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.

[Hancock330]

So, a bazillion years ago -- 1970, to be exact -- I attended a "law for nurses" conference in San Francisco. The presenter was a member of a law firm employed by the Northern California Kaiser Permanente Group. He admitted at the outset he expected to learn some things from the nurses attending the conference, and he did. At one point I raised a question. I described the situation where I worked where the policy required that an intern be called to remove any "plastic IV device" (you know, the 3/4" to 2" plastic cannulas used everywhere now that were brand new then) if it had infiltrated or otherwise stopped working. I had done that in the wee hours of the morning and the intern hadn't been angry about it but he'd made the comment that most of the nurses managed to have them "fall out" all by themselves during the night. I asked the lawyer's advice. He started in with going to nursing or hospital administration with a request for a change in policy. The entire auditorium erupted in laughter. He looked a bit chagrined then said, "I guess that's one of those things I need to learn?" Rational thought in hospitals seldom revolves around evidence based practice -- regardless of the verbiage from above. It involves politics, CYA maneuvers, personal agendas, and who knows what all else. The only thing I've ever known that makes a difference to hospital administrators is money -- and very clear evidence that they are, on this particular day, losing money because of a specific policy or procedure.

Someone put into words for me exactly what's at stake when nurses complain about physician behaviors. That surgeon/internist/etc. brings X number of patients/year to this hospital, and makes $X thousands (or more)/year for the hospital. You, the RN, don't bring even one patient/year to this hospital. So when the administration chooses who to get rid of, guess who goes? It also seems that many hospital administrators are still under the impression that nurses are a dime-a-dozen -- no need to take good care of them, just use them up then throw them away, there'll be a new crop coming this May or June. The occasional nurse shortages have not yet been extensive enough to result in an institutional-level change of mind set.

Finally, there is a little hope out there. The TRUE shared governance model in nursing can create a great work environment for nurses and a safe care environment for patients. It has to be a real shared governance, though. Names really don't matter. And nurses need to team up to create change. I heard of one hospital where the nursing staff created their own "code" call. Whenever a nurse saw another nurse being verbally abused, and it was usually by a physician and in public, that nurse would call a "Code White" with the location over the hospital PA system. As soon as the call went out, every nurse who could, immediately took a break and reported to the scene where she/he stood in complete silence behind the nurse being attacked. It was remarkably effective, or so I read. Nurses obviously can't do that everywhere (many hospitals would forbid any such gatherings, I'm afraid), but is there something YOU could do where you work to let everyone know that no one verbally (or otherwise, for heaven's sake) abuses a colleague of yours without you showing support for the colleague? Even if your colleague is in the wrong, it shouldn't ever be addressed in public, right? So instead of avoiding the situation or speaking to the colleague later, is there any way you and your colleagues can work together to show the world that you stick together and care about each other?

Just some thoughts.

[kalevra, BSN, RN]

what have you been smokin

I find it to be an interesting experiment. Maybe the unions could create a better example rather than the traditional model that most hospitals are built on today.

[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.

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.

Hospitals are not paid in FULL in cash at the start of the ground breaking. There are loans, bonds donations etc. I am sure Unions like the National Nurse United with their 185,000 members all paying $40 in union dues every 2 weeks could muster up such funds.

Where I am from union dues range around $40-$50 every two weeks.

Assuming nurses can afford to pay $40 every 2 weeks multiplied by 185,000 nurses= $7,400,000

$7,400,000 every two weeks X 2 pay periods in one month= $14,800,000 monthly dues

$14,800,000 monthly dues X 12 months= $177,600,000 a year in member dues collected.

(rough estimate)

Obviously these numbers are very very rudimentary. What I am trying to show is that there is potential to collect a large sum of funds to attract other sources of investment to build such a "Union Hospital".

[MunoRN, RN]

The main problem with a "Union hospital" is that it would be illegal; collective bargaining laws don't allow for an employer to also be the collective bargaining unit.

