Healthcare System Fail: Is This Why Nurses Are Overwhelmed?

[arthurbaird0]

One of my most memorable experiences was more than a decade ago while working for a Level One Trauma Center on the East coast. I was sitting in a hospital break room during one of my breaks as an inventory coordinator when a nurse walked in. I simply asked how her day was going and she fell into the chair next to me crying. Surprised by her reaction I asked "What's going on?" and she replied "I just lost my third patient today!" The impact of her personal experience stuck with me. Even now, looking back, I can't help but think how difficult a day it must have been for her.

Until that moment, my only experience with nursing had been as a patient. Seriously injured while serving on active duty, it was a nurse who saw me first and it was a nurse who discharged me from the hospital. It was a nurse who was responsible for all of my care. Like an air traffic controller, it was a nurse who coordinated my care as well as the care of many others.

The Most Overwhelming Parts of Nursing

What I didn't know at the time, but more than a decade later I would learn that the most overwhelming parts of nursing are the constant system failures. More than 30 percent of nursing time is spent hunting, fetching, and clarifying work not patient care. This is not the cause of any one person or processes, patient care has just evolved this way over time.

Fast forward more than decade and those experiences of stress and disappointment still exist for nurses. The reality here is that Health Care Organizations/Hospitals (HCO's) function in a way that requires nurses to focus more of their limited time and attention diagnosing systems needs rather than focusing on patients care. Nurses scrambling for linen, supplies, equipment, or waiting to clarify a medication prescription are just a few examples. It's all the unrelated system needs and its failures, not patient care, that adds real cost. Overburdened, a single nurse could be caring for as many as five to six patients struggling in a system that's failing him/her.

Between 2000-2007 Healthcare Spending Grew at Nearly 6%/Year

In recent years, the cost of healthcare has gotten a great deal of attention and with good reason. Between 2000 and 2007, healthcare spending grew at nearly six percent per year, a much steadier growth rate than inflation or wage growth. Future healthcare costs has even been a security concern--increases in healthcare spending are and will increasingly take money away from military readiness. Many scandalous stories about the costs of healthcare have been told. And while we share Americans' outrage at the cost of healthcare, there is some good news on the cost front: healthcare spending has been leveling off in recent years.

The Real Scandal of Healthcare

Progress on the cost of healthcare notwithstanding, there is a serious scandal in healthcare--the toll that healthcare takes on the people who deliver it. The burdens of regulation, cost reductions, and quality initiatives piled onto nurses and other clinicians are undeniable. The biggest current and future risk to health care is shortages of nurses and doctors. Especially in nursing, "there is growing evidence that the job people are asked to do is unreasonable and consequently moving people out of the profession"; emerging shortages are weighing down further the workload and feasibility of already overworked doctors and nurses.

In a recent study of forty hospital units, more than one third of nurses reported that they intended to leave their position within the next year; sighting emotional exhaustion and lack of personal accomplishment, two key indicators of nurse-burnout. "And as growing evidences has shown, nurse-burnout dramatically influences how satisfied patients are with their care."

The performance of nurses and their impact on quality is determined by many factors.

In the end, though, all research on the quality of nursing care either concludes the absolute necessity of support departments providing nurses with what they need, or assumes that these departments will do so. Put another way, treating nurses as customers is at the heart of all work on the quality of patient care by nurses.

Efficiency--how hospitals must operate--will loom large as the Affordable Care Act (ACA) is rolled out and sequestration cuts continue. Efficiency will equal profitability; without it continued financial pressures will mount. Leaving only two choices for HCO's/Hospital; open or closed!

[AJJKRN]

You are preaching to the choir! But thank you for singing your song!

[arthurbaird0]

Please read: The Scandal of Healthcare: Nurses, Waste & Customer Service. Amazon.com: The Scandal of Healthcare:: Nurses, Waste & Customer Service eBook: Colin Baird, David Sundahl, Adirondack Editing: Kindle Store One reader of the book wrote "This book is as true as it gets.It is not for the nurses, they live it. It is for the Leaders and Managers that create those internal processes that the nurses work in." Another wrote "Baird and Sundahl aptly portray a refreshing look at our healthcare system at the day-to-day operations level. However, most importantly they present the reader with a roadmap of how to fix the problems plaguing the system:

Best Regards

[OldDude]

I have often said the hospitals have never had a nursing shortage. They have continued to operate, unaffected, in regard to patient census as indicated above. It's the nursing profession that has shouldered the nursing shortage and we are really starting to see the effects of that now. Well written.

