a nurse's viewpoint
the nursing crisis: searching for solutions
by roberta b. abrams, rnc, ma, lcce, for healthleaders.com, dec. 3, 2001
reports on the crises in nursing and their implications for patient care have essentially become daily fodder for the journalists in this country. our local paper recently featured a two-day, multi-page series of articles that resulted in spreading fear among care-givers and care-recipients alike.
i receive frequent phone calls from family and friends, consumers of healthcare (e.g."patients") with sad tales about their encounters with the healthcare system. i also have been hearing, with increasing frequency, concerns expressed by patients, their families and friends, about potential encounters with the healthcare system.
everyone knows about the problem. some knowledgeable healthcare professionals, notably nurses, are beginning to do something about it. let's look - from a nurse's viewpoint - at what you can do.
colleagues in caring, a group of nursing leaders who are diligently engaged in looking for solutions to difficulties with the healthcare delivery system, reminds us that those solutions must be fitted to the locale in which they occur. just as good patient care must be individualized to the patient, treatment for the problems in your area must be predicated on unique local aspects of your problem.
the current nursing situation is different from any experienced in the past. the unique aspects of the today's problem have been elaborated many times, in different places. they include:
*the increase in demands for nurses and nursing services
*the aging of the population
*the technological advances which extend the potential for all people along the age continuum
*the aging of the current nurses
the decreases in enrollment in schools
of nursing due, in part to other career opportunities for women and in part to perceived problems with current conditions in nursing
increasing the supply and availability of nurses will not result from reprising solutions that worked in the past. as the situation is unique, solutions must come from different places, requiring those who would participate in the solutions to think "out of the box."
a good place to begin is with an analysis of the problem. some of the aspects that need to be examined include:
*in your facility, do you have an overall shortage of nurses, or is it greater in one area than another?
*what is the annual turnover, by unit?
*where is the greatest tenure among nurses? what are the characteristics of that unit?
*who are the real leaders in your facility?
*what are the nurses saying?
part of the etiology of the current problem belongs to managers of facilities who responded to financial problems by focusing on the bottom line. many of the financial problems that began about a decade ago revolved around third party reimbursement. instead of assessing the total situation and seeking efficiencies that could assist with reimbursement, such as improvements in documentation, billing, and in patient care, these managers called in teams of consultants.
unfortunately, many of these consultants lacked clinical acumen. they had a propinquity for traveling from site to site and imposing the same solution without in-depth knowledge of the problem. their most common recommendation was to cut staff. nursing service is usually the largest single factor on a health facility's budget. as such, it was an irresistible target for bottom line managers.
the sequelae of reductions in nursing staff was to complicate patient care. errors increased, discharges were delayed, patient complaints increased, and staff morale plummeted. remaining staff sought better places to work, or began using sick time to deal with stresses engendered by overtime and inadequate staffing. in a relatively short time, those facilities that had "improved efficiencies in staffing" began advertising for new staff, with significant sign-on bonuses. they also went to staffing agencies and began paying premiums to avail themselves of many of the same staff that they had just eliminated.
dropping the rock called "bottom line mentality" resulted in ripples that resembled tidal waves.
it is time to begin by asking those hard questions listed above. talk to the clinical staff, to nurses, to physicians, to clinical therapists, pharmacists - those whose daily responsibilities deal with patients and the staff who care for them. most facilities can still find some real leaders remaining among the staff. seek those who are there because of their commitments to the facility and its patients. ask them what problems they see and what solutions they have to offer. ask the leaders of the units with lowest turnover what they do to retain staff.
one of the factors that today's nurses find difficult to endure is their lack of real autonomy. many of them had a taste of autonomy in the shared governance programs that existed a decade ago. unfortunately, too many institutions eliminated or decimated those programs in their focus on the bottom line. magnet hospitals, those institutions that represent excellence in retention and recruitment of nurses, have, as one of their chief characteristics, a focus on nursing autonomy. establishing, or re-establishing, shared governance constructs may not be easy. it must be done.
utilize the knowledge of your clinical staff. invite them to the boardroom - and other leadership forums - to share with the facility's power brokers those things that would encourage them to remain with you and to invite their colleagues to join your staff. pay attention to what they say, and request their assistance in developing and implementing strategies for improvement.
examine some of the newer technologies with the potential to improve patient care. there are a few worthwhile computerized documentation and delivery systems that really work. they usually involve multiple disciplines, and myriad aspects of patient care. involve representatives from all those whose work will be affected by the system in its selection.
one of the potential benefits of the faltering national economy is an increase in the numbers and types of people now available to nursing and other healthcare professions. work with other patient care facilities and with local colleges and universities to establish two vital programs - "refresher" courses for those nurses who are interested in returning to the ranks of caregivers after prolonged absences, and so-called "second career" programs for women and men who are interested in a new career in healthcare.
collaborate with schools of nursing that offer degree completion programs for rns. seek out colleges and universities with programs leading to masters degrees in nursing, to midwifery certificates, or other advanced practice roles. support or sponsor programs in continuing professional education for current staff. each of these measures has been shown to increase retention of that staff.
talk with nurses who have left your facility. why did they leave? what would make them interested in returning? are they willing and able to work with you to develop and implement changes in your systems that would make them better places to work?
communicate with recent retirees. would they be interested/able to return to work - perhaps for just a year or two, perhaps for fewer hours than they previously worked, perhaps in a different setting?
reach out into your community. ask both past and prospective patients what they like and what they'd like to see improved in your facility. involve staff in assessing and implementing necessary changes.
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.