Unsustainable Healthcare

Hello my Zebras and Spoonies! Thanks for coming and visiting with me today, I am glad that you are here. Today, I want to talk about why our nurses are leaving and why we can’t attract new nurses into the field.

There have been problems plaguing the healthcare system for the entire twenty years that I have been working as a nurse and for the years that I worked as a CNA before that. Covid has made many of those problems worse, but none of them are new. But we are reaching the point where changes have to be made soon or things are going to start falling apart. One of the biggest problems that our healthcare system faces is that we don’t have enough nurses. If we don’t address this problem soon there simply will be no one available to take care of the sick, injured and dying in this country.

What needs to happen in order to retain the nurses that we have and recruit new nurses? We need better incentives to work in the healthcare setting. The work environment in healthcare right now in beyond toxic. The environment is unsafe. The staff working in healthcare are not properly supported or care for.

Increased Pay

When talking about how to retain and recruit nurses, the issue of how much nurses are paid is almost always the first thing to be brought up. Yes, nurses and all health care staff, need to be paid more than they are currently being paid. A CNA who is responsible for the health and well being of your mother should be paid more than someone bagging groceries. That’s a real problem. But it is far from the biggest problem. Because the truth is that nurses and CNAs have kept on working through a lot of crap even though we have never been paid what the job is worth. That clearly demonstrates that pay isn’t what is making nurses leave now. However, asking us nurses to deal with everything that we are dealing with and not giving a fair wage on top of that is beyond insulting. So, yes increasing our pay would help retain the nurses that we have in that it might make us believe that we are valued after all.

Emotional Support

One of the biggest reasons that health care workers are leaving the field is because of burn out. What that really means is that there are no resources for emotional and mental health support. We can’t go home and talk about our day without breaking the law. HIPAA requires that we not talk about a patient’s death or the patient that had a leg amputated. But these kinds of events have an impact on our emotional status. You go into healthcare as a profession because you want to help people and you care about people. When you see other people suffering every day, it causes you to hurt too. That’s part of the price that we have to pay for being a nurse.

I don’t know the number of times that I have cried for my patients or become angry on their behalf because of their situations. There is no way that we can completely emotionally remove ourselves from the people that we care for and would you really want us to? After all, it is this caring and compassion for others that allows us to be great in the field of nursing. But that same trait also makes us vulnerable to being injured emotionally by the things that are happening to our patients.

Healthcare workers need emotional support now more then ever with all that Covid has brought. There are so many nurses that are struggling with PTSD from having had so many of their patients die in less than ideal conditions. Many had to make very difficult triage choices that decided who got a vent and who died. That’s insanely difficult to deal with and there are no services for nurses to call upon.

The employee assistance programs are so limited in what they offer for emotional support that it renders them useless. Most are for two counseling sessions a year. That’s not going to help many nurses much. The truth is that there is isn’t much in the way of mental health services in general let alone any that are particularly designed to help healthcare workers tackle the emotional demands that we are facing in the current work setting.

Reduce the Violence

Nurses and CNAs need a safer environment to work in. When we look at the statistics on the assault related injuries for nurses, it tells a huge story. When looking at the causes of injuries in the work place, we see that 12.7 out of 10,000 of the injuries nurses received were caused by violence. That may not seem like many, but let’s put that into perspective. When you look at all other occupations combined, the rate is 3.8 per 10,000. That means that nurses are injured from violent events three times more often than every other occupation combined. Nurses are assaulted more often then police officers. Nurses are assaulted more often then bouncers at bars. Nurses are assaulted more often then the guards in prisons. Think about how completely insane that is. And the problem is only getting worse. The number of nurses getting assaulted has been increasing for years. And to be clear, it’s not just nurses. All healthcare workers are at risk for this violence.

How can you expect to retain staff when they are being punched, kicked, spit on, yelled at, threatened, called names, and having things thrown at them? I honestly cannot tell you the number of times that I personally have been assaulted during my career. The number is too many to recall. I do know that I have had major injuries because I have been assaulted by patients. I had a wrist surgery after a patient grabbed and twisted my arm. I had a broken tail bone from being shoved. I’ve been punched in the face more then once. And this is the environment that you are trying to retain people in. Is it really a mystery that people don’t want to work in a setting where violence is a daily event? And yes, it is daily. It is a rare shift that I go my entire twelve hours without someone verbally or physically abusing me. Not to mention all the times that I am groped. Which is also an almost daily event. Why would anyone want to continue to work in that kind of setting?