There are hospitals "run" by nurses, and in my experience tend to be better places to work, but the problem is still that the ability to redirect funds to staffing is fairly limited given the reimbursement structure.

[Cola89]

I can see it now: 'HAHAHAHAA Oh Tweety, Aren't you cute? How will we make money and get our bonuses if we increase floor staffing? I think your comment goes to show that more middle management should be hired, to watch over people like you and their bright ideas.'

[sammiesmom]

I heard understaffed hospital actually gets funding from the government. Terrible huh? I am really thankful that as a nurse I can go to another hospital and another floor. I am in my 3rd hospital and very happy with it.

[Hippy chick]

EBP! Baloney! Anyone can design a study to show anything, a good statistics person can make any study show anything. If it is going to decrease cost every hospital in the country is jumping on that study. If it cost money, forget about it! When they throw evidence based practice, I always ask to see the studies they are quoting. Then I want to know what the nurse patient ratios were for that hospital, what equipment they had that we don't have. How many ancillary staff the units in the study had. I told our cno that if we are going to follow the evidence we need to follow all of it to have the same results, if we pick and choose our outcomes will be markedly different. Wasn't taken very well. But couldn't argue

[Thunderwolf, MSN, RN]

If EBP demonstrated an inverse relationship between the amount of administration staff and good patient outcomes, would admin intervene on behalf of the patient? Just a tickling thought...since EBP seems to be thrown around a lot nowadays. The current catch phrase...almost to ad nauseam.

However, EBP does demonstrate that if staffing ratios are 6:1 or below, patient mortality rates decrease. If this is so, why is this even debated as an issue today? Why isn't this not standard practice across the country? Why isn't this reported as a key quality measure on hospital performance? All else pales unless this elephant in the room is addressed. Tweety is most correct.

[NurseDiane]

If EBP demonstrated an inverse relationship between the amount of administration staff and good patient outcomes, would admin intervene on behalf of the patient? Just a tickling thought...since EBP seems to be thrown around a lot nowadays. The current catch phrase...almost to ad nauseam.

However, EBP does demonstrate that if staffing ratios are 6:1 or below, patient mortality rates decrease. If this is so, why is this even debated as an issue today? Why isn't this not standard practice across the country? Why isn't this reported as a key quality measure on hospital performance? All else pales unless this elephant in the room is addressed. Tweety is most correct.

You actually have to ask "WHY"? You know why, and everybody else does too. MONEY. Because hiring enough nurses to keep the hospital staffed properly would cost too much money---and by "too much money" I mean that the CEO & upper level management wouldn't get their annual raises & bonuses. The more money that goes to nursing staff, the less that's left for administration.

This SHOULD BE, without question, one of the main quality measures for hospital performance. It actually should be THE main quality measure for hospital performance. Everybody likes to throw "EBP" around as the way they justify the policies & procedures, but when it comes to staffing, EBP is absent. I have always found it quite ironic that there is a policy & procedure for EVERYTHING, except for staffing levels. Wonder why? Because if there was a concrete, black & white policy for nurse:patient levels, if there was ever an incident where a patient was badly injured/died, the malpractice attorney could go into the policy/procedure for staffing and find that the hospital violated its own policy/procedure, making the hospital 100% liable for the incident. That's why you'll never find anything like that written anywhere. I'd be curious to know if malpractice attorneys are beginning to use the catch phrase "evidence based practice" in litigation, because it would be really interesting if the EBP with regard to nurse:patient ratios was ever brought up in a lawsuit.

[Thunderwolf, MSN, RN]

You actually have to ask "WHY"? You know why, and everybody else does too. MONEY. Because hiring enough nurses to keep the hospital staffed properly would cost too much money---and by "too much money" I mean that the CEO & upper level management wouldn't get their annual raises & bonuses. The more money that goes to nursing staff, the less that's left for administration.

I know. And I hear you.

