How Nurses Rate Hospital Care

It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. --Florence Nightingale

That basic requirement is as valid today as it was in the 19th century, and few are in a better position to judge how well it is being met than Florence Nightingale's successors. Caring for patients long after staff doctors have made their daily rounds,nurses see hospitals at their very best moments--and their worst. For this reason the professional journal Nursing?? (circ. 400,000) asked its readers just what they think of the quality of care in thehospitals, nursing homes and other institutions employing them. The results add up to a disturbing diagnosis: in the opinion of the majority of the nurses who replied, health care in general deserves a grade no better than a low B.

More than 10,000 readers answered the 78 multiple-choice questions, and Nursing says that well over 200 were so "wound up" by the issues raised that they sent along letters detailing their complaints. Jean MacVicar, director of hospital nursing services of the National League for Nursing, notes that the strong reaction is "a sad commentary, but maybe we had to hit bottom before we decided to do something." Anne Zimmerman, president of the American Nurses' Association, concedes that people may find the report "unsettling," but is pleased nurses are finally speaking out. Says she: "The nurse is, after all, the patient's advocate."

Highlights of the survey:

> Fully 38% of the nurses said they would not, if they had a choice, be treated at their own hospitals. Wrote one: "All I have to say is, 'Dear God, may I never have to be a patient.' " As expected, many of the nays came from those employed by nursing homes, already the subject of widespread criticism. But there was also a surprising number of negative responses from small (under 200-bed) hospitals, traditionally thought to be the models of tender, loving care. Reported a nurse from one of these vest-pocket institutions: "Our emergency room has been known to call in a certain dentist for some cases when they can't reach an M.D."

> The nurses generally had high regard for the medical skills of their doctor colleagues; 28% considered the doctors excellent and 53% good, about the same rating they had for their fellow nurses' performance. But they were far less enthusiastic about the level of psychological support that the doctors give the sick; as many as 77% of the nurses assessed the doctors' performance in that area as either fair or poor. The most startling figure involved fatal accidents: 42% of the nurses said they knew of deaths that could be attributed to doctors' mistakes; 15% noted that they had witnessed such tragedies more than once. In her hospital, one nurse reported, a general surgeon lost eight patients over eight years through sheer ineptness.She added, "A psychiatrist on staff said that he was out to destroy himself."

> The nurses were considerably less harsh on themselves: 18% knew of deaths that had been caused by nursing errors and 4% admitted they had themselves made mistakes that might have led to patients' deaths. One nurse who let a critically ill man accidentally--and fatally--disconnect himself from a respirator wrote, "That was three years ago and I still can't get it out of my mind."

> Many nurses griped about their increasing load of paper work. Snapped one: "If I'd wanted to get secretary's bottom I could have stayed at my old job." Others said that personnel shortages were forcing them to neglect patients' needs. But what especially irked them was the indifference of doctors to nurses' opinions about patients. As one nurse put it, "Sometimes you wonder why you have to make the rounds with an M.D. when he totally ignores your questions and/or your suggestions."

As might be expected, the survey is running into some flak. Since it expresses only the views of nurses who took the trouble to fill out and mail the questionnaire, it may well be biased in favor of those eager to air complaints. Commenting on the nurses' reluctance to seek care in their own institutions, American Hospital Association President J. Alexander McMahon cracked: "It reminds me of the joke, 'Any country club that would admit me, I wouldn't want to join.' " As for himself, he insisted, "I would have no hesitation in being admitted to any hospital in the United States." That may well be. Yet so critical a report from within the medical profession will surely have repercussions, possibly for the good. Coming at a time of rising public concern over the quality and cost (a record $140 billion in fiscal 1976) of medical care, it will give reformers new arguments in their demands for major improvements in the U.S. health system.

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