Recently I’ve begun reading allnurses.com, a website that offers an eye-opening window on conditions in U.S. hospitals. (I found the site when allnurses reprinted my post about the nursing shortage).
Clearly nurses and doctors know more than virtually anyone else about what is going on in our hospitals, but they also realize that they risk reprisals if they speak out. When I was writing Money-Driven Medicine, I was surprised by how many physicians returned my phone calls. The great majority did not know me; I expected responses from perhaps 20 percent. Instead four out of five called back. To a man and a woman, they were most passionate about what many saw as the declining quality of healthcare. “We want someone to know what is going on,” explained one prominent Manhattan physician as he described how much care had deteriorated in many of New York City’s major hospitals. “But please don’t use my name,” he added. “You have to promise me that. In this business, the politics are so rough–it would be the end of my career.”
Nurses are in an even more vulnerable position. I could not find any who were willing to be interviewed. I e-mailed quite a few, promising anonymity, but not one responded.
On allnurses.com, however, nurses speak freely, knowing that their identities are protected and that their audience is composed of other nurses. Here is what I have learned from some of the polls and forums on the site:
- When asked: “What do you do on a break?” nurses responded with comments such as: “Break, what’s that?”. . .”I feel it’s an especially good day when I get a break” . . . One nurse who has been working a 12-hour midnight shift for nineteen months wrote: “We are not allowed breaks because we get to go home at 7 a.m. instead of 7:30. . . There are usually only two R.N’s on my floor, so leaving the floor is never an option anyway.”
- Asked if they are on anti-depressants: 52.8 % of those who answered the poll responded, “Couldn’t make it without them;” over 18% checked, “No, but I think I need some;” and over 22% replied, “No, but I know a lot of nurses who are.”
- Responding to the question: “Would you call in sick because you didn’t get any sleep, just 31.5% said: “I have before and would again. Too risky not to.” Another 20% said they “probably would.” Over 34% said they “might or might not,” while over 14% responded “Never, I’d go on in.” One reported that if she called in to say that she had gotten no sleep and was too tired to work, her supervisor would tell her to take a nap and then come in. Given short-staffing this is understandable. On the other hand, as 31% of the nurses pointed out, caring for patients when you are exhausted means risking their welfare.
- Finally, when asked “Would there be a nursing shortage if nurses were paid better and had better benefits?” the answers were almost unanimous: “It’s not the pay, it’s the atmosphere that is causing the shortage”. . . “Better pay and benefits might help recruit more nurses, but they won’t STAY if the working conditions remain unbearable” . . . “It’s definitely NOT about the money. . ..You have new nurses coming on a job with BIG bonuses and making almost as much as the veteran nurses. Most leave within a year. What does that tell you? NO ONE LIKES TO BE TREATED LIKE C- – P.”
Discussing their frustrations with their job, relatively few nurses
complain about their patients, and the complaints are usually mild.
(Though be forewarned: patients who ring to have their pillows fluffed
are not well-liked.) The families of the patients, on the other hand,
draw a less charitable response– especially those who say “Can you
clean this up?” while pointing to their own empty Starbucks cups.
But by and large, it’s the hospital administration that provokes the truly bitter comments. Here is a sample:
“I was working rehab (3-11). As I was passing a patient’s room, a CNA
was yelling for help. Her patient was on the floor in cardiac arrest! I
called a code, and began the resuscitation steps. When the code team
arrived, I went back to my patients, one of whom (I had 6) had turned
bluish-purple, and had spiked a temp of 104 in less than an hour! The
patient said she was having no trouble breathing, but she felt "funny".
Called the M.D., waited…waited…waited… Went back to the patient.
Ten minutes had passed. Still blue… temp now 104.4. This went on,
with temp increasing by the minute, and the doctor finally called about
an hour after his 3rd page. I stayed with the patient most of that
time, praying…
“At 10:15 we moved her to ICU, with a temp of 105.8 and an Infectious Disease consult.
