Nurses are the glue of healthcare.
Nurses were pushed thin before COVID, and then during COVID, nurses were pushed to the limit. In the early days of the pandemic, nurses cared for patients without protective equipment and chose daily to put their lives on the line. Commitment to patients is what nurses are all about.
Despite their essential contributions and despite being the nation's largest healthcare profession at nearly 4.2 million strong, their work is often taken for granted and not understood.
Nurses are critically important to our nation's healthcare and yet consistently undervalued. While hospitals currently undervalue nurses, this may change in the future. Nurses are positioned to play a growing role in generating revenue under a value-based payment system.
Their importance may soon become evident when hospitals must rely on them to achieve specific reimbursable patient outcomes.
Nurses As Widgets
In hospitals, nurses are not recognized and appreciated by most any measure.
Hospital nurses are not considered professionals but are viewed as interchangeable work units performing license-required tasks. Widgets, in a word. Widgets with a nursing license.
In the 1990s, nurses were subjected to demeaning time and motion studies where a recorder with a stopwatch stood outside the patient's door and timed how long it took for a nurse to start an IV or administer medications. The assumption was that the practice of nursing could be reduced to a list of psychomotor skills and tasks. The assumption lingers.
At all times, nurses are reminded they are dispensable and replaceable. With sophisticated acuity systems, hospitals evaluate staffing needs every four hours. It's a numbers game. If there are a couple of discharges and no admits in sight, a nurse can be sent home without pay at 1100 or 1600 or even at 0200 in the morning.
The remaining nurses can then be moved from floor to floor and patient to patient by Staffing Office like chess pieces on a chess board. Unsuspecting patients are likewise handed off from nurse to nurse.
As interchangeable units, expert nurses and new grads are not differentiated. Inexplicably, novice and expert nurses are assigned the same number of patients.
While surveyors may be told differently, patient care assignments are typically based solely on numbers rather than expertise, ability, or patient safety.
A nursing unit staffed with primarily new grads is a concerning case of the blind leading the blind. Often new nurses are relegated en masse to the night shift, where they have fewer resources and need more support to fend for themselves, especially in facilities with high turnover.
New grads still need to gain the critical thinking skills and pattern recognition required to identify early signs of sepsis or deteriorating conditions.
The nursing unit with the most novice nurses will have the most codes and failures to rescue.
Hospitals were quick to furlough nurses during early COVID when some services, such as ambulatory surgeries, shut down. Shortly afterward, they scrambled to backfill a shortage of nurses when hospitals were overrun with COVID patients.
At that point, hospitals discovered some nurse widgets cost far more than others, especially widgets of the traveling variety.
Nurses Do Not Have A Place At The Table
Nurses have low authority and low autonomy.
In addition to pay, another sign of value is being asked for input based on the expertise, experience, and body of knowledge unique to the profession.
This does not happen; nurses fear retaliation for speaking up and voicing concerns.
Time and again, workflow processes, patient care, and nursing practice decisions are made devoid of nursing input. How often do nurses hear of a new decision by administration and shake their heads, knowing it won't work?
For example, when nurses are cut, administration frequently doesn't appreciate their contributions until they are gone.
As a cost-saving measure a few years back, charge nurses were targeted as low-hanging fruit and eliminated in several hospitals, only to be reluctantly hired back shortly afterward. It could have been a more well-thought-out move on the part of high-ranking CFOs.
Charge Nurses are Essential
Not having a charge nurse is like not having an air traffic controller at Dallas International airport. Nursing units, EDs, and ICUs are high-stakes, high-pressure chambers where chaos is controlled at best.
Even so, charge nurses are frequently expected to take patients while managing the floor and putting out fires. The unsuspecting patients assigned to that charge nurse have a distracted, unavailable nurse at best. To continue the analogy, this is like an air traffic controller flying the airplane.
While hospitals do not seek nursing input, they regularly retain consultants who come in, advise arbitrary, one-size fits all solutions, and then disappear.
