Posts Tagged nursing management
From Ian Miller at ImpactedNurse.com, a few thoughts on under-utilized and under-recognized senior nurses who are leaking out of the profession:
Nursing has few opportunities for promotion and recognition of senior expertise within the clinical setting. How often have you watched senior (and I’m talking about years of experience here) nurses move on to non-clinical management positions, or drift off into non-nursing jobs where their specialised skills are snapped up, or just stagnate on the floor (feeling little respect from the system) with nowhere to go and little exploration of the stuff they might teach.
What we are sadly lacking is a health system that gives the nursing ‘elders’ opportunity, support and recognition to pass on their profession, their experiences, their corporate knowledge and their craft to the next generations. This huge collective of nursing elders have so much to offer both the healthcare policy planning process in general and the future of nursing in particular.
As many of them are now approaching retirement the opportunity to pass on the craft will be lost forever. Skills that could be used to improve quality healthcare delivery, departmental operations and mentor-ship of other nurses. Believe me, those skills are out there in many of these people. They should be consulted not insulted.
Such a waste.
This seems to me about exactly right, and very nicely describes the position — and present frustration — of many nurses, including myself. The career path for the vast majority of nurses is pretty flat. The conventional nursing career path looks like this:
35 years service on ward(s)
I am not exaggerating — not much anyway. Any movement, to be sure, is usually in a lateral motion, e.g. from ED to ICU to PACU etc., but always as front line staff. Moving upwards almost always means a move away from your specialty. And that’s a waste too.
And there’s also this elephant in the room: would we be talking about things like wasted skills and staff retention if front line nurses were truly respected, and recognized as being the centre of what we do as a profession? Or to put it another way, if front line, bedside nursing was considered valuable in itself, would so many nurses be itching to get out?
Dinner last night with an old friend who toils in the mines of Labour and Delivery. She has worked there for four years. She told me of an incident not too long ago working the night shift, faced with a post-partum patient who was bleeding, hypotensive, and tachycardic, in short, showing all the signs of going into hypovolemic shock. She was running around, starting IV lines on flat veins and hanging blood products. Packed red cells. Platelets. Cryoprecipitate. And by-the-by, saline by the bucketful. She called for help from her colleagues. Apart from this patient and another who was walking the halls a few hours from delivery, it was a slow night.
Of course, you know the end to this story, don’t you?
No one came.
No one even popped their head in the doorway to ask, “Is everything okay?”
All of them were at the nursing station, playing Draw Something on their phones, watching the season finale of Grey’s Anatomy, what have you. Too busy to help a drowning colleague with a shocky patient.
My friend went to her educator and her manager. They shrugged it off. No biggie, they said. Clearly my friend had things under control. “The patient lived, didn’t she?” they said. And then: “Maybe you need to improve your organizational skills to handle critically ill patients.”
This last to a 50-something woman who has been nursing 25-plus years, almost all of it in critical care settings.
For my friend, this incident may well be the last straw. She is definitely leaving L & D. Why would she want to stay? The workplace culture on this unit is awful. She feels alone and isolated when going into work. She can’t trust her colleagues. “Why,” she asks, “would anyone want to work there? There is no teamwork. No solidarity. Nurses backstab each other at the first opportunity.”
The only question remaining is whether my friend will leave nursing altogether and take her 25-plus years of experience with her, which included not only the knowledge to provide expert care to patients, but the potential to share that expertise in mentoring and nurturing new nurses. She’s uncertain what she would otherwise do, but leaning towards abandoning the profession which has shaped her adult life. She only needs an out — which she hasn’t found yet. She is that disgusted.
You might tell me that stories like this are unusual and not representative of nursing. Unfortunately, we all know better. So in the end, I don’t blame my friend for wanting to leave. I would do the same.
So what would be your response?
UPDATE: Some comments from Twitter:
The second to last tweet from @NorthernMurse is probably the relevant question, don’t you think?
Posted by torontoemerg in Good Nursing Practice is Practising with the Heart and Mind, Guest Post, Nursing Naval Gazing on Tuesday 22 May 2012
by Amanda Trujillo
If the newer generations of nurses out there are more confused than ever about their roles in healthcare — they should be. I’m one of the newer generations of nurses and I — AM — CONFUSED. Seriously. Think about it. We are taught all of the idyllic, pretty things every good and prudent
nurse should know and should do whilst caring for patients. The Nurses Code of Ethics is drilled into our heads during nursing school, nursing care plans are celebrated (by our professors of course), and we are championed as the “future” and “promise” of nursing. The beautiful glowing white walls of academia ushers us out of the proverbial nursing nest with a maternal pat on the head, a gentle push, and into the place were supposed to actually do all the stuff were taught and licensed to do, and be who they taught us to be.
