Why Do Nurses Allow Understaffing?

[RNfaster]

I am preparing to begin nursing school. It boggles my mind that people work in places that understaff.

I am definitely going to go for an advanced degree. I think it can't help but get better with a masters. But if nurses banded together, couldn't something change for the better? (Consider nursing ratios in California --CA is a great state for employees overall as I see it.)

When she heard I was planning on studying nursing, a former cardiac critical care nurse told me NOT to work at a hospital. I thought she must have gotten tired of it and things surely have improved. But now, I am wondering, and thinking I will consider doctors' offices (as a NP), pharmaceuticals, etc. Maybe it's just working med-surg that is so nutty. Maybe it gets better on other units.

--I love to work hard. But not simply running my butt off. I'd like to use my mind more...to be able to care and listen to patients a little more.

When I worked in "corporate America." we had time to bond with our coworkers, to advance our skills and teamwork, to work pet projects, to really delve into things. It wasn't a crazy race just to provide the bare minimum.

Any thoughts? Sorry I was so long-winded. It was a hard night.

[RNsRWe, ASN, RN]

I always recommend that nurses find a middle ground -- say "Yes" ocassionally, but only ocassionally and only on your own terms. Volunteer to work a little extra at a time convenient for you -- when you can plan and prepare for the extra hours in advance. Volunteer more during a temporary crisis that the management could not reasonably foresee and less to compensate for long-term problems that the management knows about but refuses to address. Find a middle ground that you can live with. That way, the management will see you as being willing to help and will not retaliate against you in any significant way -- but you will protect your sanity and your health.

You've just described my take on it! I have no bones about saying "no" when I get called for an extra shift and it's inconvenient, not enough notice, or whatever. I have no problem going in for an extra shift or part of a shift to cover a gap when I'm NOT inconvenienced, have enough notice, etc. In those cases, it's usually a gap that I don't blame management for, things happen and as a 24/7 operation we DO have call-outs, personal time to take, and so on.

I go in for the extra shift if I feel fine with it. If I'm tired because the loads have been too much lately, then the answer is NO and you know what? They know that! When the workloads are distributed better, staffed better, they also have less trouble filling in the gaps. Duh!

Also, the way I see it, if I'm complaining to management to get another nurse in for the next shift because the census/acuity is too high, then I ought to help out now and then when my co-workers would otherwise be drowning. If one of them comes in to bail me out, I should remember the same favor.

[EmmaG, RN]

And I have yet to see a charge nurse who does not dread making the call to the one who is on 'administrative on call' at 11pm because there are too few nurses to cover the census.

Dread, as in not wanting to do so? Or dread, as in knowing what the answer most likely will be?

[tntrn, ASN, RN]

You've just described my take on it! I have no bones about saying "no" when I get called for an extra shift and it's inconvenient, not enough notice, or whatever. I have no problem going in for an extra shift or part of a shift to cover a gap when I'm NOT inconvenienced, have enough notice, etc. In those cases, it's usually a gap that I don't blame management for, things happen and as a 24/7 operation we DO have call-outs, personal time to take, and so on.

I go in for the extra shift if I feel fine with it. If I'm tired because the loads have been too much lately, then the answer is NO and you know what? They know that! When the workloads are distributed better, staffed better, they also have less trouble filling in the gaps. Duh!

Also, the way I see it, if I'm complaining to management to get another nurse in for the next shift because the census/acuity is too high, then I ought to help out now and then when my co-workers would otherwise be drowning. If one of them comes in to bail me out, I should remember the same favor.

That's it in a nutshell for me, too. I work per diem, so don't really have a schedule. However, I have a very full life outside the hospital and guard my time with my spouse (and he's away often) zealously. I do not work when he's going to be home. Just won't happen.

I will trade shifts. And in August I'm working 3 shifts for a gal who wanted to attend a wedding a couple of states away and had been denied the time off. She'll reciprocate with me if I even need it. I learned the hard way that working for some people becomes something that is very one-sided. You work when they need coverage, but they can never do it for you.

Nurses have to take a stand on when to work extra and when to say no. Basically, management relies on us, as a group, being enablers. By our unwillingness to hold them accountable, we enable to continue unsafe staffing practices. Is there a 12-step program for this?

[llg, PhD, RN]

I agree with you but when is management really going to take responsibility? !

They will be able to avoid the responsibility as long as bedside nurses keep "bailing them out" by taking the guilt trip and working the extra hours.

I've been in the leadership team meetings when these things are discussed. The general thought is that there is no need to do more (more money, more FTE's, etc.) as long as the current staff is willing to work the hours to meet the basic needs. Someone always says, "Well ... if the staff is willing to work the overtime, that's easier and cheaper in the long run than making bigger, more expensive changes. Besides, a lot of those nurses depend on those extra hours for their income. If we hire more staff, we will anger the staff we have who count on that money."

