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.

[nursel56]

The only argument I heard against ratios is that they don't account accurately for workload. But you have to start somewhere. The bean counters don't give a rip about workload anyway. Might as well start with ratios. Apparently studies are showing that they do have results in California.

I agree 100%. As I was reading through what Dr. Buerhaus explain what he felt was the preferable alternative to ratios, I thought that most likely my colleagues would fail to see how it would translate into their day-to-day experiences and somehow turn into something they would readily believe is a better solution.

He then talks about a "ratio mentality" wherein a nurse discards theoretical concepts when he or she embraces ratios.

(nurses would be) coming to work wondering, Is the hospital complying with the staffing ratio on my shift?” The latter mindset leads to nurses becoming focused on the ratio versus focused on understanding the patient's needs and how nursing can improve to provide the right care needed.

I think most of us can handle both pretty well!

[Hancock330]

I graduated from my BSN program, in California, in 1969. I'm now, thank goodness, retired.

As a student working as a nursing assistant and during my first 6 years as an RN in California, I had the honor to work with a few nurses who participated in the first ever strike by nurses in this country. A nurse who said she participated in the planning then said something like "One day some of us were talking about work and we agreed that we loved being nurses but also that if we didn't need the money we wouldn't be working. That was when we decided we needed to be paid what we were worth." Many nurses strongly feel that any strike by nurses is somehow immoral -- to walk away from patients needing care is unforgivable. However, when nurses organize and give adequate warning, elective admissions (for scheduled surgeries) can be postponed, stable patients can be transferred elsewhere, and the California Nurses' Association always (back then, and I'm guessing, still) provided the nursing staff to provide good care for any remaining patients. The original strike in the Bay Area was over pay. The subsequent strikes were often over what I think of as governance issues -- getting into the contract staff nurse representation on committees that determined staffing patterns, peer review committees that mattered, etc. During one such strike my students and I crossed the picket line and all of the nurses who said anything said things like "Take good care of our patients for us." And from those and other job actions nurses started getting paid more, and as the "unionized" hospitals were coerced into raising pay the ripple effect, across the country, led to other nurses getting paid more because that was the only way hospitals could keep and recruit nurses.

Another subject. There are a very limited number of ways to organize the delivery of nursing care. The names I remember are Team Nursing (the newest thing when I was a student nurse, and what I was taught), Primary Nursing (which was the next "Big Thing"), and Functional Nursing (where you give all the meds, the next licensed nurse does all of the treatments, and the nursing assistants do all of the things they're allowed to do). Each of these has had multiple names over the years, and who does what gets tweaked a bit, but I've not seen anything strangely new and different in my entire career.

Next, bean counters at hospitals NEVER study history. There must be an ironclad rule against it. The last time I was where nurses were negotiating a new contract, a "new staffing plan" that increased the number of CNAs, slightly increased the numbers of LPNs, and significantly reduced the numbers of those pesky, expensive RNs, had just been announced. One day I overheard some seasoned nurses at the hospital discussing the plan. That discussion went something like this: "Remember when they tried this in the late 1980s? It didn't work out so well and when the complication rates went up and the hospital's reputation went down, they went back to more RNs and fewer nursing assistants." "Yeah, and remember in the mid-1990s they tried it again? Same song, second verse." "So, now it's the late 2000s and here we go again. Won't they ever learn?"

Nursing staff is the biggest piece of the hospital's operating budget. (The capital or building and equipment budget is legally separate and the budgets can't be mingled.) RNs are the most expensive per employee part of that budget, and the RNs who've worked at the hospital for a LONG time are "outrageously expensive" to bean counters. They ignore the savings the seasoned nurses bring in complications avoided and are adamant that "a nurse, is a nurse, is a nurse". They do whatever they can to find reasons to fire those expensive nurses or to make them so miserable that they quit. They're convinced that if a less expensive employee can legally perform a task there is never a reason to staff so an expensive RN can perform that same task. Not only that, but once they've "adjusted" the staffing for fewer RNs and LPNs and more CNAs, the inevitable next step is either not hiring the additional CNAs the plan calls for or not replacing a lot of the CNAs lost via attrition. So, now you have not enough CNAs to do what even they can do. And so it goes.

[Ranax]

I see nit picking written all over this to comply with performance measures.