“In the meantime, my other 5 patients (who were stable, and whom I had
briefly checked on a couple of quick rounds) were waiting for their
9:00pm meds. I gave them at 10:30.
“Went home feeling pretty good about the whole thing. We had saved and
stabilized the patient with the cardiac arrest, the patient with the
strange symptoms and high temp was taken care of, and all my patients
got their meds (although a little late).
“The next day my nurse manager called me into her office. She had
written me up because one of my patients was supposed to have had her
blood pressure taken at 9 pm, and it was not taken until 11pm. AND it
was 130/80. I thought maybe she was kidding. NOPE.”
These are, of course, only anecdotes, and the polls are relatively
small polls. Nevertheless, the allnurses website confirms, in vivid
detail, what more formal studies have revealed. Nurses find working
conditions in U.S. hospitals unacceptable.
And they are voting with their feet. A 2006 study published
in Health Affairs reports that in 2004 only 56 percent of nurses worked
in hospitals, down from 59 percent just four years earlier. According to co-authors Susan Hassmiller, a fellow of the American
Academy of Nursing and leader of the nursing team at the Robert Wood
Johnson Foundation (RWJF), and Maureen Cozine, a communications officer
for RWJF’s nursing team: “The current nurse shortage is driven by a
broad set of factors related to recruitment and retention—among them,
fewer workers, an aging workforce, and unsatisfying work environments.
Too few new nurses are being trained (largely because of a shortage of
nursing school faculty), but to a greater extent, the current
shortage results from the reluctance of newly educated nurses to make
their careers in hospitals.” (my emphasis)
Here, I have to ask myself: “If newly minted nurses don’t want to be
there, do I—even if I’m very sick? Especially if I’m very sick?
The situation is far from hopeless. In the long run, electronic medical
records should make a nurse’s job easier. Today, as Hassmiller and
Cozine report: “Nurses spend much of their time searching for
medications and doctors, hunting down needed equipment, and completing
redundant paperwork.” But at this point, Washington has not committed
the money needed to wire the nation’s hospitals. And while some
hospitals have the surpluses needed to invest in healthcare IT, roughly
half of the nation’s non-profit hospitals are operating in the red.
They need help.
But technology won’t fix everything. Nurses need to be treated with
respect. A pilot program sponsored by the Robert Wood Johnson
Foundation and the Institute for Healthcare Improvement has come up
with some promising ideas. For example, some hospitals involved in the
program have initiated the use of rapid response teams, which enable a
nurse “to call on a team of clinicians to intervene when a patient’s
condition appears to be deteriorating [rather than waiting for a doctor
to respond.] This practice provides overt validation for nurses’
professional judgment and provides needed assistance for patients
before they reach a more irrevocable point of crisis” (my emphasis).
Having the power to summon a rapid response team also could reduce some
of the stress that nurses feel on the job.
Hospitals involved in the program recognize that long hours without a
break means that nurses are bound to make more errors—and the chaotic
environment found in many hospitals only compounds the problem. Some
institutions involved in the pilot program are instituting what
Hassmiller and Cozine describe as “small simple changes to improve the
work environment: For example, some units have established ‘peace and
quiet time’ for an hour during each nursing shift to promote a calming,
healing environment for patients to rest.”
These all sound like good ideas. But implementing them requires
political will and co-operation on the part of hospital management and
health care professionals. In the meantime, the nation’s hospitals are
expanding. As they compete for the most lucrative business, they are
investing hundreds of millions in luxurious new buildings, without
having any idea where they will find the nurses staff them –yet another
example of how our profit-driven health care system has it priorities
upside down.
I’m not surprised. I would think that if one looks at the causes of the nursing shortage, pay is down to at least #3 on this list if not farther down.
