Why Do Nurses Allow Understaffing?

gypsyatheart · Jul 7, 2007

I'm not sure if you're aware of this, but nurses have no choice in the staffing of our units.... You can try and work on a unit that is adequately staffed, but that is few and far between, and can change in a moments notice. Most units are like revolving doors anymore, people come, they go, people go on vacation, have babies, go out on abscences, etc. Remember, nursing is 24/7, not like the corporate 9-5 world. You are staffing around the clock plus weekends and holidays. Often many new nurses start and find this is not for them.....

Also, in terms of pt ratios...good luck. The only state now that has mandated staffing ratios is California, and even then they are not all in compliance...case in point, the hospital I work at is on a 10-day strike notice....top issue: not upholding state mandated staffing ratios. We'll see what happens.

As for going for your APN, sounds great, but don't think that being a staff nurse/charge nurse does not require you to think or use critical thinking skills! Quite to the contrary. As well, generally, getting a masters, being an NP will equal, same pay as your experienced RN, more responsibility, getting all the garbage dumped on you from the docs, etc. As an NP in an office you can expect 15 min time increments to see your pt's then on to the next one. Very hectic, busy, just like the hospital. Depends on where you are going to live and work...if you're out in Podunk, Nowhere, pace may be slower, but pay will be less, etc. Good luck to you!

GooeyRN, ADN, BSN, CNA, LPN, RN · Jul 7, 2007

Sometimes there isn't a choice, like where I work. I work and live in a rural area. There just aren't enough nurses to fill all of the positions. No one wants to drive 40 miles through the mountains and snow to get here. So its all local living nurses that work here. The hospital now offers double time to those who work over 40 hours a week. There is still a lot of short staffing. The only way to improve it more would be to offer double time to per-diem and part time staff for working above their normal hours. But then that gets very expensive for a very small, rural, poor hospital. There really isn't a way to fix the staffing problem here.

RNfaster · Jul 7, 2007

Moondancer...thank you. You've given me more to think about.

I know nurses can't really do much except vote with their feet (and they sure seem to be doing that ---as evidenced by high turnover), support legislative changes (slow), and unionization (curious to learn more about pros and cons of that).

I am very interested in trying to work in the hospital as I love the opportunities to use my mind and make a difference in human lives. I do think nursing is challenging mentally (and I would love the opportunity to really focus on a small number of patients rather than a large number). Running ragged bothers me, however.

What I see makes me think that after a couple years in a hospital I will shift to a biotech, a pharmaceutical, a research-oriented firm, a journal, or or or ... so that I could work in the healthcare realm but have a sane, challenging, and lucrative job. I've worked at several biotechs, and seen nurses work supervising clinical trials. The work is interesting and has a positive impact.

I feel like hospital work could be saner. I don't understand it. I don't feel like it's good business to shortstaff. I feel like we short the patient and the workers in such an environment - pennywise and pound-foolish. Such policies foster churn among the patients and workers. And they foster negative outcomes, some of which may be recognized as they are dramatic, and some of which may not be immediately recognized (e.g., lower patient and worker perception). I think it's also a reason that we rate so poorly on the WHO list (above Slovenia as Michael Moore points out) examining quality of healthcare by country.

I can't help but wonder if unionization and stronger legislation is the answer. I don't know enough about it. Too new to this industry. Curious what all you experienced folks have to say.

Thank you.

UM Review RN, ASN, RN · Jul 7, 2007

I am preparing to begin nursing school. It boggles my mind that people work in places that understaff.
I am definitely going to go for an advanced degree. I think it can't help but get better with a masters. But if nurses banded together, couldn't something change for the better? (Consider nursing ratios in California --CA is a great state for employees overall as I see it.)
When she heard I was planning on studying nursing, a former cardiac critical care nurse told me NOT to work at a hospital. I thought she must have gotten tired of it and things surely have improved. But now, I am wondering, and thinking I will consider doctors' offices (as a NP), pharmaceuticals, etc. Maybe it's just working med-surg that is so nutty. Maybe it gets better on other units.
--I love to work hard. But not simply running my butt off. I'd like to use my mind more...to be able to care and listen to patients a little more.
When I worked in "corporate America." we had time to bond with our coworkers, to advance our skills and teamwork, to work pet projects, to really delve into things. It wasn't a crazy race just to provide the bare minimum.
Any thoughts? Sorry I was so long-winded. It was a hard night.

