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For most Americans who work for an hourly wage, the
pressure is on to work faster and faster. Our managers
repeatedly tell us we need to be more productive in
this competitive, modern world. Even though this situation
is not unique to the nursing profession, it poses special
problems for those of us who work with patients who
trust us with their lives.
The pace on the short stay surgical unit of a nonprofit
medical center, where I have worked for almost 14 years,
has increased dramatically. A decade ago, we had an
average of 20 to 25 patients a day on the unit; now,
we have some days when we take care of more than 100
patients.
Our staff of RNs has increased from about eight to
about 45. Fourteen years ago, most of us worked full
time (five eight-hour shifts); now most of us work part
time (two, three or four eight-hour shifts). The truth
is that nursing is too stressful to work full time today.
Because of the ever-increasing number of patients,
admitting nurses on the short stay unit are expected
to accomplish each admission in 20 minutes and then,
as quickly as possible, to proceed to the next patient.
Every admission includes doing a full physical assessment,
giving a report to the anesthesiologist and carrying
out his orders for the patient (for example, giving
preop medications), starting the IV, doing any necessary
shaves, making sure all of the patient's belongings
are accounted for and secured, giving instructions to
the patient's family regarding waiting procedures and,
of course, completing the necessary paperwork, including
developing an individualized care plan.
Many patients need additional help, such as the elderly,
disabled or non-English speaking.
Increased patient loads and the consequent need for
rapid turnover of beds put pressure on the nurse assigned
to the postoperative area of the unit as well. Each
postop nurse is now responsible for four to six patients
at a time.
As soon as one of a nurse's patients has met the discharge
criteria (stable vital signs, no nausea, pain controlled),
that nurse is expected to make the bed ready for the
next patient.
Recovery times for patients vary, of course, so it's
difficult to estimate an average number of patients
per nurse per day, but it's accurate to say that the
nurse's pod of four to six beds may turn over several
times during the course of an eight-hour shift.
Consequently, the nurse is "on the go" from
the minute work begins to the end of a shift. There
is rarely a chance to visit with fellow nurses during
the course of the day, which leads to feelings of frustration
and prevents the development of a sense of camaraderie
among staff, which would at least mitigate the effects
of the constant pressure.
Management's emphasis on productivity also contributes
to a feeling of a lack of respect for the nurse's abilities
and expertise.
Along with the increase in patient loads per nurse
has come an increase in paperwork. Most of this increase
comes as a result of Joint Commission on Accreditation
of Healthcare Organizations' demands that we have an
individualized care plan for each patient, and that
we address the whole of the patient's needs (physical,
psychological, social, etc.).
This is to be done on all patients, regardless of the
nature of the procedure, and results in eight pages
of paperwork just to start the process.
Each patient is asked to fill out a three-page questionnaire
that asks such questions as "Do you learn better
by reading, listening, watching or doing?" "Have
you had any personal losses that may impact your care?"
and "At any time has your partner or anyone at
home hit, hurt or frightened you?"
JCAHO's goal is to identify potential problems related
to the patient's living environment. While the goal
is admirable, it is not realistic given the setting
of a short stay surgical unit. On the one hand, JCAHO
demands that we consider all of the patient's needs,
real and potential; on the other hand, management demands
that each admit be done in less and less time.
The nurse, caught in the middle of this dilemma, is
forced to prioritize, rushing through the least-relevant
paperwork in order to concentrate on what has to be
accomplished to prepare the patient for surgery. The
nurse may be forced to just "fill in the blanks"
in order to complete the paperwork instead of giving
each question the proper consideration.
This not only leads to feelings of dissatisfaction
for the nurse (What employee doesn't feel dissatisfied
if he or she can't do their job?), but it opens up the
possibility that mistakes will be made. The patient
likewise is understandably perplexed, repeatedly asking
the nurse, "Why do I have to answer these questions?"
