A Nurse's Viewpoint
By Roberta B. Abrams, RNC, MA, LCCE, for HealthLeaders.com, May 28, 2002
It's an annual ritual: The celebration of nurses' week. One week of 52, we hang posters, award trinkets, and have a free meal - or ice cream social. In more enlightened environments, there may even be a guest speaker - perhaps a nursing leader, or other noted individual, who appears and waxes eloquent on the subject of nursing. At week's end, the organization returns to business as usual. The celebration is an interesting gesture, but it can be vastly improved. Let's look at some ways of celebrating our nurses and the profession of nursing - from A Nurse's Viewpoint.
Instead of the usual trinkets I would like to see a series of wishes fulfilled for nurses and nursing. My first wish is for all patient care environments to have staff appropriate in numbers and preparation for the mission that they are expected to fulfill. I have read with great interest the recent spate of legislative initiatives mandating adequate staffing ratios. That is a most interesting venture. With more than 40 years of nursing experience, I have yet to find a system of "staffing by the numbers" that works.
Even the novice nurse will assure you that the ratio of patient to nurse is, at best, a flawed construct. Are the six patients assigned to Nancy Nurse physiologically stable, alert and aware, with sufficient preparation and knowledge to participate in their own care? If so, a six-to-one ratio is probably sufficient. If even one of them is unstable, disoriented, or in need of close supervision, the ratio probably doesn't work.
Therefore, we need a system to measure patient acuity. There are a number of acuity systems in existence. Most of them claim to be individualized for the involved setting. The flaw in these systems is that none of them is capable of responding to the continual changes in acuity that occur in the inpatient setting.
In most acuity systems, patients are assessed and acuity recorded every eight hours. Staffing patterns are determined by the most recent assessments. As most clinicians are aware, staffing needs can either increase or decrease hourly. In places such as intensive care units, perinatal areas, and emergency rooms, acuity is almost constantly changing.
What is needed, therefore, is the ability to provide additional staff for these crises. We need to revisit the "flying squad" idea. In this concept, a predetermined team of additional staff, prepared to provide care for the patients on the designated service, can be allocated on short notice. Protocols need to be established both for that allocation and for the responsibilities of that staff. Stipulated expected outcomes for these intercessions need to be established, and evaluations of outcomes achieved. The flying squad construct initially requires extra time and effort. It does improve outcomes in terms of patient care and staff satisfaction.
My next wish is for nursing leaders and healthcare administrators who are capable of caring for staff and patients in the present, while simultaneously preparing for the future. The list of desired characteristics of the leaders needed is not long, but it is challenging. Leaders need to possess vision and the ability to share their vision with others. They need to be able to inspire and empower their colleagues and subordinates so that they can realize shared goals and outcomes. Our leaders must be women and men who have the ability to hear and understand the needs and aspirations of those whom they lead and those for whom they care.
Our administrators need to be able to combine the pragmatic with the altruistic. They must be able to see providers not as a "cost center" but as a group of skilled professionals, whose collective efforts enable the mission and vision of the healthcare institution to become reality.
Both administrative and nursing leaders should be able to understand that "cost effective" modes means examining the whole picture for potential savings, not just looking for the deepest pocket (which is usually the personnel budget). They need to work with the staff in their own and other hospitals to achieve economies of scale. They should facilitate the clinicians' search for evidence-based practices, for new modes of care, and for labor-saving systems. They must understand that quality in care is cost effective.
My final wish is for healthcare facilities replete with colleagues of every discipline who communicate, cooperate, and collaborate with one another to reach a common goal - providing care in a manner that is rewarding to the provider and recipient alike. In these facilities, the members of the care team network on a regular basis to evaluate the work they are doing. They examine the outcomes of the care they provide to ensure that all parameters have been met - the first time. They understand that excellence is a team product. It is clear that no one discipline can achieve optimal possible outcomes at the expense of others. They know that competing for scarce resources is a battle without winners.
All too many hospitals are attempting to "fix" their staffing problems by awarding significant sign-on bonuses for new nurses. The fallacy in this policy is that the nurses who have stayed with the troubled facility find themselves working with "newbies" who have gotten these rewards - while the seasoned staff haven't. As with competition for scarce resources, an inappropriate reward has never fostered collegiality. Wise leaders avoid both.
Are these wishes just fantasy? Or pipe dreams? I think not. Each of my wishes for nursing is actualized in select healthcare facilities. Some places are closer to the goal than others. All too many hospitals however, are stuck in the quagmire of mediocrity. They repeat the same cycle of layoffs, hiring bonuses, "quality program of the moment" and short-term rewards and wonder why their staff vote with their feet and leave. They are perplexed by the repetitive pattern of patient errors. They are stumped by dismal employee morale. Perhaps someone needs to show them how "real hospitals" function. Perhaps instead of the consultants who visit and recommend yet one more round of personnel reductions, they need to seek wise counsel who have experienced fulfillment of these wishes.
Roberta B. Abrams, RNC, MA, LCCE is principal of RBA Consults, in Farmington Hills, Mich., and is on the adjunct nursing faculty at Madonna University. She may be contacted at RBAbrams@aol.com