Pens are essential
One mid-size hospital in southern California was advised by expert consultants to stop supplying pens to staff, with promises that the hospital would save thousands upon thousands of dollars annually. Overnight and without warning, all but one box of pens were removed from each nursing unit. The remaining box was locked in a high cupboard, and the secretary held the key.
Doctors were readily given a pen on request, but nursing staff had to present a defensible argument to be granted a pen from the key-wielding secretary.
The first unsuspecting nurse caught without a pen was an RN in ICU. She was pulled out of shift report to take urgent admission telephone orders from an ED physician regarding a critical patient being flown in and en route from an outlying area.
She didn't get the memo about bringing her own pen in that morning. She frantically searched for a pen while the doctor rapidly fired off complex orders and vent settings she tried vainly to commit to memory.
Gloves are essential
Likewise, supply chain management can switch out supplies without end-user input. A nurse ran to the supply room for gloves only to discover that the blue glove boxes situated in the center of the supply cart were missing.
She finally recognized a different colored box as a box containing gloves, grabbed a pair in her size, and returned to her patient room. They didn't fit. She returned and grabbed another size.
No matter what size she tried, the fingers were oddly long and floppy at the tips while too tight across the knuckles. They were stiff and ripped easily. She had to remove them to do anything requiring finesse or small motor movement, such as starting an IV. But they were cheaper.
Hospital decision-makers should consult nurses as important stakeholders.
Nursing is represented in the C-suite by the chief nursing officer (CNO) or patient care executive (PCE). CNOs and PCEs are executives by title but may not have the same leverage as the other executives at the table, such as the CFO or COO. Even though 60% to 80% of clinical staff—the largest workforce in the hospital—report to the CNO/PCE, she may be the only one at the table advocating for patients and nursing.
In many other ways, there needs to be more parity. A nurse manager may have upwards of 100 direct reports, while the higher-paid Director of Imaging has 50.
Hospitals need to make sure nursing is equally represented in the conversation. Patient care decisions should be made by those closest to patients- nurses2.
Fear Of Unsafe Workloads
Nurses want to care for patients and families and know they make a difference, but instead, often work their shifts in fear of making a grave mistake.
Nurses are stressed by too many high-acuity patients, some of whom are unstable. Given nurses' accommodating and caring natures, hospitals know they will diligently strive to perform in most any circumstance, whether it's working short in the NICU or caring for an ICU-level patient on MedSurg while waiting for a bed.
Often, this means skipping breaks, clocking out without taking meals, and staying over after working 12.5 hours to document off the clock, fearing reprisal for edge-of-shift overtime.
The unrealistic demands are driving nurses out of the hospital. Personal failure and being thrown in over their heads with their licenses at risk is overwhelming. In how many other professions do new hires admit to crying before work or sitting in their cars in the parking structure with upset stomachs, willing themselves to go in?
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My opinion is a lot of issues would be solved with better staffing, safe and fair patient ratios, enough support staff, respect and good pay, but that is the opposite of what many places are willing to do to fix the real problems which have lead to a mass exodus of nurses from the bedside. - Quote from the astute @brandy1017
Unrealistic workloads do not only leave nurses morally fatigued, depleted, and stressed; they leave patients at risk. Patients are unprotected when staffing is inadequate.
Failure to rescue and patient deaths increase with higher patient-to-nurse ratios. In a recent nurses' strike of over 7,000 nurses in New York City, Montefiore hospital nurses reported being responsible for as many as 35 patients on one shift.
Despite numerous studies that show that adequate staffing is directly related to clinical outcomes, including patient mortality, passionate calls for better staffing and more nurses to provide safer patient care fall on deaf ears2.
Unsafe assignments are not the exception; they are the norm in far too many facilities.
CA is the only state that has successfully passed legislation for minimum patient-nurse ratios. In all other states, organizations devise and impose facility-specific nurse-to-patient ratios that appear to be based on profits and not quality of care.
Combining adequate staffing and supportive work environments leads to positive patient outcomes.
Profits Over Patient Care
Credibility is lost when disparities are apparent. Nurses are told hospitals cannot provide adequate nursing staff or make wage adjustments because they operate on a shoestring. This doesn't necessarily match the optics of pricey artwork on the walls, fountains in the lobby, and ambitious expansion plans.
