1 HCA 448 Case 2 for 10/04/2018 Recently, a patient was transferred to a cardiac intensive care unit (CICU) at Methodist Hospital. Methodist is a 250-bed hospital, which is one of five hospitals in the University Health System. The patient was a retired 72-year-old man, who recently (i.e., 25 days ago) had a mild heart attack and was treated and released from a sister hospital, which is in the same system as Methodist Hospital. An otherwise health individual, Mr. Charlie Johnson (a husband, father of 4, and grandfather of 12) is in now need or lots of medication and a battery of tests. To the nurses on shift, it appears that the entire Johnson family is in patient’s room watching the clinical staff treated Mr. Johnson. The family overhears everything and they want to know what is being done to (and for) their loved one. In addition, they want to know the meaning behind the various beeps coming from the many machines attached to Mr. Johnson. Over the past 10 years, the latest U.S. News and World report has ranked Methodist Hospital as one of the Best Hospitals for Cardiology & Heart Surgery. However, it is important to note that over the past few years, the unit has dropped in the rankings. Katherine Ross RN, the patient care director of the CICU, which has 14 beds, has held this post for two years. (See Figure) The unit has a $20 million budget. Ms. Ross has worked at Methodist Hospital for 16 years. She spends 50 percent of her time on patient safety, 25 percent on staffing and recruitment, and 20 percent with nurses in relation to their satisfaction with the work and with families relative to their satisfaction with care. Ten percent of Ms. Ross’s time is spent on administrative duties. According to Ms. Ross, “I like is working with exceptional nurses who are very smart and do what it takes with limited resources. However, we don’t always feel empowered, despite the existence of shared governance, a structure I help to coordinate.” 2 Relationship with Nurses on the Unit: Nurses on the unit work a three day a week, 12 hours a shift. Ms. Ross says, “we did an employee opinion survey that went to all employees on the unit, 50 people in all, but only 13 responded. Some of them weren’t sure who their supervisor was. The employees aren’t happy but our patients are happy.” She adds that “my name is on the unit, not the medical director’s. If anything goes wrong with the unit, they blame it on nursing. Yet I’m brushed off by people whom I have to deal with outside of the unit. For example, we have a problem with machines that analyze blood gases. I spoke with the people there about the technology. This was four weeks ago. It’s a patient safety issue. I sent them e-mails. I need the work to get done, the staff don’t feel empowered if I’m not empowered. This goes for other departments as well. For example, respiratory therapy starts using a new ventilator witho.

1. 1
HCA 448 Case 2 for 10/04/2018
Recently, a patient was transferred to a cardiac intensive care
unit (CICU) at Methodist Hospital.
Methodist is a 250-bed hospital, which is one of five hospitals
in the University Health System.
The patient was a retired 72-year-old man, who recently (i.e.,
25 days ago) had a mild heart
attack and was treated and released from a sister hospital, which
is in the same system as
Methodist Hospital. An otherwise health individual, Mr. Charlie
Johnson (a husband, father of 4,
and grandfather of 12) is in now need or lots of medication and
a battery of tests. To the nurses
on shift, it appears that the entire Johnson family is in patient’s
room watching the clinical staff
treated Mr. Johnson. The family overhears everything and they
want to know what is being done
to (and for) their loved one. In addition, they want to know the

2. meaning behind the various beeps
coming from the many machines attached to Mr. Johnson.
Over the past 10 years, the latest U.S. News and World report
has ranked Methodist Hospital as
one of the Best Hospitals for Cardiology & Heart Surgery.
However, it is important to note that
over the past few years, the unit has dropped in the rankings.
Katherine Ross RN, the patient care director of the CICU, which
has 14 beds, has held this post
for two years. (See Figure) The unit has a $20 million budget.
Ms. Ross has worked at Methodist
Hospital for 16 years. She spends 50 percent of her time on
patient safety, 25 percent on staffing
and recruitment, and 20 percent with nurses in relation to their
satisfaction with the work and
with families relative to their satisfaction with care. Ten percent
of Ms. Ross’s time is spent on
administrative duties. According to Ms. Ross, “I like is working
with exceptional nurses who are
very smart and do what it takes with limited resources.
However, we don’t always feel
empowered, despite the existence of shared governance, a