And, the airline industry reference needs explanation. There is a TED talk addressing this topic, however it is meant to highlight the necessity of checklists in communication for HIGHLY Risky procedures, like taking off and landing an airplane. The parallel is made to surgery, where the "Timeout" is now utilized.

Here's the link:

Bedside handoff can and should be succinct and pertinent, a time saver, not a time eater. SBAR written form should only be used as a guideline, perhaps to increase uniformity.

[MusicGuy]

We have a for profit healthcare system. Stock holders will always be of higher importance than either customers or employees. Future changes will only benefit CEO's and stockholders. We need to be adults and acknowledge this realty. Unfortunately, only a union will be able to change anything in favor of employees. If so, the costs will just be passed along to customers.

[foreverme_85]

I work at a Magnet facility that has incorporate SBAR reporting, hourly rounding, etc. but has not addressed staffing issues and patient ratios. I've brought up staffing issues multiple times informing or manager that each nurse having 6 patients with no CNA or secretary and a charge nurse with patients makes an unsafe environment. Nothing has been done for years so I voice my concerns on the surveys, suck it up, don't complain and do the best I can!

[insel.angus]

I.C.U. Nurse addressed the main issue: staffing ratios are related to a much larger problem, spelled "money". SBARs improve communication, but, more importantly (for the keepers of the elephant), it saves time and time is money.

If you can come up with a way to not only show them the elephant but also how you can lead the animal out of the livingroom and pay for the door you need to built to get it out, the workers to built the door etc (budget, nursing shortage, shareholders.....), you might get a better but certainly not immediate response.

[chare]

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.

Thanks. I'm not sure what I was thinking when I read the original post, but this makes perfect sense.

[sherri64]

From all my years of experience, I have observed that the people who do step up and address the elephant in the room, especially staffing, become targets of administration. It is as if they are considered radical trouble makers and pretty soon, the write-ups start and they are on their way out the door. That makes it really tough to speak up when you see that happen. It is better if the staff would all get together and stand up for this issue, rather than one person who everyone else suddenly separates themselves from. Nurses and other staff need to back each other up. Address this issue in letters and petitions to your State Bds of Nursing. Get some media attention, carefully. It is a major problem and we all know it.

[Been there,done that, ASN, RN]

We have a for profit healthcare system. Stock holders will always be of higher importance than either customers or employees. Future changes will only benefit CEO's and stockholders. We need to be adults and acknowledge this realty. Unfortunately, only a union will be able to change anything in favor of employees. If so, the costs will just be passed along to customers.

Adults realize that .. there are other ways to change the "system".

[jrbl77, RN]

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.

.

This phrase comparing health care to the airline industry is one of the things that sent me over the edge as a staff nurse. Just yesterday I was talking with someone whose son just got hired on by a major airline company. She went on and on about this airline, welcoming her son as a pilot and the top executive was there to shake his hand. She said how they were all (his family) at this occasion and it was like one, big happy family. Pardon me, but I have not felt this way in the health care field for many years. The staff nurse is about the lowest on the totem pole and never seen by the top executive.

[NOADLS]

Adults realize that .. there are other ways to change the "system".

If you can't beat them, join them.

Roman explains things here (but gets eaten by a crack addicted bird):

https://www.youtube.com/watch?v=FH8huS2YrsU

[NurseDiane]

I just have to laugh when I read posts such as these.

When people decide they want to become a nurse, they have this idealistic vision. They have visions of the clean scrubs, tidy hair, patients that are so grateful for what they've done, and the appreciation and respect from administrators. They go to school and take care of a couple of patients for 1/2 or 3/4 of a day. Those patients think they're wonderful for becoming a nurse. They feel good. They graduate, take the boards, and (hopefully) get a job. And then it's like they were hit with a speeding freight train.

They're thrown onto a med-surg floor, with a patient load of 7 or 8 patients (if you're lucky), a couple of those patients really too acute to be on a floor but there's no room in the ICU. You are running around like a chicken without a head, don't get a meal break & are lucky if you can get your work done & the charting before the end of your shift. You have to deal with criticism from unit managers, supervisors. You want to do the best job you can, you want to do a great job & make a difference........but you never will. And here's why.