Inability of nursing schools to meet the demand for new graduates also seems to be more of a factor than pay. But the biggest thing, most likely, and certainly the one I hear most frequently? Working conditions. I know several nurses, and the working conditions are the biggest gripe about their jobs by far — no other complaint even comes close. I don’t hear them complaining about pay.
This creates a Catch-22 situation: Nurses face terrible working conditions (long hours, split shifts, no breaks, getting called in) partially because there is a staffing shortage. (One could also point to “cost cutting” efforts in some cases as well.) But one of the reasons more people don’t go into nursing is because they hear horror stories about the working conditions!
This becomes like a dog chasing its tail in terms of trying to resolve it. As things are now, I don’t think hospitals could get by if nurses worked 40-hour weeks. (And I’ll bet a lot of nurses would accept reduced pay in exchange for a more “normal” workweek and less brutal working conditions, were it suddenly made feasible.)
Short of that, if nurses are to continue to be working these brutally long shifts, something needs to be done in order to reduce the overload and the stress, as these lead to a greatly increased potential for mistakes.
I think this is yet another example of the effects of a for profit health system. In medicine as with any business one of your greatest expenses is staff, and as a matter of doing business you minimize the number of employees while maximizing thier output. This will of course lead to a very uncomfortable work environment. I think there is a place here to discuss compassion fatigue. Any plans on posting on compassion fatigue Maggie?
I completely disagree with you with regard to allnurses.com.
It is a private web site rune by corporate feminists both male and female who voice support for both the feminist and corporate goals and means which have produced both the nursing shortage and the discrimination against men in nursing which is now accepted.
Those individuals who voice opposition to the same on allnurses are harassed by the management of the same.
Gosh, I hope you don’t think that a poll posted to an online forum community is in any way, shape or manner scientific or the same as empirical research.
Only 214 self-selecting people (I won’t say “nurses,” because the allnurses.com website allows anyone to register, regardless of profession) answered the poll about anti-depressants. That’s a 0.00088 response rate out of the entire forum population (e.g., even if it were scientific, it’s not anywhere close to representative).
And the obvious bias is that if you’re on anti-depressants, you’ll answer the question and if you’re not, you’d have no interest in such a thread.
People answer such community polls when they appear interesting or relevant to the person. That means anything you take away from such a poll is largely for entertainment purposes, not information, and certainly not for making policy decisions or judgments about an entire field.
Tim, Dr. John. Dr. Magg and C.V.Compton Shaw–
Tim–Thanks for your comment
DocJohn–Of course online polls attract a self-selecting group, and as I noted these are very small unscientific polls.
That’s why I included the Health Affairs study. The online comments only confirm what more formal research tells us about how nurses feel about working conditions, nursing burn-out and the “compassion fatigue” that Dr. Matt points to.
But as is often the case, the voices you hear online can be more candid than the voices you hear when people are quoted for attribution in the mainstream media.
C.V. Comptom Shaw–I don’t quite know what you mean by “male corporate feminists” but I’ll take your word for it that they exist. (I assume these are males in hospital management who think women make better nurses than men?) I really can’t comment because just I don’t know anything about the dispute.
nurses need to demand more pay. save money ifyou area nurse, once you have enough money, change jobs, why put up with the bullcorn. as i see it, nurses just like to whine, if it was so bad, they would have the smarts to make a career change
I think the issues discussed in this post result primarily from a failure of management which should be fixable with appropriate leadership from the top. If I am a hospital CEO, I need to sustain the financial viability of the institution. I also want the institution to compare well against its peers on both medical outcomes and patient satisfaction. High quality nursing care is an important factor in achieving both of those objectives.
To sustain financial viability, the hospital needs to operate efficiently. However, skimping on nurse staffing ratios is likely to prove counterproductive. If occupancy rates are consistently well below where they need to be, perhaps downsizing or merging with another hospital should be explored. If the hospital has an excellent reputation in some specialties but is considered mediocre in others, maybe it should stop offering services that it doesn’t excel at instead of trying to be all things to all people. Hopefully, interoperable electronic records will find their way into all hospitals over the next few years with financial help from federal and/or state taxpayers if necessary. That should reduce costs and allow nurses to devote more of their time to patient care.
