By Shawn Kennedy, AJN interim editor-in-chief
After I last wrote to you from the NTI (the American Association of Critical-Care Nurses’ annual National Teaching Institute and Critical Care Exposition), I headed back to the exhibit hall to check out the helicopter and the Army’s mobile operating tent. But I didn’t get to either one, because I met a young critical care nurse from a regional hospital in Missouri. We chatted about her workplace, and it was obvious that she was very proud of the work she and her colleagues did. When I asked her, “What’s your biggest issue?”, she said that it was probably staffing. I expected her to cite the shortage and the difficulty of finding qualified critical care nurses. But that wasn’t what she meant—rather she was talking about bare-bones staffing because of tight budgets. Her hospital routinely switches between two tactics: it sends nurses home when the patient census is low (when this happens, the nurses are paid only $2 an hour to be on call, but must still use a vacation day to retain full-time benefits, a tactic that rapidly depletes their vacation time); or, when the patient census is higher, the hospital imposes mandatory overtime, creating havoc in nurses’ schedules, finances, and personal lives. And people wonder why there’s a nursing shortage!
This practice isn’t new; we covered it in “The Other Side of Mandatory Overtime” in our April 2008 issue. Still, when I speak with nurses who work under this system, the injustice strikes me anew. Yet nurses seem to think this is the norm. Why is this an acceptable practice?
I “get” tight budgets. I don’t get why it’s always the nurse staffing budget that’s cut to make up a budget shortfall. It’s especially irritating when one realizes that hundreds of thousands of dollars are spent on technologies that haven’t yet been shown to make a difference in outcomes—while the substantial evidence on the relationship between nurse staffing and patient outcomes continues to be ignored. (We’ve covered this many times, including “Nurse Staffing and Patient, Nurse, and Financial Outcomes” in January 2008; and look for a related story in the July In the News). Professional nursing organizations and unions have made significant strides against mandatory overtime. But if hospital workplaces are going to work for nurses, they need to address mandatory “off-time,” too.
I am a Respiratory Therapist in a small hospital, 2 therapists per shift. They are flexing us with low census. Anyone who knows Respiratory Therapist’s job duties knows that changes abruptly any second. The one Therapist that is left can be overwhelmed quickly. I have been in this field for 40 years started in my 20’s. It is so hard to deal with in my 60’s when I am trying to retire, it is also hard to watch the horrible healthcare patients are receiving due to minimal staffing. My leave is used up so I can’t take a vacation. God help me if I get sick or have to have surgery. We can’t get staff due to flexing issues so we have to work hours like 9 to 9 and then double back in the am at 0700. I don’t understand how this is legal. This is why we have travelers that hospitals are paying top dollar for. The high paid traveler stays while the dedicate employees get cut. Because the travelers have a contract. Patient care suffers more and as this cycle continues. We just bought two new robotic OR units and I am told to go home early. It’s big business now. Oh and our CEO at the not for profit made 1.8 million last year. How is this all OK m. I don’t understand why our government is letting this happen. It will continue as there is more money to be made on the backs of the employees and the patients. Our healthcare system is doomed. The patient care keeps getting worse. An 80 year old patient left in a bed for a week no bath. It’s like being in a 3rd world country. If left in the bed they are bound for long term care. What the hell is happening. Thank our politicians for deregulation.
So here is a solution which most nurses will never consider and this has happened repeatedly. When you are flexed, are you ever asked to work on another unit because they are short? I would be willing to bet you have and I would curious to know what anyone’s answer was? Typically its a no because they haven’t been trained there, don’t know where anything the unit and have any number of excuses not to cover there. Don’t get me wrong, I am not placing blame on nursing, rather the process of solution. The solution is simple. Create a staffing plan that cross trains your most highly fluctuating units so that there can be more of a pool of qualified individuals who can cover those places when census drops and be willing to do so because they know the unit in need. However, this poses the problem of orienting people to other places at a cost to the hospital. But is this a cost or an investment strategy?
At the end of the day, would you be more proud of what you built and invested in or about what you saved and lost? Nurses need to be invested in, do not discount your front line people…bad leadership creates nothing…period.
You’re right, hospitals are a business. Nursing has borne the brunt of balancing the budget since Christ was a corporal, as my hospital board chair dad used to say, and certainly since I started working in hospitals more than fifty years ago.
So what to do? Make nursing a line item cost. This was proposed decades ago and for some unknown reason one of the biggest obstacle, astonishingly, was … nursing.
