Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace - A Four Part Series

  1. One of the greatest challenges in today’s rapidly changing healthcare system is maintaining the highest standards for patient safety. Last week, we talked about the issue of inadequate staffing ratios. In part two of this four part patient safety series, we’ll focus on another area that requires our attention - inadequate nursing staff skill mix.

    Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace - A Four Part Series

    As nurses, we are bound by our oath to provide quality care for every patient. This means holding hospitals and other healthcare facilities accountable for sufficient numbers of experienced nurses to ensure patient safety and support inexperienced nurses. Unfortunately, this is often not the case.

    WHAT'S THE ISSUE?

    "I don't know how to do that" is something that experienced nurses are hearing more often from new hires, float pool and travel nurses. To their surprise, hospitals and staffing agencies are employing nurses with less than two years of experience more often than those who are more seasoned. In fact, some nursing units have up to 75% under qualified nurses, which pose many patient safety concerns for two main reasons:

    1 ) Less experienced nurses do not possess the nursing skills needed to handle the physical, mental and emotional demands of the job. Not even the best nursing programs can take the place of real-life, practical experience. Without the opportunity to gain real-life, practical experience before beginning a new nursing position, new hires often feel "thrown to the wolves", and this poses a major issue for retention and job satisfaction.

    2 ) Burnout rates are increasing among more nurses. As the overwhelming need for training, coaching, and mentoring consumes much of the time and energy of the bedside nursing staff, seasoned bedside nurses are forced to take on a greater workload for insulting pay rates and a lack of additional incentive. At the same time, new hires who are in desperate need training and mentorship are finding themselves abandoned and without skilled guidance.

    According to The American Nurse, "Research indicates that staffing numbers alone don't always tell the whole story or assure positive outcomes for patients in the absence of other considerations. Other factors related to staff expertise, including RN education level, employment status and skill mix, as well as collegiality of nurse-physician relations exert a positive impact on select patient outcomes, such as 30-day mortality and hospital readmission rates."

    The Joint Commision echoes these concerns: "Nurses are the front line of patient surveillance-monitoring patients' conditions, detecting problems, ready for rescue. Spread too thinly or lacking the appropriate skill set, the nurse is at risk of missing early signs of a problem, or missing the problem altogether."

    WHAT'S THE CAUSE?

    There are several contributing factors that lead to nursing staff with inadequate nursing skills. One major factor is that hospitals continue to have strict budget constraints, which creates freezes on nurse salary increases, and low starting pay rates. Without room for growth, in terms of opportunity to learn new skill sets, and higher pay, more experienced nurses might look for work elsewhere. This results in increased job vacancies which are soon to be filled by lower paid, inexperienced nurses.

    Another potential cause is poor efforts by facility administration to improve nurse retention. Without innovative nurse retention efforts, high staff turnover rates will continue to plague these facilities. If experienced nurses don't feel valued by an institution, they are less likely to stay at that particular job. In a recent article that highlights nurse retention efforts, it was stated that the average hospital loses $5.2 million to $8.1 million due to RN turnover, and each percent change in RN turnover costs or saves a hospital an additional $373,200. So why wouldn't hospitals be on board with improving retention efforts?

    The bottom line is that nurses report that low job satisfaction is primarily related to heavy workloads, an inability to ensure patient safety, and insulting salaries.

    WHAT ARE WE DOING ABOUT IT?

    Many national healthcare efforts are in the works to enhance nurse retention programs and increase salaries and incentives for their nursing staff. Here are a couple solutions already in progress:

    The Nurse Residency Program. To enhance nurse retention, many institutions have begun implementing nurse residency programs. Research shows that nurse residency programs are an essential strategy to retain new grad nurses. These programs are significantly longer than traditional orientation programs , which can range from 6-12 months or more, and involve much more mentorship and guidance from experienced nurses. Unlike the two day travel nurse orientation, or the two week new hire orientations that most facilities currently provide, they cover in-depth training that focuses on strong connections among workplace colleagues and work-life balance. It is also shown that other studies that focus on skill mix provide strong evidence that when nursing staff members do not have adequate time or training to carry out their work, patient safety and patient outcomes are put at risk. Understanding this fact by all parties involved in making staffing decisions is critical to assuring the effective, safe and reliable delivery of nursing care.

