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  1. Nurse Beth

    Mandated Nurse-Patient Ratios

    Ashley sank into a chair in the breakroom on her MedSurg unit in a large hospital in Florida. It was 0330, 8 ½ hours into her shift. She had not yet taken a break of any sort, including a bathroom or hydration break. In staff meetings, it was repeatedly emphasized never to miss a lunch break or stay overtime, but in the moment, it was hard to manage. Right now her stress was so high that as soon as she sat down, she struggled to keep back the tears. Of her 7 patients, she had had two rapid responses (RRTs) and one patient was sent to ICU with sepsis. She was pretty sure she had missed the early signs of sepsis in her post-op patient, with an increased heart rate and infected wound. It's just that there was too much information and she was cognitively overloaded. Her phone buzzed in her scrub pocket. Wearily she picked up the call. It was Laura, the charge nurse, sounding stressed out. "Ashley, I need you to take an ED admit in Room 4123. Is the room clean? Can you take report now, please?" Across the country in California, Lindsay works on a similar MedSurg unit. Because she works in California, she can never be assigned more than 5 patients. Her day was busy and at times crazy. She knew that adding on 2 more patients would make it unmanageable. Thank goodness it was 5 patients, and not 7. During lunch breaks her patients were covered by break nurses and she did not take her phone into the breakroom. Why is there such disparity? How is it that a patient with exacerbated CHF on Tele in Alabama has a nurse with five other patients and a patient with exacerbated CHF on Tele in California has a nurse with only 3 other patients? The reason is that California has mandated nurse-patient ratios in every hospital unit. ICU is 1:2, SDU 1:3, Tele 1:4, Med Surg 1:5. Patient Perspective If you were a patient and could choose, would you choose a nurse who has 4 patients or 7 patients? If your baby was in NICU, would you want your child to have a nurse with 1 other infant, or 2 other infants? There is abundant evidence to show that patients suffer when nurses have too many patients. The following is a quote from Ruth Neese's Talking Points for Safe Staffing. Cost to replace a single nurse burned out by overwork from understaffing was in excess of $80,000/nurse in 2012 (Twibell & St. Pierre, 2012). The difference between 4:1 and 8:1 patient-to-nurse staffing ratios is approximately 1,000 patient deaths (Aiken, Clarke, Sloan et al., 2002). Patients on understaffed nursing units have a 6% higher mortality rate (Needleman et al., 2011). This risk is higher within the first 5 days of admission (Needleman et al). An increase of one RN FTE per 1000 patient days has been associated with a statistically significant 4.3% reduction in patient mortality (Harless & Mark, 2010). Adding one patient to a nurse's workload increases the odds for readmission for heart attack by 9%, for heart failure by 7%, and for pneumonia by 6% (McHugh, 2013). Lower patient-to-nurse staffing ratios have been significantly associated with lower rates of: Hospital mortality; Failure to rescue; Cardiac arrest; Hospital-acquired pneumonia Respiratory failure; Patient falls (with and without injury); and Pressure ulcers (Aiken, Sloane, et al., 2011; Cho et al., 2015; Kane et al., 2007; Needleman, Buerhaus, Stewart, Zelevinsky & Mattke, 2006; Rafferty et al., 2007: Stalpers et al., 2015) Higher numbers of patients per nurse was strongly associated with administration of the wrong medication or dose, pressure ulcers, and patient falls with injury (Cho, Chin, Kim, & Hong, 2016). Rising patient volumes, higher patient acuity, and reduced resources lead to nurse burnout and fatigue, resulting in first year nurse turnover rates of approximately 30% and second year rates up to 57% (Twibell & St. Pierre, 2012)." Action Mandated nurse-patient ratios are a matter of public safety. There are regulated practice safeguards in place for airline pilots and truck drivers and other industries. Why not nursing? Historically nurses are a silent workforce who have allowed employers to determine clinical practice. But that is changing. The time for change is now. On April 25th and 26th 2018, nurses around the country will gather in Washington D.C. for the 3rd annual rally to urge lawmakers to enact safe staffing ratios. In numbers, we have strength and will be acknowledged. Come join allnurses in Washington DC! Meet up with the allnurses team who will be filming and interviewing, and myself, Nurse Beth! Dr. Laura Gasparis, whose conferences many of us ICU nurses have attended, is the lead speaker. By standing together, we can bring about needed reform. Will you be a part and bring about change as the nurses did in California? Be sure and read Male Nurse Disgusted by Female Nurses for a unique point of view on working conditions and ratios. What else can you do? So many things! Easily find out who your legislators are and make a call. Write a letter to support H.R. 2392 and S. 1063 Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act of 2017 legislative bills. Legislators respond to topics based on the number of phone calls and mail from their constituents. While you are in Washington, make an appointment to see your legislator. Share this article on social media. Use hashtags #NursesTakeDC and #allnursesSTRONG Please watch the following video for more information on NursesTakeDC 2018. Like this article if it spoke to you, and comment below. Thanks much. [video=youtube_share;jkWGHNB9gik] Neese, R (2016). Talking points for Safe Staffing. Retrieved January 12018. Nurse Patient Ratios | Talking Points for Safe Nurse Staffing
