Nursing Notes

April 13, 2010

The three-legged stool of quality

Filed under: Nursing — Shirley @ 4:18 pm
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This was just a small blurb I found in an email today.  I posted it because I think we forget the importance of how everything has to work together to give our clients a good outcome.  This is just a quick tip for a refresher.

I thought this was a succinct and informative description of the process we, as caregivers, go through with each and every patient we treat.  It also has a link the site for managers to get information about ways to improve this process at your facility.

I hope you enjoy.


Quality professionals often describe quality as a three-legged stool, with process, structure, and outcome measures holding up the stool. Although the results of the HCAHPS survey can be considered an outcome measure, there is another way to think about the patient experience that emphasizes its centrality to all of the aspects of quality. The patient experience can be considered the seat of the stool—essentially the purpose for which the legs exist. An organization can build a strong stool with three solid legs, but if the seat is missing or has tacks on it, no one will want to sit on it and the stool is not serving its purpose.

Similarly, it is possible for a hospital to focus exclusively on clinical quality metrics without considering the long-term relationships being built between and among patients and staff members. The hospital may receive a perfect score on the three “legs” (the outcome was good, the clinical process measures were satisfied, and appropriate structures are in place), but if the patient had a horrible experience and has lost confidence in the hospital and the clinicians, the hospital may have set the patient up for failure. The stool will eventually fall apart without a good seat to tie everything together.

Here’s the link to the original article

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January 23, 2010

Many Nursing Jobs, But Only the Strong Need Apply

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Having worked as a travel nurse in California, I can say that ratio law has made a difference in how we nurse there.  When I left my permanent job and went traveling, I was the only RN on a unit of 22 adolescents working with an LVN, who gave meds and did treatments, and about 5-6 techs.  I charted on all the patients and assessed each and every one of them.  I also was responsible for the use of any intervention to alleviate out of control behaviors in such a volatile group.

Can you imagine my surprise, when I started my shift and found I had six patients?  I thought I had died and gone to heaven.  My supervisor actually relieved me for 15 min breaks and for 30 min lunches!  I kept thinking it was a joke until a colleague told me about the new law and the cost of infractions to the facility.  Boy!  That shut my mouth hard.

I continued to take assignments in California for the next two years and over time I saw  that there is an up side but there is also a down side.  Having a law that determines how many patients you are able to care for is at first a comfort, but eventually it becomes a binding and you become complacent.  True, I spent much more time with the patients and gave better care to my patients because I could.  However, I found myself with quite a bit of free time and nothing to fill it with–my patients were all well taken care of.  I began to ask to cover for breaks and lunches, then I would go around to see if anyone needed any help.  After that, I was on my own.

Granted, having down time is not a bad thing, but I was raised to believe that if you are getting paid to work, you should be working.  So, I cleaned and organized and kept busy.  The other nurses made fun of me.

Overall, I enjoyed working in California.  I would love to go back again but probably won’t.  I would love to see some type of mandate enacted across the nation that would allow nurses to give quality care to every patient, but not necessarily  a patient ratio law.  Maybe something more like a universal acuity system for patients in every hospital across the United States.  Hospitals will not staff appropriately until they have to–they are a business and need to make a profit.


Are you tough enough?

Filling open nursing positions is no easy task for hospital administrators these days, and there’s every chance the job will get tougher.
This country has a serious nursing shortage: The American Health Care Assn.’s most recent estimates from July 2008 show 116,000 open hospital nursing positions and more than 19,000 vacancies in long-term care settings.
The economic downturn has helped some hospitals as many nurses increase their hours and postpone retirement. But experts say that any lull in shortages is temporary.
A March 2008 report by Dr. Peter Buerhaus of Vanderbilt University Medical Center and colleagues predicted that national nursing shortages could balloon to 500,000 by 2025. Predictions from the U.S. Department of Health and Human Services are more dire: It anticipates a shortage of 1 million nurses by 2020.
A lack of faculty at nursing schools across the country is preventing many people from entering the profession, thereby exacerbating the shortage. Nearly 50,000 qualified applicants were turned away from professional nursing programs in 2008, according to the American Assn. of Colleges of Nursing.
In California, the outlook may be slightly less grim. It’s the only state with legislation requiring minimum nurse-to-patient ratios in acute-care hospitals. The law, which went into effect in 2004, limits the number of patients a nurse can care for on shifts depending on the type of medical unit and the patients’ degree of illness.
A nurse working on an intensive-care unit, for example, cares for no more than two patients per shift. A medical and surgical unit nurse cares for a maximum of five.
Linda Aiken, professor of nursing at the University of Pennsylvania, is studying effects of the legislation. She has found that nurses participating in the survey reported overwhelmingly that the ratio law has had a positive effect on their day-to-day work life.
The California Nurses Assn., which sponsored the legislation, credits the ratio law with helping to mitigate the effects of the nursing shortage and points to statistics that show an increase of 100,000 actively licensed registered nurses in California since the law was adopted.
Three nurses talk about what it’s like to be a hospital-based nurse today:
Mary Bailey RN, 59 years old, medical diabetic unit at Long Beach Memorial Medical Center; nurse for 21 years

