This is an older article ran in March 2001. For those who have already read this I apologize. I thought it was concise and this new forum would be a good place to put it for reference.
From the Eyes and Ears of a Nurse
Charissa Szumiloski, RN, BSN, MB
Volume 7, #1
Nurse staffing problems won’t be getting better any time soon.
They’re probably going to get worse. The solution, says this Nurse Consultant, is
to make better use of the nurses we have.
It’s 3 p.m. Nurse Jenkins begins her shift as house supervisor at Atlas Medical Center with too many pages on her beeper. No, the battery isn’t malfunctioning; rather, grave concerns are being communicated to Nurse Jenkins from staff on various nursing units. The staff contend that nurse-to-patient ratios are insufficient. As a result, there are frantic situations that Nurse Jenkins must address throughout her shift.
The Emergency Department has been backed up with patients for hours since the nursing units are not receiving the “already-admitted” patients in a timely manner. To top it off, ten open beds on 5 West aren’t available for these patients because no one is available to work there. Several nurses on 4 North say that they are “completely exhausted from working mandatory overtime in excess of 20+ hours this week.”
“The patient in 336B just suffered a severe fall while attempting to ambulate to the bathroom on his own, just one-hour after a total hip replacement, and his family would like to speak with you immediately!” Another nurse calls to report a potential medication error since she is “uncertain how much morphine the patient in 236A has received because she has nine other patients to care for.” Then, Dr. Gleason calls to complain that his “patient did not get her CT Scan on time,” and, as a result, he cannot elicit a timely, definitive diagnosis for a cerebrovascular accident.
Suddenly “Attention please, Code Blue in Critical Care, Code Blue in Critical Care” sounds over the PA. Nurse Jenkins drops everything to handle this episode, and returns to her post only to find that Nurse Atkinson –one of the many agency nurses being utilized– has requested an orientation to the unit since she has never worked there before. Nurse Jenkins smiles sadly to herself, because in fact there’s no time to orient even the existing staff to the units where they’re being floated. Additionally, Nurse Jenkins is told that in order to reduce excessive overtime costs she must “ensure that staff are punching out at the end of their shift instead of when all of their necessary documentation has been completed” (which usually occurs about 2 a.m., if the documentation is to be complete and legible). You would think that there is no end to the madness when Nurse Jenkins hears her staff complaining that “this is unsafe for the patients” and that “they refuse to work at a place in which their license in on the line.”
Are these encounters fictitious? Is this just an unusual day for Nurse Jenkins?
Unfortunately, these kinds of nightmarish events are routine occurrences in many hospitals. The dilemma for healthcare, unlike most other industries, is that customer satisfaction is not the only business driver or “delighter.” For healthcare, customer (patient) safety is the priority in delivering a successful product. Defects or failures in the production line cannot be tolerated.
So, should a CEO, CFO, Medical Director, and VP or Director of Nursing all care about Nurse Jenkins’ day? Sure they should! Not only should these administrators take notice, but so should patients, taxpayers, and policymakers. For if we view the nursing shortage in the context of access, cost, and quality of healthcare, each of these three attributes are at stake.
From a business perspective, the nursing shortage is putting increased financial pressure on organizations that are already grappling with negative operating margins and significant reductions in reimbursement. This increased pressure results from the enormous costs of recruiting, training, and retaining nurses in an extremely tight job market. Such costs include sign-on bonuses, increased salary and benefits packages, and marketing and advertising initiatives. Additionally, the increased dependency on various agency nurses and mandatory overtime leads to sharply escalating expenses.
More importantly, high turnover of valued employees results in frustration, burnout, and increased stress for those who are left, increasing the risk of poor quality care. Other financial consequences include the closing of beds and resultant turning away of patients, escalating patient incidents and complaints leading to increased malpractice liability and compliance risks, delays, duplication, and omissions in the delivery of care, low productivity levels and rework, time spent at committee meetings to discuss issues, and, as a long-term potential consequence, the loss of market share.
Who’s at fault? Quite honestly, no one. The best way to understand this problem is to review how we got into such a mess. A variety of causal factors have been suggested. I will confine my discussion to the issues that are based on research studies, personal clinical and administrative experience, and interviews with key stakeholders.
• The nursing profession suffers from a serious image problem. Unfortunately, nursing is viewed by the public as unrewarding, stressful, and “subservient“ work.