Certainly, when hospital financing is driven by reimbursement (commercial and governmental insurance and benefit programs), it’s easy to see why the EHR is driven by billing codes, not (as commonly promulgated) by communicating and facilitating actual care. And the nursing labor cost, again as we see ad nauseam above, is considered only as a fixed cost. Therefore the best way to monetize nursing work is by having billing codes for the actual work we do as nurses, independent of implementing the parts of the medical plan of care we’re responsible for too. This would take a sea change in the attitude of the marketers and the payers. Who will drive this, make it inevitable, make it DESIRABLE to those bean counting managers?
Nursing will have to take a really hard look at specifying their value in dollars, beyond the research that has clearly demonstrated better outcomes c better staffing. And this means objective data. And THIS means taking a clear-eyed, what-have-we-got-to-lose attitude towards the research basis for what we do. I’m talking about the nursing process itself as scientifically validated by extant nursing research. I’m talking about how nurses make diagnoses and treatment plans, and carry them out. Documentation of what bean counters don’t see that make those monetary differences. I’m talking about nursing diagnosis and NANDA-I.
The rack rate of $XX per day for q m/s bed doesn’t begin to capture the nursing differences between a routine overnight stay post ortho surgery for an athlete and a TKR for a 69 yo with diabetes, food insecurity, social isolation, baseline activity intolerance, inability to do self-care at baseline, and safety issues at home that mandate nursing intervention and planning regardless of medical dx. When billing is based on medical diagnosis and treatment plan alone, our value is invisible. We need to bill for that extra time to do what only nurses do.
We cannot afford, literally, to roll our eyes at nursing diagnoses and plans of care as wasted effort and PIA that get in the way of our long list of tasks. Granted the current EHR isn’t set up to capture cost (and justify them to insurers) because we don’t value them enough to force the issue. Have enough respect for what nurses are— remember that your health insurance plan’s hospitalization reimbursement is for something that REQUIRES NURSING CARE.
I dare you to get the current NANDA-I at you online bookseller and see what power it gives you. Half of your work, enumerating nursing decision-making and care, is all done for you there already in unequivocal, clear English. Do not roll your eyes at me. This is not the NANDA-I that you remember as scoffed at by staff nurses when you were students, it is powerful stuff if you dare to apply it to exactly this situation. Economics. It has your back. Don’t be that obstacle.
I know for some folks this is gonna sound like blaming the victim or piling on. I know it will require that sea change in reimbursement. But remember: Who else will enumerate all that we do and put a dollar on it? If we don’t, well, we already know what that looks like, don’t we?
Unionize, hire an economist to do the math (like Waddell), hire a publicist (now’s a good time, alas, with COVID putting nurses in the public eye), talk to the patients and families about what you would do if you had the time, write this sort of set of comments to your newspaper My View column and the TV consumer reporter. I love the AJN but you’re speaking to the choir here. Get on it to educate the consumers about those lovely lobbies and stuff. Get testimonials from real patients — they don’t talk about the drapes. Get on your legislators.
Then strike. Yes, you heard that right. Hit ‘em where it hurts. Or you know how they’ll continue to hurt us…and, by extension, our patients. They’ll fight you back, you know they will, like spoiled adolescents who suddenly get consequences. So earn their respect by standing firm. They really can’t do any of this without us. They won’t give you power. You have to seize it.
It is sad to see that one of the biggest problems I see in the nursing profession is a problem that apparently has been going on forever. Why hasn’t the nursing staffing issue ever been fixed? We have these problems in our unit. In our intensive care unit we get “pushed back” at 5 in the morning if the census is low and they do not need you at 7 a.m., but you are not completely off the hook until 11 a.m. when they will tell you if you are cancelled or have to come in late. They do not pay us an “on-call” rate, instead they use our PTO hours to pay us for this. I find this extremely unfair because I have to sit around waiting to know if I’m cancelled or not using up PTO hours. This issue is also unfair to those that are actually working, because every time someone gets pushed back there is a person missing in the unit, and what happens when admissions come? Well they triple the nurses left and right until you have 3 vented patients, or a patient who is supposed to be a 1:1 becomes a 2:1 due to low staffing, or any another crazy combination of patients in an assignment.
I agree with your post in that why is the nursing staff budget always the one to take a hit?, I mean nurses are the back bone to a hospital and now with all the quality for payment by CMS you would think that hospitals would like to become the next Disney World of patient care. I love my profession, but I would love to do it right, in an environment that is safe for patients and nurses and a place that values nurses and nursing like the Magnet guidelines expects my hospital to do but obviously doesn’t.