[arthurbaird0]

Thank you! Nurses are the backbone of healthcare!

Best Regards

[Susie2310]

There are problems and failures in the healthcare system in regard to nurses feeing overwhelmed, but apart from the advent of the more widely used EHR for nurses, and increased documentation requirements, I do not feel that your post really addresses them. When I became a nurse 20 years ago, it was not uncommon for nurses on med-surg units in my area to have 10-12 patients with an aide. There was a larger number of experienced nurses in the work force then in my area, and newer nurses had more access to experienced nurses to ask for help. The experienced nurses who were really good nurses managed their time well, prioritized well, and took a pride in delivering quality nursing care. In spite of the high patient ratios, patients were still bathed daily or asked if they would like assistance with bathing, and then assisted. Back then, to survive as a nurse on a med-surg unit, you had to be a very good nurse.

Today, there are more inexperienced nurses working, not just in med-surg, but in areas that in my area 20 years ago were staffed mainly by experienced nurses, such as the ED. From what I have seen and experienced, the quality of patient care has deteriorated. I do not see a shortage of nurses in my area; the community colleges and universities are producing new graduate nurses relentlessly, and the health care facilities in my area do not suffer from a shortage of nurses; the shortage is of experienced nurses, but this has been by design; i.e. mass recruitment days for new nurses, and other methods such as choosing to hire nurses with only a few years of experience. None of these problems are accidents, or results of system failures that one cannot trace the cause of.

Another reason for nurses feeling overwhelmed is to do with changes in nursing education: Nursing students 20 years ago in ADN programs in my area received a lot of clinical experience in acute care facilities, providing hands on nursing care under the guidance of their clinical instructor. They were ready to begin an entry-level position in an acute care hospital without prolonged internships/preceptorships etc. They had been trained in the basics, had some experience of providing patient care and managing their time, had been taught how to practice safely, and knew when to ask for help from more experienced nurses. They had reached the beginning. Today I read about students who spent the majority of their nursing clinical time in simulation labs, or spent the majority of their clinical time "observing" patient care, or spent time in the conference room on the unit during clinical time working on their care plans.

I think too that it is more common today for people to train as nurses without even really having the desire to take care of patients physically, and it seems people often do not factor in the realities of the 24 hour nature of nursing care, and are overwhelmed by discovering that they are expected to work shifts and unsocial hours, holidays, etc. Another point is that patients today generally have to be very sick to be admitted to hospital, and I see more unstable patients on med-surg units than I used to. A combination of everything I have written above leaves me in doubt as to why many nurses are overwhelmed.

[arthurbaird0]

Today the nursing station is all but gone. Medication frequency, dressing changes, and other prescribed care are ordered from a computer located in a patient's room, or just outside the door. In a scenario we have seen repeated hundreds of times, a nurse hurries to get medication, which is nowhere near the patient's room. As the nurse hustles to the med room, her aide asks for help with another patient, which delays the nurse's ability to deliver her original patient's meds. Now already several minutes behind in getting medication, the nurse is assessing another patient who, say, needs supplies too. But unfortunately, those supplies are stocked in a different room from the medication. Leaving to get both, the nurse runs into a family member there to see their loved one. It just so happens to be her patient, and that patient needed their medication seven minutes ago. She provides a quick update and tells the family member they can see their loved one, and that she'll be right back. But then Transport calls. They're running late, which delays a patient's discharge, the one who's still waiting for the medication.

At present, nursing is a decentralized system of continually changing needs. As seen in the preceding paragraph, the failure to connect services to nurses increasingly burdens the daily activities of nursing. The difficulty arises for nurses because while nursing activities aredecentralized, supporting services remained centralized. This mismatch in operational processes ensures each nurse will spend time hunting for, fetching, and clarifying what their patients need. This is further complicated by frequent failures in these mismatched processes. It's certainly true nurses need to be available for the patient. But when nurses aren't available, it's primarily due to hospital operations failing to meet the needs of nurses as the principal providers of care to patients.

