On: The death of bedside nursing (and why it should matter to everyone…)

This picture looks old and grainy because it is. That is me in nursing school, almost ten years ago (I’m screaming internally). Sit down because I am about to get serious with you and let you in on a scary reality that most nurses know but don’t talk about.

The face of nursing is changing. It has been. It is not a good thing.

A family member was recently admitted to the hospital. I accompanied her to get her settled on the floor and in doing so met her nurse, who was being trained by another nurse  (we will call her Mary). Mary and I got chatting and she explained that she trained for a period in my unit during her nursing education. Upon discussing this she mentioned shadowing a nurse that had been on my unit a short period of time and had left. From my calculations she shadowed a nurse who had been working on my unit for 1-2 years (who was already gone) and that had made her a staff nurse for approximately 1 year or so. Subtracting a generous 12 week orientation, Mary (who has been practicing independently for a liberal approximation of 8-10 months) was now in the process of training brand new nurse.

Do you see a problem here?

This revolving door of nursing is creating problems for patients, cost increases (for everyone) and problems for those of us who do decide to stay at the bedside. Nurses are leaving in droves and novice nurses are teaching more novice nurses. According to the RN Work Project, a study performed over 10 years to track career changes among new nurses, 17.5% of new nurses left their position within a YEAR of starting a new job, 33% within two years and 60% within eight years.

What does that mean to you? That means there is a high probability of you getting a pretty “green” nurse when you walk into a hospital. You might notice that half the staff look like they just graduated college, which sometimes is true. (Scary right?)  However, just because you have an older RN it doesn’t mean that they have experience, much of the workforce is second degree nurses and you can’t trust the age to tell you about level of competence.

This matters. Statistically speaking experienced nurses help patient outcomes. This means that there are less hospital acquired pressure ulcers (bed sores), infections, etc. with a staff of experienced nurses. This study concluded that increasing experience (to an average of 5 years) and clinical hours (6 hours a day to 7 hours a day) could lower incidences of hospital acquired pressure ulcers by 11.4%, and falls by 7.7%.

What does that mean? It means $$$$$$. Experienced nurses would save hospitals money because as it stands now, hospitals aren’t being reimbursed by Medicare and Medicaid services (CMS) what they consider “hospital-aquired conditions” like pressure ulcers over a Stage II. To you non-nursing people, this means when you get a bed sore that opens up and becomes difficult to heal, its considered preventable so CMS isn’t paying for it.

Now in ways these things are preventable, just like urinary tract infections from urinary catheters, however the way to prevent those things is to have STAFF. Competent, experienced nursing staff and adequate support staff like nursing assistants to help. Pressure ulcers are preventable if you turn patients, if there aren’t enough staff on hand to do the turning, they become less “preventable”.

This is an issue not because nurses are aging out, not because of “nursing shortages” but because of the hospital environment. Nurses are overworked, understaffed. Units with a high census and acuity take a toll on even the most experienced of nurses. Patients are heavier both literally (in weight) and with more comorbidities. We have modalities to keep the most critically ill patients alive for inordinate amounts of time and these are only small parts of the cause of the bigger problem.

Money is the driver for much of the issue and we are doing more, quicker, with less support than ever before. We are required to work long shifts without breaks, hold our bladders, skip lunches and keep going. We are required to work weekends, holidays, nights, long stretches of 12 hour shifts that become 14 hour shifts. We get berated, verbally and physically assaulted, accused of withholding pain medication, letting food get cold. We are literally breaking our backs- some estimate the average nurse lifts 1.8 tons per shift. Why would you stay at the bedside?

So people leave. They go to a clinic, become visiting nurses, go back to school, pull back their hours or just stop working. Who would blame them? Advanced education means a bigger paycheck and better hours. No double knee replacements at 60 or slipped disks at 35.  Why would you stay?

New nurses look cost-effective initially, lose a nurse with 12 years of seniority to gain someone who will be paid at an entry-level rate sounds like cost savings but unfortunately this isn’t the reality. Once they finish orientation, they stay a short time and then move on to school or burnout and leave the bedside altogether. This is not cheap. According to The Costs and Benefits of Nurse Turnover: A Business Case for Nurse Retention “Recent studies of the costs of nurse turnover have reported results ranging from about $22,000 to over $64,000 (U.S.) per nurse turnover”.