There is only one real reason that nurses don't have appropriate staffing.

It's because we do not own the hospitals.

We are just employees, and nowhere in the business world do employees have any say over employment. Nowhere.

So the answer is, when nurses own the hospitals, then they will have the right to have a say in staffing.

Of course on that day, Hell will simultaneously freeze over and flying pigs will be seen cavorting in the clouds.

tntrn, ASN, RN · Jul 7, 2007

Another solution which I personally adhere to, is just say no to any extra shifts. I don't go in when they call and are desperate. I feel no obligation to bail them out, even if they whine and cry. It's not my responsibility to staff. It's theirs. If more nurses would work only what their FTE is and nothing more, they'd have no choice, but to increase the FTE's available or hire on agency, traveler's, whatever. Our place relies a lot on guilting nursing into working way over their FTE's and then wondering why people are getting sick or burnt out or just done with it all.

MIA-RN1, RN · Jul 7, 2007

If I refused my assignment because it is too heavy, another nurse would have to absorb them and then it would be worse for her. Plus I would worry about abandonment issues.

If management will only staff so many FTE's, then thats what we have to work with. We are taking 12 - 16 hours of call time per month as well as working full time or part time. Its the way it works.

I agree that a nurse-run hospital would rock but I don't anticipate seeing it happen. Bottom line is it wouldn't be cost effective because of the piddly payments from insurance companies etc wouldn't support the staffing that nursing knows is vital to patient well being and satisfaction. Meaning we'd be right back where we started from.

I am deciding what to do about the issue with my feet--changing to a floor with lower ratios and hopefully fewer staffing issues (AND NO CALL TIME YIPPEE!)

gypsyatheart · Jul 7, 2007

Sonoran.....you're on the right track, thinking all of this through! The thing you have to know about hospitals/healthcare is it has become a business....hospitals are not in this for charity or good works, etc. Many, many hospitals are owned by insurance companies and the docs definitely are, LOL, one way or another. Managed care has effected the way we practice, to some extent good, but now, far more to the extreme of not so good, not so good at all. It should be a whole class in Nursing school :The Business of Healthcare....

You see, nursing hours are not billable by the hospital, we are a huge, huge expense for the hospital. What their dirty little secret is....they need us, heck, that is why patients are in the hospital in the 1st place...they need nursing care! Think about it, if they needed to see their doc, have a procedure, get a lab draw, have a dietary consult on and on and on, they could get all of that done as an outpatient. But they are admitted, ultimately, why....? Cause they need to be under the care of a licensed nurse. We are the ones that are there 24/7, monitoring and performing skilled nursing duties. But nursing hours are not billable....so we are a "loss" for the hospital, yet they need us in order to even open their doors.

It would be nice for more nurses to organize and utilize our power, but that is another whole issue unto itself. Nursing is a great profession...like no other, w/many, many issues on the table, for obvious reasons.

The cool thing is, you have many, many choices in Nursing, and yes, w/advanced degrees, the doors just keep opening.....lots of opportunities.