• There is an under-representation of various population segments in the profession, such as men and minorities. This is compounded by an aging workforce.
• There is an increase in demand for nurses as a result of an increasingly elderly population, a growing number of acutely ill patients, and an increase in outpatient care utilization.
• The overall supply of nurses has decreased as a result of lower nursing school enrollments, other career opportunities, broken promises, and insufficient compensation.
• There has been a decrease in nurse-patient interaction, coupled with nurses perceiving that there is a general lack of professional trust, respect, and communication.
• There are liability concerns about patient safety being jeopardized because of low staffing ratios, use of ancillary staff, and excessive mandatory overtime. These conditions threaten nurses’ licensure and an organization’s compliance structure.
• Nurses do not feel as if they are part of a “shared mission,” since there are many occasions when they are not included in the decision-making process –even when those decisions may affect them directly. Such decisions often focus on the many tasks that nurses perform at the bedside, including changes in documentation, staffing patterns, policies and procedures, new processes, roles and responsibilities, and the type of delivery model.
• Nurses do not feel that they receive enough training to handle patient complexity, especially if they have just graduated. Quite often, this is exacerbated by the need to float to foreign nursing units without much preceptor support or orientation.
These problems will not be remedied anytime soon. With the average age of practicing nurses presently at 42, (it is projected to be 45 by 2010) the U.S. Department of Health and Human Services predicts that there will be a sustained nationwide shortage of nurses by 2010.1 This is supported by many studies of nursing enrollment. For example, a recent report indicates that, in the last five years, the number of nurses graduating in Vermont has dropped by 36%. Reports of a 5% drop per year are very common. Also, despite heavy advertising campaigns for clinical personnel across the US, healthcare organizations maintain vacancy rates of up to 20%. Therefore, the real question is “what can be done at the provider or facility level to better utilize the existing staff ?” Typically, we have looked at decreasing patient-to-nurse ratios in order to improve staffing effectiveness. This emphasis has had at best only limited success in maximizing the overall care of the patient.
Given the current economic disequilibrium of supply and demand, it is apparent that an increase in staffing is unrealistic, if not impossible; staffing ratios can at best only remain constant or at worse decrease further. Therefore, the appropriate factor to maximize in this situation is the percentage of a nurse’s time spent providing direct care activities to his or her patients (activities within the presence of the patient). In many inpatient settings, only half of a nurse’s shift is spent providing direct care. To increase the percentage of direct care time requires an internal assessment of factors such as staffing mix and patterns, processes, supply utilization, documentation tools, amount of paperwork, and type of education and training.
By investing in operational improvement activities, an organization can realize a significant return through enhancement of quality of care and compliance, improved reputation, better cost control, improved utilization across the continuum of care, and increased patient and employee satisfaction levels.
Of course, this is no easy task given the overall complexity and diversity of various nursing units, not to mention entire organizations. Yet, failing to maximize efficiency of internal operations and increase the percentage of direct care time will have negative consequences on a healthcare organization’s bottom line and on society at large. As the American Medical Association points out, “reversing the nation’s cycle of nursing shortages will require reforming the education and credentialing mechanisms for nursing, restructuring work environments, and developing systems of care that empower RNs to use their professional skills.”2
It is imperative to show nurses that management cares by investing in studies to improve the delivery of care. Suggestions for hospital leaders include:
• Develop community forums to discuss the above issues. Include schools, employers, providers, patients, local policy makers, and healthcare organizations.
• Involve nurses in the many decisions that directly affect them. This develops mutual credibility, trust, and collaboration between nursing and management.
• Perform an organizational assessment to identify bottlenecks and defects in the overall delivery of care that impact the nurse’s work.
• Invest in nursing personnel through training and education initiatives, employee recognition programs, and career ladders.
As overwhelming as this situation may seem, professional diagnosis of problems and the design of appropriate interventions is possible. Nurses understand that the majority of administrators desire a “win-win” situation, despite the fact that the facility may not have the time or internal resources available to achieve this goal. When nurses see that the goals of an operational improvement study are not to reduce staff levels but to improve patient care, a framework for mutual credibility, trust, and collaboration can be established. It is only from this framework that progress on the causes and effects of the nursing shortage can occur.
Charissa Szumiloski, RN, is a registered nurse and independent
health care consultant in Greenfield Center, New York. She can be reached at (518) 229-7556, or by email at firstname.lastname@example.org.