roberta hit a homerun with this commentary! karen
a nurse's viewpoint
nursing woes: a turn in the troublesome road
by roberta b. abrams, rnc, ma, lcce, for healthleaders.com, jan. 28, 2002
there's an old yankee aphorism that says: "it's a long road that has no turning." for more than five years now, nursing has been headed down a very troublesome road - a road of layoffs, resignations, increasing patient errors, and other sequelae of inadequate nursing staff.
but the road is turning. for more than a year, the real leaders in nursing have been focused on the problems. they have gathered to talk about the reasons - the specious economies of episodic staff reductions, inadequate nursing salaries, lack of recognition for nurses and nursing, and poor management. these leaders have also studied the effects: the hemorrhage of resignations, the lack of recruitment success and the effect on patients, on physicians, on hospital function, and on nursing itself.
our nursing leaders are looking at modes of resolving the problem - focusing now on the treatment. there is no single element that will "fix" the problems in nursing and healthcare - but the beginning, the platform on which the resolution is based, is better staffing. let's take a closer look at one state's actions - and what they mean - from a nurse's viewpoint.
on jan. 22, 2002, gov. gray davis of california held a press conference to announce the long-awaited release of mandated nurse-patient staffing ratios for the state's acute care hospitals. once again, california is leading the rest of the country in a step seen by groups of nurses both as an essential protection for patients and as a way to provide working conditions that will end the shortage of nurses.
gov. davis has also pledged $60 million for nursing education. he is to be commended for his efforts, noting that those efforts are only the beginning. as i have stated in previous articles, not only are too many nurses leaving nursing, but also not enough are coming in. in addition, were we able to find prospective students, we need to find skilled nursing faculty to prepare them.
geri dickson, r.n., ph.d., is the new jersey project director for colleagues in caring - a project funded by the robert wood johnson foundation to study multiple facets of the nursing crisis. dr. dickson believes, as do many others, that nursing needs a major restructuring to deal with the current crisis - and, hopefully, to prevent repetitions. in a statement quoted in nursing spectrum she states: "we hear a lot about the issues of recruitment, and retention (the current morale and status of the work environment). these are very closely related. just making an effort to change the image of nursing and recruit college students into nursing won't solve the problem. if the reality of the everyday work life changes, then you will have people wanting to go into nursing. we need to make it an attractive career."
we need to begin our reconstruction of nursing by destruction of some of the barriers that have contributed to the current nursing crisis. in my paradigm for restructuring nursing, we have four barriers to a fully functional profession: the barrier between education and practice, the barrier between leadership and clinicians, the barrier between nurses and physicians, and the barrier between disparate groups of nurses.
barrier between education and practice
the barrier between education and practice is one that has grown with the demise of the diploma school of nursing. clinical staff members protest that nursing educators are in ivory towers - removed from the actuality of patient care. (why else would they insist on those interminable care plans?) the educators, in turn, look askance at what they construe to be fragmentation of care and adherence to practices with no proof of efficacy. this is a great place to begin nursing reparations because there are already examples of how it can be made to work- with gains both for practice and education.
dr. loretta ford, emeritus dean at the university of rochester, was a promoter of what i will call the triad of nursing. all nurses should be involved in practice, education, and research. by so doing, the faculty retains clinical skills, nurses have input into education of their soon-to-be colleagues, and research ceases to be an ivory tower activity, fulfilling instead its original goal, the advancement of nursing practice. yes, i know that this takes time - it won't happen until staffing is adequate - but perhaps it's a way to increase staffing. put the faculty on the patient care unit, and put students on the unit for more realistic time periods, insisting that the existing staff nurture, instead of devour, them.
barrier between leadership and clinicians
the barrier between leadership and clinical staff has two parts to its realization. first, we must find the real nursing leaders among the rns. you know them. they are the ones who nurture their staff, who know their staff as people - not as names on a schedule. the signs and symptoms of real nursing leadership are found on the units for which they are responsible:
staff with high morale and low turnover
staff who express feelings of pride and belonging to their unit
staff who understand and share the goals of their unit
staff who support one another - and welcome new staff to their unit
staff who are committed to and enthusiastic about their patients' care
staff who articulate a sense of achievement and promote visions of improved care
units with satisfied "customers" - patients, families, and other caregivers
these units - and their leaders - must be showcased. they have solved a major part of the nursing crisis in their institutions. use them as examples in conferences, continuing education programs, journals, the media, and anywhere else where we tell nursing's story.
