The Elephant In The Room and Evidenced Based Practice

[Tweety]

Our directors are very fond of saying "evidenced based practice" when telling us what to do..like hourly rounding, bedside report, safety huddles, etc. etc. I usually have no problem with any of this. I'm a "go with the flow" type of person.

Next up is a mandatory report sheet we have to use to give bedside report, in the SBAR format. Again, I'll go with the flow and I helped create one for our floor and sent it for approval (but they lost it and it's not saved..doh). A director was talking to our unit about it, siting "we're modeling ourselves after the airline industry that greatly improved safety over the years. Hospitals have the worst safety record of all industries. Evidences shows lack of communication is one of the things that cause mistakes and evidence shows this SBAR report will help with that."

Me: "I have one word to say: ratios. Evidence based practice over and over shows this improves safety and outcomes".

They want it all...safety, great customer service scores, high profit, but don't address the one elephant in the room.

[Chisca, RN]

In California the ANA went to war against the implementation of ratios.

That was the genius of the strategy the California Nurses Association used. Staffing is a public safety issue and has to be dealt with by law. By focusing on the legislature and educating the public they avoided the trap of trying to convince people who don't have a conscience, hospital administrators, to do the right thing.

[Cafelattee]

I've got a lot of years in hospital nursing. I've seen all type of new management models. Its all been crammed down our throats because it makes some paper pusher look good.

The plans are always a failure because they want keep the nurse/patient ratio in the same zone as a retail chain. They want hospital to run like customer service suck up places but don't give us the man power.

Guess what being an old nurse and lucky as hell I don't' need my job. I like working but married for 25 years to someone that works for a power company. They are paid what-they-are worth and have kick ass bonus and other great benefits. The **** will never happen in nursing.

So I tend to be the one that talks back and lets it hang at all the meeting and the funny thing is I've never been fired. I call them on all their horse-****.

They tried to recruit me to take a management role. I do fill in work but will never do the crap full time.

There are nurses that go into management thinking they can help get better stuff for the staff nurse but then realize it ain't happening. They fall to the other side of budget crunching, doing the corporate thing and getting a yearly bonus.

[Kooky Korky, BSN, RN]

Healthcare is centered on the patient especially in terms of morbidity, mortality and patient satisfaction. Communication breakdown is a common area in the workplace that can result in a lot of conflict and breakdown. I can understand their want to standardize the report/hand-off process in order to make communication more efficient.

EBP help guide nursing practice in a way to maximize the client experience in the healthcare setting. As a profession, it is important to work together an communicate our needs is an efficient manner so we can improve patient care throughout the healthcare continuum.

Agreed. But with insufficient staff, good care is impossible. Survival is the nurse's goal and forget all the frills and all PC this and that.

[kalevra, BSN, RN]

Ratios are a politically charged and sensitive area for many people. There are far reaching after effects of implementing a state or federally mandated ratio. For one, many nurses feel that unions are not necessary to practice their profession. In fact many feel that a profession does not need unions. While on the topic of unions, there are several states where nurses forming a union is very much looked down upon. I mention unions because what happened in California in regards to state mandated ratios was a result in a lot of political maneuvering by unions.

California nurses, from my experience, pay $40-$50 per paycheck for union protection” and representation”. A hospital with 1000 nurses typically makes $40,000-$50,000 every pay period or $80,000-$100,000 a month just form union dues. These dues are used to pay lawyers, labor representatives etc. in order to lobby or advance” the nursing-agenda”.

One hospital with 1000 nurses can make about $1,000,000 a year. All those funds are used to lobby the state legislature and support political campaigns in order to further their agenda. Agendas such as mandatory ratios, retirement, and health insurance.

There are many in this country who view unions as an unnecessary entity in the profession. As professionals, communication with leadership and sharing in the same vision of patient care and proper compensation for all involved should be discussed. Many nurses feel that belonging to a union is much like paying for protection” or extortion” and would rather not take part in it at all.

[NOADLS]

One of my friends is a tech and she is in her last year of her BSN. Where she works, they've cut funding and have to manually take blood pressure. She says the management has hidden behind the defense of "evidence based practice." Good thing she can use her psychic powers to take them in the absence of being able to automatically take her patient's blood pressure.

I've concluded that most times when managers want to see "evidence based practice," my ******** meter is off of the map.

[Farawyn]

I have to say, I prefer manual.

[NOADLS]

I have to say, I prefer manual.

I work in SNF / LTC where most blood pressures are done on a routine basis for stable patients. I can safely conclude that automatic blood pressures are the way to go.

If a patient isn't stable and an automatic reading deviates far from what you would expect, it would be appropriate to manually take the blood pressure.