With respect to the day to day operating environment, senior management needs to create a culture of mutual respect. Arrogant doctors who treat nurses (and others) poorly should not be tolerated. Perhaps nurses should be afforded the opportunity to evaluate their supervisors (anonymously, if necessary) as part of a so-called 360 degree review process.
I think every job in our economy can be broken down into three main components – (1) job content and responsibility, (2) pay and benefits, and (3) personal chemistry and work environment. If the first two are good and the third leaves a lot to be desired, good senior management may able to address and fix the problems. As one concrete example, Paul Levy did an excellent job in turning around the once troubled BIDMC in Boston. It shows that it can be done.
“In the long run, electronic medical records should make a nurse’s job easier.” That is not something any nurse I know would ever agree with. You might want to inteview some nurses on what these programs are really like to use in a busy ICU or ward. Or have been a fly on the wall last night during an after-hour discussion.
Rene and Barry–
First Rene–I agree with you. That’s why I said that “in the long run” electronic medical records
“should” make a nurse’s job easier. In the short run, nurses and doctors I have talked to point out that new healthcare IT pulls nurses away from patients as everyone tries to learn the IT.
Frustrated doctors call on nurses to help them with the computers. In many hospitals, we’re not doing a very good job of introducing the IT.
But in other countries it has worked to reduce paperwork, and I do believe that “Over the Long Run” it really could cut down on the time nurses spend trying to run down the doc who has the patient record saying –in writing–which medications are authorized. EMRs also could greatly reduce the number of “medication mix-ups”–something that many rushed nurses fear.
Barry– I completely agree wtih you that this is largely a management problem. The fact that nurses harbor so much resentment toward hospital administration –and the fact that so many nurses are unwilling to work in hospitals– is a major clue that management is not recognizing how important it is to create a working environment where nurses feel that they can do their jobs well.
And I very much like the idea of nurses being able to review their supervisors anonymously.
The other sore point for nurses is that, as hospitals vie for “market-share” (of well-heeled docs and well-insured patients), they are urging nurses and doctors to think of patients as “customers” or “clients”–with the “the customer is always right” metnality that follows from that premise.
Nurses say that this leads patients’ families to feel that they can treat nurses in an abusive manner, ignoring how many patients they are tending, demanding special treatment for themselves and their relatives. Hospitals aren’t restaurants, and hospital management needs to make it clear to families that they can’t treat nurses the way rude customers treat waitresses.
Nurses should not be reprimanded or “written up” if they tell families, in a civil way, “I’m sorry, but . . . ” and then turn on heel and leave the room.
Rene and Barry–
First Rene–I agree with you. That’s why I said that “in the long run” electronic medical records
“should” make a nurse’s job easier. In the short run, nurses and doctors I have talked to point out that new healthcare IT pulls nurses away from patients as everyone tries to learn the IT.
Frustrated doctors call on nurses to help them with the computers. In many hospitals, we’re not doing a very good job of introducing the IT.
But in other countries it has worked to reduce paperwork, and I do believe that “Over the Long Run” it really could cut down on the time nurses spend trying to run down the doc who has the patient record saying –in writing–which medications are authorized. EMRs also could greatly reduce the number of “medication mix-ups”–something that many rushed nurses fear.
Barry– I completely agree wtih you that this is largely a management problem. The fact that nurses harbor so much resentment toward hospital administration –and the fact that so many nurses are unwilling to work in hospitals– is a major clue that management is not recognizing how important it is to create a working environment where nurses feel that they can do their jobs well.
And I very much like the idea of nurses being able to review their supervisors anonymously.