One of the reasons they can turn us into PRNs or force us to waste vacation days is that there IS NO nursing shortage in most hospital markets. There may be one coming, but most large hospitals are rich with applicants!
Where I work, call offs are made based on who is going to be in overtime. You know, they will be picking up that Saturday night shift that no one wanted and that nurses were begged to pick up? So, you pick it up, willing to make the sacrifice for the overtime pay, but then they call you off on your regular shift. But you still have to work the shift you picked up, or be written up. In the administrator’s mind, your Tuesday night off that they created for you (in the middle of Monday and Wednesday nights being worked) makes up for it all. It’s mean spirited and it reduces us to PRN workers who are treated with disrespect, because they don’t even honor our schedule. What’s worse is that when they call you off, they tell you that you aren’t needed that shift. Yeah right. Tell that to the nurses who got to work and could use a little help from a nurse who isn’t staffing that shift. And really, when they do this, it seems like they are focusing on saving pennies. Lay off a few administrators. Good grief, it’s just outrageous what goes on.
Nurses, never forget hospitals are run as the businesses they are. I have to point out that the writers comment that “hundreds of thousands of dollars are spent on technologies that haven’t yet been shown to make a difference in outcomes” is irrelevant. Those technologies are marketing tools, both to the patient market and to physicians (staff and prospective). The hospitals in my town are playing zero-sum marketing games – overbuilding competing clinics, touting their DaVinci surgery suites, trumpeting their beautiful lobbies and rooms… none add to outcomes, all add cost,and yet the game doesn’t end. Its marketing to drive both census, and likely the bonus and pride for senior management!
All that said, I wish they’d market more on their outcomes, nurse staff ratios, and quality of their nurses more. Educate everyone you can in your neighborhood, church, school that patient/nurse ratios matter, and why!!! Oh, and I’d suggest you unionize too.
So I wrote this post in 2012 and sadly, it appears that things haven’t changed all that much. Has enough been at a hospital where they solved this?
the hospital I work for in Urbana, IL are constantly changing the staffing grid according to the unit’s patient census. Night shift, it seems gets less staffing without a tech. On an average, night shift will get between four to eight admissions.
Nurses are put on call while other employees don’t. The CEO of a not-for-profit hospital is 2.9 million dollars. It does not matter how low the census is CEO, COO, CFO, management and leadership take home their full salaries. How can this ever be deemed FAIR? It is wrong on all levels. Some of these hospitals are faith based? Without nurses there will be no hospitals.
Jesus wept.
When someone has to pick a culprit for an industry having hard times, and they pick union workers as the bad guy rather than a CEO who makes $20 million a year, it speaks volumes about who they identify with. As Cool Hand Luke said, them pore ole bosses need all the help they can get.
And I’m sorry, but I don’t believe that bit about nursing staff being the main source of costs. I did the math myself after a shift in hell. The total cost of nursing staff — the people who actually are in front line contact with the patients and who bear responsibility for primary care and preventing errors — on the understaffed shithole where I work, if it were adequately staffed, would have been $150-200 per day. Compare that to the total daily cost of a hospital bed, probably $3000.
It’s just the MBA mindset, under the conventional management accounting rules, that labor is the only direct cost that matters. Bill Waddell, probably the foremost lean manufacturing consultant, says he’s regularly called in by corporations begging for help cutting labor costs. He tells them “You know, I notice labor is only about 6% of your unit costs. Have you ever considered cutting anything *besides* labor, like administrative costs or wasteful capital spending?” They look at him like he’s grown a second head.
Every hospital I’ve ever seen is drowning in overhead costs and stupid, stupid, STUPID capital expenditures undertaken mainly for their PR value. But administrative overhead from pointy-haired boss committees and management featherbedding, or spending $20k on a photocopier that’s a gold plated [expletive deleted] and breaks down most of the time, or spending thousands on a replacement phone system when the old one works just fine, or spending millions remodeling wards in ways that make them less functional than before — none of that counts as a cost for the MBAs, because it can just be passed on to the patient, through the miracle of overhead absorption, in the price of a $300 bag of saline.
Hospital administrators engage in wasteful capital boondoggles on the same pattern as the irrational economic planners in the old USSR, with only the vaguest idea of any actual benefit. And they’re governed by the same high-overhead, cost-plus accounting culture that prevails in Pentagon contractors, for which we can thank the $600 toilet seat.
[Editor’s note: the last paragraph of this comment was deleted because it contained profanity and did not add to the discussion.]