Moondancer...thank you. You've given me more to think about.
I know nurses can't really do much except vote with their feet (and they sure seem to be doing that ---as evidenced by high turnover), support legislative changes (slow), and unionization (curious to learn more about pros and cons of that).
I am very interested in trying to work in the hospital as I love the opportunities to use my mind and make a difference in human lives. I do think nursing is challenging mentally (and I would love the opportunity to really focus on a small number of patients rather than a large number). Running ragged bothers me, however.
What I see makes me think that after a couple years in a hospital I will shift to a biotech, a pharmaceutical, a research-oriented firm, a journal, or or or ... so that I could work in the healthcare realm but have a sane, challenging, and lucrative job. I've worked at several biotechs, and seen nurses work supervising clinical trials. The work is interesting and has a positive impact.
I feel like hospital work could be saner. I don't understand it. I don't feel like it's good business to shortstaff. I feel like we short the patient and the workers in such an environment - pennywise and pound-foolish. Such policies foster churn among the patients and workers. And they foster negative outcomes, some of which may be recognized as they are dramatic, and some of which may not be immediately recognized (e.g., lower patient and worker perception). I think it's also a reason that we rate so poorly on the WHO list (above Slovenia as Michael Moore points out) examining quality of healthcare by country.
I can't help but wonder if unionization and stronger legislation is the answer. I don't know enough about it. Too new to this industry. Curious what all you experienced folks have to say.
Thank you.

tntrn, ASN, RN · Jul 7, 2007

If I refused my assignment because it is too heavy, another nurse would have to absorb them and then it would be worse for her. Plus I would worry about abandonment issues.
If management will only staff so many FTE's, then thats what we have to work with. We are taking 12 - 16 hours of call time per month as well as working full time or part time. Its the way it works.
QUOTE]
Yes, once you are at work, it's another ball game, but not accepting an assignment at the beginning of the shift because you feel it to be unsafe is not abandonment, because you haven't actually begun the assignment. Nurses need to remember that it is Management's Responsibility to staff properly. Nurses do have to find their own coverage in poor staffing situations.
And if management only goes with x number of FTE's and NOBODY will come in on short notice to work extra, how long before they'd figure out that x number of FTE's wasn't enough? Well, okay, they're bean counters not rocket scientists, so it might still take a while, but I'll bet they'd figure it out sooner or later. Even a bean counter should be able to figure this one out quickly.
Nurses who are eager to do OT for any reason whatsoever are really part of the problem because it relieves management of properly staffing in the first place. And the longer something unacceptable (like poor staffing) goes on, the more it becomes the norma and then when you complain they'll counter with, "well, it's been like this for ever. What's the proble all of a sudden?"

MIA-RN1, RN · Jul 7, 2007

If I refused my assignment because it is too heavy, another nurse would have to absorb them and then it would be worse for her. Plus I would worry about abandonment issues.
If management will only staff so many FTE's, then thats what we have to work with. We are taking 12 - 16 hours of call time per month as well as working full time or part time. Its the way it works.
QUOTE]
Yes, once you are at work, it's another ball game, but not accepting an assignment at the beginning of the shift because you feel it to be unsafe is not abandonment, because you haven't actually begun the assignment. Nurses need to remember that it is Management's Responsibility to staff properly. Nurses do have to find their own coverage in poor staffing situations.
And if management only goes with x number of FTE's and NOBODY will come in on short notice to work extra, how long before they'd figure out that x number of FTE's wasn't enough? Well, okay, they're bean counters not rocket scientists, so it might still take a while, but I'll bet they'd figure it out sooner or later. Even a bean counter should be able to figure this one out quickly.
Nurses who are eager to do OT for any reason whatsoever are really part of the problem because it relieves management of properly staffing in the first place. And the longer something unacceptable (like poor staffing) goes on, the more it becomes the norma and then when you complain they'll counter with, "well, it's been like this for ever. What's the proble all of a sudden?"
Oh yeah I agree and I have made issue of assignments before. Just also felt the powers that be kind of trying to make me feel guilty.
Management had decreed that our ratio would be 1:5 couplets. And charges had to work within that, flexing us down to that level. (It is about 10 patients/nurse, sometimes more, sometimes less). And that is where the greatest level of stress came in, I believe. They changed it now to 1:4 couplets (strangely at about the same time the new safety nurse came on board)
We are not allowed to work overtime unless its call time that we are coming in for. Period.
Staying late gets you 'counseled'.
I don't know what its like anywhere else. Hopefully though its better where I am going.
I don't htink that there is any easy answer for these types of staffing issues. It boils down to what the other poster said about nursing not being billable. Imagine if we were---people wouldnt be able to afford us nor would patients afford their hospital stays!
People don't come into the hospital for care from a doctor; they come to receive nursing care. Its a nurse they shout for when there is a problem.
I wish that mangement could see that. Not just for me but for all nurses everywhere.