The thing that is most disgusting about the level of violence directed at nurses and CNAs is the complete lack of action that is taken. When a patient hits me, I’m asked what I could have done differently to have avoided having been assaulted. Nothing like victim blaming. How about we start actually charging people with assault when they hit nurses and CNAs? Because the truth is that many of these people are completely aware of what they are doing and simply know that they will get away with it. Nurses are a pretty safe victim. Most nurses won’t report being assaulted because it means more paperwork and no improvement to the situation. The assaulted nurse will continue to care for the patient that assaulted them. Few of those patients ever face charges.

It is rare for hospitals to provide their staff with panic buttons that they can push in the event that they are being assaulted. And when these buttons are available, they are often used for selected cases where the patient has already hurt someone. That’s not a good prevention measure. Any prevention step that requires someone getting hurt before it is used is simply not good enough. Could you imagine that mentality being used in construction or manufacturing? The technology exists. It should be a standard that every healthcare worker in every health care setting has a panic button as part of their required uniform.

Every healthcare worker should be provided self defense training by their employer regardless of the setting. It should also become the standard that healthcare staff are allowed to protect themselves with equal or lesser force when they are being assaulted regardless who the patient is or what their healthcare status is. Just because someone has dementia doesn’t mean that a nurse should not be allowed to protect herself from their assaults. If a person with dementia attacked me on the street, I would face no punishment for defending myself. Yet we are expected to leave that right for personal safety at the hospital door when we clock in. We give police officers guns, tasers and training to protect themselves. Yet a nurse is more likely to be assaulted then a police officer and we are not given basic self defense training as a professional standard. This is why we cannot keep nurses.

Reduce the Stress

Nurses need a less stressful environment to work in. It is common place for nurses and CNAs to leave their shifts crying. What other profession is this consider alright in? Granted, it is a high stakes profession and a lot of the stress cannot be eliminated. Knowing that making a mistake can cost someone their life is a stress that we cannot remove from the job. But we could do a lot to make the environment less toxic.

Why is the nurse considered the stop point when things don’t get done or aren’t done correctly? When there are labs ordered and they don’t get drawn, people go to the nurse about that. Why is that? Why aren’t they talking to the lab staff about why the lab work isn’t getting done? When a patient isn’t discharged on time, people go to the nurse. Even if the reason for the delay is that therapy is still working on getting that patient equipment to go home with. When there is a procedure scheduled for the patient, people go to the nurse. The doctor wrote an order that isn’t clear. People go to the nurse. When someone needs something from the doctor, they talk to the primary nurse. Somehow, the primary nurse has become expected to make sure that all the other disciplines are doing their jobs. This is insanity. We can easily reduce the stress of the nurses by changing the culture to each discipline answering for itself rather then everything going through the primary nurse.

Much work has been done in the realm of healthcare setting being hostile work environments. While things have improved greatly since I started nursing, there is much work that still needs to be done. We need to continue to address the reality that doctors are not always respectful when they are talking to nurses. We also need to help nurses build better coping skills so they are no longer dumping their stress onto each other in the form of complaining, passive aggressive behaviors, work avoidant behaviors and general irritability. Because all of that makes healthcare a pretty unpleasant place to work.

Breaks need to happen. During a twelve hour shift, every nurse and every CNA should be getting a full half hour lunch along with two fifteen minute breaks. We are lucky if we are given enough break time to use the bathroom. It is essential that we are allowing the healthcare workers to take care of themselves. If we don’t, the cost is that they get sick, they burn out and they stop wanting to work in the field. We need management to make it nonnegotiable. We need to stop hearing things like “It depends on the needs of the unit.” That’s insanity. When the unit is busy is when those breaks are needed the most. We need management to make it a priority to make sure that every nurse and every CNA get every break on every shift. We have to stop expecting healthcare workers to work like they are robots. They are humans and they deserve to have their human needs met even while they are at work. And I’m talking the basics here: getting drinks, going to the bathroom and having something to eat. When we expect nurses to work a twelve hour shift without having anything to eat or anything to drink and without using the bathroom, are you really surprised that they are leaving the field? We treat livestock better than that.