Technically it is best practice to take them manually, but it isn't realistic to expect it to be done manually every time. If management is going to make it hard for their employees, there are going to be employees that take shortcuts which jeopardize proper care.

[Farawyn]

I work in SNF / LTC where most blood pressures are done on a routine basis for stable patients. I can safely conclude that automatic blood pressures are the way to go.

If a patient isn't stable and an automatic reading deviates far from what you would expect, it would be appropriate to manually take the blood pressure.

Technically it is best practice to take them manually, but it isn't realistic to expect it to be done manually every time. If management is going to make it hard for their employees, there are going to be employees that take shortcuts which jeopardize proper care.

What shortcuts? Auto BP? Or "psychic" BP?

[NOADLS]

What shortcuts? Auto BP? Or "psychic" BP?

Think about worst possible scenario. Psychic BP on a critically ill patient.

I am willing to bet that at least a quarter of the periodical blood pressures taken are done via psychic powers.

[Farawyn]

Think about worst possible scenario. Psychic BP on a critically ill patient.

I am willing to bet that at least a quarter of the periodical blood pressures taken are done via psychic powers.

Then seriously, they need to come to Long Island and put that crazy LI Medium out of business. Cannot take her hair.

[NOADLS]

Then seriously, they need to come to Long Island and put that crazy LI Medium out of business. Cannot take her hair.

I am sure there are plenty of psychic health care staff on Long Island who could do the job.

[ixchel]

If you're asking have I personally addressed the elephant by making demands, refusing assignments and organizing staff protest, no I haven't.

Will I organize a protest, refuse assignments, quit for a better job, contact labor unions, march to the capital. No.

If you attempted protest in this way, you would be labeled a troublemaker and escorted out the first chance they got something to pin on you.

Planting the seeds of change don't require waging war. Look at trends recently. How are satisfaction scores? CAUTIs? CLABSIs? Falls? Readmissions? These things COST money for the hospital. (Satisfaction scores because they decrease Medicare reimbursement.)

Some people protest by simply quitting to go somewhere that seems better. Others find enough love where they are to make things better. If you are the latter, just talk. Talk to your unit manager. Talk to your hospital's quality department. Simply have conversations. If you feel voicing opinions isn't enough, bring numbers to them - numbers that illustrate how staffing is hurting their bottom line. It should be easy to find fall and infection numbers, in addition to satisfaction scores.

More Masters prepared minions without a clue to the nursing leadership rescue!

Thank you, sir! May I have another?!

I just did some rudimentary math and came up with a figure of approx. $300,000 (plus or minus a bit) that a facility/hospital may save per year by not adding one staff to any given unit per shift. Say it's a fairly small hospital and they are saving that per unit for a few units.....that adds up.

How exactly did you come up with this amount?

If the RNs make $30/hr, that's $360/shift. 14 shifts/week for one more RN per shift, 52 weeks/year, $262k/year. HOWEVER, when you consider decreased adverse outcomes and better patient satisfaction scores, hospitals should find themselves more profitable from this investment.

Nurse;8896422]I'm glad to see that you've had that culture at some point in time in your hospital, because there may very well be a lingering framework for Quality Improvement.

Hear me out: Nothing, ( and I know you will agree with me ) nothing speaks louder than Numbers to the bean counters that ration nursing FTE's per bed units.

The best way to go forward is to show the C suite suits how much money they can save by equating number of nursing FTE's to (Insert the biggest cost savings issue that your unit has at this moment). What keeps you up at night regarding your unit r/t staffing issues? (for example)

Narrow it down to one problem that can be focused on.

Do your research on that issue, get about 5 to 7 critically appraised peer-reviewed, higher level research articles about your issue together.

Perhaps you would like to get a journal club together and get whoever else on the unit together to brainstorm with you. Keep it to a handful of people to make it workable.

Figure out how the best way to run the project (for example- - - say you want to tie nursing FTE's to decreased incidences of UTI's). How many UTI's have you had in the last quarter of 2015. Each UTI costs the unit X amount of money per incidence. Find out how much that is (Talk to Performance Improvement, or Quality Assurance, Or Quality Improvement, or whatever the data people are called in your facility). They'll be able to tell you, because THEY KNOW.

Look at the staffing patterns in your unit. See if there is any way you can correlate staffing patterns to UTI's. (This is very, very simplified, but I'm using it for the sake of simplicity in the general picture).

I realize that correlation does not always mean causation, but if you can show a strong p value to support your numbers, you've got a running start.

I'd love to hear how things go. I hope that what I've shared makes a difference. That's all we really want in the end: to make a difference.

Take care

This is beautifully well thought out!

What shortcuts? Auto BP? Or "psychic" BP?

Eeeeeeeeeeee!!!!!!!! MAGICAL VITALS!!!!!!!!!