Saturday, 28 November 2009

Why has Nursing care changed?

Why aren't the nurses as visible? Why does no one answer my call bell? Why is so little getting done in the way of basic care? Why are so many nurses leaving? Why isn't the care the same that it was in 1980? Were the nurses themselves better back in those days?

Somebody actually decided to do a little research into these issues and determine just what exactly is going on.

You won't find any "too posh to wash" "too clever to care" "needs matron to knock them into line" and "it all went downhill when they started training at university" comments here. Not by a long shot. Not by a long shot. The person who wrote this article knows her stuff and did her research.

I won't post the whole article here (edited to add, I should really as this got way longer than expected) but please, please, check it out. So much is similar to what is going on in the UK.

Here are some excerpts in no particular order. These are just paragraphs here and there that I copied and pasted for those who don't click on the article. My comments in blue. I'd do more but I am getting kicked off the pc by the warcraft brigade.

*The burden of care for nurses, patients, and families has demonstrably increased since 1990.

*This situation has three fundamental causes. The first cause is a profound change in the nature of hospitalization, the kinds of illnesses and conditions of patients treated, and the level of care required. The second is the reorganization of hospitals, which has led to a reduction in the amount of time nurses spend in direct care of patients. The third is the lack of broadly accepted expectations about the caregiving responsibilities that family, friends, and patients themselves ought to assume, both in the hospital and at home, about how this care should be coordinated with the work of professional nurses and other nursing personnel, and about the appropriate ratio of direct-care nurses to patients. This report deals with each of these causes in detail.

*Pressures on families are particularly severe when a patient has been sent home from the hospital after a shortened stay or has received outpatient care for problems that were formerly dealt with in hospitals.

*Nurses report increasing dissatisfaction with their work in hospitals that have cut staff, that require frequent overtime, and that have replaced nurses with assistive personnel. Research has shown that these phenomena are related to adverse nurse and patient outcomes.

*This situation has three fundamental causes.

*The first cause is a profound change in the nature of hospitalization, the kinds of illnesses and conditions of patients treated, and the level of care required.

*The second is the reorganization of hospitals, which has led to a reduction in the amount of time nurses spend in direct care of patients. The third is the lack of broadly accepted expectations about the caregiving responsibilities that family, friends, and patients themselves ought to assume, both in the hospital and at home, about how this care should be coordinated with the work of professional nurses and other nursing personnel, and about the appropriate ratio of direct-care nurses to patients. This report deals with each of these causes in detail.

*Hospitals and hospital nursing have changed dramatically since 1990. Changes in reimbursement and demography have, in turn, added to the pressures on hospital systems, on patients, and on caregivers. Inpatient lengths of stay have declined dramatically (by 40 percent between 1980 and 1995) (Reinhardt 1996), and the average acuity of patients is higher in any given unit. Therefore, every patient assigned to an RN requires relatively intensive monitoring and care—a situation that is complicated by the fact that increased demands for documentation mean that caregivers can devote fewer hours to direct care and monitoring.
Try telling any of this to these old bats who trained in 1960 and haven't been back since 1962. One stupid bitch said that the problems were down to university educated nurses, and everyone else just repeated that statement like a robot.

*Advances in knowledge and medical and nursing expertise have enabled a greater number of seriously ill patients to survive. The shortened length of hospital stays, resulting from pressure from insurers (Or nu-labour targets), means that more severely ill patients are being discharged sooner to nursing homes, rehabilitation facilities, or their own homes. Moreover, the way hospitalization is financed and the growing number of chronically ill people and the aging of the population in general are also affecting hospitals' inpatient mission.

*Nurses, physicians, patients, and families have formed their expectations about care over many decades. Personal experiences, fictional depictions, and anecdotes from family and friends shape notions about care. The concepts care and nurse are both freighted with complex historical and emotional content. Seldom verbalized, this social legacy contributes to the public's expectations about caregiving. That the nature of hospitalization has changed, that demographic changes have brought different emphases to the health care system, that financial pressures have led to restructured and reorganized systems, and that hospitals have had to alter their mission to suit these financial and demographic shifts—all these developments have been received with gloom and anxiety by patients and potential patients and with concern by nurses and physicians.
Well it seems that everyone just blames the nurses for being lazy. Problem solved eh.

