Neither life nor nursing shifts develop in a linear fashion. Both roads are full of unforeseen swerves. I was reminded of this over the weekend while sitting with a relative in an emergency department. Our weekend plans had been put on hold to accommodate this unforeseen swerve in health.
An ED staff under stress.
I couldn’t help but notice the emergency department staff were experiencing their own set of unforeseen curves this particular shift. Although it was early in the evening, to my experienced nurse’s eye they were already exhausted.
When we arrived, the triage nurse was being verbally accosted by two people who’d walked in off of the street, ranting and high, until a trio of security officers intervened. Another nurse hustled between triage and the bay area. A photograph of her young daughter on the reverse side of her ID badge dangled from the lanyard around her neck. Everyone looked tired.
The tricky ambiguities around nurses calling in sick.
Once my relative was confirmed as stable, I revealed to the other nurses that I was a nurse and said I’d noticed how busy they were that shift. The nurses I spoke to confirmed that the past two days had been exceptionally busy in the ED. It was flu season, and they were seeing a high volume of respiratory patients. No staff member was visibly ill, but one commented that calling in sick during flu and holiday season meant feeling guilty for abandoning coworkers to understaffing.
There’s something morally wrong about a nurse feeling guilty for calling in when he or she is sick. Some hospitals create policies defining what too sick to come to work looks like, such as a productive cough, or a fever of greater than 100, which is a pretty high bar to set for adults. Some hospitals allow nurses to come to work with coughs, sniffles, rhinitis, etc, as long a they wear a respiratory mask during their shift—potentially blurring the assessment of how sick they might actually be.
Nurses coming in sick is not safe for patients either.
Hospital staffing: the same as it ever was.
It made me sad that after my more than 30 years of being a nurse, hospital staffing hasn’t effectively changed, and is perhaps worse.
Staffing is one of the largest expenses in a hospital budget, and administrators continue to find creative ways to minimize personnel. Many hospitals run significantly below operational margins, creating severe cuts to maintain their financial viability.
It is not my intent to vilify hospital administrators. Admittedly, many factors affecting the cost of operations lie outside of their control, such as Medicare and insurance reimbursement, the rising costs of medications and equipment. It requires balance, achieved through whichever factors are within their control, like staffing. The result, unfortunately, is that staffing is treated like a mathematical equation to be solved, with the assumption that nursing shifts are known quantities without variability, traveling along a straight, unbroken path, .
The unexpected should be expected and planned for.
But nurses get sick. Their family members also get sick, and need them at home. It’s part of the unforeseen swerves. Assuming that patient care will occur in a linear progression, and not providing staffing depth in anticipation of sick calls, denies the reality of the unforeseen—which in actuality occurs often enough that it should be expected and factored in to the nurse staffing equation. Administrators need to create staffing policies that anticipate the occurrence of swerves, because ultimately the accountability for patient safety lies in the decisions they make. Even the most dedicated teams of nurses and physicians can only do so much.
Cutting staffing to reduce costs: an approach that’s reached its limit.
Cutting staffing has been the go-to method for controlling hospital costs for as long as I’ve been in nursing. Substituting registered nurses at the bedside with unlicensed (read: less expensive) staff has also been tried, resulting in decreased patient safety. Using staffing as a measure of cost reduction has reached the point of exhaustion. Expecting increasingly more effort from nurses as a cost control method is unsafe and unfair.
Back in the emergency department, a staff member comes to transport my still undiagnosed relative to radiology for a chest X-ray, sans a wheelchair. It’s clear he expects them to walk, and I ask, how far? Radiology is at the other end of the hospital floor. Gently, I point out that I brought my relative to the emergency department because of an unexplained fall. That’s all I have to say, and a wheelchair is immediately produced for the safety of our patient.
Was this lapse of judgment on the part of the staff member related to short-staffing and fatigue?
It seems likely. Alternatives to staffing cuts as a means to maintain the financial viability of hospitals need to be explored for the safety of patients and nurses. It involves cooperation from the entire health care system, not just its nurses.