November 16, 2011, 9:02 pm

A Message From “Rank and File, RN”

Looks like Mr. Administrator has some ‘splainin’ to do!

And I suggest he be straight with my colleagues, because a nurse can sense BS before it is even spoken.

I am not in management, and I never will be.

No, I am one of the “rank and file.” And right now, this member of the “rank and file” is hotter than hell.


What set me off?

A comment in a post on the Health Leaders Media website, entitled Top 5 Challenges Facing Nursing in 2012. The article, written for nursing management, refers to nurses as “rank and file caregivers” and disparages their understanding of the importance of the “patient experience” to reimbursement:

If you haven’t found a way to drive home the importance of patient experience to direct-care nurses, find it now. You know how much reimbursement is at stake, but the rank and file caregivers still don’t get it.

The author goes on to state:

In fact, the nurse-patient relationship has always been about patient experience…Your best nurses instinctively know this. They already create a good patient experience. They help patients understand their care, involve families in decision-making, coordinate multidisciplinary care, sit with patients to explain complex diagnoses, and even, occasionally, have time to offer a quick hug or hand to hold.

What? This is like punching someone in the face and then offering a compliment.

I have a revelation for you – we all know it. We understand what the requirements are for a “good” patient experience and it is what we have been doing as nurses since the dawn of time.

Since “the nurse-patient relationship has always been about patient experience,” why is this a “challenge” at all? This is nursing care, and always has been!

Why are administrations freaking out now that patients will be evaluating their nursing care?

Suddenly, all these new programs are flying into place. Educate! Communicate! Medicate! Smile!

What do you think we, oh, excuse me, the “rank and file caregivers” have been doing all this time?


Let me tell you what the “rank and file caregivers” have to deal with in terms of the “patient experience”.

There is a hospital in my area that has switched their meal service into something that looks, and tastes like the old airplane food from the 1970s. It comes in segmented cardboard trays and is microwaved.

As you can imagine, these meals are not popular with the patients. They give the meals poor scores on the satisfaction surveys.

At a recent meeting, the “rank and file caregivers” were lectured by the food service department that these low scores were the fault of the caregivers for not presenting the food in a pleasing manner, laying it out nicely on the table, and describing it with glowing adjectives.

That’s right, the same “rank and file caregivers” who are managing complex medical problems on multiple patients, coordinating multidisciplinary care, educating patients and family on medication side effects and complex diagnoses and documenting until their fingers are numb were lectured for their lack of culinary presentation skills.

Who is running the freaking show, Gordon Ramsay?

No wonder morale is in the toilet.


Well, I’m off to take my blood pressure meds, and maybe some Ativan.

All I can say is this “rank and file caregiver” is going to keep on doing what she has been doing for over 30 years. They can call it “patient experience” or HCAHPS, or give it any project title they want.

I call it good nursing care, and the patients will finally have a say in what that means.

Don’t worry, admins, if your bottom line depends on the nurses, it’s gonna be alright.

Rank and file, RN, signing off.


  • The Nerdy Nurse
    The Nerdy Nurse

    November 16, 2011 at 9:33 pm

    That is insulting.

    Although, you and I both know there are a few nurses who are “rank and file” and those few bad apples sure do a number on the rest of the bunch.

    The focus should always been on patient care and reimbursement based upon positive experiences is a step in ensuring a better experience with greater consistency. It’s unfortunate that the allure of money is what is going to put the focus on customer service and improved patient care. Really we should be doing this because it’s just the right thing to do.

    This was a great read.:)

  • Sean

    November 17, 2011 at 6:09 am

    Sadly frustrating that this is slowly becoming commonplace.
    My theory is because of this:
    press ganey (pt satisfaction scores) = CMS reimbursement

  • WarmSocks

    November 17, 2011 at 6:49 am

    It sounds like you’re a good nurse. Not all are, unfortunately. What about those nurses who step into the patient’s room an hour after shift change to write their name on the patient’s dry erase board, then disappear? The next time a nurse is seen is an hour or two after the next shift change.

    If you go in and meet your patients, and then take care of them, that’s terrific. I had five days of nurses (with the exception of two people) who missed that part of their training. The type of article you cite is directed at those nurses.

  • Shawn Kennedy
    Shawn Kennedy

    November 17, 2011 at 9:40 am

    I have no doubt patient satisfaction would best be served by better staffing. On our facebook page (, I had asked, “What is the most pressing issue facing nursing today?” The overwhelming answer was inadequate staffing. In one RNs words, “Would love to be able to give great individual care — to know what’s like not to rush and feel totally exhausted at the end of my shift.”

