Another Visit With Captain Obvious – Nurses Are Overworked
We had a “more evidence of the obvious” moment recently, and it occurred to us that a dangerous long-term trend is not being managed – a potentially ugly combination.
Let’s start with the most recent article of the obvious. It appeared in the July 2019 issue of Health Affairs. The authors used multiple data sources(AHA’s Get With the Guidelines–Resuscitation registry, RN4CAST- nurse surveys, and AHA hospital info) to come to their conclusions. Each 10-point increase in BSNs (as a percentage of all nurses) was associated with a 24 percent improvement in survival to discharge with good cerebral performance among in-hospital cardiac arrest patients. They also found that “each additional patient per nurse was associated with 17 percent” decreased chance of this same outcome.
The authors did a great job with the research and presenting their findings. The question I raise is: “How many times do we have to prove that better trained nurses – caring for a manageable number of patients – leads to better outcomes, before we actually use the information?”
But maybe this is moving too fast for those unfamiliar with the subject matter. For review, HR 101 has held as conventional wisdom (since before my MBA in 1992) that the Disney and Marriott experience is transferable to all service industries. Those companies demonstrated, several decades ago, that it’s impossible to have satisfied customers if your employees are dissatisfied. But if that isn’t enough for you, review these pieces on healthcare specifically, largely by the same authors, confirming the relationship. In healthcare at least one sine qua non for satisfied patients is the key group of employees called nurses. Working them longer and harder burns them out, destroying patient satisfaction scores, and a lot of them are dissatisfied and burned-out.
For any reader who might view Human Resource management as a ‘soft science” with “touchy-feely” stuff that’s unproven, let me add one last piece of science before we move on. There is a large and growing body of knowledge provided by modern imaging techniques combined with a new understanding of how our brain function is expressed as behavior – neuropsychology. The effects of stress on the brain functioning are of particular interest in understanding how poor working conditions, perceived low pay, lack of appreciation, and increasing work-loads can structurally interfere with brain performance through a common modality – stress. A full exploration of this topic is more complex than this venue allows, but the interested reader might start to explore how the field explains the effects of stress by viewing a recent HBO special by Dr. Sanjay Gupta. He does a great job of explaining a complex medical outcome in people under chronic stress (i.e., stress-induced deterioration in pre-frontal cortex brain volume and function, and its connection to suicide, cirrhosis, and opioid abuse). Considering the stress of nursing these days in our hospitals, it’s a wonder that we don’t have even more suicide, cirrhosis, and opioid abuse in our nursing corps. The stress nurses are enduring is likely wearing out the critical part of the brain required for high-functioning in a complex environment. This isn’t “soft science” anymore.
But all my nurse friends tell me that we’re going in the wrong direction. The nurse-patient ratios continue to creep up in their hospitals. Longer shifts and mandatory overtime is getting more frequent, and the CMA (Certified Medical Assistant) ranks have become even more unstable with severe shortages and high turn-over rates. One system recently told us that their CMA ranks were repeatedly decimated by Target and Walmart whose starting salary was bid up every time the hospital gave the Assistants raise’s or enriched their benefit plan. I think it is pretty damning evidence of an unrewarding job environment when Walmart can steal your employees.
The longer the unemployment rate remains low, the worse the competition for entry level workers will be. And if you’re in a bidding war with Walmart, you are probably going to lose. And similarly, if you are in a bidding war for baccalaureate nurses, with a competitor hospital, you need another strategy. If we can’t find a way to improve the job environment for nurses in hospitals, we will continue to lose them to non-hospital work sites – pharmaceuticals, home health, physician offices, etc. The best people always have other options, and when they leave, we are left with inexperienced new graduates and, well, the “not best” employees. And let’s not forget that other alternative to address poor working conditions, especially when management consistently doesn’t, and especially where there is high pay/benefit package variability, unions.
Returning to our thesis, we have almost twenty years of data that the nursing workforce in our hospitals are not the engaged, thrilled-to-come-to-work providers of front-line care that we should strive for. We have recent confirmation that the problem is not being addressed well, and that – surprise – it’s getting worse. This is a dangerous and unaddressed trend.