More importantly,  more than cost, there is something to be lost when good, experienced nurses leave the bedside. Institutional knowledge, experience gained from years within an organization are lost and with it the patient experience suffers, or worse. In a study done of Pediatric Cardiac Intensive care unit patients (discussed here), that included 38 hospitals and 20,407 patients, they concluded that “the odds of death significantly increased when the percentage of RNs with two or fewer years of clinical experience was 20 percent or more” and going further to recommend that “pediatric ICUs should have no more than 20 percent of their staff with less than two years’ experience.”

Layman’s terms, patient mortality and outcomes have a lot to do with how long your nurse has been doing his or her job.

Nursing is a lot more than bedpans and med passes, there is a lot more that goes into the minute-to-minute decisions that aren’t taught in a classroom  or on orientation. In teaching hospitals this is even more important. Residents coming onto the floor are fresh out of med school and honestly depend on experienced nurses to be their double-check at times, nursing being the last line of protection to the patients. If the nurses are new and the prescribers are new, it can spell disaster for people in the beds. You’ve all seen the Scrubs meme where the nurse speaks to the more experienced physician saying “Doug wanted me to give this patient five hundred thousand milligrams of morphine. I thought I’d check with you before I kill a man.” This is funny because its true. Mistakes happen, you want the person giving you or your husband or wife or child to recognise the error before giving the medication.

There are so many of us devoted to this career. Who want to see it succeed. I want to work alongside a staff of experienced, dedicated staff whose priority is the patient above all. I have had the pleasure of working with some phenomenal experienced nurses throughout my career and have seen newbies blossom into some of the most amazing nurses I know. I want people to stay and for patients to get the care they expect to in the hospital (minus the expectation of dinners for their extended families and five extra pillows- I don’t work at the Hilton).

Retention is key, I want to stay at the bedside and I know many that do. The face of the bedside doesn’t need to keep changing. Management and hospital administrations need to play a more active role. Hospital administrators need to address this hemorrhaging of experienced staff, through better ratios, staffing, schedules for better work-life balance, and retention projects.  Spend the money allocated for hiring bonuses on your experienced staff and you won’t need to keep hiring. It will be more cost effective and more importantly, patient outcomes depend on it.

 

 

 

 

Advertisements

470 Comments Add yours

  1. OPL says:

    I am a LPN and I’ve used my license to the max. I’m being forced to go back to school. I have trained many RNs at the beside because most of them are not taught skills, but mostly theory. I have also had to teach many to start an IV and how to handle emergencies. I can’t understand why some think we can’t assess patients. I assess them everyday. The RN is supposed to do the initial assessment, but most are too new to do an assessment
    I hear all the time that we don’t have the knowledge you guys do, but most times we end up training some of the RNs. Why can’t we just work together and do what’s best for our patients? I hate how we do one another.

  2. Every word of this article is true. And, I will not be renewing my license this year. I do NOT want to be tempted ever to go back into bedside nursing. I was exhausted physically, mentally, and spiritually.

  3. Anonymous says:

    I’ve heard a lot of this from a neighbor nurse. I saw this at the nursing home where I had to rehab my mother. I’ve said caring for her was a window into my future. This report is not comforting to me as I’m aging

  4. Susan says:

    In my husband’s past 2 hospital stays, he did not have regular nurses, but hospitalist. Even most of the doctors were hospitalist. His care was okay, but the problem is you never see the same nurse or doctor twice. It is hard to communicate and find out exactly what is going on with the patient.

  5. Karen says:

    This could have been written by me a couple of years ago. I was an experienced CCU nurse working a Med- Surg Telemetry unit where nurses with no cardiac experience were doing charge with the implied being that the older nurses were less competent. Fortunately, I now work on a floor where everyone’s experience is value, where the nurses are helpful and supportive of each other. I cry a little inside when a new nurse talks about becoming a nurse practitioner as soon as they can, because when myself and the other nurses on my floor retire, who will take care of the patients? Coincidentally, all of the older nurses on my floor have held management positions and returned to floor nursing. How much confidence in the nurses taking care of your family member is there when the 3 nurses on the floor have more than 100 years experience between them vs 3 nurses wit a total of 6 years. Part of this problem stems from the fact that the non-patient care positions in health care have a financial return many times that of patient care staff. The CEO makes a million dollars per year. The CNA, if you are lucky enough to have one makes less than the starting pay of a McDonalds employee. Until floor staff receive a bigger proportion of the hospital budget then most of the new nurses won’t be able to financially stay long enough to become very experienced.