  2. SafetyNurse1968

    Just Say “NO” to Nurse Staffing Laws

    You’ve worked on a busy Med Surg unit for almost a year now. You were so excited to be hired right out of nursing school to the day shift, but it’s been so much harder than you ever thought it could, and so different from what you expected. It only took a few days to discover that no one does anything like they taught you in nursing school, there’s just no time. Recently you’ve been cringing every time your phone buzzes, worried it’s the nurse manager asking you to come in for an extra shift. It’s so hard to say no. You want to be a team player, but you’re just so tired. You’ve been wondering if you’re cut out to be a nurse, but maybe this is just how it is. Today is your fourth day in a row. You arrive on the unit to discover that not one, but two nurses have called in sick, and one of your nurses is a floater from labor and delivery. Normally you have five patients, but today you see with a sinking heart that you’ve been assigned seven. You sit at the computer next to your nursing mentor, trying to wrap your brain around your day, trying not to cry. He’s a good nurse and seems to notice everything. He turns to you and says, “Are you okay?” You point at the seven patients on your computer screen and reply, “How can this be safe? How can they do this to us…to our patients?” He says, “It’s a right to work state, and the hospital can do whatever they want.” You say in disbelief, “So there’s no law against this? There’s no maximum number of patients we can be assigned? They could give us twenty next time?” He shakes his head ruefully and says, “Medicare has guidelines for patient ratios, but this hospital has never followed them and we’re still running.” He looks over his shoulder before he turns back to you and says under his breath, “We shouldn’t talk about this at work, but there’s a group you can join to fight for safe staffing laws. Check it out when you get home, it’s called NursesTakeDC. It’s a dot org. But don’t talk about it here, you could get in big trouble.” Mandated Nurse-to-Patient Ratios Does this conversation seem familiar? Have you ever felt like you were working in unsafe conditions and wondered, “Isn’t there a better way?” As a patient safety specialist, I’ve always been a huge advocate for safe staffing laws as a solution to so many of the problems nurses face. But, then I read a recent article, Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care and I had to give my position a second look.1 How Can There be Controversy Over Something So ... Obvious? Opponents say ratio laws would exacerbate nursing shortages across the country, limit access to care, and take important staffing decisions out of the hands of nurses. Danny Chun is a spokesperson for the Illinois Health and Hospital Association (IHHA), a leading advocacy group for hospitals. He states that safe staffing laws are “a deeply flawed, inflexible, rigid approach to setting staffing levels that do not improve quality, safety or outcomes, but in fact would adversely affect patients.”1 The IHHA is against the Safe Patient Limits Act, a bill recently introduced in Illinois (House Bill 2604, Senate Bill 1908). Under the Safe Patient Limits Act, no nurse working in a hospital could be responsible for more than four patients at a time. The ratio would be even lower for special units like L&D, ICU and the ER. If passed, any facility that fails to comply could receive a fine of up to $25,000 per day. Critics of the bill say that the consequences could be catastrophic, causing shortages of nurses and money. There may be increased wait times for patients in the ER, and hospitals may have to turn away patients because they don’t have enough nurses to meet the ratios. In addition, an unexpected influx of patients due to epidemics, mass shootings or other disasters could make it impossible to meet the ratios. Small hospitals operating in regional areas could be forced out of business. Chun says in Illinois, “more than 40% of hospitals across the state are losing money or barely surviving.” The cost to the hospital could be passed on in the form of higher healthcare costs. The biggest criticism being offered is that mandated ratios don’t work. Chun says, “The evidence is not conclusive that ratios improved quality, safety or outcomes,”1 The Evidence Here is where I get excited. I went to Google Scholar and typed in “Safe Staffing Laws, nursing” and got 44,400 hits. I love digging into the research to find the truth (like the X-files, the truth is out there…) I found multiple review articles that speak to the state of the science on safe staffing ratios. One by Olley (2017) suggests that there is a significant research gap to support claims of increased patient safety in the acute hospital setting with improved ratios (for all the REST of the evidence, check out my Just say "YES" article