‘Go Home, Stay, Good Nurse’: Hospital Staffing Practices Suck the Life Out of Nurses

May 20, 2010

By Shawn Kennedy, AJN interim editor-in-chief

George is keeping an eye on you, by peasap / Paul Sapiano, via Flickr

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.

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  1. 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?

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  2. 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.

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  3. 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?

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  4. 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.

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  5. 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.

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  6. 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.

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  7. 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.

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  8. 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.

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  9. 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?

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  10. [...] meeting (the National Teaching Institute & Critical Care Exposition, or “the NTI”)  and my second post on a conversation with a critical care nurse about a bad staffing practice, which seems to have hit [...]

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  11. Here’s a question: does Magnet criteria or AACN’s Beacon Award criteria address mandatory overtime or “flexing down”?

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  12. 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.

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  13. 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.

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  14. I’m living that ‘dream’ as well where I work. It gets very frustrating.

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  15. 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!

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  16. 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.

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  17. 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.

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  18. 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.

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  19. 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.

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  20. 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”.

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  21. 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.

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  22. 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.]

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  23. 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.

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  24. 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.

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  25. 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?

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  26. 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.

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