By Roberta B. Abrams, RNC, MA, LCCE, for HealthLeaders.com, July 23, 2001
They've had it! Up to here! Nurses are saying they can no longer deal with a critical lack of professional nursing staff, mandatory overtime, unprepared, undisciplined and unlicensed assistive personnel, critically ill patients, unsafe working conditions, abusive managers, caustic physicians - the gamut of ills that exist in healthcare today.
The professional nursing staff is tired of excuses and promises that are never fulfilled. As a result, they're doing what many of them would have considered unthinkable - certainly undoable - a decade ago: They're going out on strike.
For many nurses, walking out on their patients is an anathema to their professional existence. Yet these professional nurses have reached the point where they are unable to see other options - and they cannot, and will not, continue to work in environments that they consider unsafe for their patients, for their careers, for their licenses.
Those of us who assiduously follow healthcare news, read almost daily stories of nurses who are on strike. Let's look at the ramifications of these events from A Nurse's Viewpoint.
What happens during a strike
We have long established that there is one reason, and only one reason, to ever admit a patient to the hospital: the need for 24-hour nursing care. The patient is deemed to be physiologically - or psychologically - so unstable that lack of constant care is dangerous to that patient's health and well being.
In a nurses' strike, that necessary work force is diminished. The quantity and quality of nurses necessary to provide safe and appropriate care are absent from the bedside. Most hospitals attempt to deal with nurses' strikes by bringing in replacement staff - either from local staffing companies or from "traveling nurse" agencies that provide nurses from around the country and/or around the world.
Temporary staff is a far-from-ideal solution. Licensed, willing, and able, they lack knowledge of the facility, of the medical and other staff, and of the structure, culture (and sometimes language) of the hospital. This lack of familiarity with the facility decreases the nurses' efficiency, and increases the probability of errors. The first group to be stricken by a nurses' strike, therefore, are the patients.
The hospital staff collectively comprises the next group stricken by a nurses' walkout. In any work setting, one main aspect of quality performance is the relationships among the staff. In an atmosphere where the staff has worked together over time, there is a mutual trust and understanding of the roles of each member. This give and take decreases the need for elaborate discussions and explanations, thereby making work processes more efficient.
This synchronicity is nowhere more easily demonstrated than in the nurse/physician relationship. Overtime, the rapport that develops between these care partners resembles a chamber music group - each knows the others' preferences, strengths, and soft points. Nurse Sally remembers that she should remind Dr. Jim to write referrals to the discharge planning coordinator for his newly diagnosed diabetics. Jim knows that when Nancy is on nights, any calls he receives will be important ones; Nancy's expertise is one reason Jim likes his patients on that unit. When the usual staff is missing from the clinical unit, that smooth collaboration disappears.
The hospital's administration is sorely stricken by a walkout of nursing staff. According to an article in The Plain Dealer in Cleveland, one replacement agency's staff nurses work 12 hours a day, "... five to six days per week, and earn $3,000 per week." Now, the contract hospital does not pay benefits to these nurses, but they often do pay for lodging and travel. It doesn't take very long, or very many nurses, for that to sink down to the budget base as a sea of red ink.
In addition, the administrative leaders must deal with their failure to meet the expectations of patients and staff, as well as the community in which they live. The mutual loss of trust, the breach in the dynamic relationship between staff and administration, is inexorably - sometimes permanently - altered. The reputation of the facility is diminished, and, in far too many cases, harm to patients leads to litigation.
The nurses are the final group to be stricken by their strike. The professional nurse, driven to this extreme action, must still try to make peace with the fact that she has, in the final analysis, abandoned her patients. That is a very bitter pill to swallow. Even when the community of healthcare providers and healthcare recipients express understanding of her actions, her professional conscience is distressed.
Options to the crisis
There are options. In those healthcare facilities where real leadership prevails, the response to the current crisis in nursing is to proactively convene a consortium of community leaders. Members of the consortium should include an assortment of nurses - those with clinical, those with administrative, and those with educational expertise. Physicians, therapists, support staff in the hospital, and, of course, patients have different kinds of knowledge that will help in framing potential solutions to the healthcare crisis.
The current compilation of problems confronting the healthcare delivery system is put on the table for discussion. Nursing has a prominent place at the table. Nursing did not create the current crisis, and nursing alone cannot ameliorate it. However, nursing must accept its share of ownership for the solution. Consultation with outside leaders, such as staff and leadership of facilities who have achieved "Magnet Hospital" credentials, may help in providing some direction.
Every facet of the healthcare delivery system is subject to review. What parts of the system can be streamlined to improve efficiency? How can technology be used to improve care delivery? A focus on outcomes, and on evidence-based practices, may result in the elimination of "traditional care elements" that no longer serve either patient or provider.
How can the facility - and the community around it - enhance the recruitment and retention of caregivers? Professional nurses seek - and deserve- a place at the table where decisions are made. It has been my experience as a nursing administrator that the staff has the knowledge and ability to resolve most of the issues that beset them. What they require is the trust and support of the administrative staff to implement the solutions.
Nursing salaries require review to acknowledge the nurses' expertise and contributions. "One size fits all" benefit practices need to be abandoned in favor of a cafeteria menu of benefits that acknowledges disparate needs - not just for nurses, but also for all healthcare providers.
Many of the benefits that were recently sacrificed on the altar of fiscal expediency should be restored. Continuing education (including tuition reimbursement for collegiate education) is a "perk" that attracts and retains nurses and other professional staff. It also facilitates care enhancement for the patients and improved delivery systems for the institution. Administrators need to focus on long-term gains for their facility, as opposed to knee-jerk responses to evanescent changes.
We need to work with our community educators to provide our youth with awareness of the benefits of healthcare careers. We need to help our elected representatives on the local, state, and national levels to cease tampering with processes for which they lack comprehensive understanding, and to instead empower those with that skill and knowledge to improve the health of our populace.
The hour is late - the risks are many. We do indeed have "promises to keep and miles to go before we sleep." Our healthcare delivery system is stricken. It must be made whole.
Roberta B. Abrams, a regular columnist for HealthLeaders.com, uses her education and experience to help further the evolution of healthcare delivery systems through her consulting group, RBA Consults, in Farmington Hills, Mich. She also is on the adjunct nursing faculty at Madonna University.