So I am taking a graduate level research class, and my textbook keeps talking about how there are all of these great care models shown to improve outcomes for patients that aren't being utilized in practice. I just keep thinking about how nurses NEVER have ANY time, and this is probably contributing greatly to the lack of research in practice. It seems like the problem is getting worse and in some cases practice is not only not evidence-based, it's not even safe. Then good nurses stop being nurses because expectations are impossible.
I guess I'm wondering if anyone has any ideas on how to improve staffing ratios? There is evidence out there that the role of the nurse as an educator is as important. How do nurses get the time they need to serve as effective clinicians?
I've read other posts with suggestions like, "cut the CEOs salary", which is a nice idea, but not likely to happen without some sort of catalyst. Does anyone know what the catalyst could be?
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
Regarding the comment that California nurses are getting paid high already. You have to realize that the Centers for Medicare and Medicaid Services factor in the wage index of a specific locality when they determine the cost of in-patient services in a hospital. Hospitals still use DRG related in-patient prospective payment systems (certain diagnoses has a money value attached to it). These rates are further adjusted based on the wage index which translates into the cost of paying employees such as nurses that provide care. If this is not done, hospitals in high cost of living cities would close.
California unions are able to secure higher compensations for nurses because of the high cost of living here in addition to making sure safe staffing is upheld with the mandatory nurse to patient ratio law in acute care hospitals. There have been publicized cases in other states where multiple hospital systems in specific metro areas have conspired to keep their nurses hourly pay similar with little yearly increases to account for cost of living as a way to control nurses' salaries despite the fact that wages are factored in the insurance payment.
Nurses could bill for a set amount for standard med surg care, (8 hrs vs 12 hour shifts), number of patients assigned ( med surge 4:1 ratio, with double paid for over four patients), with add on like, dressing changes, drips, etc, Critical care would bill for the higher amount of care nursing care administered, like 1:1 care. titrating vaso active drips, etc.
There would be set amounts for each item that we could bill for. It could be done. Cost of living in the area, would be factored into what would be charged. A fancy, state of the art Teaching Facility, like UCLA, could charge more.
It can be done. Nurses do not have the drive to get paid what they are worth. The are content to be overworked, and underpaid.
The infighting in nursing is our down fall. Areas of nursing like critical care should have a higher pay scale than med surge. Sorry folks. The shill set a nurse brings to critical care is far and above what ER, Med Surg, OB, Dialysis does.
We had a dialysis nurse who would come to the unit for in patient dialysis. She saw the nurses, "just sitting there watching the monitors", and thought that we had the easiest job in the world.
An full time day shift became open and she applied for it. She went through the entire orientation, but she was still struggling.
One day she had to take a patient down for a CT scan, and the patient coded. She had to help run the code, we sent a nurse down to help her. She freaked, and resigned the next day and wet back t to dialysis.
She realized that critical care nurses do more than sit and watch monitors. ER nurses may have vented patients, and or drips, but they are not there for the very long. Supervisors make it a priority to get these patients to the init ASAP. We frequently sent an ICU down to the ER to care for the patient, and then would take the patient up to the unit when the bed was available. The are not cared for or managed on the long term by the ER staff.
Nurses could bill for a set amount for standard med surg care, (8 hrs vs 12 hour shifts), number of patients assigned (med surge 4:1 ratio, with double paid for over four patients), with add on like, dressing changes, drips, etc, Critical care would bill for the higher amount of care nursing hours provided, like 1:1 care. titrating vaso active drips, etc.
There would be set amounts for each item that we could bill for. It could be done. Cost of living in the area, would be factored into what would be charged. A fancy, state of the art Teaching Facility, like UCLA, could charge more.
It can be done. Nurses do not have the drive to get paid what they are worth. The are content to be overworked, and underpaid.
The infighting in nursing is our down fall. Areas of nursing like critical care should have a higher pay scale than med surge. Sorry folks. The skill set a nurse brings to critical care is far and above what ER, Med Surg, OB, Dialysis does.
We had a dialysis nurse who would come to the unit for in patient dialysis. She saw the nurses, "just sitting there watching the monitors", and thought that we had the easiest job in the world.
An full time day shift became open and she applied for it. She went through the entire orientation, but she was still struggling.
One day she had to take a patient down for a CT scan, and the patient coded. She had to help run the code with the ER docs, we sent a nurse down to help her. She freaked over the whole thing, and resigned the next day and wet back t to dialysis.
She realized that critical care nurses do more than sit and watch monitors. ER nurses may have vented patients, and or drips, but they are not there for the very long. Supervisors make it a priority to get these patients to the unit ASAP. We frequently sent an ICU down to the ER to care for the patient, and then would take the patient up to the unit when the bed was available. The are not cared for or managed on the long term by the ER staff.
Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
And dialysis and other nurses have different skill sets, but that damn sure does not make us worth less than the critical care nurse. No area of nursing is "easy", and I speak for OB, GYN, float pool and currently, my specialty, dialysis.
A day in dialysis where I work can go well, all systems go---- and go to hell in the form of a code in minutes. And we have a large number of patients in our load----and technicians we supervise. We typically have in our care, the monitoring and the treatment of anywhere from 12 to 16 patients each nurse, EACH SHIFT (4 hours). Our unit runs 3-4 shifts per day so that is a lot of patients. The multiple morbidities of each patient complicate what should seem to be "straight-forward" treatments. Things change quickly in treatment and we are "it" if a patient crumps or codes until we can get EMS to help out.
The paperwork is mountainous----constant, and keeps us busy once we are done assessing, assisting technicians and medicating our patients. The day is never "over" really, just the shift. There is always something to do there, if I am sitting doing nothing, something important is not getting done.
It may not be your typical adrenalin-junkie job, but it sure as hell ain't "easy" either.
You are not "worth more" than I am by virtue of being in ER or ICU, wherever. I have done hospital nursing for years.......floated to ICU/ER. I know they are not easy, but they are "different".
That dialysis nurse you talk of was clueless and she did not represent the rest of us. We know better.
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
Personally, I feel that nursing can use a similar approach as physician (and APRN/PA) billing. As a provider, the history and physicals as well as daily progress notes I write are billed according to rules of Evaluation and Management (E&M) set by insurance companies. The complexity of the patient presentation, the degree of decision making involved, and the acuity of the diagnosis determine the E&M level - the more complex the E&M level the higher the payment.
That means a physician or NP who wrote an appropriately extensive and detailed physical examination with corresponding detailed diagnoses and plan of care gets to bill at the highest level in providing care to a specific patient on a given day. These are sometimes expressed more succintly in the provider's S-O-A-P note (subjective complaints, objective data, assessment, and plan).
Similar to Medicine, Nursing as a separate profession has developed its own set of guidelines in assessing, planning, implementing, and evaluating nursing care provided to patients - it's the dirty phrase called "nursing process". We could document a nursing care plan for each patient we encounter daily and use the information to come up with acuity codes similar to E&M codes providers use. We already use nursing diagnoses and we have a set of standardized NIC/NOC. It's just a matter of translating this data into a computer that determines the level of complexity of nursing care required.
Physicians (and APRN/PA) also bill for specific procedures performed. Every procedure in the book has an assigned CPT code. I bet you foley catheterization and peripheral IV insertion has CPT codes if you look it up. So why can't a dollar amount be attached to those CPT codes for nursing?
Specializes in ACNP-BC, Adult Critical Care, Cardiology.
RUG scores determine a payment amount given via Medicare Part A towards care of a SNF resident that is "needs-based". A SNF resident who requires many hours of PT/OT/SLP gets a higher RUG score as well as one who requires IV antibiotics. While it accounts for the required nursing manpower, it's not exactly a way for nurses to bill for their services.
Payment via Medicare Part A is a bundled amount that facilities use to pay nursing care, housekeeping, etc. Physicians and other licensed providers who provide care to SNF residents are paid via Medicare Part B and it's an amount directly awarded to the provider not the SNF. PT/OT/SLP services are also billed individually separate from the Medicare Part A payment the SNF gets.
It can be done. Nurses do not have the drive to get paid what they are worth. The are content to be overworked, and underpaid.
I was gonna post something against TOS, but I'll settle for STEP OFF!
The infighting in nursing is our down fall.
Right after saying this you go on with:
Areas of nursing like critical care should have a higher pay scale than med surge. Sorry folks. The skill set a nurse brings to critical care is far and above what ER, Med Surg, OB, Dialysis does.
Showing you're perfectly happy to pit nurses against each other when it benefits you and your pet causes. And to insult other nurses and their skills.
Specializes in UR/PA, Hematology/Oncology, Med Surg, Psych.
The infighting in nursing is our down fall. Areas of nursing like critical care should have a higher pay scale than med surge. Sorry folks. The skill set a nurse brings to critical care is far and above what ER, Med Surg, OB, Dialysis does.
JMHO and my NY $0.02
Lindarn, RN, BSN, CCRN (ret)
Somewhere in the PACNW
Seriously? I work Oncology and my skill set is not as large as a critical care nurse? Every area has a special skill set. Why am I consistently called away from my floor and patients to ICU to run chemo on their or to trouble-shoot a port if my skill set is not large? Bet my Hematology and neutropenic skills could run circles around a lot of ICU nurses. And OB nurses have to be everything for their pregnant patients; they are ER, nephrology, respiratory, etc all in one. This is because once a pregnant woman is beyond a certain point in their pregnancy they are almost always placed with OB, no matter what the patient diagnosis is. Medical-surgical nurses have their own special expertise also. I've seen ICU nurses want to run and hide when floated there and given a full load of patients. LTC nurses have extensive medication and time-management skills. ER nurses have to put that "train wreck" back into something resembling a patient before they are sent to ICU. Dialysis nurses have a huge knowledge base, including great expertise in fluid balance and electrolyte levels.
