The death of bed side nursing by Jen Kyer

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.