From the Eyes and Ears of a Nurse

[Chellyse]

This is an older article ran in March 2001. For those who have already read this I apologize. I thought it was concise and this new forum would be a good place to put it for reference.

From the Eyes and Ears of a Nurse

Charissa Szumiloski, RN, BSN, MB

http://www.cost-quality.com/restpast/v7i1a1.html

March, 2001

Volume 7, #1

Nurse staffing problems won’t be getting better any time soon.

They’re probably going to get worse. The solution, says this Nurse Consultant, is

to make better use of the nurses we have.

It’s 3 p.m. Nurse Jenkins begins her shift as house supervisor at Atlas Medical Center with too many pages on her beeper. No, the battery isn’t malfunctioning; rather, grave concerns are being communicated to Nurse Jenkins from staff on various nursing units. The staff contend that nurse-to-patient ratios are insufficient. As a result, there are frantic situations that Nurse Jenkins must address throughout her shift.

The Emergency Department has been backed up with patients for hours since the nursing units are not receiving the “already-admitted” patients in a timely manner. To top it off, ten open beds on 5 West aren’t available for these patients because no one is available to work there. Several nurses on 4 North say that they are “completely exhausted from working mandatory overtime in excess of 20+ hours this week.”

“The patient in 336B just suffered a severe fall while attempting to ambulate to the bathroom on his own, just one-hour after a total hip replacement, and his family would like to speak with you immediately!” Another nurse calls to report a potential medication error since she is “uncertain how much morphine the patient in 236A has received because she has nine other patients to care for.” Then, Dr. Gleason calls to complain that his “patient did not get her CT Scan on time,” and, as a result, he cannot elicit a timely, definitive diagnosis for a cerebrovascular accident.

Suddenly “Attention please, Code Blue in Critical Care, Code Blue in Critical Care” sounds over the PA. Nurse Jenkins drops everything to handle this episode, and returns to her post only to find that Nurse Atkinson –one of the many agency nurses being utilized– has requested an orientation to the unit since she has never worked there before. Nurse Jenkins smiles sadly to herself, because in fact there’s no time to orient even the existing staff to the units where they’re being floated. Additionally, Nurse Jenkins is told that in order to reduce excessive overtime costs she must “ensure that staff are punching out at the end of their shift instead of when all of their necessary documentation has been completed” (which usually occurs about 2 a.m., if the documentation is to be complete and legible). You would think that there is no end to the madness when Nurse Jenkins hears her staff complaining that “this is unsafe for the patients” and that “they refuse to work at a place in which their license in on the line.”

Are these encounters fictitious? Is this just an unusual day for Nurse Jenkins?

Unfortunately, these kinds of nightmarish events are routine occurrences in many hospitals. The dilemma for healthcare, unlike most other industries, is that customer satisfaction is not the only business driver or “delighter.” For healthcare, customer (patient) safety is the priority in delivering a successful product. Defects or failures in the production line cannot be tolerated.

So, should a CEO, CFO, Medical Director, and VP or Director of Nursing all care about Nurse Jenkins’ day? Sure they should! Not only should these administrators take notice, but so should patients, taxpayers, and policymakers. For if we view the nursing shortage in the context of access, cost, and quality of healthcare, each of these three attributes are at stake.

From a business perspective, the nursing shortage is putting increased financial pressure on organizations that are already grappling with negative operating margins and significant reductions in reimbursement. This increased pressure results from the enormous costs of recruiting, training, and retaining nurses in an extremely tight job market. Such costs include sign-on bonuses, increased salary and benefits packages, and marketing and advertising initiatives. Additionally, the increased dependency on various agency nurses and mandatory overtime leads to sharply escalating expenses.

More importantly, high turnover of valued employees results in frustration, burnout, and increased stress for those who are left, increasing the risk of poor quality care. Other financial consequences include the closing of beds and resultant turning away of patients, escalating patient incidents and complaints leading to increased malpractice liability and compliance risks, delays, duplication, and omissions in the delivery of care, low productivity levels and rework, time spent at committee meetings to discuss issues, and, as a long-term potential consequence, the loss of market share.

Who’s at fault? Quite honestly, no one. The best way to understand this problem is to review how we got into such a mess. A variety of causal factors have been suggested. I will confine my discussion to the issues that are based on research studies, personal clinical and administrative experience, and interviews with key stakeholders.

• The nursing profession suffers from a serious image problem. Unfortunately, nursing is viewed by the public as unrewarding, stressful, and “subservient“ work.

• There is an under-representation of various population segments in the profession, such as men and minorities. This is compounded by an aging workforce.

• There is an increase in demand for nurses as a result of an increasingly elderly population, a growing number of acutely ill patients, and an increase in outpatient care utilization.

• The overall supply of nurses has decreased as a result of lower nursing school enrollments, other career opportunities, broken promises, and insufficient compensation.

• There has been a decrease in nurse-patient interaction, coupled with nurses perceiving that there is a general lack of professional trust, respect, and communication.

