Code Green: Money-Driven Hospitals and the Dismantling of Nursing: Resources for Health Care Professionals


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

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Dana Beth Weinberg

This ground-breaking title looks at the affects of hospital restructuring on the quality and morale of nurses from a merger of two excellent care facilities in the 1990's. Weinberg takes the reader on a journey through this case as an example of what profit motivated practices in hospitals means to the nursing profession and patient care. Code Green serves as an excellent study of what strong health care organizations look like in terms of communication and alignment of leaders and staff, a clearly defined professional nursing care delivery model and judicious attention to resource management.

Softcover, 213 pages. (2003)

Book Review

Code Green: The Dismantling of Nursing by Beth Weinstein, forward by Suzanne Gordon Reviewed by Marie Manthey

Code Green: The Dismantling of Nursing, which chronicles the merger of Boston Beth Israel and The New England Deaconess, is a clear and accurate depiction the incredible challenges involved in trying to merge two organizations with deeply rooted cultures as well as of how hospital staff nursing has changed in the last few years. I personally felt the pain described in the efforts to merge these two fine hospitals. I experienced many of the same issues when I was Vice President of Nursing at United Hospital of St. Paul, and again, when I was Vice President of Patient Services at Yale-New Haven. The United Hospital merger was brand new while the Yale New-Haven merger was over 20 years old, yet many of the same issues existed in both situations, causing the same kind of stress and pain Weinstein describes. Today, CHCM is often on the front lines of helping organizations define and establish a new culture that captures the best cultures of its member institutions. It is never easy, but it doesn't need to be as brutal as the experience described in Code Green.

The author is also very clear on the impact of each hospital’s history, the administrators’ philosophy, and, not least by any means, the type of patients and medical practices had on the merger. She examines many aspects of practice that may seem small at first glance, but that become huge when studied deeply or when efforts are made to standardize them, for example: the way nurses notes were handled in both institutions. In addition, she outlines the subsequent care delivery systems of these institutions: Beth Israel's version of Primary Nursing and New England Deaconesses version of Patient Care Management within a framework of Differentiated Practice. So much of the care delivery system at the Deaconess reflects the fact that it was primarily a surgical hospital, where technical skills are of paramount importance, and where care can reasonable be expected to follow a predictable pattern. Clinical pathways are very useful in this type of care, and differentiated practice can be organized quite effectively.

What I found incredibly sad and frustrating was the childish and destructive behavior of physicians toward the merger. In some ways, their reluctance to change, even in the face of ‘best practice' evidence, brings questions to bear on their ability to fulfill the traditional leadership functions physicians have assumed authority for in the past.

Even more distressing, however is the “dismantling of nursing”. Again, kudos to the author for her deep understanding and clarity of expression as she documents the process we saw happening again and again and again throughout the 1990's. Strong leaders were demoted, clinical educator and clinician positions were eliminated, experienced staff was overloaded with work to the point of extreme stress and inexperienced nurses were placed in positions of too much responsibility. As a result, patient care was compromised, patient safety was jeopardized and no one listened to the staff nurses' lament. Not even the nursing administrative staff! In the rush take power from the nursing department, no one paid attention to the impact on patient care. Nursing’s failure is the inability to use measurement tools to describe the impact inadequate nursing has on the quality of patient care and safety.

A study of the book illuminates those factors that characterize a strong organization: shared vision; focus on patients; good communication; a strong nurse executive; a clearly defined professional nursing care delivery model; interdisciplinary plans of care; attention to resource management and meaningful outcomes measures.

As I read Suzanne Gordon’s' forward again and again, I find myself challenged to think through exactly what type of collective strength nursing needs to have, what kind of patient care regulations make sense, and most of all, how do we protect the public from “'the dangers of a market-driven health care system that puts profits over patient care.” I believe the covenant between society and the nursing profession requires bold action and I sincerely hope this book opens the door for dialog, decision and action amongst all the stakeholders in the health care system.....and especially between nurses and patients.

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