Overhaul of health care system needed to address nursing understaffing?

  1. It seems as though the nursing profession, esp hospital nursing, has reached some dire straits in the past 15 years - getting worse, in particular, over this past decade. Would you agree?

    The patient load is simply too high. Insanely so, and yet now these ratios are hard-stamped into the system due, in large part, to the way managed care reimburses hospitals. And, of course, the way managed care reimburses hospitals is rooted in a complex array of factors - more patients, more older patients, more obese patients, ever-changing medical technology, just plain more demands placed on the health care system.

    As I read through these posts, I'm simply amazed at the case loads being described - and so consistently! Such case loads are just not rational, and yet there they are, with hospitals treating them as though they're normal.

    It looks as though the only thing that can solve the nursing staffing problem is an overhaul of the health care system that embraces some tough realities. Such a (theoretical) overhaul, I think, would mandate absolutely no more than 4 patients per, say, a med/surg unit RN (with an aim of 3:1), with no corresponding sacrifice of ancillary staff. And because this would take an overhaul of the system to realize this, and would address a problem that affects the public health mightily, I really think the feds need to do it.

    It may mean hospitals, to find the money to do this, will have to close beds, will have to stop accepting so many patients - perhaps triage will have to intensify - and perhaps the feds will have to set aside money to fund hospitals to keep them afloat. And that will mean other fed-funded programs will have to get cut.

    And hospital admin people (MSHA's, etc.) AND staff nurses will have to put their heads together to figure out how to overhaul the system. Staff nurses simply must be part of the health care reform process. THEY know the realities. The "suits" don't.

    If this goal is achieved, maybe there wouldn't be such a "nursing shortage". Maybe all those thousands of current nurses out there would return to the hospital. It looks as though we certainly have enough nurses "out there", not to mention the ones being churned out of the schools yearly. But there are so few who want to STAY at the bedside, in such working conditions - we can keep churning and churning, and importing and importing, but this will serve as only a stop-gap measure.

    But... maybe that is what the "system" has settled for - constant stop-gap instead of real retention.

    Anyway, I've just seen so many posts about nursing burnout and insane case loads, and observations about how "nursing is just not the same anymore" (I believe it!), that I don't think any amount of stress management skills or even changing one facility at a time (unless we can follow the example of a "model facility") will do anything to improve the worsening nursing situation.

    If any silver lining comes out of the current systemic understaffing of hospitals, maybe it will be an increased emphasis on preventive health - i.e., the government tacitly warning us to try our best NOT to become an inpatient!

    Anyway, just my $0.02. I think I'm basically writing this out of fear - fear of what I will encounter when I graduate from nursing school. I hear about "reality shock"; but I think it's much more than that - I think it's a shock that we need to listen to - a shock at a system gone awry.

    Because they say only a newcomer to a country can really see the essence of that locale - during those first few days or weeks he/she is dwelling in that locale - before becoming acclimated. Then, once acclimation sets in, surroundings take on an appearance of normalcy, and some of the truth that was contained in that initial glimpse into the "reality of it all" is lost.

    You could say shock is the only really rational reaction to the current situation!

    If we - the public - accept today's nursing working conditions as normal, it will only get worse. I fear what the bedside will look like in 10 years. Maybe the fact that the aging boomer generation (the "gray tsunami") is about to hit the hospitals will help the public face reality...
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  2. 29 Comments

  3. by   Martinette
    My hospital has really really bad ratios. We are talking one nurse to 24 patients on a good day. These are acute med surg patients. The managers have no interest in changing or hearing about nurse/patient ratio studies and they feel that the bad nursing care is due to the nurses being "lazy" and crap". It has been my experience that the public shares the same attitude. They are refusing to hire and it is the same story throughout the country so we are stuck where we are.

    I don't think any of this will be fixed until we educate the public. If they had any idea of what nurses do and how much responsibility nurses have they would never put up with this kind of short staffing.

    Something needs to be done.
  4. by   janettalinda
    Here's my experience of nursing over the years. For years working conditions were actually improving, and wages increasing. A few years ago, maybe ten years ago, things started going downhill. Working condition are going downhill! I'm hearing about unbelievable nurse-to-patient levels. Thus, nursing care suffers. Nurses are discouraged. I think more and more nurses will organize unions. Collective bargaining can solve many problems.