*Recent changes in what people can expect from nursing and hospital care have not been widely discussed with the public. Nor have changes been discussed with nurses very often.

**. Nurses represent the primary surveillance system in hospitals 24 hours a day. An adequate surveillance system provides enough nurses to observe patients directly so that they can recognize an impending or actual problem. These nurses are the first to mobilize an intervention that often requires the coordination of the activities of others, including physicians, to save a patient's life. Silber finds nurse staffing even more important than the board certification of physicians, since physicians are usually the second to know about a complication.

*****Consulting firms brought in to help hospitals reengineer their services and achieve cost reductions usually target labor costs. But nurses and physicians often complain that consultants do not seem to understand the complexities of delivering care or to grasp the complex role that nurses play in observing, monitoring, and assessing patients' needs. All too often, cutting professional nursing staff—and replacing nurses with nurses' aides or other assistants—serve as an easy solution to budgetary problems. This is exactly what is happening in the NHS.

*I once had a chance conversation with a man who, I learned, had in the past worked for one of the major consulting companies and had been deeply involved in the restructuring of a number of hospitals. Learning that I was a nurse, he said, somewhat sheepishly, "I'm one of the bad guys." He told me about what he described as his "naive and dangerous period" and was filled with guilt over the restructuring recommendations he had made in his former job. His awakening, he said, had come when his wife had had a baby who required intensive, long-term neonatal care. During the hours and days the couple spent at the hospital visiting their critically vulnerable infant, they had a chance to see nurses at work expertly caring for—and ultimately saving—their child. In the process, he came to understand what nurses do and how important their job is. Well well well. NHS hospitals have been bringing these same kinds of management consultants in for years. Doubt they are remorseful though. They are just out of control. Prejudice against Nurses leads to managers listening to these clueless dipshit management consultants rather than frontline staff who know the score. It's the same everywhere, doesn't matter what country you are in...

*The word care has a variety of meanings, and is used to describe both personal and professional activities. But the professional care that nurses are trained to give is in many respects quite different from the personal sorts of caring that characterize relationships between spouses, parents and children, family members, and friends. Professional caregivers are independent decision-makers, whose autonomy of action is legally defined, and they are highly educated specialists who act in accordance with expert knowledge and in ways appropriate to their responsibilities.

*When a person's daily life is seriously impaired by illness, age, or disability, he or she may require the assistance of nurses—whether in a hospital, a nursing home, or at home. Unfortunately, many ambulatory settings are poorly suited for nursing activity, a situation that calls for an even higher level of professional knowledge and judgment.
In other words, care—the kind of care that nurses render, sometimes under difficult circumstances—consists of much more than giving patients confidence, assurance, and comforting words. Nurses base their practice on exacting professional standards.

*The complexity of the care given by professional nurses, however, is only poorly understood by the public at large. . Because "caring" is such a ubiquitous concept, and because the word is used so loosely, nursing care is often seen as intellectually undemanding, a "soft" profession. And this perception has been bolstered by the fact that historically, and in many nations, young men have been forbidden or discouraged from entering nursing, leading people to see nursing as "women's work" and a second-class kind of career. That nursing has been so demeaned has led men and women both to discount it, rejecting careers in professional caring for more powerful, economically rewarding roles.