You’ve all heard it, I’m sure. “Get out there and make a difference! Change the profession for the next generation! Be the example! Implement policy! Be advocates for your colleagues and your patients!” Ummmm. Yeah. Nurses should act as advocates for not just their patients but for their profession. That being said, let’s take a look at what threatens to unravel the foundational fabric of who we are as nurses and what we do that sets us apart from all other healthcare disciplines.
1. Corporate Nursing. ”We know what nursing is and what nurses do.” However, the moment you walk into the doors of any hospital, the nurse — the persona, and everything else — is redefined according to the wants and expectations and interests of the organization we work for. Nursing, as a discipline, as a science, is redefined. You are who your employer wants and expects you to be. Period. Your own nursing style or “way” of nursing? Leave it at the door, and step into the predefined mold thank you very much. Advanced education? Yeah, that’s great, but you aren’t actually supposed to use it. That MSN is supposed to look good after your name on the plaque that lists all the Masters prepared nurses on the unit you work within. A point of pride that all patients are supposed to gawk at and be impressed by when they walk into the entry way of the nursing unit. I tried using it; I tried to contribute—nope. We just want the letters from you, that’s all.
2. Teeny, tiny amount of autonomy. I mean, come on people. We still have to get orders to ambulate our patients two to three times daily after surgery, to get an incentive spirometer, to initiate pre and post-op teaching, and even to monitor ins and outs every four hours. Every state has a different nurse practice act, and there is no set regulation as to what nurses can and cannot do across the United States. Every state defines Nurses and their practice and what they can do differently. Take a group of 5 doctors—and chances are each one of them don’t even have a good understanding of what nurses are and what they do and their role. Interdisciplinary Models of Care are not the standard yet, so this inhibits a productive and working knowledge of what each provider does.
3. Disregard for Care Plans. This is a big one for me. I recently read a couple of articles that, for the most part, said care plans should just die and go by the wayside because they are useless.
4. A fractured profession. We have so many specialties that we still have failed to come together in a unified manner to advocate together for our profession and for the vital role we play in the lives of our patients, evidence based practice, theory development and application, and policy making. The result? Thousands of different visions from thousands of different nurses about what our profession “should be” and “should do.”
5. Silencing of our voices. We now have to choose between our own career survival, or own livelihoods, professional reputations, and paychecks—and speaking up in the best interests of our patients. Many a nurse has experienced this tragic conundrum, and the consequences are well documented if you log into your university libraries and do a good literature review on the topic. So, which will it be? Your pay check or your patient’s life? Well, now, that depends—can you like yourself when you go to sleep at night or when you wake up the next morning. The choice will be different for all of us.
6. Too many initiatives!!!! There are so many initiatives out there that it truly is like ‘herding cats’ to get everyone on the same page about what needs to bedone to improve, advance, and grow our profession.
What I feel needs to be done is simply this: get back to basics. All the initiatives are great. The pretty, flowery, shiny, idealistic profession they propose is in theory—just that. It seems like every time we turn around there is another nursing initiative being introduced. In fact, there are so many, we all seem to have thrown up our stethoscopes in exasperation while uttering “Whatever.” The RWJF, the NIH, AACN, the National League for Nursing, Johnson and Johnson, the Institute of Medicine and all the other organizations that produce the massive documents proposing their positions on where nursing should be by the year “such and such” need to set aside “Candyland” and get back to the drawing board.
How? Perform a learning assessment and care plan on the profession. TALK TO THE NURSES AT THE BEDSIDE—these are the stakeholders that have to carry out all the grandiose changes. ASK nurses what would motivate them to carry out change and what they need or want to learn to carry out the change. Perform a force field analysis to illustrate whether there is a greater push for or against change and where a balance can be achieved to promote success. What do nurses consider an incentive to participate in the change process? What is their currency?
Here is a good example of what happens when big organizations try to make even bigger changes sans discussion with their staff members, which is to say, their stakeholders. At one hospital I worked at the Transforming Care At The Bedside Initiative was being “enforced” as a means to improve patient satisfaction scores. I say the word “enforced” because we nurses weren’t asked about how we felt about it, we weren’t “completely” educated about what TCAB was, why we should be interested in it, or why we should participate in it. participation was an expectation and people were “assigned” to do parts of the initiative. No communication took place between management and staff about how they felt about the change process or the new “tests of change” they were being expected to participate in. So, it was not a big surprise to see my coworkers increasingly annoyed when they were being presented with “more steps” in their workday, or “more papers” to fill out or “scripts” taped to their computer monitors directing what they were to say to their patients. It was also not surprising to see that few or no staff members were attending the TCAB meetings to provide input and feedback.