on this topic).2 California is the only state in the union with a safe staffing law. AB 394 was passed back in 2004 after a massive effort by the California Nurses Union. The result of the bill is that nurses in California have approximately one less patient than the national average. Multiple studies have shown that the standard mortality rate decreased by more than 33% after the enactment of the bill.3 This seems like pretty good evidence…evidence that the law that California enacted is working in California. See where I am going here? The biggest criticism of bills in other states (and this comes from organizations like the American Nurses Association) is that there is no empirical evidence supporting specific ratio numbers. Passing legislation without sufficient evidence is potentially dangerous since legislation is difficult to change. Critics say the laws currently proposed also don’t take into account nurse education, skills, knowledge and years of experience. In Bill 394, only 50% of the mandated nurses must be RNs. Some say these laws ignore patient acuity, required treatments, length of stay, team dynamics, environmental limitations, variations in technology and availability of ancillary staff. And last but not least, these laws are inflexible and don’t allow for the changing needs of patients.4 The Bottom Line $$$ The mortality rate may have decreased, but the finances are problematic. To meet mandatory staffing ratios, hospitals in California have had to cut funding for supplies, upgrades and education and holding patients longer in the ER. The result is increased economic costs for employers, with the unanticipated side effect of an increased workload for nurses in non-patient tasks as ancillary staff are dismissed. 4 & 5 The PRO Side I’m not actually telling you to say “NO” to mandatory staffing laws. I want to get a conversation going, so please comment! To learn more about Nurses Take DC and what you can do to make a difference, take a look at my second article on the topic. Most importantly, before you speak up about safe staffing laws, make sure you are knowledgeable on the topic. We must be well educated on all sides of a topic if we want to weigh in on shaping the future of patient care. References Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care Systematic review of the evidence related to mandated nurse staffing ratios in acute hospitals. Statewide and National Impact of California’s Staffing Law on Pediatric Cardiac Surgery Outcomes Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis Mandatory Nurse-Patient Ratios
  3. Registered nurses across the US will hold a one-day strike of their own demanding higher wages and better working conditions. Over 6,500 registered nurses in hospitals in California, Arizona, Florida, and Illinois will strike on September 20 demanding higher wages and better working conditions. The strike will mark the first-ever nurse strike in Arizona, and the first hospital registered nurse strike in Florida's history. Nurses who are part of the National Nurses United union are asking for better nurse retention and nurse-to-patient ratios. Most nurses who will be participating in the strike are employed with Tenet Healthcare, a multinational health-services company that operates 65 hospitals and 500 other healthcare facilities. Nurses told Business Insider they have been negotiating with Tenet for a better contract for over a year and haven't received the concessions they demand. The union said that nurses have worked without a contract for two years in Arizona and under expired contracts for several months in California and Florida. Nurses also want lower nurse-patient ratios to improve the quality of patient care and prevent nurse burnout. Some hospitals are assigning twice the number of patients to nurses that research recommends. 2,200 University of Chicago Medical Center Nurses Walk Off the Job Nurses working at the University of Chicago Medical Center plan to strike for five days in an effort to bring additional attention to their continuing struggle to get better nurse-patient ratios. About 2,200 nurses are expected to strike. Wow, I'm in Illinois and had not heard this. Anyone participating? What's your facility's take on this? https://www.businessinsider.com/nurses-to-go-on-strike-for-better-patient-ratios-2019-9 So here's an update: From Illinois: CHICAGO (AP) — "Nurses at University of Chicago Medical Center are holding a one-day strike following what they call a breakdown of contract negotiations between their union and the hospital. The walkout began Friday morning, with nurses marching and chanting outside the hospital. The 618-bed hospital prepared for a walkout by the about 2,200 nurses by diverting ambulances and moving patients. Although the nurses say the strike will last one day, hospital officials have told the nurses to stay away until Wednesday because temporary nurses have been contracted. The walkout began Friday morning, with nurses marching and chanting outside the hospital. The 618-bed hospital prepared for a walkout by the about 2,200 nurses by diverting ambulances and moving patients. Although the nurses say the strike will last one day, hospital officials have told the nurses to stay away until Wednesday because temporary nurses have been