I want to know what I can do as a patient to have a good rapport with nurses and staff. I know they are stressed and overworked. How can I demonstrate that I support her, and that I’ll do my very best to not be a negative aspect, or add to her stress) of her day.
Leila we had a situation where people were expected to chart an item in 10 different places. Talk about waste. It came to light only after a doctor complained for the nurses. As an administrator I begged staff to weed out this waste so they could spend less time charting and more with patients. I offered monetary rewards for the best ideas. No takers.
I work 14 hour days 5 days a week (no OT or extra pay) to try to decrease the the time staff work by finding innovative ways for nursing to get the work done. Again no takers on the changes. Quit blaming others and stand up with answers that will impact the profession. I want to help but as the saying goes “it takes two”.
This has been going on my entire nursing career and continues to this date. Nurses accept what administration hands out. Nurses are fearful of making waves or being the one who stands up to speak out due to fear of consequences that could occur. Many nurses are the primary “bread winner” of their household, and this overshadows them from speaking out. They “suck it up,” mumbling how unfair it is under their breaths to each other and take what administration hands out, no matter how it affects them physically or emotionally.
I feel that nurses who become part of the administration of the hospital, forget their time as floor nurses and fall right into the pattern of the administration they have joined. They no longer are available to the staff nurses to improve the work environment as now they are part of the “establishment.”
I have friends who work 12 hour shifts, however, as any nurse whold know, an 8 hour shift usually means a 9 or 10 hour shift and a 12 hour shift means 14 hours. HELP! This is what causes burn out and is unhealthy for the very people who are providing care to make others healthy. It seems when giving has to be done when census is either high or low that it is always on the backs of the nurses to be the one to give.
The fear of not being able to speak out and having to take what is told to them, leads many of us to have feelings of low-self esteem that follows us in every aspect of our lives.
The answer is easy. Salaried nurses with no expectation for hours. Set the standard for how many nurses are to be available to care for patients. Set the budget based on avg daily census and nurses will step up as needed or have free days as appropriate. All expectations up front. No longer costs for OT or call. Nurses no longer use days off to cover the monitary needs. Nurses and hospital have a set plan and the patients can now receive safe care without short staffing.
Reduced paychecks due to lost shifts were particularly painful when I was a single mother with a mortgage. After awhile, the vacation paid leave dried up too. I needed cash. Therefore, I became agreeable to floating from PICU to related units, like NICU and general pediatrics. It wasn’t always comfortable going to an unfamiliar unit and taking patient assignments, but I found if I went with an open mind, spoke up about what kind of assignments were appropriate for my skill level, and won over a buddy or two from the unit, floating wasn’t that bad. I took CE courses in NICU subjects, including NALS and improved my skills. That improved my comfort level and patient safety. Social networking the old school way, I made friends in the units where I floated, and rarely lost a shift of work. Each new skill embellished my résumé; adding to my marketability. It’s a good tactic for nurses wanting to look experienced, instead of just aging, to employers.
Hospital administration plays an important role in successful floating experiences for their nurses. It is critical that they understand it takes more than a body with a pulse and a stethoscope to care for various patient populations. Years ago, I attended a meeting organized by the hospital. Its administrators asked nurses what would encourage us to float. I pointed out that while I was able to sustain a critically ill child on life support; if floated to labor and delivery I could reason that a slow heart rate on a fetal monitor was probably not a good thing, but all I would know to do about it was scream for help. The administrators listened, and created float area “bundles,” limiting the departments nurses are asked to float to by related acuity and skills. The tugboats helped navigate the freighter in this case.
I am grateful to have a career that provides so many opportunities for work. In this economy, nursing is one of the few jobs with any security at all.
The comment about unions being the reason for industries going bankrupt is very misinformed. Those industries went bad because the economy went bad or the industry shifted their production plants to areas where the labor is cheaper (moved from one slave labor practice to another when the workers joined unions and would no longer put up with it)
A union would protect nurses from exploitive situations such as has been described here. That’s exactly what they were formed for. Hospitals and healthcare NEED nurses and always will. They are not closing due to any demands made by nurses, they are closing because of insurance companies who are sending home sick people rather than allowing them additional days as inpatients, and because the high cost of healthcare in general (NOT nurse salaries…equipment, medications, diagnostics, physicians and insurance). Nurses who are brainwashed into spouting off against unions send us back 10 steps for every 1 the profession takes forward.