[Susie2310]

There are problems and failures in the healthcare system in regard to nurses feeing overwhelmed, but apart from the advent of the more widely used EHR for nurses, and increased documentation requirements, I do not feel that your post really addresses them. When I became a nurse 20 years ago, it was not uncommon for nurses on med-surg units in my area to have 10-12 patients with an aide. There was a larger number of experienced nurses in the work force then in my area, and newer nurses had more access to experienced nurses to ask for help. The experienced nurses who were really good nurses managed their time well, prioritized well, and took a pride in delivering quality nursing care. In spite of the high patient ratios, patients were still bathed daily or asked if they would like assistance with bathing, and then assisted. Back then, to survive as a nurse on a med-surg unit, you had to be a very good nurse.

Today, there are more inexperienced nurses working, not just in med-surg, but in areas that in my area 20 years ago were staffed mainly by experienced nurses, such as the ED. From what I have seen and experienced, the quality of patient care has deteriorated. I do not see a shortage of nurses in my area; the community colleges and universities are producing new graduate nurses relentlessly, and the health care facilities in my area do not suffer from a shortage of nurses; the shortage is of experienced nurses, but this has been by design; i.e. mass recruitment days for new nurses, and other methods such as choosing to hire nurses with only a few years of experience. None of these problems are accidents, or results of system failures that one cannot trace the cause of.

Another reason for nurses feeling overwhelmed is to do with changes in nursing education: Nursing students 20 years ago in ADN programs in my area received a lot of clinical experience in acute care facilities, providing hands on nursing care under the guidance of their clinical instructor. They were ready to begin an entry-level position in an acute care hospital without prolonged internships/preceptorships etc. They had been trained in the basics, had some experience of providing patient care and managing their time, had been taught how to practice safely, and knew when to ask for help from more experienced nurses. They had reached the beginning. Today I read about students who spent the majority of their nursing clinical time in simulation labs, or spent the majority of their clinical time "observing" patient care, or spent time in the conference room on the unit during clinical time working on their care plans.

I think too that it is more common today for people to train as nurses without even really having the desire to take care of patients physically, and it seems people often do not factor in the realities of the 24 hour nature of nursing care, and are overwhelmed by discovering that they are expected to work shifts and unsocial hours, holidays, etc. Another point is that patients today generally have to be very sick to be admitted to hospital, and I see more unstable patients on med-surg units than I used to. A combination of everything I have written above leaves me in doubt as to why many nurses are overwhelmed.

Sorry, I made a typo; the last sentence of the last paragraph should read: "A combination of everything I have written above leaves me in NO doubt as to why many nurses are overwhelmed."

[emmy27]

It's a source of constant frustration to me that the default setting for so many processes is "nursing will do that," even if it's a process entirely encompassed by another allied health profession. Nursing will do the checklist, nursing will call to confirm, nursing will clarify the order with the doctor, even if the order is for a diagnostic or therapy administered by another department. Nursing will wipe up the spill before housekeeping touches it, nursing will confirm the appointment, nursing will check with pharmacy AGAIN for the same drug for the fourth time since it was missing at 1000 medpass, nursing will redraw because the lab tech doesn't want to come back up, nursing will clean the room between patients, nursing will fill out the chart audits, nursing will do the patient satisfaction followup calls... any new task or task that falls between departments will default to nursing.

If we could bill for our ACTUAL services, the things we do that actually require nursing skills, they would find better, more efficient ways to accomplish all these secretarial/organizational functions. But as long as we're perceived as a cost center rather than a profit center, they will keep adding tasks to the job description, and staff departments that can bill will keep telling us they'll come back when we've "got it figured out" as they walk away.

[APRN., DNP, RN, APRN, NP]

I just spent almost two years of my life specializing in a Masters degree in nursing to focus on this very same issue. I would love to be able to help, and there are more and more of us winding up on units and helping to make a difference. It is just happening very, very slowly.

[Susie2310]

If we could bill for our ACTUAL services, the things we do that actually require nursing skills, they would find better, more efficient ways to accomplish all these secretarial/organizational functions. But as long as we're perceived as a cost center rather than a profit center, they will keep adding tasks to the job description, and staff departments that can bill will keep telling us they'll come back when we've "got it figured out" as they walk away.

Most nurses appear to prefer to be employees then to be independent contractors. Nurses can establish themselves as independent contractors, and can bill for their services, and some do, but the majority of nurses work in hospitals as employees. I think most people become nurses expecting and wanting to be employees, and employees do not have the independence independent contractors do. Health care facilities I am familiar with contract with providers from different specialties who provide services as part of specialty medical groups, such as radiology, emergency physicians, laboratory services, etc; but I don't believe there is a large desire within the nursing profession for nurses to establish themselves as independent contractors in the same way.