**Chief nursing officers told Gordon that nurses' greater workloads occurred mainly because patients were in and out of the hospital so quickly. Administrators said the same thing, but their agreement did not seem to translate into support for bedside nurses. Staff nurses complained of a lack of support from nursing administrators and said they felt they were reliving failed nursing delivery models of the past, such as less expensive substitutes and team nursing.(Oh Nurse Anne could tell you all about that) They said administrators blamed them for being inefficient, dismissed them as complainers when they reported problems in patient care, and constantly challenged data culled from their daily experience in providing patient care

*In addition, Sovie's study reported a declining number of RNs involved in direct patient care and a growing number of UAPs participating in patient care. (The study also showed that UAPs are being assigned an expanded role in providing patient care.) Although reductions in the number of RNs were intended to reduce costs, Sovie's findings showed that costs per day/discharge were influenced by hours worked per patient day (HWPPD) and paid full-time equivalents (FTE). Thus FTEs and HWPPD were the expense drivers, not the percentage of RNs. In many instances, as RN percentage went down, both FTEs and HWPPD rose since, with fewer RNs and more unlicensed personnel on staff, it took more people more hours to deliver care.

*The majority of these changes were cost driven; however, costs per day/discharge decreased as the percentage of RNs increased. That reengineering does not necessarily improve performance but can in fact be detrimental to it was also found in a study that examined cost per patient day at 2,306 urban medical/surgical hospitals with 100 or more beds (Walston 1998).

*It is difficult to ascertain the overall skill level of nursing staff at restructured hospitals. The American Hospital Association stopped collecting data on aides in 1993—just as hospitals had begun substituting aides for registered nurses—because, it said, hospitals balked at completing the survey (Aiken 1999). The AHA still collects data on RNs and LPNs, but, as aides are melded with other hospital personnel, it is no longer possible to calculate the nursing-skill mix.

*The training of the aides who are replacing RNs is not regulated by state licensing boards. There are no minimum requirements governing the amount of training aides or "cross-trained" workers must have before they can be redeployed (at least part of the time) to do nursing work. Training periods can range from a few hours to perhaps as long as six weeks. Ninety-nine percent of the hospitals in California reported fewer than 120 hours of on-the-job training for newly hired ancillary nursing personnel. Only 20 percent of those hospitals required such aides to have a high school diploma. The majority of hospitals (59 percent) provided fewer than 20 hours of classroom instruction, and 88 percent provided 40 or fewer hours of instruction time (Institute of Medicine 1996).

*In April 1999, nurses at several New York hospitals went on strike to protest patient loads and work hours that they deemed dangerous. In a complaint to the National Labor Relations Board, the New York State Nurses Association reported that nurses were sometimes working 20 hours out of 24 and caring for as many as 18 patients (New York State Nurses Association 1999). Many other reports tell similar stories: of nurses dealing with ratios of 1 RN to 10 patients on the day shift and 1 to 15 or even 1 to 20 on some shifts (well that sounds almost as bad as what is normal in the UK, those are our regular numbers), of nurses being expected to work double shifts, and of a growing demand that nurses work mandatory overtime.

*Anecdotal reports from nurses, doctors, patients, and families suggest a dramatic decline in the availability of professional nurses to care for acutely ill patients while hospitalized and during the immediate post-discharge period. Most of these anecdotes contain bitter complaints about the lack of nurses to meet the increasingly complex needs of patients and express genuine concern (often outrage) about the decline in the quality of care provided to vulnerable patients.
Mostly this outrage is directed straight at nurses who are caring for way too many patients at one time. Nurses are told that the failures in care are down to their laziness, their stupidity, their uncaring slovenly attitude.

* Nurses, physicians, and chief nursing officers all agreed that they could no longer provide the level of care given in the recent past. Both nurses and physicians reported that heavy workloads caused nurses to postpone or miss tasks, and nurses described a troubling erosion of their capacity for empathy because of the difficulty they had finding time to provide even basic physical care. The combination of crowded schedules and inadequate staffing permitted little or no time for education or mentoring of neophyte nurses.

*The experts did, however, make the following positive recommendations for action by public-sector regulators:

Establish standards for safe patient care, while acknowledging the extraordinary difficulty of doing so.

Establish training standards and competency (certification) exams for previously licensed personnel, through both national and hospital-based strategies.

