By: Tommy on 6/13/00
The nursing staffs currently working are overworked, underpaid and stressed. This propels many qualified, caring nurses to leave the acute care setting for less stressful working areas, including leaving nursing entirely.

Urban hospitals are having a harder time recruiting and maintaining qualified nursing staff

Rural hospitals were reporting, at the same time, that their searches for qualified nursing staff were stretching longer and longer. Nursing staff currently employed were becoming more resistant to working flexible schedules and shift schedules, too.

Agency and contract nursing services are being used more often by larger and urban healthcare facilities, the study noted. What does that mean for the independent nursing.
RESPONSE: Registry work chief redeeming factor here is that when you've had enough you can go somewhere else. The extra pay doesn't compensate. Stress gets you regardless of the pay. Besides there are a lot of disadvantages to Registry work. That prevent 99 % of nurses from becoming Registry in lieu of staff.

Retention is a major issue. Why is it so hard to keep well-trained, highly qualified staff, once you've got them? Many reasons: lack of leadership models, stress in the workplace, burn out, lack of advancement opportunities, lack of educational support for advancement and other facilities offering better working hours and benefits.
RESPONSE: All of those issues exist Im sure,but short staffing with overload assignments along with admissions are what I hear and see are clearly the primary factor. I see nurses crying and hear grumblings 90:1 about overwork and the unlistening management.

Management can help change the perceptions shared by nurses wanting to be clinical specialists or executives/managers. Is it? Or is management too focused on meeting the bottom line, making the spreadsheets balance?
RESPONSE: Sure they can help, but they won't and clearly havent since the exacerbations began in abt.1980

The dissatisfaction among nurses is spreading to other healthcare members--other nursing staff, technicians, and physicians--and this has to have an impact on acute care and patients. How can we intervene, as managers, nurses, doctors, techs? How do the patients feel about this? Is this being addressed in nursing education programs? How prepared are nurses coming out of degree programs for the stresses, like the ones mentioned above, in the modern acute care setting?
RESPONSE: Patients hate it. That's what I've heard them say. Theyre afraid they'll get worse service if they complain many tell me

The top three critical priorities in nursing staffing, from the AONE and ANA study, were, in order: finding nurses with appropriate skills, competency and experience; scheduling staffing practices, and patient-to-nurse ratio and quality of care. Of these, the recruitment of qualified nursing staff seems to be the most critical to the 388 study respondents. However, is this part of the nursing shortage problem.

Many of the respondents indicated that their difficulties in finding qualified nursing staff seemed to stem from weaknesses in nursing training programs: "...in school
RESPONSE: Maybe so, but you should have enough experienced staff there to support these new inexperienced nurses. Management is the reason they left in the first place,now they have a larger percentage of inexperienced nurses unleashed! Of course hospitals have always put the least experienced staff on the night shift where the experience is really needed. This management paractice existed before 1980.

Some of the study respondents were concerned about flexible staffing requirements. With fewer nurses, staffing has been forced into flexible staffing and shift scheduling that does seem to stretch the medical staff's ability. "...many of the shortages we create ourselves. We make decisions to deliver a certain care delivery model or to open more beds without considerations of what the market will support, and without adequate planning to ensure you are going to have the staff in place." (Research on Nursing Staff Shortages)

If you ask people to do more with less, you will get less." (Research on Nursing Staff Shortages)
corporate hospitals are burning hospital nurses out. This is such hard work, and they are leaving the profession now. People don't always have to work now, why should they put up with this?" (Research on Nursing Staff Shortages)
RESPONSE: Its not just hard but its down right dangerous when staff is forced into these despicable positions.

What is the role of management in this process? So far, it seems to have taken the route of short-term fixes, not looking at the overall problem for nursing staff and management. There may be a nursing shortage, certainly there is a shortage in specialty areas, specifically, but if management doesn't change its current mindset, there will be a larger crisis in the field, as the shortage of qualified, competent staff spreads.
RESPONSE: How is mgmt going to change its mindset? They listen to kiss ass yes men/women who are managers and wannabes. All they hear is the some ole rhetoric. I told my administrator such ethical suggestions back in 81 and he said yes butI slowly became unpopular with most of administration due to my suggestions.

How do we solve the nursing shortage crisis? First, define it. Is it a shortage of nursing staff in general, or is it more focused on specialists? Is nursing management in crisis, too? Once we have it clearly defined, then we can look at curing the overall problem, not just band-aiding the symptoms.
RESPONSE: JCAHO should poor over this issue,but don't. Besides managers skew numbers but with proper management, guidance, and training in nursing education programs but the main issue seems to be lack of vision across the board.

Hospital administrators, managers: right now, ask yourself: are the nursing staff you know part of the management? Part of the leadership? How can you empower them? If you don't know, you should find out, before your competition does, and your nursing staff leave your facility for better conditions elsewhere.
RESPONSE: Management is going to way one of 2 things: Yeah,yeah yeah or I'd like to, but I'll keep my job no thanks.

