3 thoughts on “The Future of Nursing revisited”

1. Well, I recently, and only for a very brief period of time, worked as risk manager for a prison hospital.

   What I observed scared the hell out of me and I think it is indicative of what is coming along.

   I think one of the problems we face is that we tend to extol the virtues of nursing and to refer to often to the very best care available. There are, for example a bit more than 100 magnet hospitals in the country. With good reason people point to their successes and tend to forget that there are thousands of hospitals in the country, meaning that there are thousands of non-magnet hospitals.

   So, what did I observe at a prison hospital in the state whose Governor is the former CEO of HCA?

   In the year before my arrival there were concerted efforts to strip resources from nursing. In the few months just prior to my arrival, and during the two months I was there, virtually all the inpatient staff were offered jobs in outpatient services.

   The effect? Staffing for inpatient services was 60-70% temporary staff. On many shifts, all the staff were agency staff. Few agency staffers came back after 1-2 shifts because they knew there was nobody who knew how to do the paperwork, nobody who where the supplies were, nobody who knew what the protocols of care were. They, as did I, soon concluded that simply working there, even for a single shift, posed a danger to their professional licenses and reputations.

   What led me to leave was not that it was a bad situation – but the recognition that I, nursing, and the nursing director, were being undermined at every opportunity. The final blow was when I realized that the nursing director was being forced to cut an already inadequate staff by 32%. After going through the re-staffing exercise with the nursing director, analyzing exactly what that re-staffing would look like, and knowing that outpatient services was consistently over-staffed, it was clear that the intent was to destroy what was left of a functional inpatient service.

   I could drone on for months about all the ways in which nurses were prevented from working well. I’ll give a couple.

   The policy on Medication Administration Records was that they had to be filled out by hand and the longest period allowed on one form was 7 days. A monthly MAR would have reduced the work involved by close to 80%. So what happened as a result? Missed doses, transcription errors, and excessive work.

   Some agencies had good staff, some did not. Sadly, the agencies with the worst staff tended to be the most astute in discerning how to get their bids in. The system was first come – first taken but despite months during which the agencies with the best staff failed to respond first, these agencies could not even be told that they needed to get their bids in within 2 minutes of the staffing request going out by email. Instead, they consistently responded too late to get their staff approved.

   As is so often the case, the burden of declining nursing staffing fell disproportionately on the shoulders of the few remaining staff who cared deeply about the quality of care. They had to work extra shifts when other staff did not report, they shouldered the burden of compensating for the high agency workforce, they were the ones who had to write the redundant incident reports for errors committed by the temporary staff nurses whose job duties they had to cover because they weren’t being performed.

   Why do I bring this up? Because it is, in sharp relief, precisely what is going to be happening across the country, and around the world, as the budgets for health care providers are slashed. Why are budgets going to be slashed? Because in most “developed” economies the inter-generational promises that have been made, and the poor stewardship of public resources, mean that historical patterns of funding are simply unsustainable. We cannot continue to spend thousands of dollars on personal mobility devices when the cost will be borne in years to come.

   We cannot continue to produce profitable carve-outs of specialty medical supplies and services such as the highly advertised diabetes care programs and catheter suppliers because the profits these entities are earning for these extremely limited benefits are depleting overall resources at an alarming rate.

   The dozens of magnet hospitals will most certainly be hurt as this unfolds over the next couple of decades. But they will not be hurt anywhere near as much as the thousands of non-magnet hospitals that provide most of the care for most Americans and disproportionately large numbers of the poor, homeless, and elderly on fixed incomes.

   Nor are magnet hospitals going to be hurt as much as long term care centers and home health agencies as the resources for these services decline at the same time the demand for such services is rising to historic levels.

   There is, I fear, an air or unreality in the nursing profession. It is akin to the band playing as the Titanic sank.

   I would suggest that we need to invest far more energy on what we are doing terribly badly at, than what we are doing very well at, if we want to head off the coming decline in quality and quantity of care.

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   • Thomas,
     Thanks for sharing your observations and experience. Any ideas for how we can make positive changes to shape the future of nursing (and patient care)?

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     • 🙂

       Oh, I have lots of ideas – but the most important area of focus needs to be on inefficient health care finance mechanisms like capitation, Diagnosis Related Groups, episode based care, and the Prospective Payment Systems.

       The problem is that these mechanisms are so inefficient that nothing else we do will have much impact if we do not address the fact that health care providers are functioning as their patients’ inefficient health insurers more and more every day and that most health care reform proposals are going to increase the use of such mechanisms.

       We can make marginal improvements in quality and efficiency of care on a micro level in all settings but improving efficiency by 1 – 2% per year while the inefficiencies in health care finance mechanims are increasing at the rate of 20-50% each year is a losing battle.

       To make a March Madness metaphor: Having the best and brightest nurses working full speed ahead making marginal improvements where they work, while politicians and policy wonks are working full time to destroy what little is left of our health care (finance) systems is like asking the top seeds in the NCAA tournament to play blindfolded and expect them to prevail merely because they are the best without blindfolds.

       We nurses simply cannot compensate for the exponential collapse occurring in our health care (finance) systems because the current macro trends dwarf the best possible effects of the changes we can make.

       I want to be very clear here. I am not suggesting that we ought not recognize the best we do, only that we are failing, year after year after year, to address the most significant changes occurring in health care settings and you need to recognize the source of the problem before you can fix it.

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