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.

[NotReady4PrimeTime, RN]

Evidence-based practice. Quality improvement. Loaded buzz words... the look good on paper and they're what the accreditation crew look for when they do their thing.

But just how closely is the evidence followed? On my unit, a high acuity pediatric ICU, our medicine staff decided in the early 2000s that we needed to lower our VAP rates (which were actually quite negligible) so we adopted the VAP prevention bundle. Sort of. There were sections of the bundle that were never utilized because they disagreed with physician preference. It seems like the most significant and enforced item on the list was the HOB position > 30°. One of our docs is well-known for walking by a patient's bed and without knowing anything about what's going on, saying, "Let's get that head elevated." Did our VAP rates drop? No.

Quality improvement. Checklists for everything. What happens to the information collected from the checklists? Well, on our unit we have two separate physician teams, cardiac surgery and general peds critical care. Data is collected on every cardiac patient - CLABSI, CAUTI, unplanned extubations, readmissions, length of stay and morbidity - and benchmarked against other units across the continent. Very little data is collected on the other (double the beds) cohort. Where it gets murky is the data on bed utilization. Data is collected regarding the number of days a patient sits in the ICU after they've been deemed transferable to a lower level of care and the money essentially wasted on them. But because we are one big nursing pool, the data reflects all patients, not just the cardiac ones. So right there, accuracy might be questioned. But it sure looks good on paper!

I won't quote Nurse Diane's post, but she has made a good number of points. Single-payer health care won't eliminate any of the behaviours she describes. They're just as common in Canada, where single-payer health care has been a fact for more than 5 decades.

Now back to Tweety's staffing ratios. He has a good point. All the rest of it is meaningless if the nurse has only enough time to tick the boxes, and not to provide the best possible care. There will be things that don't get done when workload overwhelms the worker... psychic BPs anyone? I understand his reluctance to point out the elephant; the squeaky wheel might get the grease, but more often it's simply replaced. Wearing a bullseye isn't a fashion accessory, it's a target. After a lot of years of squeaking away and being treated like a pariah, I opted to divide and conquer. I became involved in a working group to create guidelines for which patients could safely be 2:1 on the unit, where most are too ill to be more than 1:1. The group included management, charge nurses, staff nurses and physicians. They were finally rolled out about 6 months ago, and there have been far fewer incidents of unsafe workloads. So it can be done. Keep reminding them Tweety. Maybe some day they'll hear you.

[noyesno, MSN, APRN, NP]

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.

Fantastic explanation!

[Tweety, BSN, RN]

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

Not exactly. You have to calculate in recruitment, orientation, and benefits as most employers are paying some of our insurance and other benefits. Not just the persons salary. A nurse doesn't come cheap.

Still, if you balance to cost of errors, infection rates, reimbursement, nurse burnout and the constantly revolving door the expense of having more nurses and safe ratios is worth the cost. Not sure why they don't invest in this.

I'm hoping with reimbursement from medicaid tied to outcomes, such as infection, and them not paying for nosocomial issues, the bean counters will see this and invest in human resources.

I did mention this yet again in a "shared governess" meeting in which it was noted that our customer service scores were falling. It co-incides with a staff short and high ratios. Do the math.

[kalevra, BSN, RN]

The majority of current modern American Healthcare Industry is a for profit system. Even when hospitals report that they are a Not For Profit”, they still need to make a profit due to their inclusion in a multifaceted corporation that may or may not have healthcare as a core product. There are ways to make a profit, reinvesting it into a venture and still keep a legally functioning Not For Profit designation. An example given to me by a colleague, the hospital can loan” out money with a return rate of 25% for certain entities and to be repaid within 48 hours.

I am no forensic accountant, I am not a lawyer, and this is just hearsay. In no way am I a legal representative of any kind and what I write is merely speculation and carries no legal weight at all.

[kalevra, BSN, RN]

There appears to be a lot of pro-unionization responses on this discussion. There also appears to be a lot of anti-administration responses on this discussion,

If Administration is the problem, why not propose the unions build a hospital from the ground up as a union facility. A hospital where even the CEO is also part of the union and has to answer for his actions. A hospital where there are no private shareholders to appease with ever increasing profits. I propose a hospital where all the staff are part of a union and take part in a profit sharing plan, so that everyone has a vote in how the hospital runs.

With all the money unions across the nation makes a year, I am sure there are enough funds that can be gathered in order to accomplish such a goal.

I would think it to be an interesting experiment.

[ProgressiveActivist, BSN, RN]

what have you been smokin

There appears to be a lot of pro-unionization responses on this discussion. There also appears to be a lot of anti-administration responses on this discussion,

If Administration is the problem, why not propose the unions build a hospital from the ground up as a union facility. A hospital where even the CEO is also part of the union and has to answer for his actions. A hospital where there are no private shareholders to appease with ever increasing profits. I propose a hospital where all the staff are part of a union and take part in a profit sharing plan, so that everyone has a vote in how the hospital runs.

With all the money unions across the nation makes a year, I am sure there are enough funds that can be gathered in order to accomplish such a goal.

I would think it to be an interesting experiment.

[djh123]

"We need to be adults" and accept things the way they are, etc etc etc. I agree that we have little power, but at the same time, did American colonists during the Revolution accept things the way they were? I'm not advocating revolution, simply saying that things never change unless people start speaking up. I'd probably prefer working for a non-profit hospital, although I'm sure they have problems too - maybe just different or perhaps fewer problems, I don't know.

[NurseDiane]

The problem is, there is going to have to be a revolution to change things in healthcare.

[NurseDiane]

There appears to be a lot of pro-unionization responses on this discussion. There also appears to be a lot of anti-administration responses on this discussion,

If Administration is the problem, why not propose the unions build a hospital from the ground up as a union facility. A hospital where even the CEO is also part of the union and has to answer for his actions. A hospital where there are no private shareholders to appease with ever increasing profits.

Wouldn't that be interesting? It would have to be a "union" formed by healthcare providers, not one of the current nursing unions that are swirling around the states these days. It's a proven fact that employee-owned companies are more productive, more profitable & do a better job than their competitors. The problem is that it would cost so much money to build that hospital----and when you start getting investors to back the project, they become the private shareholders wanting a return on their investment.

What have I said so very many times in my previous posts?

IT'S ALL ABOUT THE MONEY!! HE WHO HAS THE MONEY HAS THE POWER & CAN CONTROL AN ENTIRE INDUSTRY. HE WITHOUT MONEY IS POWERLESS.

[Tweety, BSN, RN]

"We need to be adults" and accept things the way they are, etc etc etc. I agree that we have little power, but at the same time, did American colonists during the Revolution accept things the way they were? I'm not advocating revolution, simply saying that things never change unless people start speaking up. I'd probably prefer working for a non-profit hospital, although I'm sure they have problems too - maybe just different or perhaps fewer problems, I don't know.

I think nurses haven't been quiet. Any good nursing organization has advocated for safe ratios ad nauseum. Many studies have been published. Many of us speak out.

I've worked for both non-profit and for profit. I prefer non-profit, but the ratios area the same.

[nursel56]

In my state the union system is an unholy hash of separate camps, who if they acknowledge the existence of the other at all, make negative comments (related to why they wanted their own camp in the first place) I always felt the better approach would be to emphasize the idea that LPNs, ADNs, etc would have their higher rung colleagues to embrace and help people to grow as nurses and create a unified voice.

[Tweety, BSN, RN]