and cost control measures, there is often disengagement when the scores are interpreted by leadership, and what happens in the clinical reality of care in healthcare facilities, which leadership seldom sees.

I was reading some of the newsletters I frequently receive via e-mail, and happened to come across two articles of interest to me, and happened to read them both on the same day. Of the articles I read, one was about the high rate of turnover in healthcare at all levels, and the other was about nurses challenging authority.

Just a few days earlier, I had a conversation with a colleague who felt demoralized because her superiors were pressuring their oncology unit to raise their Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. She felt like they’d been doing a great job all along, until a new leader came along and decided it was not up to par.

Perception is not the same as reality, and patients value things that are not captured in these survey instruments. They may perceive certain things to be important that staff are not aware of, so they cannot communicate about them and come up with solutions, even though dissatisfaction may be communicated in the HCAHPS scores.

My colleague felt like she needed to push back against this new expectation because there was already not enough staff and they were being stretched too thin. But she also felt like she would risk her job if she said anything to this executive.

When you want to measure a construct, such as satisfaction, you have to validate it first. This ensures you have a clear definition, and understand the limitations, of that construct. If you don’t, you will be getting extraneous data and contamination of your results.

Validated scores still only measure what they were defined and intended to measure. When they are applied in a variety of human conditions, when humans are working with humans, you can’t forget that there are things outside of the constructs that are contaminating the data you are collecting. In oncology, we are working in situations that require a great deal of care that may not be captured by HCAHPS, or experienced by leadership.

It’s important to remember we are working with human beings, not machines. We cannot dial up our pace past a certain point, we make mistakes and increase our error rate the faster we go. Chemotherapy demands a safe pace. So do our patients, and their families.

Healthcare has become business-focused, but patient care really can’t be a transaction. It’s a service, and subject to much variation from hospital to hospital, patient to patient, time to time, shift to shift, doctor to doctor, and nurse to nurse.

Demoralization of employees happens when they are expected to keep pace, even with short staffing, with unsafe conditions, or whatever unknown odd event happened on a particular day that skews the scores. No wonder we have such high turnover costs. Turnover affects care, and leadership should be held accountable for this.

Nurses are not comfortable with challenging authority, yet we must advocate for our patients. If we cannot stand up to the powers above us and protest conditions we feel are unsafe or affect our ability to do our jobs, we have a duty to say something. It’s a skill that must be learned to be comfortable with it. Likewise, leadership must be comfortable with being challenged, and that’s a skill that needs to be learned to keep employees feeling valued and respected.

If I had a nickel for every time a nurse told me something along the lines of, "If you protest, you will get canned. They’ll show you the door."

My response to that is, "Is that such a bad thing?"

If you are feeling uncomfortable with your workplace, you can take steps to start looking elsewhere so that you can take charge of your own career. If nurses would start challenging authority when it is clearly not in the patient’s best interest to care for them under the existing conditions, and band together to face authority, we would exert more influence.

We must work as a team and demand adequate staffing, or other conditions that ensure patients are safe, and our practice is safe. We need to demand respect from authority. When we do that, we will have less turnover.

It’s not a factory, you are not a machine, and your patient is not a widget.

Even so, machines need to be oiled, allowed time for a good cooldown, and some TLC.