Having gotten my Masters Degree I quickly realized what was missing was a well-planned approach to the change process. A crucial step within the change process is involving every person that could possibly be involved in that change: polling people, studying your stakeholders and what their motivations are, illustrating what is ‘in it for them’ should they take part. Failing to study all of your stakeholders and ask for feedback prior to initiating change is simply wasting a lot of time and yelling through a megaphone at an empty nursing station. I did some further research into the TCAB Initiative by immersing myself in the RWJF website for a couple of weeks.
After doing so, I discovered that our organization was not implementing TCAB as it was meant to be implemented. The organization was taking bits and pieces of the initiative and implementing them. The focus of the initiative — promoting happy nurses to promote happy satisfied patients — was not the managerial focus, as it should have been. It was strictly designed for patients, completely overstepping the spirit of the TCAB initiative as it was meant to be implemented. Lastly, the TCAB initiative was designed to be an interdisciplinary effort. The way it was being pushed at the organization I was at, the focus was just on nurses. I put together a white paper and power point and submitted them to my manager hoping it would help to get the project on track. I was promptly shut down with an annoyed response that my work looked plagiarized. (This is what an MSN on a nursing floor gets you)
So, managers, here are some lessons learned. If you want to make change on a large scale you must invest the time, no matter how long or how involved the effort, to study the people who have to carry out the work. Find out their goals, wishes, motivations, concerns, what makes them happy, angry, and frustrated. Find out what their knowledge base is and what must be learned to carry out the major initiative. Ask for their input. Discover who your “downers” are, why they are resistant to change, and how can you get them on board. It’s called “buy in.”
Lastly, harvest your talent. Take a fresh look at who your voices and cheerleaders are on the unit and give them “room to bloom where they are planted.” This is how and where you become a transformational leader instead of a leader who suppresses the creativity and potential of your nursing staff. One note: if you are going to implement something huge like the RWJF TCAB Initiative, don’t just take pieces of it and throw together your own version and expect it to work.
This, in my opinion, is what all of the large nursing organizations who want to transform healthcare need to do. Round everybody up for a week-long conference, every stakeholder — not just administration and management figures or politicians either. The real people: the bedside nurses, pharmacists, lab workers, patients, doctors, PA’s, housekeepers and so on. Paint the closest picture you can get to a collective vision everyone seems to share. Then, figure out how to get there, one step at a time.
All the big goals are great.I love the visions of where the RWJF and the IOM and the AACN see our profession, healthcare, and nursing education headed. But the visions are a problem too. There are too many ideas, initiatives, and too many people “other than bedside nurses” generating them. Our profession is fractured enough. It is not feasible, nor is it realistic, to expect every wonderful idea and vision to be carried to fruition when there is currently a longstanding lack of unity and disarray within nursing.
So, for the time being, let’s set aside the huge mountain of ideas and initiatives and take a deep breath. Now, start over with the A-B-C’s: Airway, Breathing, Circulation. Set the sights on resuscitating the profession of nursing first, before we attempt to heal the ailing healthcare system and the world. Take it back to the old school, and do the assessment first. Then, make a plan: implement it, evaluate it, and do it all over again until we get nursing back on track with a unified focus. Only THEN can we climb the mountains set in front of us by the RWJF or the IOM or the NIH. We cannot build castles without a strong foundation of earth below it.
By the way . . . Did anyone notice how often I used the word “initiative?”
Amanda blogs at NurseInterupted. This is a slightly modified version of a post which originally appeared on her blog.
A Texas hospital has declared war on the scourge of obese nurses:
A Victoria [Texas] hospital already embroiled in a discrimination lawsuit filed by doctors of Indian descent has instituted a highly unusual hiring policy: It bans job applicants from employment for being too overweight.
The Citizens Medical Center policy, instituted a little more than a year ago, requires potential employees to have a body mass index of less than 35 — which is 210 pounds for someone who is 5-foot-5, and 245 pounds for someone who is 5-foot-10. It states that an employee’s physique “should fit with a representational image or specific mental projection of the job of a healthcare professional,” including an appearance “free from distraction” for hospital patients.
“The majority of our patients are over 65, and they have expectations that cannot be ignored in terms of personal appearance,” hospital chief executive David Brown said in an interview. “We have the ability as an employer to characterize our process and to have a policy that says what’s best for our business and for our patients.”