It's reasonable to deduce that hospitals prioritize profits over patients when low-paid patient care attendants and nursing assistants are cut, giving the remaining attendants and assistants upwards of 12-16 patients while at the same time exponentially increasing CEO salaries.
A recent study found some hospital CEOs earning millions annually while nursing wages remain stagnant. It's not unusual for CEO salaries to double, quadruple, and even increase 700 % in 5 short years. It would be ludicrous if any doctor or nurse or anyone outside of the entertainment industry or pro sports industry saw that kind of increase in salary in such a short time.
More important, researchers found that CEO salaries had no meaningful connection to patient outcomes or safety.
Even without the benefit of a business background, nurses understand that reducing nursing turnover decreases costs. Improving nurse retention improves patient outcomes which increases reimbursement.
Nurses view prioritizing this month's labor budget at the expense of next year's patient safety and long-term outcomes as shortsighted. Cutting costs to increase profits immediately is costly-it's stepping over a dollar to pick up a dime.
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Turnover is costly.
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Labor disputes are costly.
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Burnout and low morale are costly.
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Poor patient outcomes are costly.
Recruiting young people into the profession while nurses leave the bedside is challenging. The younger generation has career options that do not include stressful, strife-ridden jobs where they are treated unprofessionally.
As businesses, hospitals need to invest, but they need to invest proportionately in their most valuable resource-nurses.
Not-For-Profit And For-Profit
According to the NYT, nonprofit and for-profit hospitals increasingly resemble each other. They both have hierarchical corporate structures. They both prioritize the bottom line, and in many cases, both have strayed from their original charity missions.
Strategic, subtle shifts from original faith-based mission statements are noticeable in rebranding.
Even though Dignity Health began in Dublin, Ireland, and was founded by six Sisters of Mercy, Catholic Healthcare West dropped the "Catholic" to become Dignity Health.
Seventh Day Adventist Health's (Advent Health) mission statement of "Living Jesus' love by inspiring health, wholeness, and hope" quietly became "Living God's love by inspiring health, wholeness, and hope".
Over half of the country's 5,000 hospitals are nonprofits. Ascension Health, Common Spirit Health, and Providence are some of the largest.
Nonprofits: what they are not
Not-for-profit is a term not well understood by many nurses. Not-for-profit implies the organization is motivated by other than profit. But nonprofits do make profits or excess capital.
Not-for-profit doesn't mean the CEO works for pennies. Nonprofit CEOs are making millions alongside their for-profit counterparts. Dr. Hochman of the giant nonprofit Providence earned $10 million in 2020.
Nonprofits: what they are
Not-for-profit is a tax status granted by the Internal Revenue Service (IRS).
Not-for-profit hospitals are classified as charities by the IRS, even those healthcare systems that seem far from charitable. Not-for-profit is a lucrative tax status. Not-for-profit hospitals do not pay
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Property taxes
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State taxes
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Federal income taxes, or
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Sales taxes
For example, Providence's healthcare system avoids more than $1 billion yearly in taxes.
Nonprofit healthcare systems must benefit the local community in exchange for their tax-free status. For example, they can assist communities in promoting health and providing free health care to the poor.
For-profits
Like Twitter or Apple, or any Wall Street company, for-profit hospitals are owned by investors. Their goal is to make profits for their shareholders. HCA Healthcare, Community Health Systems, and Tenet Healthcare are prominent for-profit hospital chains in the U.S.
Nurses As Costs, Not Assets
Despite the appearance of excess, astronomical CEO salaries and artwork are not the problem. They are symptoms of the problem, which is the economic structure of our healthcare system.
Healthcare systems and policymakers do not prioritize supportive workplaces.
Doctors generate revenue. Nurses do not. Doctors are on the revenue-generating side; nurses are on the labor-cost side. Nurses come with room service, along with housekeeping services and meals.
As nurses are labor costs that do not generate revenue, hospitals are incentivized to keep the number of nurses down and to pay them as little as possible.