  • Michele Roberts
    Michele Roberts

    November 17, 2011 at 1:16 pm

    Kim, I always relate to what you write, because it is EXACTLY what I would write if I was as eloquent as you are and able to speak beyond my anger!
    I never understand what it is that “administrators” think we, the “rank and file”, are doing when we go to work.
    Whie I can only speak to the ER environment, and I know I don’t have to tell you of all people –

    The shifts when it has been slow enough for me to be able to spend the time with my patients that I ALWAYS WANT TO SPEND WITH THEM have probably been the most rewarding shifts of my life. And guess what? Those very same shifts have probably resulted in the most satisfying “patient experiences” for those I took care of as well.

    So why is it that these yahoo hospital administators don’t get it? If you expect me to take care of too many people at one time, without ancillary support to delegate supportive care to (because it wasn’t in the budget)and expect me to take care of patients with higher and higher acuities with limited resources (because new and/or sufficient equipment wasn’t in the budget), how is it that you expect to improve your (financial) bottom line?
    Do they not teach students about positive correlation in MBA/MHA programs??

  • Nurse K
    Nurse K

    November 17, 2011 at 2:04 pm

    “Rank and file” members of an organization (eg. nurses at a hospital) simply means the nurses who are not management. In the military, it’s the soldiers who are not officers, etc.

    Why are we getting bent out of shape? I’m confused. You said you didn’t want to be management and never will be. You are, by definition, rank and file. Vocab fail.

  • RehabRN

    November 17, 2011 at 5:32 pm

    I love these quotes:

    “In fact, the nurse-patient relationship has always been about patient experience. ”

    The best article though is this one:

    Patients will have a better experience if their nurse feels like management really gives a c*(p that they show up and do a good job, as well as SUPPORTING them with the things they need to do that (like housekeeping, good management,etc.)

    We just gotta get out of the overhead category. When nursing becomes a profit center, they will think differently. People who heal well and faster because they get time with their nurses are just not recognized in the system we work in today.

  • Terri Polick
    Terri Polick

    November 18, 2011 at 6:11 am

    Sadly, this is typical. Administrators commonly take a systems problem and make it into a people problem. Usually the people are nurses. I love the example of the cardboard hospital food. I can hear it in the boardroom now. “The food sucks, but lets blame the nurses for their poor presentation of this crap.” And, as nurses, we accept the role of scapegoat, and create task group to look into the problem. I have an idea of what Gordon Ramsay would have to say about all of this.

  • Shane

    November 18, 2011 at 6:16 am

    I have to disagree with you on this one. As a patient, not a healthcare worker, the state of nursing care is abysmal even in the best facilities. A great nurse makes an astonishing difference — as I related to you when we first started working together so many years ago — but great nurses are few and far between. Most are unhappy, unhelpful, and have absolutely no clue about (or at least concern for) “patient experience.”

    I wouldn’t be surprised at all if this was primarily related to morale, but it’s a reality nonetheless — great nurses like you excepted 🙂

  • Melissa

    November 19, 2011 at 9:53 am

    I love being able to provide excellent care to patients and happen to be a very customer service driven nurse,but the system we work in doesn’t support nurses. It can be very difficult to deliver that above average care when you are floated from another unit, yelled at by the doctor who everyone avoids like the plague, and the patient to nurse ratio happens to be dangerous! As soon as management wakes up to the fact that they need to take care of their nurses, happier patients will happen! Most upper management “just don’t get it.”

  • Adan Harris
    Adan Harris

    November 21, 2011 at 10:57 pm

    Nurses can increase patient experience provided the management is aware of nurse’s experience. I strongly agree with what Melissa has stated. Upper management need to care about nurses, they are the cornerstone to that patient experience, we regard optimum. Imagine hospitals without nurses, what utter disaster and mismanagement it could bring.

  • […] is on her soapbox about giving appreciation where it’s due: the oft-browbeaten “rank and file RNs” who’ve been busting their butts to give good nursing care for decades. We are thankful […]

  • Carolyn Thomas
    Carolyn Thomas

    November 25, 2011 at 6:37 am

    Dear Rank & File Kim
    I’m not a nurse, but I worked with nurses for 10 years at our local hospice palliative care unit. After carefully observing my nurse-coworkers year after year, I learned to unequivocably say: “I don’t care how much we’re paying these people – it’s not enough!” Yes, of course there are the burnouts that should have retired years earlier, and understaffing can wreak havoc on even the most saintly nurse’s demeanour, but the truth seems to be that nurses bear the brunt of all complaints from both patients and their worried family members. Bad hospital food included.

    Thanks for this,

  • Dr Dean
    Dr Dean

    November 25, 2011 at 3:43 pm

    Kim,I agree with the points you made. And the way this was presented was very poor. The management pyramid is upside down with too much management.