It all sounds so, well, high-schoolish, and I don’t think the CEO is seventeen, though he’s acting like it. I mean, can you get any more shallow? Since when does physical appearance have anything to do with competence or worth or dignity of any health care professional?
Or maybe David Brown doesn’t really believe nurses actually have skills — we just stand around as decoration, lookin’ pretty.
And fitting the ”representational image” of hospital employees to meet patient “expectations?” What the hell does that mean, anyway? If patients expect this (and this is a pretty common “representation”)
then hiring practices should make sure all nurses are boobalicious? What if the patients want all-white nurses? Or all females? Or no Muslims?
The man is a bit of a dink, obviously. I can only imagine how valued overweight nurses employed by this hospital must feel.
The article goes on to note that this David Brown, CEO of Citizens Medical Center, has some issues. In 2007 he wrote memo about some foreign-born physicians in which he stated: “I feel a sense of disgust but am more concerned with what this means to the future of the hospital as more of our Middle-Eastern-born physicians demand leadership roles and demand influence.” He continued, “It will change the entire complexion of the hospital and create a level of fear among our employees.”
Needless to say, there is a discrimination lawsuit over that.
So let’s summarize what the leadership at Citizens Medical Center believes: scary scary fat nurses scaring patients. Scary scary dark-skinned physicians scaring employees and patients.
Clearly a place where I would want to work. Or be treated.
News flash! From Fierce Medical News, here’s the shocking headline:
Docs, nurses miscommunicate on respect, job role
When you guys pick yourselves off the floor from laughing, here’s the money quote:
In particular, the survey found differing views of how doctors treat nurses. According to 42 percent of nurse leaders, physician abuse or disrespect of nurses was common, whereas only 13 percent of physician leaders said it was common. Fifty-eight percent of nurse leaders considered disrespect for nurses uncommon, while 88 percent of physician leaders said it was uncommon at their healthcare organizations.
“I do believe nurses and physicians are on two different pages when it comes to communication,” Pam Kadlick, vice president of patient care and chief nursing officer for Ohio’s Mercy St. Anne Hospital, said in a HealthLeaders Media article. “Nurses have a tendency to give a very detailed report, more than what a physician may want to hear; hence, the physician may interrupt, seem to be abrupt, even rude at times.”
But most physicians don’t consider such behavior to be disrespectful, she noted.
You’re telling me abuse of nurses is all about physicians being insensitive, maybe, and nurses having too many hurt fee-fees? Really? And nurses are supposed to be surprised that physicians “don’t consider such behavior to be disrespectful?”
Why does this sound like a ’80s sitcom?
Why does this sound like this report is trying to validate abusive physician behaviour?
You can only shake your head. And you just know, somewhere, in a darkened office maybe, in an obscure corner of a mega health care corporation, a manager is reading this report and exclaiming, “I knew nurses were to blame!”
I will very happily concede abusive behaviour of all kinds has declined markedly in my own time as a nurse, though I will say I work in an institution that enforces a zero tolerance policy against abusive behaviour. Moreover, the physicians I work with, shoulder to shoulder, are lovely and professional, and there is a true sense of collaboration. This makes for excellent patient care.
However, by no means is this true everywhere. So let’s not pretend the brow-beating, the mocking, the chart-throwing, the patronizing — to be blunt, treating nurses like you wouldn’t treat your mother, daughter, wife, bank clerk, Wal-Mart greeter, housekeeper, or dog — still doesn’t go on. Denial will never fix the problem, either from physicians — or nurses.
Via ImpactedNurse.com, another study showing prolonged emergency department stays are less than optimal:
There were 41,256 admissions from the ED. Mortality generally increased with increasing boarding time, from 2.5% in patients boarded less than 2 hours to 4.5% in patients boarding 12 hours or more (p < 0.001). Mean hospital LOS also showed an increase with boarding time (p < 0.001), from 5.6 days (SD ± 11.4 days) for those who stayed in the ED for less than 2 hours to 8.7 days (SD ± 16.3 days) for those who boarded for more than 24 hours. The increases were still apparent after adjustment for comorbid conditions and other factors.
In other words, two consequences from lengthy Emergency department admissions: first, you are about twice as likely to die if you are admitted for more than twelve hours, and secondly, if you stay for longer than 24 hours (and survive, of course) you’re likely to be hospitalized for three extra days.
Clearly something bad happens when patients are admitted in EDs for long periods of time. The study’s authors identify a few reasons for this. Care for admitted emergency department patients are poorly prioritized by both physicians and nurses; a preference bias occurs because less acute patients tend to get beds more quickly (a phenomenon which is a frequent occurrence in my hospital as “easy” patients go off-service to Paeds or Post-Partum or General Surg); there are also delays in the getting appropriate treatment started, which negatively affects mortality.
