I've been a member of my hospital's newly established nurse retention committee for the past few months. I represent 1/2 of our large med-surg floor. After much discussion and brainstorming about retention ideas, I decided to write a letter to my manager and unit director as well as 2 other senior managers and the CEO of the hospital. The letter basically stated that, after almost 10 years as a med-surg nurse, I'm convinced that the only way to retain nurses on our floor is to reduce the nurse to patient ratio. More money won't keep burned-out nurses at the bedside in the long run. Large recruitment bonuses will not KEEP a nurse in a chaotic, stressful environment for very long. Morale is bad, quality of patient care is down, while I think more errors are occuring. I also sited statistics from the 2002 Aiken study in my letter. http://www.dpeaflcio.org/policy/factsheets/fs_aiken.htm
We are averaging 6 to 7 patients for all shifts, 1 PCT (aide) for 12 to 18 patients some evenings I work. Acuity is not a consideration in patient assignments and staffing, and we're told that this is the "benchmark" or "norm" for med-surg units in most hospitals, and that is why we are staffed the way we are.
BUT-- If you're having trouble RETAINING your nurses and you can't RECRUIT new nurses, in spite of throwing money at them, wouldn't it be wise to consider reducing the ratios and investing that money in hiring additional help? From the Aiken study: "RNs working in hospitals with the highest patient-to-nurse ratio are twice as likely to be dissatisfied with their position and experience job-related burnout as those working in hospitals with the lowest patient-to-nurse ratio. By increasing RN staffing levels and thereby lowering the patient-to-nurse ratio, hospitals could reduce turnover rates by decreasing the job dissatisfaction and burnout that may lead to resignation." (I keep having this overwhelming desire to say DUH!) Also from the study: "Satisfactory nurse-to-patient ratios can save money as well as saving lives and decreasing RN turnover. Estimates indicate that the cost of replacing a hospital medical and surgical general unit nurse... as $42,000."
I know from reading many threads here at allnurses that 6-7 patients is generally the norm on med-surg. If my 6 patients are self- to partial-cares and none have a serious problem during my shift, I can certainly be busy, but not inordinately; I may even be able to leave the floor for a 30 minute dinner break. But USUALLY, I'm running almost my entire shift (I work 3-11) with post-ops, admissions, patients going for tests, calling doctors, hanging blood, covering LPN's patients, etc. etc. etc. I'm almost embarrassed to say we have an IV team, so we don't start our own IV's, and yet I hear that many of you have to draw your own blood for labs, start IV's, do respiratory treatments in addition to your patient load..... How do YOU do it all? Do you have more nurse's aides? I'm having trouble just managing 6-7 patients and I fortunately have IV nurses and phlebotmists to help. Nurses who work med-surg will also know that some nights, just THREE patients can be a lot of work, depending on their problems and acuity.
Anyway, a meeting is being scheduled with me and the 4 managers I wrote, and I guess they'll then report to the CEO. I'm not worried; I wrote a respectful but truthful letter about our med-surg working conditions, and I'm not afraid to talk about them. I want to work med-surg; I have no desire to work anywhere else, but I can't stand to see unhappy, stressed-to-the-max co-workers, to not be able to give the kind of care I'd like to give, to see new nurses and new hires bail after a few months, and to often dread going to work myself.
Does anyone have any words of wisdom I can take with me for the meeting?
Don't be surprised if the suits shoot down every good reason you give them for changing the status quo. I went throught this and in the end, NOTHING changed. We got lots of promises but no action. Nurses have left in large numbers, they are not able to fill positions or keep new staff longer than 1 year. Hope it turns out better for you, but a staffing quota by legistative means is the only answer.
One more idea... maybe from left field but it's based on the things I hear from my wife (an RN). I know that hospitals charge the insurance companies for everything. So, the better the people on the floor can document (# of aspirins, #of treatments, #number of foleys, etc) the more accurately they can pass those costs along. If you can make a case that more staff will help "capture" those billable items it should help you. Perhaps point out that there is a gap between the supplies that come to the floor and the supplies that are charged and that more staff could help with that? Again, maybe from left field since this isn't my profession (yet) but it's another area of money that should get their attention.
And, as I mentioned above, there's the issue of what we in industry call rework. If a treatment isn't done when it should be, and complications arise, and the patient must stay in the hospital longer, does that cost the institution money? The answer here might be "No" but, something to think about.
Thanks for the ideas-- I'm willing to try anything if it lowers the nurse to patient ratios, but I also don't want to saddle nurses with more paperwork and time away from patients. I already implemented a cost-saving program on our units to try to save money with patient hygeine supplies. We also have a hospital-wide program where you can make suggestions and offer ideas to improve care or systems, and I suggested what you did about charging patients more directly for supplies and meds, but was told that the current system of budgeting certain flat amounts for each unit was somehow better than keeping track of each patients' supply usage.
Hmmmmmmmmmm...... if you don't have access to the numbers. Perhaps just use your best intuition as to where the money will be found with more staff. Use lots of phrases like "save money, reduce budget and expenses, increase revenue, decrease costs."