llg, PhD, RN · Jul 7, 2007

Another solution which I personally adhere to, is just say no to any extra shifts. I don't go in when they call and are desperate. I feel no obligation to bail them out, even if they whine and cry. It's not my responsibility to staff. It's theirs. If more nurses would work only what their FTE is and nothing more, they'd have no choice, but to increase the FTE's available or hire on agency, traveler's, whatever. Our place relies a lot on guilting nursing into working way over their FTE's and then wondering why people are getting sick or burnt out or just done with it all.

:yeahthat: I agree completely. I have often thought about why more nurses don't put their feet down and "just say no."

Some are afraid that they will lose their jobs or suffer some other sort of retaliation if do that, but I have not seen that happen. The worst I have seen is that nurses who don't volunteer for extra shifts are not the ones given bonuses or promotions or glowing evaluations. That seems like a small price to pay for staying healthy and not burning out.

Other people seem to feel that everything is their personal responsibility -- and/or have a pathological need to rescue everybody else from having to bear the consequences of their actions. I'm all for taking responsibility when it's appropriate, but we also have to let other people take responsibility for THEIR actions. The management needs to be forced to take responsibility for the results of the management practices. Society needs to take responsibility for the decisions it makes about the funding of health care. etc. etc. etc.

I always recommend that nurses find a middle ground -- say "Yes" ocassionally, but only ocassionally and only on your own terms. Volunteer to work a little extra at a time convenient for you -- when you can plan and prepare for the extra hours in advance. Volunteer more during a temporary crisis that the management could not reasonably foresee and less to compensate for long-term problems that the management knows about but refuses to address. Find a middle ground that you can live with. That way, the management will see you as being willing to help and will not retaliate against you in any significant way -- but you will protect your sanity and your health.

MIA-RN1, RN · Jul 7, 2007

I'm all for taking responsibility when it's appropriate, but we also have to let other people take responsibility for THEIR actions. The management needs to be forced to take responsibility for the results of the management practices. Society needs to take responsibility for the decisions it makes about the funding of health care. etc. etc. etc.
I always recommend that nurses find a middle ground -- say "Yes" ocassionally, but only ocassionally and only on your own terms. Volunteer to work a little extra at a time convenient for you -- when you can plan and prepare for the extra hours in advance. Volunteer more during a temporary crisis that the management could not reasonably foresee and less to compensate for long-term problems that the management knows about but refuses to address. Find a middle ground that you can live with. That way, the management will see you as being willing to help and will not retaliate against you in any significant way -- but you will protect your sanity and your health.

I agree with you but when is management really going to take responsibility? Lets face it, a bad outcome is going to first be attributed to the bedside nurse, even if its a staffing issue. ("The nurse should have refused the assignment." "The nurse should have asked for help from her coworkers.")Management will not end up accountable because they will fall into the us and them mentality. Bedside nurse vs management is a common theme in nursing I think. I would love management and nursing to work together--maybe these new 'unit council' ideas will help.

But the reality I have seen is that if you call management because of a staffing issue on the off hours, you are told to figure something out. And I have yet to see a charge nurse who does not dread making the call to the one who is on 'administrative on call' at 11pm because there are too few nurses to cover the census.

So yes, management should be forced to take responsibility but the reality is that the burden will continue to fall on the bedside nurse.

I wish there were a good and simple answer.

This is a great topic for discussion!