3. structure I help to coordinate.”
2
Relationship with Nurses on the Unit:
Nurses on the unit work a three day a week, 12 hours a shift.
Ms. Ross says, “we did an
employee opinion survey that went to all employees on the unit,
50 people in all, but only 13
responded. Some of them weren’t sure who their supervisor
was. The employees aren’t happy
but our patients are happy.” She adds that “my name is on the
unit, not the medical director’s. If
anything goes wrong with the unit, they blame it on nursing.
Yet I’m brushed off by people
whom I have to deal with outside of the unit. For example, we
have a problem with machines
that analyze blood gases. I spoke with the people there about

4. the technology. This was four
weeks ago. It’s a patient safety issue. I sent them e-mails. I
need the work to get done, the staff
don’t feel empowered if I’m not empowered. This goes for other
departments as well. For
example, respiratory therapy starts using a new ventilator
without informing us. We have never
seen this machine nor have we been trained on it. They don’t
phone or e-mail. So I make the
decision that we’re not going to use the machine. With
surgeons, when I tell them to wash their
hands, they roll their eyes. It takes tremendous energy to deal
with this.”
Megan Smith, RN, age 25, is a clinical nurse in the CICU where
she has worked for six months;
she has been at the hospital for nine months. Ms. Smith spends
40 percent of her time dealing
with patients (turning, suctioning, and changing dressings); 30
percent talking with physicians
(negotiating plans of care and medication plans); 20 percent on
medication administration and
conversations with the pharmacy; and 10 percent on
miscellaneous activities. She has worked on

5. the day shift for only three weeks now but was also on days for
three months during orientation.
Ms. Smith says she is challenged to get the core services she
needs. If she has to give a 2:00 PM
medication, she would like the medication by 1:00 PM but she
gets it by 4:00 PM, even if she
3
calls. Ms. Smith stated that she finds it difficult to discuss
complex difficult cardiovascular terms
and process to patients’ families. She states that it is very hard
to explain what happened and
what is going to happen. Ms. Smith stated that when she needs
additional medical expertise, it is
hard to find the cardiac surgery consultant when she needs them
and doesn’t have their pager
number. Ms. Smith’s main satisfaction comes from working
with her patients.
Ms. Smith comments that Ms. Ross is “good about getting stuff
if you ask her. She deals with a
lot. Ms. Ross goes around and talks with families, provides
continuity, helps out when we’re

6. short. Lately she’s not been so stressed out and is more
accessible. When we were short, Ms.
Ross and the unit secretary admits patients, helps with codes,
and patient deaths. Ms. Ross gets
respect from the nurses, but she doesn’t trust us enough. For
example she asks us why we were
sick and to bring a doctor’s note. Ms. Ross is spread thin. There
is no assistant director, so the
unit secretary helps her. Ross took the job having had no
management experience.
Relationships with Families:
Ms. Ross says, “I’m clear with them in orienting families to the
unit, to how we do our job. We
treat families with respect. Families watch me, and mentoring of
nurses is important. Ms. Smith
agrees that the unit generally does a good job supporting
families. She says, “families are kind
and happy. There is a problem with turnover of doctors and
residents, who aren’t here two days
in a row. The plan of care can get lost with the attending
physicians, when they change every

7. week. Families get stressed out and are often far from home. I
listen to them and ask, ‘do you
have any questions? ‘What do you want to see done?’ and ‘do
you have any questions for the
doctors?’ I ask them if they want to participate in rounds.
Sometimes we just listen. When
families can’t come in they can call me every two hours as we
have an in-house phone that
accepts outside calls.
A survey of families in a California hospital about their
experiences and their suggestions for
improving the quality of end-of-life care found that:
• Parents want to be involved in the decision-making process
• Isolated incidents are extremely painful (e.g., poor
communication, feeling dismissed)
• Delivery of difficult news is an issue – families found it
important that a familiar person
deliver this news (one caregiver in charge)
• A language barrier is an issue – families felt isolated and
under-informed
• Bereavement follow-up is helpful and appreciated
• Pain management is an issue – families describe anguish