Consider Our Backs

Another important safety factor for nurses is all the patient handling that we perform. The truth is that there aren’t always the proper devices readily available to make sure that we are doing that lifting safely. When a confused patient is getting up by themselves we aren’t going to go hunting for those devices, we’re going to run in that patient’s room and do our best to keep them safe in the moment. This often leads to nurses and CNAs getting hurt. We need to better about making the safety equipment readily available. We also need to ensure that we are regularly training nurses and CNAs on how to prevent injuries that occur when helping people walk, transfer or move in bed. Because the truth is there is no such thing as a “No Lift Facility.” That’s propaganda bullshit.

The truth is that not all of these kinds of injuries can be prevented. There will be times that a patient’s functional level fluctuates or they stumble and because we’re holding onto them we can end up injured in those scenarios. So another factor to this is making sure that nurses are getting the proper care that they need when they are injured. Because these are worker’s compensation cases, the focus isn’t on making sure the nurse is getting the best care but on getting the nurse back to work as soon as possible. Nurses are often finding themselves injured and getting pressured to be back on regular duty before their bodies are ready. This has to change. For one it doesn’t create a great environment that people want to stay in. But it is also about making sure that we are keeping our nurses as healthy and as functional as possible so they can work as nurses for as long as possible.

Nurses are hurt twice as often (when not looking at violence related injuries) at work then any other occupation. The most common body part injured is the back. Older nurses are also much more likely to become injured than younger nurses. Yet, we still expect an older nurse to work the same way younger nurses do. It makes perfect sense that someone in their fifties is more likely to sustain an injury than someone in their twenties. This is true in every day life. Yet, we don’t allow nurses in their fifties to perform less lifting. There are no work accommodations for age related risk factors. Working in nursing is all or nothing. Either you can do all the lifting or you can’t. If you can’t, you can’t work as a nurse. This means that most older nurses simply accept the increased risk for back injuries.

This doesn’t make sense because it is these older nurses that have the most valuable experience and knowledge base that we desperately need to maintain in the work field. Yet, we are cutting many of them out because they can no longer lift a two hundred pound patient. We are allowing many of them to become injured in ways that lead to disabilities that prevent them from working in the field. We need an environment that acknowledges that not every nurse is built the same and thus cannot do the same amount of lifting. We work that accommodates our bodies even when those limitations aren’t the result of a work related injury.

Better Patient Ratios

Having increased patient assignments is a high risk game that will not play out well over the long term. This has been a problem for years. Hospitals want to have as many patients admitted as possible because that’s where the money comes from. Yet, there isn’t always enough nurses for the hospital’s capacity. Instead of creating hard limits to the number of patients a nurse can take, we are simply being expected to accept more patients in our assignment. This is unsafe. It’s unethical. Patients should be outraged that this is the standard in the healthcare field. Yet, most patients have no idea.

Let’s look at this from the perspective of the medical surgical setting. The general idea is the same no matter the setting, it just changes what the numbers are and what those numbers really should be for the sake of patient safety.

Consider it in context of the amount of time spent with each patient. In a twelve hour shift, I am working ten hours with those patients. Every shift includes a half hour report time at the beginning and end of the shift. I should be getting a half hour lunch break along with two fifteen minute breaks for a total of an hour worth of breaks. This means that there are two hours in my twelve hour shift that I am not available to do any work for my patients.

You with me?

That means with a five patient assignment, each patient can get two hours of my time. That’s for everything for that patient. That includes doing my charting, making phone calls on the patient’s behalf, engaging with the family along with the direct patient care that I provide to each patient. The amount of time I actually spend with a patient providing direct care is usually about one hour per patient in this scenario. So, if I have you as one of my five patients over a twelve hour shift, you can expect to see me in your room for a measly one hour that entire shift. That’s the time that I use to assess your condition to make sure that your status is stable. My assessing your medical status is the single most important factor in your outcomes. If things start going badly for you and no one is there to assess you then you will not get the help that you need. This is the fact: me being in my patient’s room is what keeps them from dying.