Also, it tends to be somewhat ironic that the cost of Administration oftentimes subtracts more from the hospital's bottom line than do the salaries of nurses. And yet....nurses are often the first to be cut or not replaced. Over the years, it tends to unfortunately show, the more the number and/or levels of Admin in any given hospital, the higher the cost of services are sought and submitted for payment to both patient and/or insurance. Nurses don't jack up costs. Admin does. But that is a separate issue altogether.

[NurseDiane]

I know. And I hear you.

Also, it tends to be somewhat ironic that the cost of Administration oftentimes subtracts more from the hospital's bottom line than do the salaries of nurses. And yet....nurses are often the first to be cut or not replaced. Over the years, it tends to unfortunately show, the more the number and/or levels of Admin in any given hospital, the higher the cost of services are sought and submitted for payment to both patient and/or insurance. Nurses don't jack up costs. Admin does. But that is a separate issue altogether.

I took a class in grad school that had to do with exactly this----the costs of administration in hospitals & how much it decreases the bottom line. The administrative costs are usually what eats up the funds, not staffing. When I first started nursing 27 years ago, in most hospitals---whether they were smaller community hospitals or large teaching hospitals in big cities---there wasn't nearly the administrative staff that there is today. On each unit, there was a "head nurse" that worked 7-3 and was the head honcho of the unit. They were usually older, seasoned nurses that had worked many years in the specialty & knew the unit inside & out. The head nurse took care of the budgets, general unit operations,etc. Went to a lot of meetings, lol. Then there was a charge nurse for each shift. The charge nurses directly oversaw the bedside nurses----they did the schedules & that's who you'd go to if you needed time off or there was a problem. There were house supervisors that did the bed board, considered to be Assistant Directors of Nursing. Then there was the Director of Nursing. Now, there is a Chief Nursing Officer, numerous Assistant Nursing Officers that sit in meetings all day long & never walk onto the floors, nursing supervisors that are walking around the units doing practically nothing but looking very authoritative, a couple of nurses handling bed board, Nurse managers & assistant nurse managers for every unit, Nurse Educators for every unit, sometimes Clinical Nurse Specialists for certain specialty units like ICU, Peds and ED, nurse managers that are doing quality improvement & chart audits................but the number of clinical bedside nurses are the minority. Very top heavy. Maybe it justifies all the policies & procedures because there are nurses there to enforce them? I don't know. But, if clinical bedside nurses are the minority & the fewest in the lot, why is so much nursing administration necessary?

And then there is "regular" hospital administration. The CEO, the assistant to the CEO, the assistant to the assistant to the CEO, the CFO, the assistant CFO, the assistant to the assistant to the CFO, Senior Vice President positions, Vice President positions, etc. My local hospital has more administration than I've ever seen anywhere before, and they ran the place into the ground. They had to be bought by another hospital system or else they would have gone bankrupt. But, they have valet parking, a lovely water fountain outside the entrance, grapevines planted outside, a brand new atrium with a big white grand piano inside.........and they were so far in the red, it was mind boggling. The CEO was in the newspaper every other week, with a picture of himself doing something that had no bearing on staffing or patient care---new landscaping, new lights in the parking lot that would stay on 24/7, a "Garden Party" for fundraising, etc.

That's where the money goes. And when it comes time to negotiate a new contract for the nurses, the administration balks at every single thing presented---3% cost of living raise, fully paid benefits, vacation time, sick time, staffing ratios, etc. Whatever the nurses want they should get, within reason. Many places go on strike because of this, and then the nurses are looked at as "ungrateful"----but usually the hospital gives in after a few days because the patient care ends up being horrendous because the nursing administration doesn't now what to do. And those are the people that are supposed to know every evidence-based policy and procedure, right?

[JenMacBSN]

We share the same problems, ratio is 1:5 for a heavy medical floor. Now they are planning to limit our assistants to only 2 for a floor of 22 pts. How is your typical hospital staffed w/ CNAs and LPNs?