  6. Gail Speer says:

    Great article. My father was hospitalized for a gallbladder surgery which was delayed because various doctors failed to read the instructions and testing results run by other consulting physicians. The nurses just read the last order and went by that, never checking to see if they were at cross purposes with the continuance of life. Everything was at cross purposes! His gallbladder ruptured prior to unnecessarily delayed surgery and the resulting gangrene nearly killed him. The nurses were overworked and disinterested. He had become combative after surgery due to the anesthesia so he was tied down. No one gave orders for him to be untied so he was not. When he progressed to a liquid diet it was delivered but no nurses fed him and he was tied down. So, no nourishment. His IV fluids were discontinued but the nurses only saw a different doctors note of nothing by mouth. He went three days without any food or drink. When he crashed and the resucitation team had to respond they determined he was so severely dehydrated he was almost dead. While they were at his bedside the person In the room next door crashed. Same issue. Completely dehydrated because no one noticed they they weren’t getting any fluids anymore. My father was moved to ICU where the level of care was excellent. I didn’t leave his bedside again for longer than 15 minutes during the next 8 months in the hospital while we dealt with MRSA, medicine mistakes, etc… I began keeping copious notes and stayed with him 24/7. How can people survive without a family advocate at their bedside ? I had to fire incompetent doctors, demand from the administration that nurses be removed from his bedside because they were administering improper drugs or dosages. I was the proverbial squeaky wheel. The hospital is a level 1 trauma center and has no excuse for poor care. I was an EMT 40 years ago, certainly not up to date with my knowledge and yet I caught error after blatant error by the nursing staff who seemed to have no practical bedside learning experience. The fact he survived is miraculous. Your article is excellent and certainly no surprise to me.

  7. Sandra Taylir says:

    My husband was a patient after total knee replacement but his nursing care was horrible. The call bell was answered but never responded to – his IV ran dry, pain meds were late and help getting to bathroom never came. His home meds were never started back up ( he has an underlying cardiac disease) so he was discharged in CHF and no one even noticed, in spite of my telling them this fact. I was ashamed of the lack of compassion and knowledge of the nursing staff.

  8. Beth Ballew says:

    Exactly why I retired early-loved my job, but hospital was pushing for higher education-all new nurses want jobs with high pay and 9-5 jobs-I worked second shifts and on call, weekends and holidays-after 10 years, then you were rewarded with straight days-I had experience on the floor. then charge in Recovery for 14 years-was on committees and finally transferred to the outpatient center with weekends off-we were cross-trained in 3 areas-pre-assessment, pre-op, recovery or OR-after 40 years, I had had enough-but I do realize that these “green” nurses may be taking care of me one day and only hope administration will read this

  9. Brenda Atkinson says:

    This has been a problem for years is the main reason nurses burn out. Experienced nurses now days are hard to find because they are usually getting older and taking supervisory positions or administration positions. I agree with it being all about money now. It didn’t use to be this way but back then patients where not as sick as they are now or living as long. I love being a nurse and the one thing I miss is being able to have time to actually talk to the patients and the families but with having so many patients and documentation for reembursement has to be perfect, thisvis gone. I have been a nurse for 40 years and being able to touch and talk to a patient is one of the most important things to me.
    Thank you for writing this!

  10. Nurses are the eyes & ears to call Docs for orders in the wee hours of the night. God Bless them for looking out for your family. says:

    Amen. Your family, you?? The bedside nurse means life or death. Put a dollar amount on their services or expertise?

  11. Una says:

    It’s very sad to say. Every inpatient needs their own advocate to insure recovery. It’s seems so much has been compartmentalized no one sees the whole picture.

  12. Suzette Konzem says:

    I am an RN, bilingual, w/ a BSN & 44 yrs of experience. After working 22 days straight for a large Hospice, I had 1 day off & then received an 8:30 a.m. wake up call informing me my services were no longer needed due to a “corporate restructure”. I was not given any other job offer. I was merely used & then thrown away! So why indeed would a young nurse want to face this?!

  13. Heather Book says:

    Same thing goes for long term care facilities. You can’t make up some of the stuff I have seen/experienced since 1990 both as STNA and LPN!

  14. Anonymous says:

    It’s sad that hospitals care more about making money then they do about the true reason why they are there. Staffing is about the care not the numbers. A hospital that cares is one that is well staffed with extra employees. Not workers employed to do the work of 2 or 3 just to save$. 😭 So sad that’s what it has come to.