    Nursing wage and incentive increases. The American Nurses Association has created a Bill of Rights, which states nurses have the right to fair compensation for their work, that is consistent with their educational preparedness, knowledge, experience and professional duties. As a result, many nursing leaders have begun research initiatives to prove that higher salaries for nursing will result in better outcomes for everyone. According to an article published by NCBI, staff of direct patient care nursing roles in hospitals and nursing homes have reported dissatisfaction with wages, as well as non-wage benefits such as: health care, tuition reimbursement, and retirement benefits. Wage rates and distribution should match nursing staff skill levels to encourage entry into the profession and retention within the institution. Competitive wages, combined with good benefits will recruit adequate numbers of nurses to meet the ongoing care demands of the upcoming decades and prevent cyclical shortages that have defined the past half century.
    As a result of such healthcare initiatives, you may find salaries and bonuses for nurses to be back on the rise as hospitals strive to attract more longevity within their nursing staff.

    As we push forward in working hard to correct the disproportionate nursing skills within our healthcare facilities, I am confident that our devotion to upholding the highest standards for patient safety will lend itself to creating positive change for all.

    Best Wishes!

    -Damion

    For other articles in this series, go to:
    Last edit by tnbutterfly on Oct 26
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    About Damion Jenkins, ADN, MSN

    Damion is the founder and CEO of The Nurse Speak, LLC. - a nurse education and consultation services company and blog. He specializes in creating individualized consulting services that helps his clients develop strategies for success. He loves to teach, and enjoys helping others reach their academic and professional goals.

    Joined: Nov '17; Posts: 49; Likes: 103
    Nurse Education Consultant, Tutor and Writer; from MD , US
    Specialty: 7 year(s) of experience in Individualized Tutoring

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    9 Comments

  3. by   Daisy4RN
    Very good article! I would also add that it should not be mandatory for bedside nurses to be assigned a nursing student. Not all nurses are cut out for this and/or want to have a nursing student, if that is the case you are doing a disservice to both student and nurse. You should start with volunteers and work up from there with incentives etc. Also, somebody should be paying attention to what the Instructors are doing, and having accountability, I have seen Instructors just sitting around doing paperwork and this should not be happening, again disservice to both student and nurse. If the students are not gaining the knowledge in school how can we expect them to do good after graduation.
  4. by   Damion Jenkins
    Thank you Daisy4RN, ADN for your contribution to this discussion!

    I agree that nurses should not be forced to take a nursing student or new hire if they do not want to, especially if they do not have the appropriate training to do so. In fact, most nurse residency programs have designated staff that have willingly entered into the role of a trainee/mentor for new comers. Typically this involves additional training and credentialing through each facility, and often includes an hourly pay increase while they are paired with students and/or new hires. Unfortunately, not many facilities are on board with compensating their staff for facilitating the learning of nursing students, however some facilities do, and we need more to do the same.

    As a clinical instructor myself, I completely agree that instructors should be involved, present, and available to the nursing students and facility staff at all times. Sometimes we must break away during down time to complete necessary documentation - especially since none of us get paid to do the work off the clock, however I will agree that we should not make an entire clinical day out of it.

    Finally, for the facilities that do not have designated or willing staff nurses to take on nursing students, which unfortunately has happened several times before, the students become very upset and immediately feel unwelcome. In fact, over the past 8 years of teaching, I have had several students drop out of nursing altogether because they did not want to work in such stressful and hostile environments. As I always respect the wishes of each facility and their staff by not assigning students to staff nurses and/or patients per the staff's request, this still results in creating negative perceptions for the students. Of course I do my best to smooth over any ill feelings, and I work harder to find lots of learning experiences for the students. But at the end of the day, despite all my efforts to engage, teach and persuade the students of otherwise, it doesn't change how the students feel about the overall situation.

    Nurse Educators are desperately trying to get our students through our programs and licensed so that they can become part of the solution. So let me close by asking this: If our healthcare facilities won't provide the incentives to gain our willingness to train the next generation of nurses, then what will?

    Thank you again for contributing to this discussion!

    Best,

    Damion
  5. by   Daisy4RN
    Seems a little over the top that someone would become "very upset" and/or quit nursing school just because they did not "feel welcome". Every Instructor should know that the hospital environment is stressful and pass that on to students so if they are the type to take things personally, they would realize that its not them (personally). I remember when I was in school Instructors told us that as a group. We were also told not to sit around talking all day and to help wherever we could. I have witnessed way too many students just sitting (and may I add, in chairs meant for staff that were very limited!) chatting about their life issues (not school related). I used to enjoy having students but over the last 20 years things have significantly deteriorated. The hospital environment has radically changed so nurses have very little time for students, while at the same time students come in unprepared for the day, do not even attempt to help, and as I stated some instructors sit in the breakroom all day "working" and are not supervising the students at all (maybe that is where the hostility comes from?). If "health care facilities wont provide incentives... what will". I don't have the answer to that because it needs to come from the facility, if nurses do not have time to train/assist students it is just simply not going to happen. Nurse Educators/Instructors should understand that the nurse will put the patient (and own license) first and foremost before the student. Universities and Hospitals should address this together for a resolution. I feel bad for the students that want to learn but it still doesn't change the fact there very little to no time!
  6. by   Bklyn_RN
    Well it seems that some things never change. Except that the public is now "woke" to what is going on.
  7. by   Damion Jenkins
    Thank you Daisy4RN, ADN for your continued contribution to this discussion!