    Don't moun, organize-Joe Hill,1915
  5. by   bren3299
    HI,
    We have the same issues here in Canada. We have 12 vacancies for nurses on our general internal medicine teaching unit that only has a total of 32 positions (full and part-time combined). Our ratios look good on paper (4-6 pts per nurse on days, 30-32 pt total on unit and 2 health care aids for day and evening shifts) but I am not able to deliver optimal care every single shift. You usually feel like "well I did the best I could"... not how I want to feel at the end of the day. All the stress adds up and you leave for easier or more supportive enviornments. There are just so many options for nurses now why would someone put themselves through it day after day? We wrote a letter to all of the higher ups and they did respond by hiring a private HR guy to do 1:1 interviews with all the staff. He is supposed to generate a report. It is too late for me. I am going back to my teaching job as a clinical instructor and the whole while I am teaching the "right way" I will know that in certain areas they will be lucky just to keep their pts breathing through the shift. I am on a much lighter unit (cardiology) this time with the students per my request as the former ward just feels unsafe on so many levels. The disparity between workloads on this cardiology unit versus the general medicine one seems almost criminal at times but I am taking advantage of it this time. I refuse to play the martyr anymore and will try to effect some measure of change from the inside by trying to educate students to fight for improvements in the future. I still hope something positive comes from our most recent attempt at making managment accountable.
  6. by   Minty80
    nice topic. Marie! Well said!
  7. by   marie-francoise
    Thank you for the replies so far - I appreciate your honesty.

    And, my goodness - 24 acute med/surg pts to 1 nurse! On days! (or nights, for that matter!) That sounds like something out of a novel from the reformist era when we were trying to combat the social ills of the Industrial Revolution - like something from an Upton Sinclair novel - except that it's today! Incredible.

    And I agree with the poster who says she refuses to be a martyr anymore - I can see how that feeling of self-sacrifice can buoy one up for a little while, until survival instinct kicks in and tells you, "Um, this is NOT worth it!"

    I already have some qualms about direct patient care - but that may be me & a personality thing, and may be overcome in due time with practice.

    But I'm having huge qualms about the ratios I'm hearing about. Even someone who loves nursing would throw in the towel eventually and leave the bedside, faced with these incredible ratios. I keep hearing it, "I go home defeated, feeling like I couldn't deliver the care I wanted to - that I was lucky to leave all my patients still breathing."

    I wonder how many nursing students know about the ratios they'll be facing, combined with all the other stresses now piled on top of nurses. Kudos to the poster who said she wants to instill advocacy in her students - I don't hear a word from my instructors about the true state of nursing today.

    I just think these ratios are a systemic problem, and I don't want to become another replaceable cog in the wheel (feeling miserable while I am that temporary cog). I know, despite all that's said, that a year or two in med/surg is the best way a new grad can learn. But I'm absolutely cowed by the prospect of entering med/surg nursing given these ratios.

    Some type of collective action is needed - whether from government or from unionizing. No wonder nurses want to unionize! They have good reason.
  8. by   Martinette
    This is not only a US problem it is global. I work in a country that has national health taxpayer funded government run hospitals.

    There is a nurse I work with who is the best nurse I ever saw. She is smart, hardworking, caring, she thinks fast..the patients all get the best care when she is around. It's like she is supernurse. I can't say enough nice things about her. She is leaving because of the high ratios and abuse and management cannot wait to see her go.

    They have had a recruitment freeze in place for years. They want to make 500 nurses redundant but the community had a fit so they are hoping that people get fed up and quit. This is all because Blair's government (I am in the UK) targets have left the hospital with extreme debt. They are increasing beds and driving nurses away. We are 2 hours away from another hospital. The people in charge of our hospitals have no clinical nursing or medical experience.

    If I were a chief executive I would fight to keep nurses like her around. I am also going but I am probably too burned out to be any good anyway. Just waiting for my husband's visa and we are off abroad. Not too long now!!!

    I also work with another RN who is fantastic. She was dealing with an IV med and had a major reaction (allergy) and coded. She ended up in a vent in ICU and when she came off that vent our matron was telling her to get herself discharged so she can get her ass back to work. I couldn't make this stuff up. She is leaving as well. This community cannot lose any more nurses.


    I think that the problems we are all seeing are NOT down to the type of system (private vs socialist model) that we have in place.

    The bottom line is that nurses are disrespected and treated like crap and will always be the last consideration of hospitals/governments. Hospitals centre around nursing care and yet no one wants to make nursing a priority. This directly hurts patients and ruins nurses but no one seems to be making the connection.

    Things will only change when nurses are understood. But no one wants to listen to "a nurse". I am afraid that it will never happen and nursing will continue to deteriorate. Nurses will continue to get a bad reputation and people will listen to us less. It doesn't matter what system is in place.
    Last edit by Martinette on Dec 19, '07
  9. by   marie-francoise
    Martinette, Your perspective is informative - especially since it's from a country where they do have a social health care system, and with such bad results for nurses.

    And your point about nurses not getting respect is fundamental. They are expected to do so much, and know so much, and basically be super-women (or super-men), and yet don't get the respect commensurate with that expectation. It's as though they are so much replaceable chattel. And, yes, how can one influence if one is viewed as chattel?

    One nurse told me once, "People are all too ready to say, oh, that stupid nurse did such-and-such" when something goes awry - before thinking about whose fault it really might have been (in this case it was about a dressing the doctor had put on!). It's just a knee-jerk reaction I guess.