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Until nurses are not an expensive labor cost for hospitals but are seen as revenue generators and as vanguards of quality, which they are, we're going to keep having this problem, said Betty Rambur, professor of nursing at the University of Rhode Island.
As long as reducing the number of nurses and keeping wages stagnant increases profits, nothing will change.
Nurses Underestimate Themselves
Nursing itself needs to do a better job of articulating its value.
Some nurses mistakenly and proudly believe that starting an IV is the best evidence of their skills. Psychomotor skills do not set one apart professionally.
The cognitive work of nursing is what nurses contribute. It's invisible and undervalued, even by nurses. At each point of patient contact, nurses assess, pivot, and respond.
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When a nurse casually chats with a patient, she evaluates his level of consciousness and compares it to his baseline.
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When she holds her hand just above but not touching a reddened calf, she can assess the heat rising from the inflamed tissue, view the imperceptible spread, and know the potential danger.
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When she jokes with an elderly male who is undergoing heart surgery and is afraid, she is telling him he is safe in the subtext.
As patients pass through illness, trauma, childbirth, and more, nurses are at their side, navigating on their behalf, watching out for danger, and providing the knowledge and expertise to keep them safe.
Nurses provide safe passage.
Value-Based Care
In the past, Medicare paid the majority of hospital bills without question and regard for quality outcomes. The result of CMS signing the check was overutilized services and increased healthcare spending.
Now CMS is requiring hospitals to measure against outcomes of care. With the advent of value-based care, hospital revenue is increasingly tied to positive patient outcomes.
This makes hospitals and nurses partners in a new way.
Hospital nurses have already seen the move towards value-based care. All nurses recall the massive drill-down on Press Ganey HCAHPS scores when nurses were coached to use the word "always" when talking to patients, as in "We hope you will always recommend us to your family," the goal being to increase patients' "always" response in patient satisfaction surveys.
As disingenuous as this seems, it is because patient experience is tied to Medicare reimbursement. The highest-performing hospitals are rewarded financially.
An example is the Hospital Readmissions Reduction Program (HRRP), designed to prevent readmissions, especially in specific high-volume patient populations, such as heart failure, acute myocardial infarction (AMI), pneumonia (PN), total hip arthroplasty, total knee arthroplasty (THA/TKA), and chronic obstructive pulmonary disease (COPD).
The focus on Hospital-Acquired Conditions (HAC) such as Central Line-Associated Blood Stream Infections (CLABSI) and Catheter-Associated Urinary Tract Infections (CAUTI) is due to hospitals being penalized for poor outcomes.
It is a worthy goal to reduce hospital-acquired infections. However, nurses prefer hospitals to be transparent rather than spinning these measures as the "right thing to do."
Preventing CLABSI and CAUTI is unarguably the right thing to do, has always been the right thing to do, and is not suddenly more right because it's financially rewarding. The excellent news is CLABSI and CAUTI prevention is doable with adequate nurse staffing.
In hospitals with better nurse staffing, mortality rates are lower, 30-day readmissions are lower, and pressure ulcer prevalence is lower1.
Nursing Sensitive Indicators
What if quality patient outcomes were rightfully attributed to nursing care? It's happening. Nursing-sensitive indicators directly reflect nurses' value.
The National Quality Forum (NQF) compiled the NDNQI, which includes nursing-sensitive measures based on the relationship between nursing and patient outcomes.
For example, these indicators include CLABSI and CAUTI rates (outcomes indicators).
Some indicators have a direct impact on hospitals' performance scores, such as CLABSI and CAUTI, and others have an indirect impact, such as pressure ulcer prevalence and ventilator-associated pneumonia. In the future, more indicators will have a direct impact.
Evidence-based practice is vital to establishing nursing's value and subsequent impact on reimbursement.
Conclusion
Nursing is the sleeping giant of healthcare that has not yet realized its professional potential.
The future of healthcare is for hospitals and nurses to embrace value-based nursing practice.
Hospitals can only provide quality care with highly skilled, well-educated nurses.
Nurses can only provide consistently high-quality care in environments that value nurses' contributions, as demonstrated by fair compensation, investment in nursing education, and a supportive work environment.
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