[kdkout, BSN, RN]

There are problems and failures in the healthcare system in regard to nurses feeing overwhelmed, but apart from the advent of the more widely used EHR for nurses, and increased documentation requirements, I do not feel that your post really addresses them. When I became a nurse 20 years ago, it was not uncommon for nurses on med-surg units in my area to have 10-12 patients with an aide. There was a larger number of experienced nurses in the work force then in my area, and newer nurses had more access to experienced nurses to ask for help. The experienced nurses who were really good nurses managed their time well, prioritized well, and took a pride in delivering quality nursing care. In spite of the high patient ratios, patients were still bathed daily or asked if they would like assistance with bathing, and then assisted. Back then, to survive as a nurse on a med-surg unit, you had to be a very good nurse.

Today, there are more inexperienced nurses working, not just in med-surg, but in areas that in my area 20 years ago were staffed mainly by experienced nurses, such as the ED. From what I have seen and experienced, the quality of patient care has deteriorated. I do not see a shortage of nurses in my area; the community colleges and universities are producing new graduate nurses relentlessly, and the health care facilities in my area do not suffer from a shortage of nurses; the shortage is of experienced nurses, but this has been by design; i.e. mass recruitment days for new nurses, and other methods such as choosing to hire nurses with only a few years of experience. None of these problems are accidents, or results of system failures that one cannot trace the cause of.

Another reason for nurses feeling overwhelmed is to do with changes in nursing education: Nursing students 20 years ago in ADN programs in my area received a lot of clinical experience in acute care facilities, providing hands on nursing care under the guidance of their clinical instructor. They were ready to begin an entry-level position in an acute care hospital without prolonged internships/preceptorships etc. They had been trained in the basics, had some experience of providing patient care and managing their time, had been taught how to practice safely, and knew when to ask for help from more experienced nurses. They had reached the beginning. Today I read about students who spent the majority of their nursing clinical time in simulation labs, or spent the majority of their clinical time "observing" patient care, or spent time in the conference room on the unit during clinical time working on their care plans.

I think too that it is more common today for people to train as nurses without even really having the desire to take care of patients physically, and it seems people often do not factor in the realities of the 24 hour nature of nursing care, and are overwhelmed by discovering that they are expected to work shifts and unsocial hours, holidays, etc. Another point is that patients today generally have to be very sick to be admitted to hospital, and I see more unstable patients on med-surg units than I used to. A combination of everything I have written above leaves me in doubt as to why many nurses are overwhelmed.

This. Totally agree. I'm seeing this too, as a RN with 20 yrs experience, who precepted for much of it. Some new grads, often the young ones with little life experience, do not seem to think they will be working weekends, holidays, nights and have a sense of entitlement about not doing so right out of school. Some have unrealistic expectations of what the job entails, I suspect because they "drank the koolaid" from their schools and werent really told. I often see them coming out schools VERY inexperienced. I am guessing that these days you can generally find some college that will take you because ultimately all colleges want your money. With our litigious society in the U.S. I've heard from teachers that it can be very hard to "weed out" the kids who should not be in the nursing program. People are ready to sue. Hospitals are happy to hire that inexperienced new grad because they are cheap, healthcare is a business like anything else, and ultimately it's about money.

Even when I was getting my BSN in the 90s, I suspected that I was not being adequately prepared for the "real world" of nursing. We were "babied" in our clinicals & rarely had patients of our own. I'd talk to the "old" diploma nurses that would discuss how they basically "ran the unit" while in school....and yet we had to consult with our teacher for every little thing. (I do understand why). I sucked at clinicals because I feared the judgement of my instructors and would often "freeze" under stress. What did I do? I took CNA jobs, & later I got a job as a Patient Care Tech. In the state I was in, a PCT was essentially an LPN. And, most importantly, when I worked I worked my butt off and all but begged the nurses to teach me, let me watch procedures, etc. They were more than happy to do so since I was eventually going to be one of them....and because they were more my coworkers and peers and not grading me, I was able to learn so much more.

This is what I wish for many new grads. I wish they'd get "real" internships in the areas they hope to work in. I wish they got "real" jobs while in school so they had some experience when they came to me. I wish I didnt have to teach them some basics about life and having a job, in addition to teaching them about the actual nursing job. It can be really hard to be a preceptor in those situations.