"I believe we will decrease employee turnover and reduce hiring, training, and the expenses of termination by....."
"I'm sure you will agree that better patient outcomes can lead to higher national rankings for our hospital and future growth...."
Maybe volunteer to work with the bean counters to quantify some of this?
It's always best to already have the numbers. But, second best is to appear that you absolutely know what you're talking about and that, of course, no one could possibly disagree with you. Especially if you are willing to work with them to verify things.
You need to prove that it is cheaper to retain than to hire. Suggest you try and find out what is the cost-to-hire at your hospital (check with HR), what are the training costs for a new RN (orientation), what is the turnover rate, retention rate, etc.??? If you can't find out the exact hospital figures you might do a search on Goggle for retention issues.
Don't be surprised if the suits shoot down every good reason you give them for changing the status quo. I went throught this and in the end, NOTHING changed. We got lots of promises but no action. Nurses have left in large numbers, they are not able to fill positions or keep new staff longer than 1 year. Hope it turns out better for you, but a staffing quota by legistative means is the only answer.
Please let us know how it goes.
*SIGH* :stone I know. I feel prepared for that, especially with the one manager whose rank is just below the CEO's I think.
How can they NOT see the costs-- financial and otherwise-- of continually losing and replacing staff?
Originally posted by Ned the Red
Hmmmmmmmmmm...... if you don't have access to the numbers. Perhaps just use your best intuition as to where the money will be found with more staff. Use lots of phrases like "save money, reduce budget and expenses, increase revenue, decrease costs."
"I believe we will decrease employee turnover and reduce hiring, training, and the expenses of termination by....."
"I'm sure you will agree that better patient outcomes can lead to higher national rankings for our hospital and future growth...."
Maybe volunteer to work with the bean counters to quantify some of this?
It's always best to already have the numbers. But, second best is to appear that you absolutely know what you're talking about and that, of course, no one could possibly disagree with you. Especially if you are willing to work with them to verify things.
"save money, reduce budget and expenses, increase revenue, decrease costs." "save money, reduce budget and expenses, increase revenue, decrease costs." "save money, reduce budget and expenses, increase revenue, decrease costs." (I'm practicing my new mantras-- )
Seriously, though, I will be printing out your ideas and discussing them with my husband who I know would suggest similar emphases, especially the one about "I'm sure you will agree that better patient outcomes can lead to higher national rankings for our hospital and future growth...." because they are looking into the possibility of attaining magnet status.
Thanks again, Ned the Red and to others who've responded!
You need to prove that it is cheaper to retain than to hire. Suggest you try and find out what is the cost-to-hire at your hospital (check with HR), what are the training costs for a new RN (orientation), what is the turnover rate, retention rate, etc.??? If you can't find out the exact hospital figures you might do a search on Goggle for retention issues.
Thanks, I'll see what I can find out. The one manager on the retention committee who encouraged me to send the letter in the first place is a good ally, and I'll see if she can help me get more facts and figures. I'm not sure that HR issues aren't confidential, though.
The only fact I have is a general one which I sited in my first post from the Aiken study, "Estimates indicate that the cost of replacing a hospital medical and surgical general unit nurse... as $42,000." Again, I'll see if the retention committee manager can help me with more specifics for our hospital.
Best of luck to you. The med-surg nurses in my hospital have a terrible job. I hope you can do something to help your staff.
Thank you! It seems to be the same everywhere with med-surg. Reading med-surg nurses' comments here at allnurses on various threads since I've been a member has heightened my awareness of the poor working conditions and staffing in this specialty, and it's way past time for a change. Even on the retention committee meetings where most units in the hospital have a representative, they speak about us med-surg nurses with pity in their eyes and sympathy in their voices.
I actually got off the floor for dinner this past weekend and ate with a PCT in nursing school and a newly graduated RN. The PCT said she would not want to be a patient on our floor and would never work our floor after graduation after what she sees. The new RN said she would not stay long on our floor and would look to another hospital for a job. When I asked her if she thought conditions would be different at another hospital, she said she thought they would be. But I don't think so. I worked at another hospital in the area for 4 years and I can say it was worse than the one where I'm currently employed. We had 6 patients, NO aides, AND started our own IV's. I have no idea how I lasted as long as I did.
The meeting with management was yesterday and, overall, I feel fairly positive about the meeting itself. I'm feeling less positive about the possible results of it today, though.
They went over points I made in my letter and I mentioned up front that I didn't want this to feel adversarial in my letter or the meeting, but that we want the same thing: To retain nurses. I gave specifics about the conditions, mentioning that it's not a true 1 to 6-7 patients ratio because RN's have to sometimes take on LPN's patient problems in addition to their own, due to LPNs' scope of practice. (RN's have to do all admission assessments, initiate care plans, do IV push meds, hang blood products, take patients with PCA's or epidurals, call for and sign off doctor orders, etc. etc. We are frequently staffed with 2 RN's and 2 LPN's.)
