A Nurse's Viewpoint
Temporizing solutions for the staffing crisis
By Roberta B. Abrams, RNC, MA, LCCE, for HealthLeaders.com, Jan. 14, 2002
The staffing situation in too many hospitals has reached the crisis stage. Professional nursing staffs are unwilling to work in situations that they consider unsafe. They are unwilling to work with insufficient personnel. They are unwilling to work 60-hour weeks. They are fed up with mandatory overtime. They are unhappy with wages and benefits that are insufficient for their needs. They dislike the treatments that they receive from their "managers" - including phone calls to their homes inquiring about their reason for calling in sick. They have talked with those "managers" ad nauseam. Nothing has changed. They have voted with their feet - they have left to seek other places, other opportunities. Maybe it won't be better; probably it won't be worse.
Is this the situation in every hospital? Of course not. There still exist hospitals where staff members are content in their professional environment. They value their colleagues, and their service. There are still hospitals where the nursing staff feels proud of the care that it delivers.
There are still hospitals to which physicians and nurses refer their families and friends, confident in the treatment that their loved ones will receive. There are still hospitals with leaders - visionary folk who understand the stresses and strains of today's healthcare, and like the sea captains of old, keep the ship on course, visiting neither the Scylla of Inappropriate Staffing, nor the Charybdis of Cost Overruns.
Unfortunately, the number of dysfunctional care facilities is growing. At this point, it is difficult to point with certainty at the beginning of the Gordian knot that epitomizes this problem. Suffice it to say that the knot is growing in size, and that neither the "managers" of the dysfunctional facilities nor the "consultants" from whom they seek wisdom appear to have the knowledge or ability to unravel the knot.
Lack of sufficient care staff is not the only problem confronting healthcare today. However, it certainly is a major issue. Let's look at one all-too-common attempt at solution from A Nurse's Viewpoint.
A growing number of hospitals are attempting to ameliorate their staffing through the use of professional nurse staffing agencies. Staffing agencies may be local, national, or international in scope. The local agencies seem to have little or no difficulty picking up those nurses who have either been laid off in a local "productivity improvement" effort or who have left their former place of employment because of job dissatisfaction.
In this situation, the hospital winds up using the same nurses that it laid off - or who resigned - but at a significantly higher price. The nurse works in a familiar environment, with peers of long standing, and has the opportunity to share her new situation with her friends. The contract between the hospital and the staffing agency specifies the duration of the nurse's employment.
The hospital seeks to gain by having the flexibility to match staff with census and acuity. It has been my observation, however, that hospitals with significant turnover lack the ability to use these nurses only on an episodic basis. The result is more fragmentation of staff, lack of continuity of care (which usually has an adverse effect on patient care), absence of institutional loyalty, and increased costs. A West Coast facility is currently paying one staffing agency $54 per hour, about $20 per hour more than the hospital would pay for its typical employees, including payroll taxes and employee benefits. Industry estimates for nationwide staffing agencies cite revenues of more than $7 billion per year.
Hospitals with major staffing problems have attempted to fix them by utilizing agencies that provide "traveling nurses." The nurse contracts with a staffing agency that pays her salary (today's range is $18-$35 per hour, with some special situations garnering $40), and provides benefits including housing, health insurance, continuing education, retirement funding, and travel expenses. The usual length of a contract is 13 weeks, but the nurse may choose to extend that contract if the need continues (and in today's market, it usually does). The agencies providing this type of service state that they have approximately 16,000 open positions.
It is not difficult to postulate a use for this type of service in areas such as Maine and Florida, which have major seasonal population changes. Providing increased staffing commensurate with predictable but temporary increases in population is a prudent use of resources.
The problem arises when the "traveling nurse" becomes a regular part of the hospital's staffing. The first problem - continuous staff orientation - can be dealt with by providing interactive computer programs that do the major portion of orientation. The usual problems implicit in temporary staff focus on relationships with other staff, staff commitment, and potentially fragmented care. The major issue, from my perspective, is that in no way does this temporizing solution deal with the underlying problem of staff retention. Why are staff members leaving? What is being done to assess the problem? Who is working on solutions?
There exist a growing number of hospitals with extensive and extended nurse staffing problems. Many of these have been troubled for more than a decade, and are, of course, seeing their problems exacerbate in the current nationwide dilemma. Evidently, neither local nor national agencies are able to meet the needs of these institutions, and so they seek relief from their problems by recruiting nurses from other countries.
The problems arising from the recruitment of nurses from other countries begin with differences in preparation, differences in culture and customs, and, potentially, differences in language. All too frequently, there is the added issue of separation from families and friends. Some of these nurses come here with the intent of securing permanent employment. They plan to establish roots and bring their families to join them.
Many others, basically rooted in their own environment, come here only for an interval - seeking what they perceive to be an opportunity for economic improvement. It is not uncommon for these nurses to come with high hopes - hopes that are dashed when they deal with the reality of differences in the costs of living, expenses of travel to see family members, and other fiscal issues.
Others have significant linguistic problems, especially in areas with idiomatic speech. A frequent complaint by nurses from other cultures revolves about the way in which they are treated. Care givers and care providers alike become irritable when the nurses have difficulty in communications. Nurses from other lands occasionally find solace in banding together with others from their homeland. While this solves one problem, it may cause resentment from colleagues who see this as "special treatment."
While agency staff is a realistic first aid treatment for the healthcare agency that lacks requisite staff, those who are responsible for providing staff need to recognize that this is, at best, a temporizing solution. It is the responsibility of the nursing and hospital leadership to diagnose the root cause for staff turnover. It is the responsibility of those groups to meet with the human resource staff and to formulate plans to so structure their facility that it becomes a place where those who seek employment find personal and professional satisfaction.
It is not uncommon to find that at least part of the problem is in the existing titular leadership. A suitable remedy then begins with recruitment of a new leadership team - optimally, a team whose members have a track record of high rates of staff retention and high caliber of patient care. It's rarely a quick fix -you'd better start now.
Roberta B. Abrams, a regular columnist for HealthLeaders.com