"Professional nursing services" could be billed to the insurance companies (which largely follow the Medicare and Medicaid guidelines), but the insurance providers would not pay those charges. Heck, there are a lot of things they do not reimburse as it is now. The private carriers would (collectively) "LOL" and the government agencies would just send in the auditors.
As for "Nurses As Costs for Hospitals", they certainly are, as are Aides, Techs, office staff, administrative staff, etc. Personnel (including wages, benefits, etc.) is usually one of the highest costs of running any business or entity. Facilities costs are an entirely separate part of any budget (or should be, if the place is being run well), and are often a large group of items. Just keeping the building running (utilities, maintenance & cleaning supplies, repairs, etc.) is huge.
What about eliminating or markedly reducing the CEO's salary? Now there's an idea. While it may feel really good to some for a while, that money would have to be moved to a different budget section and line in order that it be spread among nurses and aides. Just for the heck of it, run the numbers. If the CEO makes (for the sake of round numbers and simple math) one million gross( i.e., before taxes) dollars per year, and all that money is divided among all those who perform direct patient care, how much is that for 500 people (smaller hospitals usually pay their CEO's less money and employ fewer staff)? We know that, if said money is only distributed among the "hands-on" staff, there will be cries of "Unfair!" from those who work in the offices, prepare the food, clean and repair the facility, etc. Yup... that would be two thousand dollars per year for each patient care staff member... a nice (and well-deserved by many) bonus, to be certain. Alternatively, hiring more staff is a possibility, but how many staff could actually be hired, trained, and retained with that million dollars? At $50,000/year, that would be twenty people (including wages and benefits) or an increase of four percent. Then, they have to spread those people among all affected and necessary areas, maybe not equally and cries of, "Unfair!" will ensue.
Next, who is going to run the place well (or take the responsibility if it fails) for little or no compensation? Good luck with that. Now, taking this a step farther, we could make the government pay for the CEO's salary and limit it to something far less than a million dollars per year. Again, finding a capable CEO who wants to work for that little could be, at best, a daunting task... at worst, it would likely be impossible.
The above is obviously not intended to be a criticism of nurses and related staff members, but rather an invitation to "run the numbers" in each of our own situations and facilities. Should "the numbers" be a part of health care? Most definitely, if the facilities plan to exist far into the future and provide the best care they are able.
i have to differ with you. Physicians also have different skill sets and training. The difference is that physicians charge for their services. And they charge more as their skill sets and training increases. The hospital also charges more for a bed in ICU than a bed in med surg. Why? Because ICU provides more care, specialized care, than on Med surg, etc. ICU is the, "high rent district", in the hospital for a reason.
Neurosurgeons charge more then neurologist, cardiac surgeons charge more than cardiologists, etc. Why? because they have education and training far above what is provided in medical school.
Med surg is taught in nursing school. As is peds, ob, and psych. ICU is not. I managed chemo in ICU, CVVHD in ICU, without minimal assistance, if any, consulting with Dialysis nurses, or chemo nurses.
LTC manages med surg issues, not critical care issues. Just because someone can run around like a chicken with their head cut off in LTC, does not make that a special skill set. ICU nurses have extensive medication and time management skills as well, as we have two ICU patients to care and manage.
ER nurses keep patients alive to move them to ICU, where ICU nurses do long term management of vents, drips, CVVHD, IABP, management, etc. If I can manage CVVHD, and IAPB patients, I certainly can manage fluid and electrolyte issues. I have had my share of patients on neutropenic and hematology precautions, and another ICU patient to manage as well, and Swans, multiple IVs.
Nurses from other areas of the hospital do not float to ICU and take a patient assignment. If they float to ICU at all. But ICU nurses float to all other areas of the hospital and take an assignment. We are the hospital float pool. They float us all over, and if we get an admits, and need another nurse, we have to call a nurse to come in to staff the ICU. And pay Overtime for the nurse to come in.
In other words, ICU nurses can do everyone else's jobs, but everyone else cannot do, and are not trained, to do everyone else's jobs.
Nurses need to validate their self worth and self importance, by making everyone the same, regardless of the education and training that is put into a specialty.
As I stated above, doctors, charge more as their training and expertise increases. No one questions it at all. Why do nurses insist that everyone is the same? We are not, and should be compensated for increased education and training.
The private carriers would (collectively) "LOL" and the government agencies would just send in the auditors.
Mindful, RN
306 Posts
... well, this is why California Nurses Assn. is here.