Saying "yes" all the time to the extra hours sends the message that the nurses WANT the extra hours. Saying "No" at least some of the time will send the opposite message -- a message that needs to be sent.

[yankeeRN]

It's the nurse managers that allow understaffing, it's called the "BUDGET". There are staffing guidelines according to census, and unfortunately for us staff nurses, the managers get a bonus at the end of the year if they don't go over budget. We had a nurse mgr like that, but after several poor satisfactory employee surveys we gave her, the powers that be fired her :-)

[Love-A-Nurse]

Mangers have to follow orders too, don't they? They are in a difficult position, most of the time, wanting to help those under them with staffing, increase pay, etc., moreover, they have to "watch" the money too.

I personally don't feel if the nurses refuse overtime [additional shifts] it would get managment thinking "our" way. Agency will be called in to replace the "needed shifts.

[muffie, RN]

they cancel or's when there are no OR nurses or csu beds to take care of the pts

but

if we are short a nurse on the floor, we get 5 pts instead of 4

thank you management, very very much

[mamalle]

seriously what are we to do? do you think we like to run understaffed and we enjoy saying at the end of our shift" thank god I didnt kill anyone today?" nursing isnt the same and as much we like to think that managment listens and cares about us nurses- think again.. It wont take long to see what its all about. I swear I would be rich for everytime a manager was called in the middle of the night and tells the charge nurse " do the best you can".... that is the very reason I try and stay out of the hospital setting. I do my 2-3 shifts a month and will help my coworkers out if they need time off since management wont. Most of my summer shifts are done after the schedule comes out so I can help a fellow nurse out with their time off. Im really not sure what the answer is because administration surely doesnt care..

[BBFRN, BSN, PhD]

Managed care has effected the way we practice, to some extent good, but now, far more to the extreme of not so good, not so good at all. It should be a whole class in Nursing school :The Business of Healthcare....

You see, nursing hours are not billable by the hospital, we are a huge, huge expense for the hospital. What their dirty little secret is....they need us, heck, that is why patients are in the hospital in the 1st place...they need nursing care! Think about it, if they needed to see their doc, have a procedure, get a lab draw, have a dietary consult on and on and on, they could get all of that done as an outpatient. But they are admitted, ultimately, why....? Cause they need to be under the care of a licensed nurse. We are the ones that are there 24/7, monitoring and performing skilled nursing duties. But nursing hours are not billable....so we are a "loss" for the hospital, yet they need us in order to even open their doors.

Yes- I took a health care economics course last Summer, and it was a big eye opener regarding how hospitals are managed. Nurses being included in the room rate definitely is a big problem.

[celeste7767]

seriously what are we to do? do you think we like to run understaffed and we enjoy saying at the end of our shift" thank god I didnt kill anyone today?" nursing isnt the same and as much we like to think that managment listens and cares about us nurses- think again.. It wont take long to see what its all about. I swear I would be rich for everytime a manager was called in the middle of the night and tells the charge nurse " do the best you can".... that is the very reason I try and stay out of the hospital setting. I do my 2-3 shifts a month and will help my coworkers out if they need time off since management wont. Most of my summer shifts are done after the schedule comes out so I can help a fellow nurse out with their time off. Im really not sure what the answer is because administration surely doesnt care..

I'll tell you one thing you can do but unless you want to get fired like I did, you better get most of the nurses on your unit to do the same thing. After I explained what would work to the other nurses, I was let go the next day I came back to work. This is it: Say you are shortstaffed and you're in charge; or you aren't in charge but you have a number of very sick patients or too many patients so that you can DOCUMENT THE REASONS CLEARLY WHY IT IS UNSAFE. You type it up, name the date, shift, and the supervisor(s) you notified about the problem and why it could result in poor patient outcomes or even a sentinel event. DO NOT USE PATIEN T NAMES IN YOUR REPORT SINCE THAT WOULD BE A BREACH OF THE HIPPA LAWS. USE EITHER ROOM AND BED NUMBERS OR MEDICAL RECORD NUMBERS TO IDENTIFY THE PATIENTS WHO ARE AT RISK. Explain how you presented your case to your immediate supervisor, then called your unit Manager and tell her that as a courtesy you are notifying her that you will be filing a report documenting the circumstances surrounding the events that have transpired thus far and any untoward events that may result possibly due to the understaffing issue. Explain that you will have a copy sent to the hospital administrator, the Director of Nursing or Executive Nursing Officer and keep a copy for yourself. Tell her this is the only way you can see that you will not be held ULTIMATELY LIABLE SHOULD A SENTINEL EVENT OCCUR, since without any evidence stating any different it might be construed that you never notified any of your superiors of the conditions on the unit during that shift.