8. witnessing their loved one in
pain.
• Families’ interactions with staff are as important as medical
aspects of treatment
Ms. Ross and Ms. Smith feel that families are a very important
part of what they do, that the unit
has special structures and processes to involve families, and
that what they are doing is generally
working. But they lack concrete ways of measuring unit
performance in this regard.
4
Relationship with Social Work:
Ms. Ross says, “There is a social worker who deals with
complex heart cases. However, the
service is fragmented and I have difficulty getting her to come
to the unit. I will go to her
director or my director if I have to. I understand she has other
responsibilities, but she need to
come to rounds, to deal with issues around getting nurses for

9. home care. Of course, social
workers can’t wave a magic wand.”
Maria Montez, the unit social worker, has worked in the CICU
for ten years. She spends 75
percent of her time on the floors with families. She works from
9:30 a.m. to 5:30 p.m. five days a
week. There is limited social work coverage at other hours. The
kinds of issues Ms. Montez
deals with are: requests for a visiting nurse; medications and
associated education; ordering
oxygen; ordering a special intervention team at home if there is
a need to assess; and physical,
occupational, and speech therapy. If a patient is dying, she
discusses with nursing what they can
do together when crises arises.
Ms. Montez says she has a good relationship with Ms. Ross, and
that she orients with new nurses
to social work. Ms. Montez respects the work that nurses do.
”We’re invited to each other’s
rounds. The work is so intense, there are so many patients.
We’ve reached a level understanding;

10. if there’s a problem it’s not personal, it’s what we’re all going
through.
We discuss each of the 37 patients in the three CICUs once a
week at an interdisciplinary
conference. Montez concludes that if I could advise the hospital
administrator, I would tell him
or her to take care of your nurses.”
Last month, Katherine, Megan, and Maria had lunch in the
cafeteria. They discussed what
“taking care of your nurses” really means from a hospital point
of view. A summary of
highlights of their discussion follows:
Ms. Ross: I don’t know, why should taking care of nurses be
any different from taking care of
any of the clinicians who are working under stress in the
hospital? Oh, I’m sure the
hospital administrators would say we pay the nurses enough. I
think the hospital should
do more to reward the patient care directors. None of us got into
this business to do
management, and they aren’t really giving the tools to do what
needs to get done for our

11. patients.
Ms. Montez: Staff is doing all we can for the patients and
families, and we’re providing good
care. I think things are fine as they if we could be sure that we
won’t be short staffed, and
if other departments would respond better to our requests to
help our patients.
Ms. Smith: But Maria, don’t you agree that sometimes nurses
get stressed out and that this isn’t
good for those nurses, the other nurses, the patients, the
families, or the hospital? How do
5
you determine what’s “stressed out”? Well, it automatically
flows form the number of
patients, the complexity of the treatments, and the numbers of
the staff and support staff.
Families can tell you when the nurses are no longer providing
the services at the level or

12. quality they were providing before.
Ms. Ross: I wonder what more I can do as a manager to deal
with this problem. I think our
regular nursing staff has a pretty good deal here, if you want to
work with these patients.
And we’re provided generally with the support to take good care
of these patients and
families. Nurses work three days on and four days off. Four
days off is a lot of time to
recover from stress, I believe that after a number of months
working in the unit, our
nurses should work with patients who are less acutely ill. But
I’m not sure everybody
wants to do that.
Recently, the vice president of patient care services has been
talking about the importance of
continuity of care and is investigating the concept of patient
navigation. However, Ms. Ross, Ms.
Montez and the rest of the cardiology unit are not sure of the
need for this position.