In the 1990's, as Weinberg explains, many U.S. hospitals became increasingly desperate to make ends meet. Rising health care costs had been a major problem for many years. Reimbursement rates began to drop as private insurance entities gained power to bargain in the managed care era, and dropped sharply in the wake of the Balanced Budget Act of 1997, which restricted Medicare reimbursement. As a result, the hospital industry increasingly turned to prevailing private sector business practices to cut costs, including consolidation, internal restructuring, and lean staffing. This often meant that fewer nurses struggled to care for more patients. Many tasks previously done by registered nurses simply did not get done, or were performed by assistive personnel with far less training, even though hospital patients were now sicker and rushed in and out of facilities because of these same reimbursement pressures. Weinberg aptly describes this situation as a "code green," a reference not only to the increasingly "money-driven" nature of care, but also to a term used at some hospitals for an urgent facility failure.
However nurses with these differing perspectives might have integrated in an ideal merger, what Weinberg found in her focus groups, interviews, and other data shows that the BIDMC merger was not ideal. The restructuring and the new "flex staffing" policy effectively increased the patient loads of individual nurses, and made them responsible for more tasks in the hospital as support positions and resources were cut back. At the same time, the formerly powerful Beth Israel Nursing Department was splintered, greatly reducing the profession's institutional status. Increasingly frantic bedside nurses became alienated from nursing administrators, who reacted defensively to concerns for patient safety, which they characterized as a self-serving resistance to change. Weinberg also shows how nursing practice was disrupted by particular problems flowing from the restructuring in specific units, such as coordination problems in the new combined Emergency Department, and turf battles between surgeons from the two original hospitals in the new cardiothoracic unit that led to a decline in nurse-physician collaboration.
Weinberg's analysis of the efforts to strengthen nursing was apparently so scary to hospitals, that the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) on the nursing shortage because of hospital complaints about her "perceived bias."
This is not to say that Weinberg does not appreciate what nurses do, including their effects on patient outcomes. Indeed, perhaps the most eloquent statement of Code Green's support for nursing in its embattled state is in the dedication. After her parents, Weinberg dedicates her fine book to "the nurses, for the care they want to give."
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The First World War brought about great changes in the nursing Design aspects and distinction took a back seat, and functionality became the most important feature in a nurse’s uniform. Nurses had to be fast and provide quick care for the many casualties they had to tend during the war. Sleeves were rolled up for easier movement, bulky aprons were taken off and shirts shortened for convenience. After the first world war that nurses realized they needed a uniform that combined functionality with femininity. The resultant look is the precedent of the white nurse’s uniform that we know as the standard nursing image now.
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Weinberg does an excellent job of describing the effects of the nurse short-staffing at ground level. Her account is dispassionate but at times heartbreaking, as nurses desperately tried to provide basic survival care, often at the expense of the patients' long-term interests and psycho-social needs, not to mention the nurses' own mental and physical wellbeing. The nurses felt powerless to fight the changes in any meaningful way, instead turning inwards, sacrificing and blaming themselves for the poor care many felt they were providing. The book certainly presents the hospital administrators' contrary views, but Weinberg effectively suggests that the quality of patient care was affected, relying on anecdotes, survey data, and broader research by Penn nursing scholar Linda Aiken and others as to the role of nursing status and resources in patient outcomes. Weinberg notes the increase in complaints to the BIDMC central nursing office. She might also have noted that because much key nursing care takes place in nurses' heads and is not well understood by non-nurses, its absence might not be easily recognized by patients and families, to say nothing of administrators and their financial consultants.