The time I spend with my patient drops quickly with each added patient. If I have six patients for that same ten hours of work time, each patient gets 1.6 hours of my time. So about one and half hour per shift. Will still take me an hour for each patient to do the charting, prep the medications, talk to other care providers, engage with family and all that. This means that with the addition of just one patient, you will only see me in your room for a half hour instead of an hour. That’s a big difference for the addition of just one patient. With eight patients, I get 1.25 hours for each patient. That reduces my patient engagement time to just fifteen minutes. If I am given ten patients, there is literally no way that I can do all the out of your room things for you and actually see you once in that entire shift.

Now, let’s keep in mind that all those things that I do for my patient outside of their room are also important. I need time to safely prepare medications. I need time to talk to the pharmacist about the safe and proper way to hang an IV medication. I need time to be able to talk to the doctor to clarify orders and ask questions regarding the patient’s care plan. I need time to talk to the family to keep them updated and to get important background information from them. All of these things that I do outside of the patient’s room are also important tasks towards giving good care. We can’t just ignore those tasks so that we can spend more time in our patients’ rooms.

Keeping the nurse to patient ratio low is what keeps our patients safe. This is the single most important thing that we can do in healthcare to prevent adverse outcomes for our patients. Yet, the alarming trend is that the patient ratios are going up. Covid has only made things worse. Hospitals are now using the culture of a crisis as a reason to increase this ratio, but we shouldn’t be accepting this.

But this isn’t just about the patients getting good care, though I do feel that is the most important reason to fight for low patient nurse ratios. Keeping low patient ratios helps address all the other factors that we’ve talked about thus far. So, low patient ratios is also about retaining nurses. If we think about it, this makes sense. Having more patients is only going to exacerbate the feeling that we aren’t getting paid enough. Having more patients exposes us to more emotional trauma during our shift. With each patient we care for we are more likely to be caring for one that has a terminal illness, just received a difficult diagnosis or is actively dying. Having more patients increases our risk for violence. The reality is that a patient is less likely to assault you if there is a witness. There is more likely to be a witness if there is a lower patient ratio. Having more patients clearly means the nurse will also have more stress. Having more patients also increases our risk for injury. When we have more patients, it increases the chances that one of them is a fall risk or total care. Both of those factors increase the chances that we will become injured when we are caring for them. Having more patients also means that we are going to be doing more physical work which leads to fatigue which increases the risk for an injury. What all of this means is that if we were going to do only one thing to try to address the nursing shortage, it should be ensuring that the patient ratios remain low.

It’s Not Customer Service

We need to stop treating healthcare like going to a bank or grocery store. I do not take care of customers. I take care of patients. It is essential that keep that at the center of what we do. There is no need to track customer service indicators in the setting of healthcare. All this does is create the false impression that these things matter when you are sick or dying. In context of healthcare, having to wait is always going to happen. Not getting everything you are asking for is going to happen.

As a nurse, I can focus on giving good customer service or I can focus on giving good patient care. They rarely overlap. Good customer service means you get your pain medication when you ask for it. Good patient care means that I make sure that you never get enough medication to overdose you and that often means that I make you wait for your next dose of pain medication. We have to ask what really matters in healthcare. Do you want everything right now? Or do you want everything to be right so you don’t die?

Society needs to shift back to the idea that being in hospital sucks, because that’s what’s real and honest. We need to stop lying to our patients that we can provide a hotel like visit. It’s a lie. You’re going to wait for your dinner tray because I am in the middle of getting someone’s life saving medications. You’re coffee will probably get cold while I’m making sure that your next dose of antibiotic is delivered from the pharmacy. I cannot put the priority on you having TV to watch or interesting books to read. I need to put my priorities on the things that will keep you alive. That means that you will often have cold food and you likely will be bored while you are in the hospital. But does that boredom and cold food matter much in the context that you didn’t die?

We need to stop expecting nurses to be putting their focus on how good a time the patient is having rather than how safe and healthy the patient is. I’m not sure what is driving this, but it isn’t good for anyone. It’s not good for the patients. Every moment the staff focuses on how good a time the patient is having is a moment that we aren’t trying to keep you alive. It’s not good for healthcare workers because it only makes a stressful job more stressful. It doesn’t get the hospital more business. People aren’t looking up hospitals to see who is providing the best food and WIFI when they are in the middle of a heart attack.