After 20 years as a hospital nurse, I got a law degree and left nursing. The weekends, holidays, night shifts, floating, and the mandatory over-time and call-offs wore me out. I was so burnt-out near the end that I would start crying sometimes in the car on the way to work because I dreaded it so much. I did not understand what was going on because I had always loved being a nurse. I left in 1998 making $20/hr. Within 5 years I had tripled my income and got control of my life. I am now a huge advocate for nurses. It is no surprise to me that we are looking at the largest nursing strike in history on June 10th. It’s about f*#king time!
I’m living that ‘dream’ as well where I work. It gets very frustrating.
In the ICU I’ve seen, they have a lottery where if the night shift is going to be a slow one, anyone who wants to participate can go in the draw to be sent home. It’s entirely voluntary. If you decide you’d rather have the time at home than the pay, it works out.
It would be nice if it worked both ways: I get send home on $2/hour call pay when census is low, but I also would like to make $2/hour for each additional patient when census is high. Often times it just does not seem right. We run and run and run all day but as soon as we catch a break we get send home.
Here’s a question: does Magnet criteria or AACN’s Beacon Award criteria address mandatory overtime or “flexing down”?
I do understand budgets – but I find it hard to believe that this is the only workable solution to the problem. Is there really no other solution or is it that nurses have accepted this so why look for another way? Some hospitals have avoided this – how do they do that?
This is a tough issue and one with few easy answers. I do work in a facility that routinely “flexes” nurse when census drops however has no solution for the reverse issue of increased census. Most of the time nurses are not placed on call – perhaps in the ICU and yes it is for $2/hour. I understand that hospital economics is tricky and complicated but in the end not providing safe, quality care is more much more costly. A law suit or even lack of reimbursement cost so much more than staffing adequately.
There is no way that unions are the answer. Remember the steel industry? Unions caused steel companies to go out of business with their demands and the car industry is another example of bankrupcy due to union demands. This is not about someone making money at nurses’ expense. You cannot get paid if there are no patients. So if patients go home, so do the providers. Doctors bill directly, not the same thing at all. We need to stop being so naive and stupid about business. If nurses want to sound credible then come up with some solutions.
Administrations could make a sacrifice…Just saying…
I just quit a hospital that was doing this. Not only were we voluntarly going home, and using our paid time off, but we worked short when it was busy again. I felt my license was in jepordy.
Budget was great for the doctors they were trying to recrute, but not for retaining or training nurses. I realize you have to have doctors to bring in patients, but you can’t run a hospital without nurses.
CEO had a closed door policy and Nursing admistration were all friends and ran the hospital as a dictatorship. There was no staff in put. One board member told me it will never change and you can’t do anything about it. Sad that this community hospital is run that way.
This is disappointing. Nurses have to start understanding the economics of hospitals and healthcare. It is not dissimilar to running your own household budget. If there is not income coming in from patients in your beds you cannot afford to pay staff. Period. This is an efficient way to run a hospital. Staffing is the biggest expense in a hospital and professional staff the biggest staff expense. Blame reimbursement changes that are only going to get worse for this, not hospital administrative practices. If nurses want to get a seat at the table to change this fine, but if you have no solutions then don’t simply complain. Hospitals are going out of business and losing reason for a reason. It is not because they are making money by sending nurses home.
So you obviously must be a shirt that sits at meetings all day…I’m sure you get your lunches and your breaks… We work crazy short staffed and extra shifts… But as soon as the census goes down we are asked to go home at our expense, after being an employee at the same place for 38 years
When I get flexed enough, I update my resume. When your census picks up I will not be available. My mortgage payments do not decrease. My kids still expect 3 meals a day. Gas, electric etc. do not flex. The Ceo still drives a new Porche.
Because of this practice many more hospitals are being unionized. One thing people need to realize about unions is that they give you a voice at the table.
Shawn, that’s a great question! I found one article on bNet.com that talks about physicians’ on-call pay – if it’s accurate, the difference is surreal, with on-call pay for docs in the hundreds of dollars: http://bit.ly/9JcVWO.
Apparently, although on-call pay is covered under the Fair Labor Standards Act (FLSA), it’s as not clearly regulated as overtime pay. Readers who want to investigate further might start at the DOJ’s FLSA page: http://www.dol.gov/compliance/laws/comp-flsa.htm.
I’d love to know how typical that $2/hr rate is for nurses. Readers?
Just thinking – does this routinely happen with any other health care workers? In other industries?
I’m not talking about recent furloughs b/c of current fiscal crises that many organizations are going through, but as a “norm” like it is for nurses.
I agree, we should not be penalized by having to use our vacation days, or take a day without pay, when we are called off. We are fortunate not to have mandatory overtime at my hospital, but there has to be a better way to manage staff and census fluctuations. Any ideas out there?