The other sore point for nurses is that, as hospitals vie for “market-share” (of well-heeled docs and well-insured patients), they are urging nurses and doctors to think of patients as “customers” or “clients”–with the “the customer is always right” metnality that follows from that premise.
Nurses say that this leads patients’ families to feel that they can treat nurses in an abusive manner, ignoring how many patients they are tending, demanding special treatment for themselves and their relatives. Hospitals aren’t restaurants, and hospital management needs to make it clear to families that they can’t treat nurses the way rude customers treat waitresses.
Nurses should not be reprimanded or “written up” if they tell families, in a civil way, “I’m sorry, but . . . ” and then turn on heel and leave the room.
Take a very close look at EMR. Though I concur it will be the best way for future medical record keeping, there is a reason it is being rushed into the system. It has not been shown by any well designed study to improve health outcomes, it has however been shown to increase billing reimbursement and capture. I doubt it is paying for itself in any significant way however, the software and licenses are terribly expensive, the equipment to run it again, expensive, and instead of having a few people who know the alphabet maintaining medical records you have whole departments of “IT” specialists. This is a costly endeavor, as far as decreasing medical mistakes, it has yet to be shown it is only assumed. Remember what happened when we assumed antiarrythmics were a good treatment post MI. If we are to apply EBM we need to certainly apply it to the likes of EMR (especially considering the expense). A colleague at one local practice confided in me that when his practice got EMR, he was expected to increase his personal patient output by up to 15% to pay for it, that certainly will no improve the quality of care.
Dr. Matt–
I, too, am concerned about the commercialization of EMR.
And the fact that instead of having a single platform (the way other countries do– where the govt. was much more involved)we have competing companies trying to peddle their wares at the highest price possible.
Ultimately, systems at different hospitals will have to be made compatible so that they can “talk to each other”–another expense.
That said, the VA’s use of electronic medical records really does show that you really can reduce mistakes (particularly medication mix-ups)and do a much better job of co-ordinating care.
I’ve written about this in my book–but see also “The Best Care Anywhere.”
(These days the VA has some major problems related to the fact that, since 2000, they’ve been grossly underfunded while caring for more and more patients–from Iraq and the Gulf War as well as aging Vietnam Vets. But that’s a separate story.)
And the VA put together its EMR system on a shoestring–without a single penny of extra money from the government. Of course the VA has the advantage of being a system where all of the doctors work for the VA and are willing to co-operate as they tne learn the system.
By contrast, some Solo practioners deeply resent the time that it takes to learn a hospital’s new EMR system –when they coudl be seeing patients in their private practice.)
Moreover VA docs tend to be a bright, self-selecting group of academics who like working with Vets.
In the long run healthcare IT can, I believe, reduce mistakes –and maybe even save money. But we’re going about it in the least efficient way possible.
Dr. Matt–
I, too, am concerned about the commercialization of EMR.
And the fact that instead of having a single platform (the way other countries do– where the govt. was much more involved)we have competing companies trying to peddle their wares at the highest price possible.
Ultimately, systems at different hospitals will have to be made compatible so that they can “talk to each other”–another expense.
That said, the VA’s use of electronic medical records really does show that you really can reduce mistakes (particularly medication mix-ups)and do a much better job of co-ordinating care.
I’ve written about this in my book–but see also “The Best Care Anywhere.”
(These days the VA has some major problems related to the fact that, since 2000, they’ve been grossly underfunded while caring for more and more patients–from Iraq and the Gulf War as well as aging Vietnam Vets. But that’s a separate story.)
And the VA put together its EMR system on a shoestring–without a single penny of extra money from the government. Of course the VA has the advantage of being a system where all of the doctors work for the VA and are willing to co-operate as they tne learn the system.
By contrast, some Solo practioners deeply resent the time that it takes to learn a hospital’s new EMR system –when they coudl be seeing patients in their private practice.)
Moreover VA docs tend to be a bright, self-selecting group of academics who like working with Vets.
