This letter was sent to a
nurse I worked with in Hawaii who moved to the mainland where she was very happy
until recent changes in nursing administration created tremendous discontent and
animosity among the nurses. Then she hated her work. Finally, she gave up and quit. I think this
was the goal of the newly appointed manager in her unit….to rid herself of the
experienced nurses making higher salaries and to replace them with new
graduates that come cheap, and grateful for the job. But, she was an
outstanding nurse with decades of experience and passionate about her work. She
will be difficult to replace.
Unfortunately, this is not an
isolated incident as I have been witness to many who have complained about
similar conditions in Hawaii……… My
comments were nevertheless intended to console my friend who is at this moment suffering
quietly at home. While I believe in what I wrote
below, my comments were not meant to categorically condemn all hospital administrators.
Some are very competent and fine people,
and some have done tremendous work under very difficult times….as the saying
goes, some of my best friends are hospital administrators. Maybe they will feel differently after
reading this letter…..
Dear ………..
I’m really
sorry to hear that you finally quit your position. I was hoping for your sake that things would
get better for you and the other nurses in the unit. I’m sure you won’t be placated by the ranting
discussion below, but I want you to know that I really feel your pain and the
pain of others in this increasing hostile national work environment. I truly believe you have been a victim of the
system.
Just as in
your state, nurses make a decent salary, especially experienced ones. By one account, Honolulu has the 4th highest
nursing salaries next to three communities in Northern California (San Jose
gets the prize – salaries as high as 130k).
What is also evident is the significant range of salaries from the
lowest to the highest. For example, from
the website: (http://www.payscale.com/research/US/Job=Registered_Nurse,
the variation in salary for nurses in Honolulu ranges from roughly 44 to 100k. And this doesn’t include overtime and holidays
which can markedly drive up annual income. Moreover, it doesn’t include salaries of
nursing administrators that are usually higher than staff nurses. Presumably, years of service, experience and
expertise, advanced degrees, etc; all have a role in determining salary for
nurses.
You know how supportive I am of nursing. As you recall, I was the Director of the
Neonatal Intensive Care Unit (NICU) at Kapiolani Medical Center for over 20
years, and a practicing physician for circa 35. I can confidently say that
there is nothing more valuable than an experienced dedicated nurse to insure
quality bedside care. Indeed, many of the
nurses that we worked with are still there in the NICU providing skilled
nursing. They call upon decades of
experience and seasoned judgment to distill their formula for supporting life
through advances in technology while considering the family dynamic at every
decision point. They are the conduit for
every other medical service to access the patient; they are the insurance in
providing compassion and consistency in care.
These skills cannot be developed instantly and without accumulated
wisdom stemming from years of experience.
No one would argue that healthcare costs are out of control
and that something needs to be done. But
nursing salaries are not the only culprit: virtually every aspect of healthcare
has gotten more expensive including health insurance, drugs, hospital services,
nursing and medical care, surgery, cancer treatment, outpatient services, etc. The possible exception to this endless list
of increasing costs is physician reimbursement for medical and surgical care. Yes,
doctors are getting squeezed.
Nevertheless, since nursing care account for 25% of the
hospital operating budget and 44% of the direct care costs, nurses are understandably
targets by health care administrators to stem the tide of increasing costs and
to execute cost containment efforts. I
have similar comments and assertions to the ones you have shared with me. Among
them are the following:
- · Cost cutting opportunities can be accomplished through reorganization of nursing services.
- · Seasoned nurses are expensive; in some locals, you can hire two new graduates for the price of one long termer.
- · New graduates are often younger, more energetic, and compliant with authority and therefore more valuable. And they work harder than those long termers.
- · Seasoned nurses are set in their ways and less flexible to change to downright inflexible in some instances. Some are also lazy and know how to beat the system.
- · There is a lot of down time in nursing care….time when patient care needs are stalled by admission delays, early discharges, cancelled procedures….you name it, humans are notoriously unpredictable when it comes to when they need care.