    I'm wondering how and when the situation will change. My guess is, is that it will worsen before it gets better. But my hope is that it will get better, eventually.
  10. by   Martinette
    It seems to be the same all over. Most of my friends colleagues are nurses from the Phillipines, India, and Singapore. In India it is 1 nurse to 60 patients yet their hospitals are really modern and high tech. In Singapore it is 1 nurse to 20 and if there is any kind of screw up or complaint from a patient they demote you to nursing assistant.

    Nothing but disrespect all over. The role of nursing has changed so much due to changes in the way health care is delivered and technology. People's attitudes are not changing. I had someone tell me that they thought that a childcare worker had the same level of education as a nurse.
  11. by   Retired R.N.
    Quote from marie-francoise
    Thank you for the replies so far - I appreciate your honesty.

    And, my goodness - 24 acute med/surg pts to 1 nurse! On days! (or nights, for that matter!) That sounds like something out of a novel from the reformist era when we were trying to combat the social ills of the Industrial Revolution - like something from an Upton Sinclair novel - except that it's today! Incredible.

    And I agree with the poster who says she refuses to be a martyr anymore - I can see how that feeling of self-sacrifice can buoy one up for a little while, until survival instinct kicks in and tells you, "Um, this is NOT worth it!"

    I already have some qualms about direct patient care - but that may be me & a personality thing, and may be overcome in due time with practice.

    But I'm having huge qualms about the ratios I'm hearing about. Even someone who loves nursing would throw in the towel eventually and leave the bedside, faced with these incredible ratios. I keep hearing it, "I go home defeated, feeling like I couldn't deliver the care I wanted to - that I was lucky to leave all my patients still breathing."

    I wonder how many nursing students know about the ratios they'll be facing, combined with all the other stresses now piled on top of nurses. Kudos to the poster who said she wants to instill advocacy in her students - I don't hear a word from my instructors about the true state of nursing today.

    I just think these ratios are a systemic problem, and I don't want to become another replaceable cog in the wheel (feeling miserable while I am that temporary cog). I know, despite all that's said, that a year or two in med/surg is the best way a new grad can learn. But I'm absolutely cowed by the prospect of entering med/surg nursing given these ratios.

    Some type of collective action is needed - whether from government or from unionizing. No wonder nurses want to unionize! They have good reason.
    Instead of waiting for the government or a union to "Fix Something," why don't we professional nurses take on the responsibility of doing it ourselves?

    First, we start by admitting that the present system of expensive, taxpayer-subsidized nursing education does not adequately prepare students for the reality of the beginning jobs that await the students after graduation. Once upon a time, when most nurses graduated from hospital diploma schools, they had all the clinical experience they needed to hit the ground running.

    However, the self-appointed (?) leaders of nursing decided that everyone needed a baccalaureate degree to be considered "Professional," They did such a good job with their infamous "White Paper" in dividing the ranks of practicing nurses that they spent all their time fighting each other instead of being concerned with what was happening to the employment status of hospital nurses.

    If we nurses won't make the necessary corrections, we probably won't like the ones made by the government or the unions.
  12. by   RN1989
    Preach on Retired RN!!! Have you considered running for governor? I'll work on your campaign for free!
  13. by   RN1989
    Quote from Martinette
    In India it is 1 nurse to 60 patients yet their hospitals are really modern and high tech. In Singapore it is 1 nurse to 20
    Ok, so now my thought is....Is there a nursing shortage in those countries caused by recruiters in the US stealing the nurses?

    I swear that there are hospitals units in the DFW area where none of the nurses speak American English as a first language. All of the nurses on those floors are from other countries.

    I understand that the Phillipines is probably the only place where there are too many nurses for one area and nurses are the biggest export. But what about other countries?

    Are U.S. employers purposely keeping things in bad shape to force US nurses to quit nursing so that the employers can recruit nurses from other countries who are less likely to be vocal about the conditions? And what are the ramifications of these business tactics in those other countries?
  14. by   pickledpepperRN
    Quote from janettalinda
    Here's my experience of nursing over the years. For years working conditions were actually improving, and wages increasing. A few years ago, maybe ten years ago, things started going downhill. Working condition are going downhill! I'm hearing about unbelievable nurse-to-patient levels. Thus, nursing care suffers. Nurses are discouraged. I think more and more nurses will organize unions. Collective bargaining can solve many problems.

    Don't moun, organize-Joe Hill,1915
    We ARE doing much better in California.
    No hospital CEOs don't respect nurses. They view us as costly but take us away and you just have a building.

    The public trusts and respects us more than any other occupation. We need to continue and expand our advocacy to earn that trust.

    Just calling in a union is useless. BUT together continued working together won safe staffing ratios with the obligation that the hospital increase staffing by acuity.
    WE together can work to improve patient care and nurses working conditions.

    http://www.calnurses.org/nnoc/

    http://www.calnurses.org/assets/pdf/nnoc_101.pdf

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