The Impact of the Environmenr,
Henrietta is a 72-year-old woman who has been in the coronary care unit for 4 weeks following a large anterolateral myocardial infarction (MI). She has suffered from heart failure, pulmonary edema, and hypotension, and now has developed acute respiratory distress syndrome (ARDS) and renal failure. Currently, she requires maximal ventilator support, CRRT, and inotropic agents because of her low cardiac output. Her husband and her son visit often and seem to be supportive, but also cm:rwhclmed by this sudden change in her health.
After 2 weeks without improvement and with episodes of worsening hemodynamic instability, the nurses are concerned that their care is prolonging Henrietta's inevitable death. Furthermore, during intervals when her sedation is weaned, the patient grimaces and reaches to remove tubes which the nurses interpret as an effort to communicate her discomfort with the current treatment modalities. Rhonda, the patient's primary nurse on dayshift, asks the physician, Dr. Smith, if a family conference should be planned. Dr. Smith responds that he has spoken to the family several times and •Tuey just don't seem to get it. I think it's a waste of time to schedule another meeting. We'll just keep going until she codes, I guess." Rhonda is uncomfortable with this plan. Here are two possible outcomes of this situation that differ based on the work environment:
Healthy work environment
Rhonda uses skilled communication to engage the physician in further conversation. Using a professional tone, she states "I understand that you fed that a family meeting is a bad use of time but I am concerned that we are not caring for our patient appropriatdy. Is this a good time for me to share my thoughts with you?" By restating what the physician has said, she demonstrates an understanding of his perspective. By referring to "we" and "our," she conveys her desire to collaborate in the management of this patient. Because Rhonda's communication is professional and clear, Dr. Smith agrees to talk further. "What are your thoughts?" he asks.
Rhonda recalls a workshop on palliative care communication skills that she attended, as part of the hospital's meaningful recognition program. She suggests "Maybe instead of trying to explain to them how sick she is, we should ask them what they think she feels about all this. I think we need to better understand what the patient would want." After a 5-minutc conversation, Dr. Smith and Rhonda agree to plan a family conference for the following day.
When the time for the conference arrives, Rhonda asks her charge nurse to cover for her, so they can meet in the conference room. The charge nurse, Susan, replies that she cannot cover the patient on CRRT, as she is already covering for a nurse who has to t2ke a patient to radiology. Recognizing that the meeting is important to Rhonda and her patient, Susan suggests that the doctor and Rhonda speak to the family in the patient's room. Rhonda agrees, and the charge nurse asks a nursing assistant to move extra chairs into the room so that Rhonda, the physician, and both family members can all sit.
Per the decision that Dr. Smith and Rhonda reached on the prior day, Rhonda starts the meeting with an open-ended question. She asks "Can you tell us a little more about Henrietta? We know about this illness but in order to make the right choices about her care we need to know more about her as a person." In prior interactions, neither man said more than a few words but with this invitation to ta1k about their wife and mother, they begin to speak with great affection. "You know, we've been married almost 50 years, and I've never seen her sit still for more than a few minutes. She is always on the go. You all must be giving her a lot of medicine to make her lie there so still. "The physician sees an opening to provide information about Henrietta's disease and states "The medicine does keep her calm, but she is also very sick." "Will she get better soon?" the son asks. And Rhonda, recalling another palliative care communication skill from her past training, replies "We hope she will get better, but we are worried that she will never be as healthy as she was before the heart attack. "The husband, tears in his eyes, asks, "So you're saying that all this." He gestures to the equipment in the room "may not be enough to get her back to who she was?" Rhonda instinctively takes his hand and nods "That is exactly what we are saying. And we need your help to understand what Henrietta would say about that."
Unhealthy work environment
Rhonda, having experienced moral distress when patients who dearly had a poor prognosis underwent CPR feels a surge of anxiety when the doctor suggests this will happen to Henrietta. Because other interactions between nurses and doctors in this unit have been characterized by incivility and mutual disrespect, she avoids further conversation with Dr. Smith. She continues to feel troubled by the care she is providing, however, and so decides that she will broach the issue with the family herself the following day. She wishes that she had been able to attend a conference on talking to patients about endof-life care, but her request was denied. The nurse manager is dealing with the unit's short staffing by limiting the number of schedule requests that staff can make.
The next day, Rhonda is in the patient's room when the spouse and son arrive and ask her for an update. She wants to answer honestly and begin a discussion that will allow her to help her patient but she is unsure how to do so. She explains the ventilator settings, the fluid balance, and the rate of the inotropic drip. The family nod but it is unclear how much of this information they take in. At that moment, Dr. Smith arrives and asks the family to wait in the waiting room while he examines the patient. Still troubled, Rhonda seeks the advice of the charge nurse but finds her totally overwhelmed and in need of support hcrsclf"We have a road trip today and a call out on the next shift and it's such pain that I'm in charge!" Just then the unit manager approaches to ask Rhonda why the family members arc in the waiting room. "You know, we've already been written up fur not adhering to the open visitation policy. You have to let the family stay in the room when they visit!• she tells Rhonda. Rhonda returns to Hcnrictta's room and completes her shift, mechanically providing the necessary nursing care.
Which of the healthy work environment atandarda were evident in the film: venion of the cue?
Which of the healthy work environment atandards were notably ab1ent in the second version of the case?