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Preserving a positive image of nursing in a complicated healthcare environment

Yetter, Dawn MS, BSN, RN, ONC

doi: 10.1097/01.NME.0000368743.21924.19
Department: On the Horizon



Bedside nursing care has become increasingly complicated and stressful. Changes in technology, patient acuity, patient populations, and workflow patterns have all had an effect on the nurse's role in the hospital setting. Providing the patient-centered, holistic care that has defined nursing is more challenging than ever. In this article, I'll not only discuss the complications we're currently facing as nurses, but also provide tips to help you focus on maintaining a positive and professional image of nursing in a complicated healthcare environment by using the mnemonic IMAGE to organize bedside patient care as you begin each shift.

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A positive image of nursing

The American public has identified nursing as the profession it most trusts. In the 2008 Gallup poll, 84% of respondents rated nurses' ethical standards and honesty as "high" or "very high." Nurses have received the top ranking in this poll since 2002, ahead of physicians, teachers, and pharmacists. Also, in 2009, President Obama declared that nurses are the "backbone of the healthcare system," recognizing that nurses are the individuals most involved in patient care.

Satisfaction with hospital nursing care has been identified as the main factor influencing patient satisfaction with the overall hospital experience. One study identified categories of nursing care that were important to patients and influenced their satisfaction with their hospital stay. Patients identified the following factors: being treated as individuals with unique needs, receiving explanations of care and treatments being provided, knowing that the nurse is watching over them, and receiving timely responses to requests. Patients also expect competent nursing care and accurate, comprehensive education related to their inpatient and discharge needs. When nurses meet these expectations, patients report satisfaction with the hospital experience.

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A complicated healthcare environment

The role of the bedside nurse has become more complex and intense. Patients are more acute and often have multiple comorbidities that affect their recovery. Shorter hospital stays require that patient care and treatments be provided in shorter time periods, with an emphasis on early discharge. Bedside nurses need to provide more education to patients and their families to ensure that healthcare needs are met when they return home from their short hospital stay. These conditions, combined with heavy workloads, have created a stressful work environment for nurses.

Constant system changes affecting care delivery also contribute to the demands on the bedside nurse. Continuous modifications to forms, procedures, policies, and documentation methods affect workflow. Although these modifications are an attempt to improve the quality of care, they often interfere with the time the nurse is able to spend at the bedside caring for patients. This situation has become so commonplace in the hospital environment that a group of nurses and nurse educators in Minnesota has identified it as complexity compression. Complexity compression is defined as "what nurses experience when expected to assume additional, unplanned responsibilities while simultaneously conducting their multiple responsibilities in a condensed time frame." Up to 40% of the bedside nurse's role is reported to be spent on system demands that don't involve direct patient care. These demands are a significant stressor for nurses who are frustrated and discouraged with work that takes them away from their patients.

Advances in technology have placed additional demands on nurses who are often required to master new equipment, perform technical tasks, and interpret information obtained from new devices. Nurses are challenged to keep the patient at the center of care in the midst of an increasingly technologic environment. For example, the use of electronic medical records for documentation has become common in the healthcare environment. Many of these systems were developed without nursing input, aren't user-friendly, and often increase the time spent documenting. In addition, nurses who aren't experienced with using computers sometimes have difficulty adjusting to these documentation systems.

Increasing job stress in the hospital environment combined with an aging nursing workforce is reported to lead to the decreased productivity of bedside nurses. In one study, nurses reported an inability to meet the needs of their patients 12.7% of the time. Almost one in four of the nurses studied reported a work-related injury, with back pain being the most common cause. Fifteen percent of the nurses reported they plan to leave the nursing profession within the next 5 years; the majority cited stress as the reason. Other factors influencing the stress level of nurses included multiple home responsibilities, health problems, and difficult working conditions.

U.S. hospitals are currently experiencing grave financial problems due to the economic recession. Concerns about job loss and increasing out-of-pocket costs have caused a decrease in patients undertaking elective medical procedures, which are a source of profitable revenue for hospitals. Increases in the number of uninsured patients unable to pay their medical bills and a decrease in government reimbursements have compounded hospitals' financial problems. In the fourth quarter of 2008, over half of the hospitals in the United States reported financial losses. These economic problems have led to cost-cutting efforts, including staff reduction and layoffs. According to the American Hospital Association, 22% of hospitals have reported a reduction in services since September 2008. These measures have had adverse effects on an already overburdened system.