Find new ways to regulate the sites in which nurses practice. Such regulations might include requirements that address the issues discussed in this report (for example, closing beds when RN staff is reduced below a particular level and adding clinical nurse specialists to units).

Require that clinical assignments be given only to persons qualified to perform them.

Require that all staff performing clinical tasks be properly identified.

Encourage state legislatures to establish commissions on nursing to address issues of regulation as well as the adequacy of the supply of nurses, as has occurred, for example, in Maryland and California.

Create a nursing assignment registry that provides information about training and background in ways that earn the respect of members of the profession and others.

Establish licensing requirements that reflect the different capabilities of nurses with different educational credentials, in response to employers of nurses redesigning jobs and rewards that reflect differences in education.

*The experts offered the following recommendations to address the issues:

Adopt the ANA Principles of Nurse Staffing, either as an industry standard or by regulation.

Require hospitals to report nurse-to-patient ratios publicly on a regular schedule. (Note: This is not a recommendation of required nurse-to-patient ratios.)

Establish protocols to prevent the circumvention of technologies designed to prevent medical errors (for example, turning off alarms that would alert staff to problems).

Establish a more effective standard hierarchy of expertise in nursing service; in particular, establish as a norm the strong presence of persons with substantial recent clinical experience at the highest levels of management as well as in team leadership in patient care areas.

Provide opportunities for education and career progression for all hospital positions. Encourage hospitals to improve working conditions in order to be eligible for Magnet Hospital Recognition, awarded by the American Nurses' Credentialing Center.

The experts recommended that policymakers in government, provider associations, and nursing should:

Improve working conditions, compensation, and benefit packages for nurses to encourage long-term institutional employment, so that nursing can compete more effectively with other professions.

Tie repayment and forgiveness of educational loans and grants to the recipient remaining in nursing, in hospitals and other health care agencies, for periods of time related to the extent of support granted.

Make nursing education more efficient by reducing the number of nursing schools in hospitals and community colleges and increasing capacity in baccalaureate and graduate degree programs. See my posts on patients of degree educated bedside nurses having highter survival rates.

It's an excellent article. It's not that long. You can read it in 5 minutes. Check it out of you get a chance. I am so sick that the changes in nursing care in hospital being blamed on uncaring, overeducated, lazy nurses. Nurses are just a soft target eh? Why is that? Why is it so easy to target Nurses? That answer can easily be found in the history of Nursing. That's a blog post I am still working on.


Nurse Anne said...
This comment has been removed by the author.
Nurse Anne said...

Let me sum it up.

The people who run hospitals are idiots.

Neither the Anerican or British model of healthcare can deal with the changes in demographics that are occuring i.e more elderly, more chronic patients, more acute inpatients etc etc.

The things that those in charge have done to deal with it have been short sighted failures that have created more costs and problems i.e. losing RN's in favour of UAP's (unlicensed assistive personel). The RN still has to do all the work, she just has to cover a larger number of patients. She an only deal with the top priority issues and the rest gets left undone.

No one has the balls to be straight with the public.

Nursing Student said...

Great post, thanks alot Anne. Can't wait for your history of Nursing post. And thanks alot for putting a link to my blog, but could you do me a favour and change the link to my main page? only you linked to my BBC article and it's not one of my best! haha. I'm trying to find a way without arsing my HTML to get your link in tonight on my blog. Meanwhile I'm off to read the original article you posted about.

Emily x

Nurse Anne said...

Oh I liked your BBC article but okay I'll change it.

Anonymous said...

Claire Rayner article in todays Observer. 2nd last para.

Anonymous said...

Great paraphrasing of the article! I see you cited Suzanne Gordon. She is an excellent nursing journalist! If haven't yet, you should read Nursing Against the Odds. It is the most insightful book on nursing I have EVER read! No fluffy crap. No sappy sentimentality. Just the cold, hard facts. I am glad we have a REAL journalist our corner. God knows we need one!
Casey in the USA

Nurse Anne said...

Thanks Casey. I like what I have seen from Gordon. She's cool, and her book is on my xmas list.

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