In the long run healthcare IT can, I believe, reduce mistakes –and maybe even save money. But we’re going about it in the least efficient way possible.
I agree that the “potential” of the EMR is great. Strangely when I worked for the hospitals that had it they were not open to criticizm of it in any form (seems to if you want improvement you MUST accept and consider all well thought out criticizms). Currently however I believe the reduction of mistakes that are measurable (believe me there are a great deal of medical mistakes that go unnoticed) does not out weigh the quality of care lost by seeing more people in less time so that the system can be paid for. The math doesnt add up if I save 10 mistakes a month but now rush through 50 visits a months that I know required more time I have created very fertile ground for further mistakes, this is a net loss. In regards to the VA, very good system overall, it helps that thier overhead does not have to be paid for by number of patients seen, this is the way EMR can flourish. It is a good system, we might do well to look at it as a model for the future (the whole va system that is).
PS, I also wrote about EMR in my book.
Our problem is political, and I don’t think we have any disbelievers in that arena. If politicians were not paid off by the healthcare industry we would have fixed this long ago.
We simply have to mandate a one-size-fits-all policy, and the VA VistA system is a reasonable start. Being a programmer in a previous life I can assure you that we cannot leave this to a thousand different “free market” programmers to put together a common structure that everybody must (or can) comply with.
I’ve written about this in a blog piece at http://tinyurl.com/ynkkr6 (click on the COMPLETE printed article HERE link).
It is solvable, but it may take a complete turnover in congress to achieve.
Jack– Thanks for your comment– I agree.
I’ve never heard about this web site, but after your post I suppose I will take it to favorites.
http://www.air-lifeline.com
An important post – thanks – but unless I missed it, you don’t discuss what is to most nurses the most obvious solution to this abhorrent situation: Mandated safe staffing levels by setting minimum RN-to-patients ratios.
Just as we have minimum staffing ratio requirements for childcare settings to offset the financial pressures that exist for management to reduce staffing levels in those facilites, we must enact requirements for safe RN staffing ratios on inpatient units. It is absolutely crazy that this basic patient protection and worker protection doesn’t already exist.
Registered nurses are being forced to care for too many patients at once, and patients are suffering the consequences in the form of preventable errors, avoidable complications, increased lengths of stay and readmissions. Piles and piles of rigorous, independent research results prove what we nurses who’ve worked on inpatient units already know to be fact.
Tragically, hospital management executives, their trade associations (ie AHA), and their well-heeled lobbyists have put hospital financial self-interests above the interests of safe patient care and adequate working conditions for nurses. These hospital executives and management-types have, without exception (to my knowledge) repeatedly blocked ongoing efforts to institute safe staffing.
And they’re cutting off their nose to spite their face b/c better staffing levels would quickly save the hospital money! guaranteed improved working conditions lead to more satisfied staff who will stay in their jobs. This is a sound argument that plays out in terms of savings gained from lower nurse turn-over (is at a high rate now in most places) which means less money spent on recruitment and new-hire orientation, and much less use of agency nurses, whose rates are very expensive b/c teh hospital must pay for the nurse and for the temp. agency’s profit.
California is the only state so far that has enacted a RN staffing ratios law. Here in MA we have been working to pass our safe patient care/safe RN staffing law for 10 years now. The current version (2007-08 session) is House Bill 2059, the Patient Safety Act. It calls upon the state Dept. of Public Health to review the research and to set a safe limit on the number of patients a nurse is assigned at one time. In addition, the bill calls for staffing ratios to be adjusted based on patient needs.
The bill also bans mandatory overtime and includes initiatives to increase nursing faculty and nurse recruitment.
There’s also a Rn-to-patient staffing ratio bill filed at the federal level. We need more nurses and physicians to be active on this front; even if you’re not a hospital-based clinician (or nursing home-they need it too) you owe it to your profession and to the public’s health to advocate for this sensible policy to become law. Learn more at
http://www.protectmasspatients.org/