Within this fast-paced, chaotic environment, it's no wonder that today's nurses are challenged to provide caring interventions and demonstrate the professional behaviors that define nursing.

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Using the mnemonic IMAGE

Nurses providing bedside care are inundated with interruptions that make it difficult to concentrate on a series of tasks. Frequent pages, phone calls, and requests from patients and other staff are common occurrences in the normal shift of a bedside nurse. The use of a mnemonic can be helpful in reestablishing a train of thought after being interrupted.

The mnemonic IMAGE stands for "introduce yourself," "medications," "assessment," "goal," and "explain and educate." This mnemonic is a reminder to present a positive image of nursing while providing organized, efficient care that meets the needs of your patient. Let's take a closer look.

  • Introduce yourself. This is the first step in developing a trusting nurse-patient relationship. Introducing yourself and your title and explaining your role provides your patient with access to a resource for questions or concerns and lets him know you're available to make sure his needs are met. Inviting him to call for you through the call-light system or by phone is another welcoming interaction that establishes the beginning of a trusting relationship. Using a dry-erase board or writing your name on a piece of paper and leaving it with your patient lets him know who'll be caring for him during the shift and denotes accessibility.
  • Medications. Provide and explain each medication ordered for your patient. Accessing the medication record, double checking the five medication rights before giving the medication, and using two patient identifiers are all methods to ensure medication safety and prevent costly errors that erode the patient's trust in the nurse. Explaining the availability of as-needed medications and their use is another valuable intervention that invites your patient to call on you if necessary.
  • Assessment. Conduct a head-to-toe assessment. Performing a comprehensive assessment of your patient at the beginning of your shift provides a baseline that allows you to compare any progress or decline in his status over the shift or series of shifts. Being sure to address all spiritual and psychosocial needs in addition to physiologic needs ensures that your patient receives holistic nursing care.
  • Goal. Assist your patient in setting a goal for the day. The patient is the one who's best able to determine his goals for healthcare; he's also the one who's most accountable for the results. Helping your patient identify what he hopes to accomplish each day sets in motion the plan for the shift. If you work on the evening shift or night shift, take the time to review your patient's daily goal and assess his beliefs about whether progress has been made or the goal has been achieved. It's important to ensure that the goal reflects your patient's hopes and desires, rather than your own.
  • Explain and educate. Explain the care plan and educate your patient regarding treatments and any discharge needs. Beginning the shift by explaining to your patient what's expected to occur and what treatments and procedures are planned helps him understand and cooperate in his care. Working together on anticipation of a discharge date helps avoid last-minute planning and arrangements and provides a smoother course for your patient, preventing anxiety about leaving the hospital.

Students, interns, and new orientees can all benefit from using this mnemonic as they begin to develop their style of interacting with patients. Often, individuals who are new to the nursing environment aren't sure how to begin. Using this mnemonic gives them a starting point on which to build. Seasoned nurses can also benefit from using the mnemonic to ensure that they're taking the time to individualize the care of each patient in a fast-paced environment. Remembering to demonstrate the presence of caring will help nurture a relationship of trust with your patients and promote a positive image of nursing.

Figure. I

Figure. I

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Condition critical

These are challenging times in the world of bedside nursing. Nursing has earned its reputation as a trusted profession by providing caring interventions to the patients we serve. We're privileged to be allowed to interact with people who are in some of the most vulnerable situations of their lives. It's critical that nurses continue to focus on providing the best possible care to their patients in the current stressful healthcare environment. Finding ways to organize care efficiently and effectively while maintaining a trusting nurse-patient relationship and upholding the values of the nursing profession is paramount.

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Memory Jogger



To help organize patient care at the beginning of your shift, think IMAGE:





Explain and educate.

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Learn more about it

Almerud S, Alapack RJ, Fridlund B, Ekebergh M. Beleaguered by technology: care in technologically intense environments. Nurs Philos. 2008;9(1):55–61.
    .American Hospital Association. 2009 health and hospital trends.
      Gibson HA. Using mnemonics to increase knowledge of an organizing curriculum framework. Teaching and Learning in Nursing. 2009;4(2):56–62.
        Krichbaum K, Diemert C, Jacox L, et al. Complexity compression: nurses under fire. Nurs Forum. 2007;42(2):86–94.
          Letvak S, Buck R. Factors influencing work productivity and intent to stay in nursing. Nurs Econ. 2008;26(3):159–165.
            . Nurses again top annual honesty, ethics poll..
              .Sounart A. Hospitals face recession woes.
                © 2010 Lippincott Williams & Wilkins, Inc.