Combatting the Nursing Shortage, Part 2

Here we continue with our overview of the nursing shortage, which we started last week in Combatting the Nursing Shortage, Part 1. This segment's topic concerns on-the-job issues.

Understaffing, Stress, and Burnout

The nursing shortage has become a self-perpetuating cycle. Fewer nurses mean that existing staff must assume heavier workloads, which leads to high staff turnover and contributes to the nursing shortage. In Where Have All the Nurses Gone?, Satterly noted that a nurse's job is more demanding than ever before. The patient to nurse ratio has increased over the past decade, and shorter hospital stays mean that the nurse has to deal constantly with patient discharges and familiarize herself or himself with the status of newly-admitted patients. More patients are presenting with severe illnesses, chronic conditions, or multiple conditions, and require intensive monitoring and care from their nurses. Nurses must also stay up-to-date with new advances in medication, medical procedures, and technology.

The 2001 American Nursing Association (ANA) Staffing Survey of 7,300 nurses painted a grim picture of the hospital work environment. Thirty-eight percent of nurses reported feeling "exhausted and discouraged" at the end of a workday. More than a third of respondents felt "discouraged and saddened by what they couldn't provide for their patients," and 20% feared for their patients' safety. These concerns have been corroborated by numerous studies that demonstrate that nurse understaffing and nurse fatigue puts patients at risk.

The ANA survey also found that nurses were sacrificing their personal and professional needs to meet the needs of their patients. Seventy-eight percent of nurses reported "skipping meals and breaks to care for patients," 58% felt "pressured to work voluntary overtime," and 51% suffered from "increased stress-related illness." Worst of all, about 41% of the nurses felt "powerless to effect change necessary for safe, quality patient care."

It is clear that the status quo cannot continue, and hospital managers and nurses will need to collaborate to improve working conditions for nurses.

The Role of Management

In Where Have All the Nurses Gone?, many nurses expressed anger towards hospital administrators, whom they felt ignored the needs of nursing staff, and were more concerned about balancing budgets than providing quality patient care. Since many hospital administrators do not have a clinical background, Satterly recommended that administrators should hold periodic question and answer sessions with nursing staff, or spend a day "shadowing" their nurses to gain a better understanding of a nurse's duties.

Rather than automatically assigning more work to remaining nurses when there's a staffing shortage, employers should explore options such as hiring temporary nurses, travel nurses, or permanent part-time float nurses. Although this will be an unpopular option, hospitals could also consider closing some beds.

To help relieve work-related stress and burnout, some hospitals are offering group counseling, onsite fitness classes, and general wellness programs. An article in the February 2007 issue of the British Journal of Nursing proposed using professional development programs to teach nurses resilient behaviors to help combat workplace stress.

However, these are all short-term solutions. In the long term, hospitals must change the work environment so that nurses feel valued, respected, and able to balance their professional and personal lives. The best way to do this is to allow nurses greater control over their work environment. An article that appeared on July 24, 2000 in NurseWeek recommended that managers give nurses the maximum amount of input in all decisions that affect patient care. Some facilities, such as the University of California at Davis and the Neuroscience Critical Care Unit (NCCU) at Johns Hopkins Hospital, have nurses present patient cases during rounds. This practice allows nurses a greater amount of participation in the patient's treatment, and also benefits patients, since nurses spend the most time providing direct care and may observe symptoms that a doctor misses during short visits. Other successful strategies include flexible scheduling, improved communication between nurses and managers, and concrete actions that recognize the importance of nurses' work.

New graduates can feel bewildered when they first hit the hospital floor, and hospitals can help ease the transition process by matching new nurses with experience mentors, and offering orientation programs for new employees. It's also important for hospitals to offer ongoing training to help all nurses keep up with new developments. In order to make bedside nursing an attractive long-term career, hospitals can provide educational incentives for nurses to upgrade their training (and qualify for more pay and responsibilities), and more opportunities for promotion and advancement.

The Role of Nurses

Nurses must demand change before it can occur. Satterly pointed out that many nurses grudgingly accept high workloads and constant stress because they see self-sacrifice as a necessary part of their profession. Although well meaning, this attitude is ultimately harmful, since it increases the likelihood of burnout, prevents positive change in the workplace, and deters new nurses from entering bedside nursing. Rather than enduring poor working conditions or leaving bedside nursing altogether, nurses need to think of how their work environment can be improved, and then communicate those ideas to the management.

Nursing associations can also play an important role in improving work conditions. For example, the American Nursing Association is lobbying state legislatures to pass new regulations that will prohibit forced overtime hours, and offer more protection for whistleblowers. The ANA also wants each healthcare facility to collect data on their nursing workforce and the quality of patient care provided. Lastly, the ANA recommended the establishment of patient classification systems, so that the appropriate level and mix of nursing staff (RNs, LPNs, nursing assistants) can be calculated. Labor unions and specialty nursing associations can also work to promote better working conditions for nurses.

People Not Paper

Many nurses say that the best thing about their job is the ability to make a difference in their patients' lives. However, increasing amounts of administrative duties are drastically reducing the amount of time nurses are able to spend at the bedside. A study published in the spring 2003 issue of Johns Hopkins Nursing found that nurses in one post-operative care unit spent only 30% of their time at the bedside. The rest of their time was spent on paperwork, retrieving medication, and other tasks, all of which required the average nurse to walk one mile per hour.

Although the amount of paperwork required is unlikely to decrease, hospitals can use innovative solutions and new technology to make the work easier. A computerized clinical documentation system is one option. Nurses can enter patient information into the computer system right from the bedside, which shortens charting time and also improves communication between all members of the healthcare team. However, such computerized systems also come with a multi-million dollar price tag, and are not affordable for some hospitals. Johns Hopkins opted for simpler timesaving devices such as bedside cabinets to hold commonly used supplies, and beds with internal scales for weighing patients. Other labor-saving technologies that hospitals have employed include computerized IV pumps and bar coded medications so that nurses can quickly match prescriptions to the right patient by matching the barcode on the medicine with a wristband worn by the patient.

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Tackling the nursing shortage will require a concerted effort from hospitals, nursing schools, governments, and nurses themselves. Despite current problems, hospital nursing still offers many rewards, including relatively high pay, good job security, opportunities for advancement, and the satisfaction of making a real difference in patients' lives. Some even see the nursing shortage as an opportunity in disguise – a chance for nurses to gain greater autonomy and become even more valued members of the healthcare team.

Also see our previous article, Combatting the Nursing Shortage, Part 1.

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