• There are liability concerns about patient safety being jeopardized because of low staffing ratios, use of ancillary staff, and excessive mandatory overtime. These conditions threaten nurses’ licensure and an organization’s compliance structure.

• Nurses do not feel as if they are part of a “shared mission,” since there are many occasions when they are not included in the decision-making process –even when those decisions may affect them directly. Such decisions often focus on the many tasks that nurses perform at the bedside, including changes in documentation, staffing patterns, policies and procedures, new processes, roles and responsibilities, and the type of delivery model.

• Nurses do not feel that they receive enough training to handle patient complexity, especially if they have just graduated. Quite often, this is exacerbated by the need to float to foreign nursing units without much preceptor support or orientation.

These problems will not be remedied anytime soon. With the average age of practicing nurses presently at 42, (it is projected to be 45 by 2010) the U.S. Department of Health and Human Services predicts that there will be a sustained nationwide shortage of nurses by 2010.1 This is supported by many studies of nursing enrollment. For example, a recent report indicates that, in the last five years, the number of nurses graduating in Vermont has dropped by 36%. Reports of a 5% drop per year are very common. Also, despite heavy advertising campaigns for clinical personnel across the US, healthcare organizations maintain vacancy rates of up to 20%. Therefore, the real question is “what can be done at the provider or facility level to better utilize the existing staff ?” Typically, we have looked at decreasing patient-to-nurse ratios in order to improve staffing effectiveness. This emphasis has had at best only limited success in maximizing the overall care of the patient.

Given the current economic disequilibrium of supply and demand, it is apparent that an increase in staffing is unrealistic, if not impossible; staffing ratios can at best only remain constant or at worse decrease further. Therefore, the appropriate factor to maximize in this situation is the percentage of a nurse’s time spent providing direct care activities to his or her patients (activities within the presence of the patient). In many inpatient settings, only half of a nurse’s shift is spent providing direct care. To increase the percentage of direct care time requires an internal assessment of factors such as staffing mix and patterns, processes, supply utilization, documentation tools, amount of paperwork, and type of education and training.

By investing in operational improvement activities, an organization can realize a significant return through enhancement of quality of care and compliance, improved reputation, better cost control, improved utilization across the continuum of care, and increased patient and employee satisfaction levels.

Of course, this is no easy task given the overall complexity and diversity of various nursing units, not to mention entire organizations. Yet, failing to maximize efficiency of internal operations and increase the percentage of direct care time will have negative consequences on a healthcare organization’s bottom line and on society at large. As the American Medical Association points out, “reversing the nation’s cycle of nursing shortages will require reforming the education and credentialing mechanisms for nursing, restructuring work environments, and developing systems of care that empower RNs to use their professional skills.”2

It is imperative to show nurses that management cares by investing in studies to improve the delivery of care. Suggestions for hospital leaders include:

• Develop community forums to discuss the above issues. Include schools, employers, providers, patients, local policy makers, and healthcare organizations.

• Involve nurses in the many decisions that directly affect them. This develops mutual credibility, trust, and collaboration between nursing and management.

• Perform an organizational assessment to identify bottlenecks and defects in the overall delivery of care that impact the nurse’s work.

• Invest in nursing personnel through training and education initiatives, employee recognition programs, and career ladders.

As overwhelming as this situation may seem, professional diagnosis of problems and the design of appropriate interventions is possible. Nurses understand that the majority of administrators desire a “win-win” situation, despite the fact that the facility may not have the time or internal resources available to achieve this goal. When nurses see that the goals of an operational improvement study are not to reduce staff levels but to improve patient care, a framework for mutual credibility, trust, and collaboration can be established. It is only from this framework that progress on the causes and effects of the nursing shortage can occur.

Charissa Szumiloski, RN, is a registered nurse and independent

health care consultant in Greenfield Center, New York. She can be reached at [phone], or by email at [email protected].

[-jt]

Michigan Nurses Association/UAN/ANA

http://www.minurses.org/news/general/VanDorenTestimony.shtml

The following testimony was delivered Friday, July 2, 2001 to the House Subcommittee on Apropriate Supply and Utilization of Michigan's Health Care Workforce of the Standing Committee on Health Policy:

Elaine Van Doren, Ph.D., RN

Coordinator & Instructor

Kalamazoo Area, RN Studies Program

University of Michigan, School of Nursing

Testimony regarding nursing shortage

I have been a practicing nurse for over 30 years in this State. During this time, I had come to believe that I had seen it all as far as nursing shortages and the ways in which people respond to them. However, the past several years have surprised even me. I am increasingly concerned about the health and safety of both those who are seeking care from our health care organizations and the staff providing that care. Today, I would like to talk with you about those concerns, based on my own direct observations and from the many conversations I have had with students.