contracted." https://qctimes.com/news/state-and-regional/illinois/nurses-hold--day-strike-at-university-of-chicago-hospital/article_fa1892c8-2311-5c36-aefd-2b190bba2d14.html From Florida: HIALEAH, Fla. (AP) — "Registered nurses staged a one-day strike against Tenet Health hospitals in Florida, California and Arizona on Friday, demanding better working conditions and higher wages as the nation's labor movement has begun flexing muscles weakened by decades of declining membership amid business and government attacks. About 6,500 National Nurses United members walked out at 12 Tenet facilities after working toward a first contract for a year in Arizona and under expired contracts for months in California and Florida, the union said. They plan to resume working Saturday. Members also passed out leaflets in Texas, where contracts at two Tenet hospitals in El Paso expire later this year." https://www.stltoday.com/business/national-and-international/nurses-staging--day-strike-at-hospitals-in-states/article_b86900c9-5800-564b-bdbe-1af836fcd8e7.html
  4. SafetyNurse1968

    Just Say “YES” to Nurse Staffing Laws

    In my Just Say "No" article, I listed the evidence from California against mandated nurse-to-patient ratios, the only state to have a safe staffing law. Despite a reduction in patient mortality, California hospitals are struggling with the cost burden of mandated ratios, and nurses are busier than ever, just not with direct patient care. All you have to do is read the articles and comments posted on allnurses for a few minutes to confirm what you already suspect. We need some kind of change. A recent New York Times article reported on thousands of nurses on strike in California, Arizona, and Florida. They were striking for better patient care, improved working conditions and higher pay. Their No. 1 demand: better nurse-to-patient ratios. In a survey of nurses, only 20% felt staffing levels were safe.1 Rules and Regulations Fourteen states currently have official regulations for staffing ratios: CA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, and WA. Seven states require nurse-driven staffing committees: CT, IL, NV, OH, OR, TX, WA. California is the only state with a law that requires minimum nurse to patient ratios to be maintained at all times by unit. Massachusetts passed a law specific to the ICU that requires a 1:1 or 1:2 nurse to patient ratio depending on stability of the patient. Minnesota requires a CNO or designee to develop a core staffing plan with input from other nurses, similar to Joint Commission standards. Five states require some form of disclosure and/or public reporting: IL, NJ, NY, RI, VT. New Mexico has asked stakeholders to recommend staffing standards to the legislature. The department of health will collect information about the hospitals that adopt recommended standards and report the cost of implementing oversight programs.2 Federal regulation 42CFR 482.23(b) requires with Medicare certification to "have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient." However, no figures are mandated. Each state determines how to meet the Medicare requirement.3 Illinois passed the Nurse Staffing by Patient Acuity Act in 2007. The Illinois Health and Hospital Association cites the law as sufficient for governing nurse staging. But the law isn’t enforceable. Though it requires a committee to be formed to make up staffing plans based on acuity, less than a third of respondents to a 2018 survey by Nurses Take DC said their hospital had a staffing committee. Of the hospitals that did, less than half include enough nurses, or committee recommendations weren’t followed.4 The Price of Nursing I’m going to refute the argument that a shortage of nurses will cause hospitals to close units or limit services if mandatory ratios are enacted. At issue here is that there are plenty of nurses. In Arizona 37,000 licensed, active RNs are not currently working as nurses.5 Why is that? The issue isn’t that there aren’t enough nurses, the issue is how poorly nurses are treated. A survey in 2014 demonstrated that nearly 1 in 5 nurses leave the first job within a year, and 1 in 3 leave within the first two years.6 Nurse turnover costs hospitals a lot of money, so why wouldn’t they want to keep us happy? Because we are expensive. Nurses make up almost 40% of operating costs for healthcare facilities. Hospitals would prefer to find a less expensive way to improve patient outcomes.7 California paints a vivid picture of this problem. Critics of AB394 were concerned about its increased financial burden on hospitals, especially safety-net hospitals, to maintain a mandated ratio. Economists found that the mandated ratio resulted in financial pressure on hospitals and declining operating margins in CA hospitals compared with other states.8 Current Nurse-to-Patient Ratios What is the national benchmark when it comes to nurse-patient staff ratios? Pinning down a specific number is hard to do, given the legal vagaries from state to state. California RN-to-Patient staffing ratios range anywhere from 1:2 in intensive/critical care, PACU and L&D, to 1:6 in postpartum women only, med surg and psychiatric.3 Aiken and colleagues found that in England, the average patient-to-nurse ratios for all hospitals was 8.6 but varied 5.6 patients-per-nurse to 11.5 