    To help you better understand, nursing programs do in fact prepare students to handle the stress of providing care to others, as well as introduce them to the complex interpersonal relationships that they will experience as students. One thing that we have not been successful in teaching (as it is impossible to gauge this), is how to internalize and process how others act towards them. You may think it's over the top that we lose really good students to this type of situation, but it is no surprise that 60% of new graduates leave their first position within six months (Nurse.org, 2018) due to this exact same thing. Whether it is verbal abuse, such as a staff nursing telling one of my students "I hope you know you're going to fail!", or another staff nurse aggressively flailing their hands at a student because she asked "one too many questions", or whether it's simply because they feel like they are fighting an uphill battle without any support - we are losing too many good candidates to help bring nursing to the next level.

    Of course I can't speak for the other instructors you are mentioning in your descriptions, but I have experienced staff nurses exclaiming some of the same things about me and my students, and I'd like to clarify a few things:

    1) Each nursing instructor is limited to exactly how much "help" they can provide to the nursing staff each given day. For example, the school I teach for restricts how many patients I can assign per student, as well as how many patients I can administer medications to. All invasive skills, and medications must be supervised by the instructor, and sometimes its difficult to be with all eight or so students at once. For these reasons there may be some time where the students appear to be "hanging out".

    2) Each school of nursing has their own preassigned clinical coursework they want the students to complete during their clinical rotation. This may include days where they provide zero direct patient care. On these days, the students are to focus on that particular assignment only - so that they do not get distracted and miss essential information/data to help them complete their assignments. This may also lend to the issue of the students "sitting around and not helping."

    3) I must be frank and say that justifying hostility in any means is absolutely absurd, and it only exacerbates the chronic dysfunction that nursing faces on a daily basis. Please understand that I am very aware of all of the challenges you mention, and you are 100% correct in stating that the hospital environment has radically changed, which makes time for practically anything near impossible. Albeit true, this does not give professional nurses or nursing staff the right to act inappropriately to those trying to be a part of the solution.

    Lastly, please do not forget that nursing instructors are nurses too, and we fully understand the implications of protecting our patients and licenses. In fact, clinical assignments for our students are more calculated than a typical staff assignment because we are considering students' strengths, weaknesses, staffing preferences, and exposure to various learning experiences. I myself am very outgoing and make sure that I meet each staff member and provide them with a detailed plan for the students on each day.

    Again, I cannot speak for all of the other instructors you've worked with in the past, but one of the best things I can recommend to help resolve any issues you may be having is to directly communicate your feelings/concerns with the instructors directly. Each instructor should have an understanding that we are guests within the facilities, and should always do our best to accommodate the staff.

    Best,

    Damion
  8. by   Daisy4RN
    Quote from Damion Jenkins
    Thank you Daisy4RN, ADN for your continued contribution to this discussion!

    To help you better understand, nursing programs do in fact prepare students to handle the stress of providing care to others, as well as introduce them to the complex interpersonal relationships that they will experience as students. One thing that we have not been successful in teaching (as it is impossible to gauge this), is how to internalize and process how others act towards them. You may think it's over the top that we lose really good students to this type of situation, but it is no surprise that 60% of new graduates leave their first position within six months (Nurse.org, 2018) due to this exact same thing. Whether it is verbal abuse, such as a staff nursing telling one of my students "I hope you know you're going to fail!", or another staff nurse aggressively flailing their hands at a student because she asked "one too many questions", or whether it's simply because they feel like they are fighting an uphill battle without any support - we are losing too many good candidates to help bring nursing to the next level.

    Of course I can't speak for the other instructors you are mentioning in your descriptions, but I have experienced staff nurses exclaiming some of the same things about me and my students, and I'd like to clarify a few things:

    1) Each nursing instructor is limited to exactly how much "help" they can provide to the nursing staff each given day. For example, the school I teach for restricts how many patients I can assign per student, as well as how many patients I can administer medications to. All invasive skills, and medications must be supervised by the instructor, and sometimes its difficult to be with all eight or so students at once. For these reasons there may be some time where the students appear to be "hanging out".