  15. DonB says:

    Add to this the burden of fitting the electronic record parameters. Nurses (and doctors and all hands on caregivers) are required to use EHR’s and conform, search, train, and spend an inordinate amount of time recording. They get into the field for hands on care, and are either treated like this or move up to manage staff and meet budgets and are no longer hands on caregivers. I would think it would be very discouraging.

  16. Briana says:

    You don’t like it? Then YOU can be and advocate for the change but it does not mean that the idea that nurses are able to chose to go a BS/BSN to DNP route should be looked upon negatively. There are extremely important gaps that those DNP’s need to fill as well.

  17. Sheri Monti says:

    I retired recently after 36 years and this article brought up some very valid issues, one I think needs added is how I saw new nurses being treated, my heart breaks for them back in my day we were so welcomed and now there are so many demands that I feel the new nurses are thrown out there pretty much sink or swim the senior nurses just can’t do what is expected and orientate too and it is absolutely about the buck ,more politics in the medical field than in Washington, what the answer is, is beyond me just wish the new nurses could have experienced what it was like when you truely could give your pts quality care, and of course the is just my opinion…

  18. James Andrew Bailey says:

    One of the Magnet hospitals I recently left would only allow nurses with LESS than two years experience to train new grad nurses, because the “older” nurses would pass on our ‘bad’ habits. This institution had one of the worst revolving doors for staff I had ever experienced in 25 years, but somehow had gained Magnet status over and over again. So don’t let little things like Magnet accreditation fool you. I had emergency surgery there, was admitted to another unit than mine, and received the most shameful piss pore care. I was ashamed of my profession, and this was what prompted me to leave. The higher ups don’t want to hear from people with experience, they like the new grads who will just assume that all nursing is like this, they won’t know any different.

  19. Kate says:

    I wish I would have seen this article earlier. I live in a town with a big teaching hospital, med school and BSN program. Some of the BSN students have preceptorships where I work. I stopped being a preceptor when they weren’t coming in with the most very basic skills. The clinical instructor would travel around and check in but not really teach. I mentioned my particular student didn’t seem to know how to use a manual BP cuff, and she told the student to stop in the lab for help. I was flabbergasted that the clinical instructor could not take a few minutes to review with her.
    My mom was recently admitted to the hospital. While she sat in the ER for a very long time, I kept waiting for them to come in and do some very basic functions and they never did, until I asked, and helped. My mother is very modest and I would rather not have been involved.
    Nursing is nothing when we forget about the basics.
    I agree the art of bedside nursing has been slipping away for a while. Too much to do, training that doesn’t emphasize the basics enough etc.
    Great post.

  20. I feel the frustration mentioned here, and I feel it deeply, too. Before I was a nurse and was in process of taking nursing pre-reques, I was a bank teller. One of my customers asked me what I was studying (I told her I was in school). I said, “Nursing.”

    She was old…like…80. She was also short, stout and cranky. She looked me in the eye, and said, “oh…please don’t go into it for the money. You’ll be a bad nurse.”

    LOL…32 years later, I look back at my life as a nurse. Oh…how I’ve had to “Fight” through all the things mentioned here. And I’m still doing it. Over the years, I’ve had three or four burn outs. It was not the money that motivated me (though it was and is PERFECTLY ACCEPTABLE” to earn a good living). But that lady was right…Money is not a great motivator for inspiring great care. What IS inspiring is accepting the duty of nursing and taking great pride and self esteem in that WE hold the standards of good care, and also it is up to US to be ever aware of the leadership role we are asked to take when we passed our boards and got that license that holds us accountable to “Care.” We are called into leadership on day one of passing that board.

    “Advocate for the consumer even in opposition of the physician” is what the California business code state for all licensed healthcare practitioners. It doesn’t make anyone a leader to engage this principle, but it dose that “Leadership skills” to do it. All nurses have been formal educated to be leaders and to develop leadership skills at every stage of the nurses’ development – from beginning to end.

    I’m so proud of you all for doing that.

    Please visit my Blog, “Let’s Leave it Open: A Nurse’s Spiritual Journey of Personal and Professional Perspective. I support you. Let us support each other like the nursing code of ethics asks, “Do for yourself (collectively) what you do for your patients.”

    https://letsleaveitopen.com/2017/06/21/a-nurses-calling-to-passionate-duty/

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s