Along Came Covid

While these things have been problems for the entire twenty years that I have been a nurse, there is no denying that the arrival of Covid has done nothing but made things worse. We cannot ignore the impact that Covid is having on the healthcare system and hope to have a sustainable system. The fact of the matter is that Covid is going to be present for years. As such, it will continue to have a significant impact on how we provide healthcare in this country. It is essential that we shift out of crisis management mode and shift into a long term management plan. There is no such thing as a sustainable crisis management plan. We cannot sustain crisis management for a decade. Our system will collapse.

We must recognize that Covid is going to be like tackling smoker’s lung cancer as far as the medical field is concerned:

1. There is a clear way to prevent the disease.

2. People are refusing to make the social changes to prevent said disease.

3. Those choices can have an impact on the risk for disease for the people around them.

What does that mean?

1. Covid is going to remain in the top 10 causes of death in the USA for a while yet. Probably for years.

2. The healthcare field will have to continue to provide education regarding the benefits for getting the Covid vaccines.

3. We need to make adjustments within the healthcare system to accommodate this lasting impact on our health resource usage.

4. As individuals, we will need to decide how much masking and social distancing we are going to continue with over the long term.

Because what is real is that Covid is not going to go away anytime soon. This is something that is going to be around for years and we need to change our planning and management to that mind set. We as a country are unable to palate the political choices that would it would take to make this a shorter term problem. Thus we need to switch to a long term game.

The really shitty health care management reality: You can lead a horse to water, but you cannot force them to drink.

So, now that our horses are choosing not to drink, what’s next? We need to stop trying to figure out ways to force them to drink, because medical history has proven that is unachievable. Instead, we need to figure out how to make the system work in context of having a lot of thirsty horses.

Reinstate Preventative Medicine.

We must get back on track with preventative medicine. Without preventative care, we will only see more and more chronic illness patients needing acute care resources. This puts an enormous strain on the system. Sixty percent of American adults have a chronic illness and that number is only increasing in light of long Covid. We cannot afford to ignore these health issues in favor of Covid care any longer. Continuing to focus on new Covid cases rather than focusing on our chronic illness patients will lead to more acute cases in the long term. We are already beginning to see this. We are already struggling to provide acute care services as it is. We cannot afford to have that number increase further.

Consider Covid a Long Term Problem

We cannot continue to allocate our resources to covid as if it were a short term crisis. It is not. This is going to be around for years. Thus, we need to accept that covid deaths are going to be a part of our statistics for a while yet. This sucks, but there are limits to what we can prevent when the patients are not choosing to follow healthcare recommendations. That being said, we need to re-evaluate or system management and our social recommendations in the context of Covid being around for another five years or maybe more.

Clearly, in the context of Covid being a long term problem we cannot continue to maintain our system in a crisis state. So, let’s get about problem solving what’s next.

Add Some Tinsel

My final thoughts on retaining nurses is that if you want to make nursing attractive, it wouldn’t hurt to throw some tinsel onto it. Give us some perks for working in the field. How about creating programs that pay off our college debt if we are actively working as nurses? And I mean government programs not ones that the companies we work for can opt out of as soon as they feel their profit margins are getting to thin. Make sure that we are getting good health care benefits so that we can maintain our own health so that we can stay healthy enough to continue working. Give us a good amount of vacation time. Because getting two weeks for the entire year is pretty pathetic when you consider all the stress that is piled upon us. Giving us regular breaks from that stress would go a long way to making sure we didn’t burn out. Ensure that there is good work life balance. Work with nurses so that they can spend time with their families. Right now, most nurses are missing out on the baseball games and family holidays especially if they are working night shift.

Some articles to read:

  1. On the Front Lines: Violence Against Nurses on the Rise
  2. Preventing Workplace Violence in Healthcare
  3. The Top 5 Reasons Nurses Quit Their Jobs
  4. U.S. Faces Crisis of Burned-Out Health Care Workers
  5. Occupational injuries and illnesses among registered nurses

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