The reality is that as a nurse, you are never going to make a difference or change anything. The insurance companies and our own government are controlling healthcare & the money circulating in healthcare. They are setting the regulations (patient satisfaction survey based reimbursement, anyone?) and reimbursement rates. Hospitals are run by MBA's, not healthcare providers. Sure, there is a chief nursing officer, but she is told what to do by the CEO and the CFO, and all of those things have one central focus: MONEY. THE ADMINISTRATION DOES NOT CARE ABOUT NURSES or NURSE/PATIENT RATIOS!!!! They care about one thing----whether they are going to be able to get their bonus at the end of the year. MBA's have no idea why a nurse can't take care of 26 patients---they never have, and they never will. The only things that make any administrator pay attention is when somebody is severely injured or or dies at the hands of a hospital employee, and their malpractice insurance rate is going to get jacked up and they get sued. See, nurses care---they care about the patients they care for, they care for other nurses and they care about the working conditions. Administration could care less about any of that. Administration cares about the spread sheets coming out of the CFO's office. They care about the photo ops in local newspapers, with stories about the big donation they received from some former patient or new wings or OR's being built, to bolster their reputation in the community. They care about how many donations are being received in the finance office. They care about how nice the exterior of the hospital looks, with valet parking & fountains & grape vines. Do you know what they could care less about? NURSES. When you start going up the management ladder in a hospital, nurses think they are hot stuff, talking about evidence based practice, nursing process, blah blah blah. They can talk a good game. That's their job. They blow a bunch of hot air out of their mouths because they like to hear themselves talk. Very few of them have EVER instituted any kind of change in their institution and are puppets to the upper level administration. They're just "messengers", for lack of a better term. Their job is to make it work with what they have. The unit managers have a budget (handed down to them fro the CFO) and they must function within that budget. And guess what makes the unit function within that budget? More patients, less nurses.

Administration doesn't give a hoot about "evidence based practice", nurse/patient ratios or working conditions. Their train of thought is if you don't like it, go find another job because there are millions of unemployed nurses out there who would take your job in a heartbeat. Healthcare has been turned into some sort of service industry, like a restaurant or hotel, because that is what our government has made it. Basing reimbursement on patient satisfaction surveys is ridiculous---it's like those surveys on the tables at one of those chain restaurants/steak houses. Administrators only do what they have to do to get paid as much as possible. And don't ever think that is there is any money leftover at the end of a fiscal year, that any of that money will go into improving staffing levels----that money goes into bonuses for the upper level administration. Administration will forego hiring patient care staff if it means a higher bonus and salary for themselves.

We went into nursing because we care. However, it takes a while to realize that if you don't care, you're better off. Go to work, do your job, manage with what you have & do the best you can but don't give that much of yourself to an employer who could care less if you drop dead after you walk out that door. (Just don't slip on the urine on the floor & break your ankle before you get into the parking lot---they don't want any worker's comp claims or disability payments hovering over them.) We are not going to change healthcare. In the almost 30 years that I have been doing this, healthcare has gone down the drain. Washington has allowed it to happen. They've allowed pharmaceutical companies to charge far more than what they should be allowed to. Why? Because big pharma gives a crap ton of money to politicians & those politicians remember that when they are deciding on healthcare legislation. They've mandated that everybody has to have health insurance----and the majority of those people have to purchase it from private, for-profit companies. The people that can't afford it can jump on the Medicaid bandwagon, increasing the premiums for private health insurance exponentially, to the point where it is an unsustainable system. Why? Because the insurance companies wrote the ACA---they wanted "healthcare reform" to get more people signed up on their rosters, to increase salaries and bonuses for upper level management. And they jacked up the premiums, all the while they drastically cut reimbursement. Physicians can't even treat their patients anymore----they have to ask permission from the insurance companies to order tests, to order medications. With a system like that, why do we need physicians anyway? Just call up you insurance company, tell them what's wrong and then they can tell you what you're allowed to do about it.

Once you accept this simple fact of healthcare and nursing, you're fine. Giving even the slightest damn about what administration says or does is what destroys you. you can care about the patients, but not too much. Don't get personally invested in them. Healthcare is set up to get them out of the hospital as fast as possible----whether they are ready for it or not----so Medicare and the insurance companies don't have to pay for a longer hospital admission. It doesn't matter what nurses think. When you control the money, you control an entire industry.