patients per nurse. They found a similarly wide variation in patient-to-nurse ratios across hospitals in every country studied.9 The Evidence In 2002, Aiken, Clarke, Sloane, Sochalski, and Silber found that adding an additional patient per nurse was associated with a 7%increase in the likelihood of dying within 30 days of admission and a 7% increase in death resulting from a complication.9 In 2007, Kane and colleagues conducted a meta-analysis of 28 studies. They found that increased RN staffing resulted in lower hospital mortality and adverse patient events. They hypothesized that patient and hospital characteristics, including the hospital commitment to quality care contributed to the causal pathway.10 In 2008, Aiken analyzed data from 10,184 nurses and 232,343 surgical patients in 168 Pennsylvania hospitals. When staffing ratios were optimized, nurses reported more positive job experiences and fewer concerns with care quality. Patients had significantly lower risks of death and failure to rescue in hospitals with better care environments.9 CMS began the Hospital Readmissions Reduction Program under the Affordable Care Act in 2012. At the time, researchers found that higher levels of RN staffing were associated with lower readmission rates.8 In a systematic review of 43 articles, Lang et al. (2013) showed better nurse staffing is associated with lower failure-to-rescue rates, lower inpatient mortality rates and shorter hospital stays.11 In 2018, Driscoll et al looked at 35 studies in a metareview and found higher staffing levels associated with reduced mortality, medication errors, ulcers, restraint use, infections, pneumonia, higher aspirin use and greater number of patients receiving percutaneous coronary intervention within 90 minutes. They looked at 175,755 patients from six studies and found that high nurse staffing levels decreased the risk of death in the hospital by 14%.12 Aiken has looked at patient outcomes in both California, which passed its ratio law in 1999, and Queensland, Australia, which passed one in 2015. She said the result for patients has been fewer complications, fewer infections, fewer injuries — and even lower mortality.9 The Solution The American Nurses Association has a position statement on safe nurse staffing, stating, “We all agree that there should be safe staffing. Safe staffing is essential to patient and nurse satisfaction and for safe patient outcomes. What we need is evidence of what those safe staffing practices are. Eliminating unsafe practices will improve our healthcare system.” The ANA supports that appropriate staffing levels reduce mortality rates, length of patient stay, number of preventable events like falls and infections.7 The ANA states that fixed staffing levels are problematic. Staff levels should depend upon: Patient complexity, acuity or stability. Number of admissions, discharges and transfers. Professional nurses’ and other staff members’ skill levels and expertise. Physical space and layout of the nursing unit. Availability of technical support and other resources. The ANA supports a legislative model in which nurses create flexible staffing plans for their unit. What is needed is greater nurse involvement. Take action by writing Congress to support safe staffing. Share your story about being an everyday advocate with Janet Haebler, Senior Associate Director, State Government Affairs, janet.haebler@ana.org, (301-628-5111). You may also be interested in The Safe Patient Limits Act (H.R. 2581/S. 1357). This bill is currently sitting with committees in the senate and house. The bill sets limits on the number of patients a nurse can be assigned, depending on the hospital unit. Any facility that fails to comply could be subject to a fine of up to $25,000 for each day it is out of compliance. The bill factors in a plan for acuity adjustments that need to be made for patients and staffing. The goal of Nurses Take DC is to get the legislation passed to the Senate and House of Representatives where they can be put up for a YES vote. For more information, click NURSESTAKEDC.1 REFERENCES 1. NursesTakeDC 2. Update on nursing staff ratios 3. The Importance of the Optimal Nurse-to-Patient Ratio 4. Why mandated nurse-to-patient ratios have become one of the most controversial ideas in health care Tung, L. (Nov 29, 2019). 5. Nurses in Four States Strike to Push for Better Patient Care Ortiz, A. (Sept. 20, 2019). 6. Nearly 1-in-5 nurses leaves first job within a year, survey finds Becker’s Hospital Review (Sept 5, 2014). 7. American Nurses Association (n.d.). Nurse Staffing Crisis 8. Effects of Public Reporting Legislation of Nurse Staffing: A Trend Analysis deCordova, P. B. & Riman, K. (2019). 9. Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T. & Cheney, T. (2018). Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes. Journal of Nursing Administration, 38(5), 223-229. 10. Kane, R. L., Shamliyan, T. A., Mueller, C., Duval, S. & Wilt, T. J. (2007). The Association of Registered Nurse Staffing Levels and Patient Outcomes. Medical Care, 45(12), 1195-1204. 11. Lang, T. A., Romano, P. S., Hodge, M., Kravitz, R. L. & Olsen, V. (2004). Nurse-Patient Ratios. The Journal of Nursing Administration, 34(7/8), 326-337. 12. Driscoll, A. et al. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6-22.