    2) Each school of nursing has their own preassigned clinical coursework they want the students to complete during their clinical rotation. This may include days where they provide zero direct patient care. On these days, the students are to focus on that particular assignment only - so that they do not get distracted and miss essential information/data to help them complete their assignments. This may also lend to the issue of the students "sitting around and not helping."

    3) I must be frank and say that justifying hostility in any means is absolutely absurd, and it only exacerbates the chronic dysfunction that nursing faces on a daily basis. Please understand that I am very aware of all of the challenges you mention, and you are 100% correct in stating that the hospital environment has radically changed, which makes time for practically anything near impossible. Albeit true, this does not give professional nurses or nursing staff the right to act inappropriately to those trying to be a part of the solution.

    Lastly, please do not forget that nursing instructors are nurses too, and we fully understand the implications of protecting our patients and licenses. In fact, clinical assignments for our students are more calculated than a typical staff assignment because we are considering students' strengths, weaknesses, staffing preferences, and exposure to various learning experiences. I myself am very outgoing and make sure that I meet each staff member and provide them with a detailed plan for the students on each day.

    Again, I cannot speak for all of the other instructors you've worked with in the past, but one of the best things I can recommend to help resolve any issues you may be having is to directly communicate your feelings/concerns with the instructors directly. Each instructor should have an understanding that we are guests within the facilities, and should always do our best to accommodate the staff.

    Best,

    Damion
    I totally agree with and understand what you are saying. I would never condone hostility toward others but am merely pointing out issues that may lead a nurse to lose it. I do remember nursing school, how difficult it was, and would never want to do anything to hurt students. I think that just like most issues it is a problem with no easy answers. I had a lot of very good instructors in school and also have seen many good ones as a bedside nurse also. I am not saying that all Instructors are bad, I know that most work very hard and are caring people. I think that both Instructors and nurses are spread too thin which has a negative impact mostly on the students. I think that the bottom line of the almighty dollar is too blame and we are all collateral damage. It should change if we want to graduate and retain new nurses! Thank you for the article and for caring!!
  9. by   Damion Jenkins
    Thank you very much Daisy4RN, ADN for your thoughtful contribution to this discussion! I understand that you personally would not condone hostility - many of us rarely do. I am very happy that you fully understand the context and severity of this very important topic. Yes, we are all spread very thin, and this does add to the stress and frustration. I do believe however that we are fully capable of creating the necessary positive change - as long as we team up and join the collective front. Rather than taking our frustrations out on one another (which unfortunately happens all the dang time), we should do EVERYTHING we can to protect, empower, and demand growth for our colleagues and our profession.

    Thank you again for your supportive words, and I look forward to more collaborations in the near future!

    Best,

    Damion
  10. by   Decade1
    As a bedside nurse with 15 years of experience I am at the top of the pay scale. There is no more room for career growth for me financially. I got an accounting degree and am starting at the bottom in a career where I have the potential to make more income in the future. I continue working in nursing part time to supplement a beginner's salary, but as my accounting income grows I will leave the field altogether. This financial motivation is separate from my other concerns regarding lack of support, unsafe and poorly staffed shifts, and general dissatisfaction that prompted me to look into other fields. I do not think I am alone in taking this path.
  11. by   Damion Jenkins
    Thank you Decade1 for sharing and adding to this discussion! You are not alone in taking this sort of path out of the profession. In fact, we already know that a lot of nurses leave the profession altogether. Whether the reasons are financial in nature, or due to an unwillingness to endure the stress and abuse of bedside nursing, the attrition rates are alarming.

    One of the challenges that I provided for myself was to find a way to use my nursing knowledge and experiences to move up the pay scale.

    The first thing I realized VERY EARLY within my nursing career was that hospitals DO NOT SUPPORT their nursing staff they way they support other members of the healthcare team. Therefore I removed myself from a staff nurse position and pursued agency nursing. Initially I took contracts, and then eventually I enjoyed the freedom of picking my own schedule so I moved from contracts to per diem through a local agency.

    From there I served as an adjunct faculty at a local community college, and remained on a contractual basis. When I decided that I wanted even more control over my income and schedule - for example - not getting cancelled by the hospital I was picking up shifts, I decided to open my own nursing education and consulting business - The Nurse Speak.

    Here I help nursing students, new graduates and professional nurses alike develop strategies for success. I still use the per diem agency nursing as a means to supplement my income on slow weeks, but I have found myself empowered, and IN CONTROL of my schedule and income.

    So although I have not left the nursing profession altogether, I have shifted the power and control back to myself and I have never been happier in my role as a nurse!

    Good Luck to you!

    Best,

    Damion Jenkins, RN, MSN

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