If you're a nurse, or a nurse educator, ask yourself: how can I be a role model for other nurses? How can I be part of the leadership, able to make an impact on policy and management decisions, not just reacting, but being proactive? How much do I know about management? How can I increase my management skills?
RESPONSE: Administration love this…its good for PR,but they don't carry out anything significant. Theyre like polititions at re election time .but then most people vote for the liar,Nixon(almost beat JFK in 61) and won eventually,Johnson,and Clinton. All PR and lies and the public buys it!

Nurses and managers need to work together to create a vision of the well system, and work together.
RESPONSE: For all intents and purposes nurses and managers don't and wont work that well together. Managers are mini me ceo mentalities. They talk the talk but don't walk the walk.

We as a species are crisis oriented when it comes to change. Management is even more resistant. Failure is what forces change. Many of us are failing and I cant guess when its going to force a change at the top. But its going to get worse befor it gets better applies.

Tommy Gunn

By: tammy on 6/13/00
We are in a very difficult situation with our nursing staff and leadership/management. There is clearly a disconnect. Each not understanding one anothers roles and possibly not wanting to understand. The primary burden of responsibility will fall to the leaders and management. They will have to be the ones to make the culture change. For it is their actions that will have the greatest impact on the nursing culture which affects physician and patient satisfaction.

Nurses are people who care about their patients and what is needed for them. It becomes difficult to support leaders and managers when you feel they no longer care about you (nurses). Nurses are the first to be shuffled around with layoffs, downtime, and a counted body in a unit one is not use to working. Nursing staff, who I consider experts, are left out of strategic and management meetings. Nurses have a great deal of information to offer regarding operations and patient care delivery.

I think majority of nurses care and want to be proud of where they work, proud that their organization cares about their well being, proud that their organization cares about their patients and proud that the organization listens to and improves the care process for patients. Majority of nurses would love to be part of this system. All people not just nurses love being an integral part of the organization and feel like they are making a difference in their organization. We must figure out how to make this happen. It will be the patients that suffer more than anyone else.

By: ktmann on 6/14/00
Anne Marie - I think your comments in your thoughtful essay are right on target.

Clearly the alarming report of the AONE and ANA which you report shows a multifactorial problem requiring a systems perspective. Lack of insistent and independent nursing leadership, overwork, inadequate pay, lack of resources for ongoing training, lack of attention to burnout and subsequent attrition…all, and more, are contributory factors.

And, each factor impacts one or several others. Lack of an emphatic nursing leadership which protects nurses from burnout leads to burnout of nurses and attrition. Attrition of nurses and burnout leads to a lack of a pool for nursing leadership.

Imagine using an affinity diagram model and posting up all of the clusters of causes to the nursing shortage. Then systematically examine each factor in relationship to every other one and draw an arrow indicating which factor of those two is more influencing the other (or if there's no relationship between them - then draw no arrow). Now, tally up the in and out arrows for each cause cluster. What you'll see is that there are a variety of powerful causes which are impacting the whole system. (If anyone's interested in learning more about Affinity Diagrams and Interrelationship Digraphs, please feel free to e-mail me and I can send you more info and/or links)

Unfortunately, our general notion of "management" has gotten corrupted. Managers are supposed to be able to serve as a bridge, a TWO-WAY communication link between executives/administration and the workforce they oversee. Alas, most are just extensions of the administration - they serve as a one-way communication FROM administration TO the workforce.

In this way, I very much agree with Tommy's comments above.

What's it going to take?

Empowerment. Short and simple. And that empowerment may not come from above (as a matter of fact, it's likely not going to!). It's going to have to come from within, and from the workforce you supervise. If your staff is telling you "we're fried" - then it's incumbent upon you as a manager to attend to that. If a workplace is unsafe - for the workers or for the receivers of services, in this case patients - it's incumbent on the nurse manager to emphatically state that. S/he may lose their job over it. That's the risk of leadership. But that's the kind of leadership it's going to take to change this awful mess.

What kind of leadership may we then envision? Perhaps one in which select departments of a hospital are the equivalent of a cabinet, and any department chair has veto power. If you as a nurse manager/chair say you need more staff - your decision is final - you need more staff. That's why you're a manager. Of course it goes against the short term bottom line. And short term leaders don't like that. But that's what you need. And you may take a lot of heat. And that's where the CEO needs to go back to the finance committee and find out how that's going to be made possible, because made possible it must be, because you said so.

In healthcare, we all have to advocate for what we feel is needed - we need to passionately speak our truth. In my field, I had to repeatedly oppose certain managed care companies' stances with regard to "treatment non-authorizations". Ultimately, rather than continue this relentless compromise of quality of care, I was forced to conclude that I had to bow out of all managed care contracts - it was too much a challenge to my ethics (and my sanity). And I did this at the risk of a loss of income from "decreased patient referrals". And I did take a financial loss as a result of it, especially seeing that managed care has about a 75% penetration in this area. But we must speak our truth. And eventually, our speaking our truth will become a chorus.

Unfortunately, if nurse managers don't empower themselves, then nurses all over are going to speak their truth with their feet - and walk out, not only of the organization but out of the profession!

Kernan Manion, MD
Work/Life Design
Concord, MA
"Wellbeing! Within Your Reach. Imagine!"
kmanion@pol.net