Believe me, documentation is the last thing administration wants because they have no or very little defense when faced with the cold hard facts that they each blatantly ignored. If you are in Charge, you may need to call the Executive Nursing Officer if your manager will not step up to the plate and find a solution like closing the unit to further admissions or coming in herself to work. If you are a staff nurse you can document only what your personal situation is with the patient load you have and explain in great detail why it is unsafe and that you do not want to risk not only a person's life but your professional license as well should things go south. You may also want to notify some of the physicians of your patients who you know would be sympathetic and concerned about your plight and their patient's welfare.

I was the charge nurse in an ICU in a small community hospital and I was forced to type up such a report. I also explained to my nurses what I was going to be doing and allowed them to read it. I told them that uncontrovertible documentation is their only defense when faced with Shift Supervisors who refuse to get permission to close a unit to further admissions or worse with Nurse Executives and CEO's who won't back up their nurses because of the bottom line. Not one nurse would relate that they believed that they were understaffed and their patients at risk (even tho' they all complained about it to me) and they did not lose their jobs. I did lose mine but when I filed a wrongful termination claim with the Arizona Dept. of Economic Security, the Hospital was found in the wrong and I received 3 months of unemployment pay. Unfortunately, I have learned in 30 yrs of nursing that most nurses talk the talk, but are ultimately afraid to walk the walk and take that chance by fighting the good fight. Maybe if more would do it, hospitals would become more afraid of that tactic and might try a little harder to get staffing.

[tntrn, ASN, RN]

I'll tell you one thing you can do but unless you want to get fired like I did, you better get most of the nurses on your unit to do the same thing. After I explained what would work to the other nurses, I was let go the next day I came back to work. This is it: Say you are shortstaffed and you're in charge; or you aren't in charge but you have a number of very sick patients or too many patients so that you can DOCUMENT THE REASONS CLEARLY WHY IT IS UNSAFE. You type it up, name the date, shift, and the supervisor(s) you notified about the problem and why it could result in poor patient outcomes or even a sentinel event. DO NOT USE PATIEN T NAMES IN YOUR REPORT SINCE THAT WOULD BE A BREACH OF THE HIPPA LAWS. USE EITHER ROOM AND BED NUMBERS OR MEDICAL RECORD NUMBERS TO IDENTIFY THE PATIENTS WHO ARE AT RISK. Explain how you presented your case to your immediate supervisor, then called your unit Manager and tell her that as a courtesy you are notifying her that you will be filing a report documenting the circumstances surrounding the events that have transpired thus far and any untoward events that may result possibly due to the understaffing issue. Explain that you will have a copy sent to the hospital administrator, the Director of Nursing or Executive Nursing Officer and keep a copy for yourself. Tell her this is the only way you can see that you will not be held ULTIMATELY LIABLE SHOULD A SENTINEL EVENT OCCUR, since without any evidence stating any different it might be construed that you never notified any of your superiors of the conditions on the unit during that shift.

Believe me, documentation is the last thing administration wants because they have no or very little defense when faced with the cold hard facts that they each blatantly ignored. .

Wow! I started reading your post and looked to see if my name was at the top of it! The difference being is that we have an Unsafe Staffing Report form and I encourage nurses to use it because without the documentation you mention, they (admin) gets off scott free. Our form has everything you mentioned on it and copies go to the Union office (which is where we must differ as I suspect your hospital doesn't have one), the admin, the nurse and someone else gets one too but my early morning brain can't remember who.

Last weekend we had a severe staffing crisis. One of the 12 hour night shift nurses worked 20 hours, then came back in 4 hours for 12 more. Another of the nurses has filled out the report form and now our NM and the CNO want a "meeting" with her. She's a smart girl and said, "okay, but not without my union rep." The minute she told me they requested a meeting with her, I said, "they will try to talk you into not filing the report and then there's no paper trail proving a problem existed that they ignored." So precisely what you said: they hate documentation more than anything.

And intimidation is something they are very passive-aggressive about. They won't intimidate the nurse I mentioned above, or me, but I can name some who are already so shy and afraid that getting them to fill out one of these reports probably will never happen.

This is my 31st year in nursing and my! oh! my! hasn't it changed in that time. I seriously fear the direction it's taking. Too many machines and not enough hands-on care. As confident and proud I am of my own patient care skills as I am sure other nurses are too, I will insist on being or having a family or friend as a patient advocate if hospitalization is necessary in our family.

Where I work, we now have the computer charting: well, that's another topic entirely, but many of our nurses are now staying over to chart when they never did before. Another lie that it gives more time for patients and takes less time to chart. We do housekeeping duties on evening shift also. Not that I'm too good for that, but to pay me a nurse's salary for cleaning beds seems to be a misuse of funds. You'd think the bean counters could figure that one out.

[hogan4736, BSN, RN]

...if we are short a nurse on the floor, we get 5 pts instead of 4

thank you management, very very much

only if you tolerate it, will it continue to happen...

I am a house sup, and make daily staffing decisions...I would NEVER do this to my floor nurses...the charge would get an assignment, I would take an assignment. I would call in the director...