  5. As nurses, we are bound by our oath to provide quality care for every patient. This means holding hospitals and other healthcare facilities accountable for sufficient numbers of experienced nurses to ensure patient safety and support inexperienced nurses. Unfortunately, this is often not the case. WHAT'S THE ISSUE? "I don't know how to do that" is something that experienced nurses are hearing more often from new hires, float pool and travel nurses. To their surprise, hospitals and staffing agencies are employing nurses with less than two years of experience more often than those who are more seasoned. In fact, some nursing units have up to 75% under-qualified nurses, which pose many patient safety concerns for two main reasons: 1 ) Less experienced nurses do not possess the nursing skills needed to handle the physical, mental and emotional demands of the job. Not even the best nursing programs can take the place of real-life, practical experience. Without the opportunity to gain real-life, practical experience before beginning a new nursing position, new hires often feel "thrown to the wolves", and this poses a major issue for retention and job satisfaction. 2 ) Burnout rates are increasing among more nurses. As the overwhelming need for training, coaching, and mentoring consumes much of the time and energy of the bedside nursing staff, seasoned bedside nurses are forced to take on a greater workload for insulting pay rates and a lack of additional incentive. At the same time, new hires who are in desperate need training and mentorship are finding themselves abandoned and without skilled guidance. According to The American Nurse, "Research indicates that staffing numbers alone don't always tell the whole story or assure positive outcomes for patients in the absence of other considerations. Other factors related to staff expertise, including RN education level, employment status and skill mix, as well as collegiality of nurse-physician relations exert a positive impact on select patient outcomes, such as 30-day mortality and hospital readmission rates." The Joint Commision echoes these concerns: "Nurses are the front line of patient surveillance-monitoring patients' conditions, detecting problems, ready for rescue. Spread too thinly or lacking the appropriate skill set, the nurse is at risk of missing early signs of a problem, or missing the problem altogether." WHAT'S THE CAUSE? There are several contributing factors that lead to nursing staff with inadequate nursing skills. One major factor is that hospitals continue to have strict budget constraints, which creates freezes on nurse salary increases, and low starting pay rates. Without room for growth, in terms of opportunity to learn new skill sets, and higher pay, more experienced nurses might look for work elsewhere. This results in increased job vacancies which are soon to be filled by lower paid, inexperienced nurses. Another potential cause is poor efforts by facility administration to improve nurse retention. Without innovative nurse retention efforts, high staff turnover rates will continue to plague these facilities. If experienced nurses don't feel valued by an institution, they are less likely to stay at that particular job. In a recent article that highlights nurse retention efforts, it was stated that the average hospital loses $5.2 million to $8.1 million due to RN turnover, and each percent change in RN turnover costs or saves a hospital an additional $373,200. So why wouldn't hospitals be on board with improving retention efforts? The bottom line is that nurses report that low job satisfaction is primarily related to heavy workloads, an inability to ensure patient safety, and insulting salaries. WHAT ARE WE DOING ABOUT IT? Many national healthcare efforts are in the works to enhance nurse retention programs and increase salaries and incentives for their nursing staff. Here are a couple solutions already in progress: The Nurse Residency Program. To enhance nurse retention, many institutions have begun implementing nurse residency programs. Research shows that nurse residency programs are an essential strategy to retain new grad nurses. These programs are significantly longer than traditional orientation programs , which can range from 6-12 months or more, and involve much more mentorship and guidance from experienced nurses. Unlike the two day travel nurse orientation, or the two week new hire orientations that most facilities currently provide, they cover in-depth training that focuses on strong connections among workplace colleagues and work-life balance. It is also shown that other studies that focus on skill mix provide strong evidence that when nursing staff members do not have adequate time or training to carry out their work, patient safety and patient outcomes are put at risk. Understanding this fact by all parties involved in making staffing decisions is critical to assuring the effective, safe and reliable delivery of nursing care. Nursing wage and incentive increases. The American Nurses Association has created a Bill of Rights, which states nurses have the right to fair compensation for their