then we have the managers. the people who try to rule instead of govern; intimidate, instead of inspire - the sairy gamp's of nursing. they, too, must be identified. they need to be given clear understanding of their deficiencies, with a template and timetable for their amelioration. those who become leaders should then be encouraged to help in the transformation of their colleagues. those who are mired down in the morass of mediocrity need to be "helped to discover" different careers.
barrier between nurses and physicians
the barrier between nurses and physicians probably dates back to my mother's days in nursing. it began with the rule of primus inter pares - only the doctors of that day did not see any equals. this barrier is gradually eroding due to improved understandings, improved collaboration brought about by more complex patients, and shared stresses and concerns.
dr. michael greenberg, a dermatologist in elk grove village, ill., wrote a commentary entitled, "hailing one of healthcare's priceless resources - nurses" for the american medical news. in it, he said: "in the fragile ecosystem of medical care, nurses are the ones who create the protective environment essential to the well-being of both doctors and patients. we cannot function without them. their job is to provide knowledge, comfort, care, and compassion." i can't say it any better. thank you, dr. greenberg.
barrier between disparate groups of nurses
the barrier between nurses is a symptom of "victim mentality." unable to appropriately deal with pressures and stresses imposed on our profession delivered by "oppressors" of various stripes, we turn on our own. critical care nurses feel that they are "better than" nurses in the general practice units. labor and delivery staff claim to possess higher skills than postpartum nurses. nursing specialists have "more prestige" than the "clinical" staff. and novices - new graduates - must be "tested" to see that they are worthy of membership in our profession.
first of all, it's just not true. as stated before in this column, we are a tapestry. differing in practice patterns, skills, and yes, levels of expertise, each of us makes a unique contribution whose loss would be felt in the profession as a whole. it is my studied contention that the real experts among us find no need to promote our own adulation. the best nurses i know are the ones who embrace their colleagues - and give and get as the needs demand.
what we need to do
as the barriers are coming down, we need to begin our rebuilding. there are three phases to the process: recruiting, reframing, and retaining.
we need to recruit from two sources: students to begin careers in nursing and existing nurses who have left. our ability to recruit new people into nursing means that we have to work on nursing's image. we need to publicly celebrate nursing's victories; we need to publicize the good that we do. there are victories in nursing every day: the "micronate" who not only survives her eonatal intensive care unit stay, but does so in good health; the accident victim who is healed and returns to family and workplace; the nurses whose research on pain control improves the quality of life for patients with terminal illnesses. we are very good at airing our problems. let's instead celebrate the myriad good things that are part of every day's nursing.
we need to collaborate with guidance counselors and teachers in schools across the country. we need to tell them, and through them the students with whom they work, about who has the potential to succeed in nursing and why they should choose nursing as a career.
we should hold more career fairs. not just for those about to enter college, but also for those who may consider nursing as a second career. i heard recently from a woman who was entering nursing after years in another profession. she was well aware of the problems in nursing, but said that there were problems in every career. she thought she would join us and be able to help to resolve nursing's issues.
it's time to extend a welcoming hand to colleagues who have left nursing, and are contemplating a return. for those who have spent significant periods of time away from nursing, there will be a need for updating knowledge and skills. it is time for our hospitals and other agencies to collaborate with the nursing educators and come up with reality-based refresher courses. we will also need to provide mentors for and time in the clinical units for our returnees to regain their clinical proficiencies.
we need to reframe. for too many years, nursing salaries have fallen behind other professions. we start out on a parallel with the others, but the salary ladder lacks the reach to retain nurses with advanced skills. it is easy to illustrate the fiscal folly of this action. think of replacement costs, skills lost, and morale depressed, just to name a few. far too many of our good nurses leave the bedside where their skills and knowledge are sorely needed to satisfy their economic needs.
nursing deserves a place at the table of decision and governance. nurses are intelligent people. they are innovators. who better than the clinical nurse to frame discussions about improvements in patient care? who is more aware of what needs to be done to retain nurses?
retention of nurses will become a reality when, and only when, we have improved staffing, improved conditions for work, and have given nurses a voice and a share in the governance of the patient care arena.
let us begin.
roberta b. abrams, a regular columnist for healthleaders.com, uses her education and experience to help further the evolution of healthcare delivery systems through her consulting group, rba consults, in farmington hills, mich. she also is on the adjunct nursing faculty at madonna university.