First, let me tell you that my students come from all over West Michigan; from as far away as Benton Harbor, Albion, Grand Rapids and Sturgis and all points in between. These men and women are already RNs, they have Associate Degrees in nursing from a variety of community colleges. They come to the RN Studies Program so that they may meet the requirements for a BSN, the Bachelor of Science degree in Nursing. Nurses obtain their BSNs to develop greater skill in applying the nursing process for their clients and/or to expand their career opportunities. The majority of my students are also employed full time and provide direct service to clients as staff nurses in acute care, outpatient and long term facilities. Most are married and have children; some are single parents. Given all these characteristics, it should not be surprising for me to tell you that I find my students to be some of the most dedicated, hard working professionals I have ever met. Unfortunately, over the last several years, I also find them to be increasingly more discouraged and frustrated. Like other American nurses, they are very dissatisfied with their work settings.

There are 3 issues I would like to address:

The routine use of mandatory overtime is a major problem in too many acute care settings. One Tuesday night a student called me in tears to tell me she couldn't attend class the next day because she had been mandated to stay at work for 4 more hours after working her usual 12 hour shift. She still would have come to class, but was also told that she had to work the 7 am to 7 pm shift that next day due to a opening in the schedule. Please note that the nurse had approximately 7 hours in between shifts and the last day was the 3rd day in a row she had worked 12 hours. Extending a shift, rapid turnaround for shifts and last minute changes in scheduling are common occurrences.

Ethical conflicts are increasing for today's staff nurse as a result of such scheduling and staffing problems. Each year as part of a course, my students complete an ethical analysis. Five years ago, most of the situations presented related to clinical issues such as assisted suicide and stopping treatment. In the last several years, the students' present conflicts such as being threatened with patient abandonment if they refuse to work, ill prepared nursing assistants, lack of control over nursing personnel and inadequate staffing issues.

In general, nursing is hard work with limited monetary rewards. Nursing salaries have not kept pace with the rate of inflation, potential salary growth is limited, and retirement benefits are usually inadequate. Additionally, health care employers after laying off nurses in the 80's, cut benefits in the 90's. Ten years ago, many students had full tuition coverage, now most are significantly limited either by hours or total dollars.

I have tried to provide just a few examples of the issues faced by staff nurses in our area. As you and I know, these situations are the result of complex factors within the health care system. While the causes may be complex, the results are becoming more understandable. In a major study by Needleman and Buerhaus from Harvard, consistent relationships were found between nurse staffing variables and negative patient outcomes.

Nurses and the Public need your support and commitment in:

*Increasing funding for education at the associate degree and baccalaureate level.

*Opposing mandatory overtime as a scheduling choice

*Supporting salaries and benefits that not only will attract but retain nurses.

*Encouraging the involvement of direct care nurses in staffing decisions.

Thank you

Elaine Van Doren, Ph.D., RN >>

http://www.minurses.org

[natalie]

Michele,

That's a great article to re-post here. This one just came out:

http://dailynews.yahoo.com/h/ap/20010717/pl/medical_mistakes_1.html

Government Makes Hospital Suggestions

By ANJETTA McQUEEN, Associated Press Writer

WASHINGTON (AP) - Dispensing medicines by computer, hiring more nurses and making sure patients better understand their treatments are ways that hospitals can reduce medical errors, the government said Tuesday.

The trouble is, few hospitals follow even the most effective ways to cut out mistakes, federal health researchers said.

``The nation's health care leaders need to know what the science says about where the opportunities exist to make patient care safer right now,'' said Health and Human Services (news - web sites) Secretary Tommy Thompson.

The department's Agency for Healthcare Research and Quality reviewed 79 patient safety practices. It said 73 are likely to improve patient safety - including many that the researchers considered highly proven to work, but are not performed routinely in the nation's hospitals and nursing homes.

Among the highly proven practices are giving patients antibiotics just before surgery to prevent infections; using ultrasound to help guide the insertion of central intravenous lines and prevent punctured arteries and other complications; and giving surgery patients beta blockers to prevent heart attacks during or after the operation.

In the case of computerized prescriptions, just 13 percent of 500 hospitals answering a recent survey said they used electronic prescription systems, researchers said. An additional 27 percent said they were working on installing such systems.

While 80 percent to 90 percent of surgical patients received pre-surgery antibiotic treatments, 25 percent to 50 percent of them may not have been given the treatments in the proper manner, at the right time or for the duration needed, the report said.

The researchers said some practices haven't been sufficiently tested or carry important potential risks. For instance, some studies have recommended large increases in antibiotics to prevent infections, but the practice also has the potential to create antibiotic resistance.

The agency's latest report comes as concern rises about medical mistakes. Estimates in recent years say 44,000 to 98,000 people die each year because of medical mistakes, the researchers said.

The agency reviewed hundreds of studies and programs expressly focused on reducing or preventing mistakes.

Researchers were surprised that even highly touted practices - namely, increased use of computer technology, improved hand-washing compliance and more nurses - had not been studied closely.

``There needs to be more research in these areas so that we know more about which practices are most effective and how complex or costly they would be to put into place,'' said Dr. John M. Eisenberg, who directs the health care quality agency.

The agency also stressed that hospitals need to do more to coordinate their fight against mistakes.

The agency will award nearly $50 million in grants over the next few months to support patient-safety research.