work, that is consistent with their educational preparedness, knowledge, experience and professional duties. As a result, many nursing leaders have begun research initiatives to prove that higher salaries for nursing will result in better outcomes for everyone. According to an article published by NCBI, staff of direct patient care nursing roles in hospitals and nursing homes have reported dissatisfaction with wages, as well as non-wage benefits such as: health care, tuition reimbursement, and retirement benefits. Wage rates and distribution should match nursing staff skill levels to encourage entry into the profession and retention within the institution. Competitive wages, combined with good benefits will recruit adequate numbers of nurses to meet the ongoing care demands of the upcoming decades and prevent cyclical shortages that have defined the past half-century. As a result of such healthcare initiatives, you may find salaries and bonuses for nurses to be back on the rise as hospitals strive to attract more longevity within their nursing staff. As we push forward in working hard to correct the disproportionate nursing skills within our healthcare facilities, I am confident that our devotion to upholding the highest standards for patient safety will lend itself to creating positive change for all. For articles in this series, go to: Inadequate Staffing: Patient Safety in Today's Healthcare Marketplace Inadequate Nursing: Patient Safety in Today's Healthcare Marketplace Alarm Fatigue: Patient Safety in Today's Healthcare Marketplace Compassion Fatigue: Patient Safety in Today's Healthcare Marketplace
  6. Nurses all over the country have united in protest against the comments made about nurses on The View. One single act has managed to unite many despite the inter-nursing battles of different specialties, RN versus LPN, and varying entry-level degrees. It's great to see nurses unite, but can we keep that momentum going to effect change in patient care? Yes, ignorance of the role of the nurse is common within the population. It just so happened that some of those expressed their lack of knowledge on public television to quite a large crowd. Perhaps this will give nursing the visibility and opportunity to educate the public as to our role in health care. But there are many other issues plaguing nursing that, in my opinion, are much more crucial in providing safe, effective patient care. Staffing ratios To date, only California has managed to pass legislation mandating nurse: patient ratios. We need to look to our legislators and put the pressure on them to start introducing bills reflecting safe, doable ratios. Lack of uninterrupted breaks We all need the opportunity to recharge during a shift, get nourishment, and empty that overfilled bladder. But how often does it happen that while on an unpaid break the phone rings or the pager goes off, and that break gets interrupted? Mandatory overtime How safe is it to force someone to work more than their scheduled shift because of a lack of adequate staff? The longer one nurse works, the more likely it is that he or she will be tired and prone to mistakes. We deal with people's lives where mistakes can mean serious harm or even death. Lack of adequate functional equipment How often do we have to run around the unit looking for that one piece of some type of equipment that actually works? How often are we borrowing from other units? How closely do we guard that computer on wheels we managed to claim at the beginning of the shift? Why are the powers that be not providing what we need? Potential for injury How many facilities offer enough lifting equipment and manpower to move patients without risk of injury to the staff or the patient? What about violence from patients, visitors, and even other staff members? There are not enough states with laws on the books specifically to protect nurses and other healthcare staff. Focus on customer service Nurses are not customer service representatives. We are knowledgeable healthcare professionals responsible for the care of patients to return them to their optimum level of health. Scripting, patient satisfaction scores, and a focus on "the customer is right" idea lead to actual healthcare coming in a distant second to keeping patients happy. So where do we go from here? How many of us are members of organizations that are pushing for such changes? Many state nursing associations as well as specialty organizations have sections on their web pages addressing such issues, with ideas of how to fix them. National Nurses United (again, personal opinion) appears to be much more in touch with the issues of the bedside nurse than another national organization. What can we do to continue being #nursesunited and push for the necessary changes? I will admit that one thing that turns me off of some nursing organizations is the political spin and endorsements, but is that really as important as working to improve nursing? Can this sudden unity over something that may be insulting yet not very significant in the day-to-day life of a working nurse continue?
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