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Code Green

Code Green: Money-Driven Hospitals and the Dismantling of Nursing

Dana Beth Weinberg
Foreword by Suzanne Gordon
Copyright Date: 2003
Edition: 1
Published by: Cornell University Press,
Pages: 240
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  • Book Info
    Code Green
    Book Description:

    We are on the verge of the nation's worst nursing shortage in history. Dedicated nurses are leaving hospitals in droves, and there are not enough new recruits to the profession to meet demand. Even hospitals that were once very highly regarded for the quality of their nursing care, such as Boston's Beth Israel Deaconess Medical Center, now struggle to fill vacant positions. What happened?

    Dana Beth Weinberg argues that hospital restructuring in the 1990s is to blame. In their attempts to retain profit margins or even just to stay afloat, hospitals adopted a common set of practices to cut costs and increase revenues. Many strategies squeezed greater productivity out of nurses and other hospital workers. Nurses' workloads increased to the point that even the most skilled nurses questioned whether they could provide minimal, safe care to patients. As hospitals hemorrhaged money, it seemed that no one-not hospital administrators, not doctors-felt they could afford to listen to nurses.

    Through a careful look at the effects of the restructuring strategies chosen and implemented by Beth Israel Deaconess Medical Center, the author examines management's efforts to balance service and survival. By showing the effects of hospital restructuring on nurses' ability to plan, evaluate, and deliver excellent care, Weinberg provides a stinging indictment of standard industry practices that underestimate the contribution nurses make both to hospitals and to patient care.

    eISBN: 978-0-8014-6492-8
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Foreword
    (pp. ix-xiv)
    Suzanne Gordon

    For almost thirty years, the Beth Israel hospital in Boston served as an icon for the empowerment of nursing. With its chief nurse executive Joyce Clifford working in a unique partnership with CEO physician Mitchell Rabkin, the BI helped to pioneer an innovative model of nursing care called primary nursing, which assigned one nurse to one patient. That nurse was responsible for that one patient throughout a hospital stay and, when possible, during subsequent hospital stays. The hospital also employed an almost all registered nurse staff, hired only RNs with bachelor’s degrees, and was committed to enhancing the collaboration between...

  4. Acknowledgments
    (pp. xv-xviii)
  5. Introduction
    (pp. 1-18)

    In 1998 my then graduate studies adviser, Mary-Jo DelVecchio Good, was hospitalized at Beth Israel Deaconess Medical Center with a life-threatening condition. Soon after she was transferred from the intensive care unit, Good, always the social scientist, could not help but notice that her nurses seemed frustrated and harried. Driven by curiosity and concern even in her weakened state, she began to ask questions and to interview her nurses from her hospital bed. Over the course of her few-day stay at the hospital, she listened to her nurses’ stories about their work. Several lamented, “This isn’t what I went into...

  6. 1 A Troubled Hospital
    (pp. 19-42)

    In 1995, Mitchell Rabkin recognized that the hospital he had headed since 1966 now faced some serious problems. Quickly approaching retirement, this icon in the Massachusetts medical community needed to think about how to safeguard his hospital’s commitment to its patients and employees and still compete in an increasingly hostile, competitive medical marketplace. With Vice President of Nursing Joyce Clifford, Rabkin had transformed this Jewish community hospital into one of the bestknown medical research and teaching institutions in the world. Beth Israel Hospital, fondly known as “Harvard with a Heart,” stood out among the other Harvard teaching hospitals for its...

  7. 2 No Working Model for Nursing Practice
    (pp. 43-75)

    Before I officially began my research, one of BIDMC’s board members confided that even though Beth Israel and the Deaconess had officially merged and were supposedly the same hospital, he still would much rather be admitted to the Beth Israel part of the medical center. Why? Because of what he felt was a striking difference in the quality of nursing at the two institutions. The Deaconess nursing service could not hold a candle to the professional, personalized nursing care provided at Beth Israel, he said. During a board meeting, he related his preference to Joyce Clifford, the head of nursing...

  8. 3 Dismantling Nursing
    (pp. 76-97)

    In March 1999, Joyce Clifford announced she was leaving the position of Senior Vice President of Nursing and Nurse-in-Chief at BIDMC to become the Chief Nurse Executive at its parent company, CareGroup. She tried to put a positive spin on her decision. The move was a sort of promotion: Rather than guide nursing at one hospital, Clifford now had the opportunity to influence and build professional nursing practice at all of the hospitals in the CareGroup network.

    A number of observers had a different take. They saw Clifford’s move as a graceful, face-saving means of exit. They believed that Clifford...

  9. 4 Power Contests and Other Obstacles to Providing Patient Care
    (pp. 98-115)

    On a typical day in the Emergency Department in 1999, patients waited. And waited. And waited. When they first arrived, they waited to be examined by the triage nurse. Then they waited for an examination room. Then for emergency room doctors and nurses to examine them. After that, they waited for tests, lab results, consultations, and assessments from doctors from other departments.

    Once the ED staff stabilized an incoming patient, their ability to provide further treatment could be hampered by delays or problems with any one of these tasks. A backlog in radiology could mean an additional two-hour wait for...

  10. 5 Doctor-Nurse Relationships
    (pp. 116-136)

    Melissa Fortunado, a nurse whose first and only jobs as a nursing assistant and then as a nurse had been at Beth Israel Hospital, experienced great trepidation and sadness on the dreary Monday she and three other nurses closed the Beth Israel Cardiothoracic Unit, 8 Feldberg. Each caring for only one patient, the nurses rode in ambulances across Brookline Avenue to the Deaconess Cardiothoracic Unit, Farr 6, to complete the merger of the units from the two sides. “It was sad,” said Fortunado, “I cried when I left the floor.” As they were leaving, her patient’s wife took note of...

  11. 6 Not Enough Staff
    (pp. 137-159)

    During our focus group, the nurses on the General Medical Unit angrily recounted a recent conflict with management over staffing on the unit. As the evening shift progressed—from 3 P.M. to 11 P.M.—it became clear that the nurse supervisor planned to pull one of the three nurses scheduled for the night shift to work on another unit that was understaffed. With authorization from the nursing directors, the plan was to limit the number of patients on the General Medical Unit to twenty and run the unit with two nurses. This would create a minimum staffing ratio of one...

  12. 7 Was Quality Affected?
    (pp. 160-174)

    At BIDMC and across the country, nurses’ voices echo in a chorus of increasingly serious complaints about the quality of care in their institutions. Nurses are crying out at hospitals across the country as their workplaces transform in response to market pressures. The 1996 American Journal of Nursing patient care survey (Shindul-Rothschild, Berry, and Long-Middleton 1996) reported that of 7,355 nurses responding to their survey, only 43 percent thought that the quality of care they provided met their professional standards. Has hospital restructuring threatened the quality of care?

    A recurrent theme in this book has been the conflict between nurses...

  13. Conclusion
    (pp. 175-192)

    Across the country, health care professionals claim that sweeping changes in the health care industry compromise their ability to care for patients. They insist that an institutional emphasis on profit-maximizing behavior and productivity interferes with the relationships and activities that promote sound medical and nursing judgment and healing. Despite these indictments, restructuring and cost-containment efforts in the health care industry continue at a rapid pace. Professionals’ claims tend to be viewed with cynicism and dismissed as ploys to protect professional power, jurisdiction, and privilege. The conventional management wisdom is that the danger to patients is exaggerated and that, in general,...

  14. Appendix: Studying Change at BIDMC
    (pp. 193-198)
  15. References
    (pp. 199-206)
  16. Index
    (pp. 207-214)