As far as talking numbers and money, I spoke about all the costs beyond the $42,000 it costs to replace a med-surg nurse if the working conditions didn't improve including: Overtime paid in missed meals and staying late (I had 5.25 hours overtime in the last pay period for working 5 8-hour shifts), increased potential for med. errors, increased potential for patient safety problems (like falls), increase in patient care problems due to infrequent turning and hygiene care (incontinence), increase in sick days due to mental health days or stress-related illness, increased potential for injury of staff, higher acuity patients needing more observant nursing care with subtle changes in condition being missed, and a few other details.
I asked for more PCT (aide) help, but I was told there isn't enough money for them, and because we live in a more affluent area, it's difficult to attract people who want to be PCT's beyond nursing students who come and go.
They are hiring nurses to work 4 hours during a period where there are holes in staffing and we work short-staffed between 3 p.m. and 7 p.m. They also are considering hiring an RN to work the floor between around 1 p.m. and 9 p.m. when we have the most activity (admissions, post-ops, transfers, etc.) just to do stuff for LPN's like Dr. calls, sign off orders, do admissions, etc.
I also mentioned hospital-wide "systems" that are making our jobs more difficult-- problems with pharmacy, supplies, housekeeping, and the like.
All in all, I was able to say almost everything I had wanted to, and the tone was very positive and constructive. I didn't get emotional, and I felt they were empathic about the nursing situation, but thinking it through today, I don't think that much was accomplished. Only time will tell.... How many more nurses will quit? Will it be a patient's family suing over poor care that will finally cause changes in ratios?
New Analysis Confirms Direct Link Between Nurse Staffing and Patient Complications and Deaths in Hospitals
Press Release Date: May 29, 2002
Analysis of data on nurse staffing levels confirms that there is a direct link between the number of registered nurses and the hours they spend with patients and whether patients develop a number of serious complications or die while in the hospital.
Funded by the Agency for Healthcare Research and Quality (AHRQ), investigators reexamined and refined their previous analysis released by the Health Resources and Services Administration (HRSA) in April 2001 as part of an ongoing collaboration within the Department of Health and Human Services to improve nursing care in American hospitals. The partnership also included AHRQ, the Centers for Medicare and Medicaid Services, and the National Institute for Nursing Research.
The original HRSA report and the new analysis, which is being published in the May 30, 2002, issue of the New England Journal of Medicine, were conducted by Jack Needleman, Ph.D., of the Harvard School of Public Health, and Peter Buerhaus, Ph.D., R.N., F.A.A.N., of the Vanderbilt University School of Nursing.
"AHRQ was very pleased to be a partner in this important project to ensure that we fully understand the significant role that nurses play in ensuring that patients have safe hospital stays and are discharged in better health than when they were admitted," said Carolyn Clancy, M.D., AHRQ's acting director. "We now must use this information to work together to resolve the nursing shortage in American health care and to make sure that nurses have adequate education and improved working conditions."
Needleman, Buerhaus, and their colleagues, reviewed their original discharge and staffing data from 799 hospitals in eleven states--California, New York, Maryland, Virginia, West Virginia, Arizona, Massachusetts, Missouri, Nevada, South Carolina, and Wisconsin--to estimate nurse staffing levels for RNs, LPN/LVNs, and aides, as well as the frequency of a wide range of complications that patients developed during their hospital stay. These data cover 6 million patients discharged from hospitals in 1997.
Specifically, they confirmed their initial findings that low levels of RNs among a hospital's nurses were associated with rates of serious complications such as pneumonia, upper gastrointestinal bleeding, shock, and cardiac arrest, including deaths among patients with these three complications, as well as sepsis or deep vein thrombosis. These complications occurred 3 to 9 percent more often than in hospitals with higher RN staffing.
Both studies also found that rates for urinary tract infections, a less serious but common infection among hospital patients, and length of time spent in the hospital were also higher in hospitals with lower RN staffing. When comparing hospitals, the study controlled for how ill patients were in different hospitals and differences across hospitals in how likely patients were to suffer these complications.
Researchers again found an association between nurse staffing and deaths from more serious complications, but they found no evidence of an association between nurse staffing and overall deaths among medical or surgical patients.
"Low RN staffing at hospitals makes it more likely that some patients will suffer pneumonia, shock and cardiac arrest, and gastrointestinal bleeding, and that some patient may die as a result," said Dr. Needleman. "We will need to address nurse staffing in hospitals if we are going to prevent these complications."
"This research clearly shows that we need more and better-educated nurses to ensure that hospitals patients don't suffer needlessly from complications," said Dr. Buerhaus. "However, we need more research to understand the factors influencing nurse staffing levels and the mix of different types of nurses working in a particular hospital."
New Analysis Confirms Direct Link Between Nurse Staffing and Patient Complications and Deaths in Hospitals. Press Release, May 29, 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/press/pr2002/dilinkpr.htm
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barefootlady, ADN, RN
2,174 Posts
Don't be surprised if the suits shoot down every good reason you give them for changing the status quo. I went throught this and in the end, NOTHING changed. We got lots of promises but no action. Nurses have left in large numbers, they are not able to fill positions or keep new staff longer than 1 year. Hope it turns out better for you, but a staffing quota by legistative means is the only answer.
Please let us know how it goes.