I would add the obvious, that expecting Emergency departments to run as Emergency departments and simultaneously as ICU/Post-Op/Med-Surg/Urology/Gyne/Surgical Outpatients/Paediatric unit(s) is probably not a reasonable expectation, if for the simple reason acutely ill new ED patients will always take priority over admitted patients, except when those patients are actively crashing. Additionally EDs are not set up to take care of admitted patients. We are not given the resources to do the job properly.
I don’t expect this study would surprise anyone who has actually worked in an Emergency department. We’re used to seeing patients decompensating before our eyes. What it does is give us ammunition. When some manager tells me, “I’m not going to do those bed moves for that patient because you only have seven admits — which I have actually heard fall out of a manager’s mouth — I can cheerfully reply, “You’re increasing the risk of that patient dying to 1 in 20.” When the ICU tells me to wait till after lunch, I can counter with “You are increasing the patient’s overall length of stay with every hour’s delay.” Most importantly it adds a sense of moral urgency. Get the patients upstairs, or increase the risk of killing them. It’s pretty simple.
Posted by torontoemerg in Good Nursing Practice is Practising with the Heart and Mind, Nursing Naval Gazing, Random Thoughts on Tuesday 31 January 2012
Ian Miller, blogging over at ImpactedNurse.com, notes a disturbing trend in Australia, one, I’m afraid, is becoming more common in North America. “These days,” he writes, “being a nurse is tough. Really tough.”
I look around and see many struggling at the bedside. I see the increasing perception that this is menial or bottom-of-the-professional-foodchain work.
I see more and more of this sort of feeling online.
What our brightest and best nurses should be doing instead of creating a culture of escaping the bedside or doing time at the bedside is acknowledging that it is the nurse providing direct care to the patient or client that is the absolute most important domain of our increasingly diversifying profession.
Nurses do not really want to be business entrepreneurs, unless they have no other choice. They want to be nurses.
I would even argue that if you are not regularly within arms reach of your patient/client you are not nursing. And if you have not done this for a long time you are not really a nurse. You are something else. Strong stuff1 I know.
The bedside nurse should be re-valuing themselves not re-inventing themselves.
Miller’s solution is “8 in 8,” i.e. having non-bedside nurses work an 8 hour shift every 8 weeks at the bedside as a condition of their registration. This is an idea I like the more I think about it. However, it would be complicated to implement, not the least because of resistance from said non-bedside nurses — and can you see all those functionaries from nursing regulatory agencies or upper management pulling on scrubs and Crocs and tending to stool incontinence and urinary drainage bags?
Hmmm. Maybe not.
But Miller’s premise, that bedside nursing itself is demeaned and devalued to the point where many of us — including myself — are plotting our escape to greener pastures is sadly true. But why? The reasons for this are pretty simple. Despite years of education and rhetoric, nurses aren’t really permitted to practice to the full scope of our knowledge. We all have heard managers speak of their time at the bedside like it was a prison sentence. Television shows like Grey’s Anatomy tell us bedside nurses are stupid. We know that hospitals view nursing not as a valued added service, but as an expensive cost centre, and that Human Resources thinks of nurses as a “problem” to be managed, like the kitchen guys who make the salads, not as practising professionals.
To be clear, we menialize ourselves as well, when we view nursing as a job rather than a profession, or when we see nursing as a series of tasks to be completed before shift change, rather than a process requiring frequent periods of critical thinking.
It’s all pretty overwhelming, and though I will publicly stand up for the value of bedside nursing, and argue strenuously to its central importance in health care, there are times when even I have a little shadow of doubt.
So really I’m not very surprised if nurses of all ranks and positions view the bedside as menial and demeaning. If people around you all day tell you you’re worthless and menial, and if you view what you do as being more or less thankless and trivial, pretty soon you’re going to believe you are worthless and menial — and so is your professional practice.
I would like to tell you my own motives for escaping the bedside are pure, but when I seriously reflected about it, I realized some of my reasons for wanting to leave had much to do with decent hours and status. And something else: the ability to act autonomously and effect change in a real way.
In other words, it’s all about power, and this explains why bedside nurses are so demeaned and devalued and want to escape.
Because we have none. Or think we do.
(I would argue front line nurses have far more power to shape their practice and workplace culture than they realize, but we all have been indoctrinated since the first day of nursing school never to question their place in the food chain and to always ask permission. And I’m not speaking about “making a difference in patient’s lives” — a phrase which has always struck me as infantile and meaningless. But this is a subject of a whole other post.)