So, what is to be done? Again, Captain Obvious to the rescue. Abraham Maslow, and his followers, gave us the answers in the 1950’s. When pay is competitive, more money (or benefits) won’t make people happy. Inadequate pay makes workers unhappy, but you can’t make up for a horrible work environment with money. Get to work on improving the work environment. And before the CFOs start screaming, it’s not an expense. Its an investment. The return is improved quality and safety, reduced rework and waste associated with inexperienced workers, and – the obvious – a reduction in very costly turn-over.
How do we do that? Again, Captain Obvious from HR – there are many ways to enrich the work environment. Offer defined paths for advancement in the organization through in-house educational programs. Engage the workers in managing their environment. Ask them where the stressors are and then do something meaningful about it. (Bad idea – more resiliency training. Good idea – do something with that clunky EMR that was selected by the revenue cycle team.) And most obvious of all - limit the work-load. Diversions, transfers? Blasphemy! I say YES! It’s a reasonable strategy that every union will secure first – controlling the work-load. Are you going to wait for a union to mandate it? It’s simple really. The number of nurses that can be reliably scheduled multiplied by a reasonable nurse-patient ratio gives you your “staffed beds.” Remember when “staffed beds” meant something? Exceeding that census number should be for defined short-term emergencies only. Anything else takes you down that slippery slope to overworked, unhappy workers delivering sub-optimal and more expensive care.
I’m reminded of a great scene in Ghost Busters where Janine (played by the wonderful actress Annie Potts who is now playing Young Sheldon’s mee-maw) answers the phone, during a futile request for help, by shouting into the receiver: “Ghost Busters, wadda ya want?” I fear that we are pushing our nurses beyond their limits. I have witnessed very similar interactions by nurses working mandatory overtime with high patient counts and little CMA help, answer a call bell with: “This is your nurse, what do you want?” This is not a unique result for nurses. Hospitalists tell similar stories. And it’s not a unique result in healthcare. But I challenge you to name one business that can survive when they consistently attempt to serve more customers than their workforce can handle. And our customers depend on us for more than a hotel room or an amusement park ride. A well-managed work-force that is eager to serve is required to hit our targets of best care, safety, a pleasant experience, and at the lowest cost possible.
One final suggestion that is more experimental in healthcare, although old-hat in software development companies. It’s called Strategic Innovation. The concept is for an organization to adopt as strategy (not an implementation tactic, but a true strategy - a characteristic that separates and distinguishes the organization from its competitors) to create environments where people are more likely to innovate. Typically, their workers have time for engagement with each other and their patients; time to think about making their work more efficient and meaningful instead of just working harder and faster; time to interact with support personnel (EMR programmers maybe) and imagine solutions to the electronic documentation demands. This isn’t impossible. With off-the-shelf EMR software I have seen teams meet my demands of “eliminate 3 clicks every week”. By giving quality “quiet-time” in a relaxed environment, front-line clinicians were able to interact with programmers, explain their frustrations, and the programmers were soon delivering 4 and 5 “eliminated clicks” per week.
My mother was a nurse. When I became a doctor she told me, “Nurses can make you or break you, and it’s your choice!” Remembering that advice served me well and would serve us all now as leaders in healthcare, faced with a troubling trend. Piling more work on fewer, less trained nurses has got to stop.
Its way past time to take better care of our nurses.
Thank you Captain Obvious
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In Hospitals With More Nurses Who Have Baccalaureate Degrees, Better Outcomes For Patients After Cardiac Arrest Health Affairs v38, No. 7 July 2019 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.05064
Nursing: A Key To Patient Satisfaction Health Affairs, v28, Supplement 3; 2009 Health AffairsVol. 28, No. Supplement 3 https://www.healthaffairs.org/doi/10.1377/hlthaff.28.4.w669
The Longer The Shifts For Hospital Nurses, The Higher The Levels Of Burnout And Patient Dissatisfaction Health Affairs Vol. 31, No. 11 November 2012 https://www.healthaffairs.org/doi/10.1377/hlthaff.2011.137
Nurses’ Widespread Job Dissatisfaction, Burnout, And Frustration With Health Benefits Signal Problems For Patient Care Health Affairs Vol. 30, No. 2 February 2011 https://www.healthaffairs.org/doi/10.1377/hlthaff.2010.0100