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Your Nurses Are Worried. Are You???

July 24, 2009
by Mark Hagland
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The American Nurses Association recently asked nurses to participate in what it called a “Safe Staffing Poll” on its website. And the results are concerning, even if you take into account the fact that the ANA is almost certainly going to be using the results for advocacy/lobbying purposes, and the fact that the nurses participating in the survey knew that.

Here’s what’s interesting, though: when 14,993 nurses were asked questions on staffing levels and their impact on patient safety, during the period from March 31 to June 5, large numbers of staff nurses, who made up the bulk of the respondents to the survey (74.7 percent) indicated strong worries about staffing-related patient safety.

Asked, “Do you believe the staffing on your unit and shift is sufficient?” a full 71.9 percent said “no”; asked, “Would you feel confident having someone close to you receive care in the facility in which you work?” a full 49.5 percent said “no”; and, asked, “Are you currently considering leaving your position?” a whopping 52.7 percent said “yes.”

So there you have it: most nurses don’t think there are sufficient nurses on their shifts, don’t feel confident enough to recommend their own facilities to others for care, and are considering leaving their current positions. Yikes. Indeed, even accounting for the nature of the survey involved, such figures should be viewed as deeply concerning.

Now, we’ve known about the problem of nurse burnout for a very long time, and as an industry, we’ve been working on that problem in various ways, often unsuccessfully. But these kinds of results—again, taking into account that the respondents to this survey almost certainly knew the results would be used for lobbying and persuasional purposes—are rather alarming. Indeed, let’s look at a couple of other questions for added reinforcement of our perceptions. Asked, “How often are you able to take your full meal break?” 11.7 percent of respondents said “never”; 24.1 percent said “rarely” (defined as “less than monthly”); and 24.7 percent said “sometimes” (defined as “once a month”). Put another way, only 41.1 percent (actually, fewer than that, since 4 percent didn’t respond at all to the question) of nurses were able to take full meal breaks more than once a month. Again, yikes.

What’s more, it doesn’t require surveys like this one to easily uncover anecdotal evidence of nurse burnout nationwide, as well as of nurse concerns over patient safety. And this, at a time when healthcare purchasers, payers and policymakers are more determined than ever to force improvements in patient safety in hospitals and health systems across the country.

Of course, there are two fundamental sets of solutions to the problem, both of which I’ve written about extensively both in the pages of Healthcare Informatics, as well as in my two books, Paradox and Imperatives in Health Care and Transformative Quality: The Emerging Revolution in Health Care Performance. The first set of solutions clusters around the intensive efforts that pioneering hospital organizations are making, using performance improvement methodologies like Lean management, Six Sigma, and the Toyota Production System, to fundamentally remake care delivery by examining underlying processes. One organization I wrote about in my first book, VirginiaMasonMedicalCenter in Seattle, completely reworked its nurse staffing strategy. Leaders there looked at the standard accepted form of nurse deployment, which is based on caring for individual patients during shifts, and found that it actually made things much worse; so they reworked everything, and implemented a purely geographical staffing system that not only made the nurses dramatically more efficient, it also saved on hiring additional nursing staff.

And the other set of solutions clusters, of course, around information technology. When intelligently deployed, the full range of IT solutions, from automated meds administration solutions to wireless communications devices, can dramatically improve nurses’ efficiency, effectiveness, and workflow. But it is important to underscore that such solutions only reach their full potential when they are deployed as part of broader initiatives that yoke together performance improvement and IT implementation. Otherwise, technology can actually make things worse, by simply adding another layer of stuff on top of sub-optimized processes and workflow.

But if one thing is clear during the current federal debate on healthcare reform legislation, it is that the current costs of the healthcare system are completely unsustainable. And that means that, in addition to working to cover the millions of Americans who lack health insurance, federal lawmakers are inevitably going to have to press down even harder than they have previously, on hospitals and other healthcare providers, in order to have any impact on spiraling healthcare costs system-wide.




Mark Hagland,

In addition to the survey data, I've see statistically valid studies showing an association between inadequate staffing levels and quality indicators including infection rates.