Changes in the way the short stay unit is run are continually
being made as administration searches for ways to streamline
the process of accommodating more and more patients.
This constant change contributes to the pressure put
on the surgical nurse. Procedural changes happen so
often that it is challenging to keep up.
One example is the method the admitting nurse uses
to determine which patient has priority. Is the nurse
supposed to choose the patient who has the nearest time
of surgery, or be responsible for certain operating
rooms and restrict the choice to these patients only?
Another example involves the point in the admission
process that the shave is to be done. Does the nurse
assume responsibility during the admission, or is this
to be done later by an aide in the holding area? Not
only are the changes made continuously, but they seem
to run in a circular fashion. I've seen them come and
go again and again.
Although it is true that any business needs to change
in order to adapt and prosper in today's world, a change
made solely in order to increase profit margin can be
frustrating, especially when it seems to contradict
the stated mission of the organization.
A good example of this was when our short stay surgical
unit discontinued the service of filling prescriptions
for patients at time of discharge.
Patients repeatedly told us they appreciated this service,
which benefited the nurses, too, because the pharmacist
was on the unit and available for consultation, if needed.
The service was too expensive and thus discontinued;
at the same time, management insists that our mission
is to serve the needs of the patient.
This blatant contradiction in philosophy is transparent
and leads to frustration of patients and poor staff
morale.
The stress of the nurse's job today also could be made
more acceptable by management's support of providing
educational opportunities for nurses. Nurses at the
hospital where I work used to be able to attend occasional
educational conferences at the hospital's expense.
Today, it is difficult to arrange for time off to attend
these events, which the nurse must pay for. More educational
opportunities not only would make the pressure of the
job more acceptable, it also would boost morale by demonstrating
management's support of its nursing staff.
The need for continuing education is especially true
for surgical nurses, considering the pace of advances
in surgical technology. Education, it seems, should
be a regular part of the nurse's time at the hospital,
not just something each nurse has to arrange.
I served for three years on the education committee
on my unit advocating, along with other nurses, time
to be set aside for education during the workday.
We wanted regular, scheduled educational in-services
at some point during the day with staffing coverage
so we could attend on a rotating basis.
We were repeatedly advised by management that this
wasn't necessary because we should be able to watch
the available educational videos at "quiet times"
during the day; or to watch each other's sections while
the other watched the video, if the unit was busy.
On rare occasions, this can be done, but it is a far
cry from a regularly scheduled program of continuing
education.
The education committee (along with several others)
is a part of the "shared leadership concept"
and is supposed to have a voice in how the unit is run.
In my experience, however, the committee was essentially
powerless to bring about any real changes. It's a committee,
along with the others, in name only.
Our nurse manager, in fact, dictates policy while committee
members spin their wheels. The pressure is on all workers
to perform up to management's expectations, but for
nurses, the issue is especially critical because life
and death may literally hang in the balance.
Hospitals are businesses that must consider, like all
other businesses, their bottom lines. They must strive
to make their employees as efficient as possible and,
of course, they must satisfy the standards outlined
by JCAHO.
All of us-nurses, patients, hospital administration,
JCAHO-want the best surgical unit we can have. But some
hard questions need to be answered:
- Is the function of the short stay unit to prepare
patients for surgery or is it there to consider all
of the potential needs of the patient?
- Does hospital administration support a short-term
outlook that emphasizes profit or a longer-term one
that concentrates on improving service?
- Does management have sufficient trust in its staff
to make them a full partner (as opposed to a nominal
one) in the process of improving the design?
Pressure doesn't have to be a bad thing.
If the pressure we are experiencing as nurses unites
and mobilizes us to action, it could be considered a
good thing. We need to come together and demand a real
say in how the health care structure is organized.
Nurses take pride in their work. We are professionals
who are well equipped to prepare patients for surgery
quickly and safely.
Hopefully, we all can work together to provide the
best environment for accomplishing this.
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