- · There are obvious methods that can be employed to reduce redundancy in nursing through cross training
- · Non nursing personnel can substitute for nurses in the performance of many medical care duties and procedures
It is my contention that some of the bullet points listed
above are at best partial truths, in large part they have resulted from faulty
reasoning or are completely wrong. I agree with you that many
hospital administrators lack the skills and the background to understand
clinical medicine and patient care. Even
nursing administrators, unlike in the days when Cora Freitas ruled over L&D
with an iron fist but also worked as a staff nurse in her own
unit, have lost touch with clinical nursing.
Moreover, they demonstrate disdain and disrespect for the dedication and
skill set needed in their profession, in an unsuccessful attempt to compensate
for their lack of clinical acumen.
Indeed, it is my contention that these same nurses would experience a
meltdown if they had to work the increasing congested and overloaded clinical
schedules they have imposed on their staff nurses, and yet they somehow have been
given the authority to control them with impunity. And they continue a charade of professing quality
care, patient safety, collaboration and vision, while they keep staff nurses in
toe through micromanagement and intimidation.
I know I’m preaching to the choir and that you agree with everything
that I have said.
Parenthetically, some managers have so little experience in management;
the sentence below literally flew off my fingers…….Some managers rule their
units like an unassuming child who plays with a chemistry set, experimenting by
mixing different chemicals in vials and looking for results, while in reality are
unwittingly unsure of what they are doing
and never able to anticipate the explosion that blinds their eye or burns their
skin.
In these circles, the bottom line has
replaced any concern over human care and caring, and safety. And the bottom line not only requires
consideration of nursing demographics, but also regulating and containing nursing
shift assignments. A study published in
JAMA in 2002 tells the story: http://jama.jamanetwork.com/article.aspx?volume=288&issue=16&page=1987
“In
short, the study found that when a unit is understaffed, patient mortality rose
by 2%. When nurses' workloads increased during shifts because of high patient
turnover, mortality risk also increased. If all three shifts were understaffed,
mortality rose by 6%. Each additional patient that was added to a nurse’s
workload increased the odds—with a 7% increase in failure-to-rescue, a 23%
increase in burnout, and a 15% increase in job dissatisfaction. Burnout and job
dissatisfaction predict nurses’ intentions to leave their current jobs within a
year. Although it’s not possible to accurately predict how many of these nurses
actually did change jobs, when considering published estimates that the cost of
replacing a nurse ranges from $42,000 to $64,000 (depending on specialty),
improving nurse staffing may not only save patient lives and decrease turnover
but also reduce hospital costs.”
I know that we both would agree that experienced nurses
should never be replaced by new graduates; they should work side by side as
mentor and mentee to continue an endless process of professional development and
succession planning. Further, nursing
staff assignments that are at the cusp of understaffing carry horrendous risks
to patient safety. Other points can be
argued as well. Importantly, it is my
strong view that the focus of hospital cost containment need not embrace what
is RIGHT in American medicine. Rather, hospital
administrators should look themselves in the mirror for the obvious answer.
Rather than focusing on nursing, hospital
administrators plagued by concerns over the bottom line would do better to
focus on themselves; the cost of hospital administration. In fiscal year
1990, administration accounted for 24.8 percent of total hospital costs, up to
31% in more recent years in the United States — which is nearly twice the share
in Canada. Where do these dollars go and for what? Now, I ask you, not as a nurse but as a human….
no matter what your background, profession, political party affiliation, gender
and philosophy of life, which category would you chose to cut back on if you
had your way? The lifeblood of the hospital:
nursing, or the nearly equally large fund that pays for hospital
administration?
I think that even hospital administrators – especially when
they are themselves hospitalized and in need of competent and compassionate care
would chose their profession to cut from rather than nursing….in fact I’m sure
of it.
If there is anything I can do to help you in your time of
need, please let me know. Perhaps you
can visit me soon and we can talk further about your future…
Your friend,
David
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