What has been your experience with systems that quantify nursing care needs and provide that information to rationalize staffing and planning functions?

Mark Harvey and Joe Bormel,
Thank you both for your excellent observations and comments! Mark Harvey, thank you for sharing your wife's storyit definitely underscores the challenges facing hospital and health system leaders today. And I agree with you, the gradual but continual withdrawal of supports for RNs has left them in multitasking hell, and more disgruntled and unsatisfied than ever. What nursing student would want to learn that she or he was facing a job in which they were only going to spend 20% of their time on patient care, and the rest running around doing non-patient care tasks? Yet that's what they face. And Joe Bormel, I agree, I've seen some of those same studies regarding inadequate staffing levels.

And in both my first and second books, I include case studies of organizations that have thought about nurses and nurse staffing. In particular, in Paradox and Imperatives, my first book, I have a case study from Virginia Mason Medical Center in Seattle, which used Toyota Production System principles to analyze nurse workflow and completely rework nurse staffing. It's a fascinating case study!

In any case, thank you both for your fine observations and comments!

You make more good points here than can be easily commented upon. Let me just make a couple of observations...

The issues that surround nursing are vitally important to the future of our healthcare system. But I'm afraid that they are too far under the radar to get much attention until the system begins to feel real pain.

I have an interesting perspective on this, because my wife is one of those Boomer nurses who is likely to leave the workforce for good within the next 10 years. For the last 25 years or so, she's spent most of her time working in ambulatory environments she's presently one of the best outpatient medical oncology nurses in the country.

But a few years ago she got to missing the care she used to give at the beginning of her career to inpatients on the floor. She took a job at a local hospital on the cardiac step-down unit so she could "be a nurse" again.

Her skills, attitude, and approach to the job took a back seat to no one, but within the year she threw up her hands in despair and went to do something else.

Her complaint? She felt like she was on a treadmill- running constantly, but never getting anywhere. It was impossible for her to provide the kind of care to her patients that she thought of as her ministry in life.

Was she just not geared up to work as hard as she had to? Heck no. She began her practice in the 70s when floors were always full with patients who were staying 10 days post-cholecystectomy. She expected to work.

I don't claim to have all the answers, but an interesting point to consider is the trend toward "total care".

Not many years ago, the hospital floor was a model of efficient division of labor. Aides bathed and turned patients, changed beds and handled bedpans. LPNs administered treatments, monitored vital signs, and changed dressings. RNs managed IVs, performed assessments and supervised patient care. Doctors ped in every day to review records and write orders.

Many hospitals have eliminated most of those positions, motivated perhaps by concerns over regulation, staffing, whatever. I suspect that the nursing organizations were at least somewhat complicit in those initiatives, maybe thinking that it would build reliance on the RN and make them more valuable.

The real result is that the scarcest, most expensive, and most highly trained resource available (next to the physician) spends an inordinate amount of time doing the most menial work.

Combine this trend with the effort to use the nurse's skills to supplement the doctor's work so that the physician can be more productive. What's left is nurses who are getting squeezed in the middle.

How did nurses let themselves get into the situation they have? This is one of those sweeping generalizations that's backed up by nothing but personal observation, but I believe that nurses are drawn into the field by certain personal characteristics. One of those characteristics that I've seen often is that nurses are not prone to complain. (Except when they go home at night.)

Nurses make do.

If that means skipping a dinner break, they will. If it means clocking out and going back to the floor to finish charting, they will. If it means writing everything down on paper and typing it into the computer when the shift is over because the system is poorly designed or the COW won't hold a charge beyond an hour, they will.

Finally, one day, they take their sore feet and varicose veins and go drive a truck or something.

Just in case I haven't ticked enough people off yet, let me make one more observation.

I would suggest that we are often setting new nurses up for failure, frustration, and burnout by the failure of nursing education to properly prepare them for the workplace. If you know a recent nursing graduate, ask him or her how many IVs they had to start successfully before they graduated nursing school and hit the hospital floor.

(For many the answer is ONE.)

Into those trembling hands we commit the health of our aging population.