    But patient care is not universally excellent. Staffing is part of the problem, burnout is part of the problem, and lack of training on patient relations is part of the problem.

    The good thing is that these surveys will allow an opportunity for management to understand the importance of supporting “rank and file” better.

    The transition may be tough for all of us!

  • Orfyn RN
    Orfyn RN

    November 28, 2011 at 8:16 pm

    We went through an inservice from one of the corporate clones from our multihospital system HQ telling the OR staff about how important it was to be compassionate. Her lack of sincerity was so apparent, people were struggling to hold back laughter. This from a Barbie Doll dressed to the nines, who after the inservice was over was heard yelling into her cell phone to some poor minion about getting her BMW washed and waxed.

  • John

    December 10, 2011 at 7:37 am

    What is so worrying is that these attitudes also run into the NHS here in the UK. As someone with extensive experience of working with surgical ward nurses, it is obvious that in effective high performance wards, all members of the team work together. The surgeons rely on the experience of the nurses to identify post operative problems. Administrators are just a different breed. They are outside this relationship.

  • Andi

    December 15, 2011 at 1:47 am

    If I could see you in person I would hug you. I am so thankful for those that actually speak up about these issues. Every time I am involved with any type of leadership/management thing (currently my hospital is trying to attain magnet status..bleh) I am always so amazed at how detached they are from reality. It’s all about the bottom line (or dollar for that matter). The reality of nursing and patient needs are rarely understood nor are they met and I think if any lay person had to step in the shoes of a nurse for a day they would be amazed at what we endure for our patients!

  • Grace @ Sterilization Services
    Grace @ Sterilization Services

    December 15, 2011 at 7:47 am

    Great post! I would feel so frustrated if I worked long, exhausting shifts, was constantly cast as the scapegoat for administrative screw ups, and then to top it off was accused of lacking empathy. How infuriating!


  • Mika

    December 23, 2011 at 7:44 am

    It is frustrating that now that ratings in regards to care, quality, and performance have suddenly made some administrators more aware. I think it all depends on the facility you are working in, and the leadership. I feel as though from a leadership perspective when you work in a positive environment (or as managers create it) you have fewer issues (there are bad apples in ANY environment). From the trenches (he he he I get to say that now that I am a veteran and a nurse) I still think it is dependant upon good leaders and good nurses. However, the individuals that have not been at the bedside in years and do not understand the issues at hand with over-patienting (i.e. understaffing) and not using quality products to optimize care (what good is an EMR if it us un used or not upgraded to allow for concise use?). I wonder if my view will change even more when I move into the NP world. I hope not.

  • Southern Yankee, RN
    Southern Yankee, RN

    January 3, 2012 at 11:11 am

    I am a new blogger, and relatively new nurse, but I have seen my share of nurses who “need” instruction like that, both in nursing school and at my first floor job. Now I’m in ICU, and the nurses there are of much higher quality, and as you said, Kim, have been giving good nursing care since the dawn of time. But even on our floor we are seeing results from the new laws-such as reimbursement according to “customer” satisfaction. They just instituted hourly rounding on ICU patients! As if we’re not in the room enough already! But that’s just to make the pencil-pushers who don’t understand nursing happy.

  • Pattie, RN
    Pattie, RN

    January 10, 2012 at 6:48 am

    Kim, you are spot on about this! Yes, there are indifferent or poor nurses, just as there are burnouts and idiots in ANY profession.

    However, when you are considered to be in the same category as the electric bill and housekeeping, instead of a trained professional, it is hard to keep your balance and cheer…especially when being lectured by a “Clipboard Nurse” with a fake tan, fake boobs, and a REALLY fake smile of concern.

    Then, of course, there is the “danger” of having patients with personality disorders and/or a sense of total entitlement who are all too eager to crap all over nurses for not providing Dilaudid, a blanket, a “sammich”, diapers for the visiting toddler, and a bed and meals for their significant other FAST enough. AND….so many of these are having their stay paid for by~~~US!

  • SmalltownRN

    January 12, 2012 at 2:56 pm

    Well I am not familiar with the reimbursement aspect when it comes to patient care. We do patient survey’s now called “client” as a result of influences south of the boarder. Patient care has always been the focus. That’s what was drilled into us in nursing school, empathy, compassion, listening, and the list goes on. I’ve never stopped. Some days to my detriment. I have stayed late to accommodate a patients need or the family member of the patient as I know that would decrease their stress level and hence provide a better health outcome.

    My take is administrators are always looking at ways to justify their existence. Nursing will never change we are the foundation for healthcare.

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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