Fifteen years ago, with a six- or seven-patient assignment, probably four of them could get up and about. A typical patient [today] has totally restricted movement, so we have to keep turning them as much as possible [to prevent] blood clots.
At the same time, this person can require IV medications every six hours and can be taking three different antibiotics every two to three hours and pain medicine every two hours. We are monitoring all of their lab results, making sure any tests that have been ordered have been followed through, and prepping patients for tests.
That’s just one patient — and I can have up to five.
It would be a good day if I had one patient who could get up and walk around and get to the bathroom and take care of washing up [on their own]. More often than not, I have at least three that require total care, meaning that everything has to be done for them.
It’s pretty hefty — a day with four patients is OK, five is pushing it. It only takes one extra person to push you over the edge in terms of trying to manage your day. They don’t get into the hospital easily nowadays. Insurance companies won’t cover the cost of hospitalization unless the patient is pretty ill.
About 20 years ago, I had nine patients. I think the ratios, by allowing us to only care for a certain number of patients depending on their acuity [degree of illness], has helped immensely. We have more time to see our patients and to do our job adequately.
Martha Kuhl RN, 57, pediatric cancer and hematology unit at Children’s Hospital and Research Center Oakland; nurse for 27 years

As a new nurse in the 1980s, my patient load was probably three to four patients, which is what it is currently in pediatrics, but the patients were not as sick as they are now. There’s been a definite change over time to a higher acuity [sicker] patient, requiring more technology, more paperwork, more intensive monitoring. If you had a patient assignment in the past, you might have one sick patient and several patients on the mend. But that has changed.
Ten years ago, before ratios, if I wanted to have a meal break, my employer didn’t have to provide additional care while I went for my meal. So you had to make a choice as a nurse: Do I stay and watch my patients? Do I leave somebody who is already really busy with their own patients to watch my patients? You know, a buddy system.
And so what you used to do is try to get everything done you possibly could, make sure everybody was comfortable and safe, and then you would run and take your meal break and ask somebody to listen out. Essentially, your patients would not get care while you were gone.
Whereas now, with the ratio law in effect at all times, the employer provides additional nursing care for breaks so that I can say, “OK, this child needs pain medication, can you give it and I can go to dinner?” That’s a huge difference for a family, to not have to wait to get care.
I [used to] go home and be falling asleep and would wake myself up thinking, “Oh my God! Did I do such and such? Did I tell the next nurse about this or that?” Because you’re so rushed you would be continually questioning, “Did I get everything done, was everybody safe?”
I didn’t consider leaving the profession, but I know a lot of nurses did. I know a lot of nurses told me they wouldn’t tell their sons or daughters to become a nurse. But I was one of the people who chose to work hard to get regulations and to make improvements in my collective bargaining agreements so that I could stay a nurse.
Because I like being a nurse, I want to provide patient care, I want to be a patient advocate.
Geri Jenkins RN, 59, intensive care unit nurse at UC San Diego Medical Center; nurse for 32 years

There are all kinds of complicated procedures and technology that the nurse is responsible for monitoring that didn’t exist 10 years ago. A lot of patients are on continuous dialysis with machines. A lot of labs and drugs have to be given on an hourly basis. There are very critical IV drips, and you’re titrating the drugs up and down based on the patients’ clinical picture, and there is constant bedside decision-making with each patient.
We also have [many more] patients who are on isolation precautions [because of infectious diseases] than we used to, which means gowning and gloving every time you walk into their room. That’s very time-consuming, but very, very necessary. There is a much greater risk factor for people who work in healthcare now and it makes the care more complicated. There are a lot of things that have changed over the years that make the delivery of care a lot more complicated.
I still enjoy what I do. I think people who go into nursing don’t go into it for the money but go into it for a sense of altruism and wanting to help and be in a caring profession. But it’s a very high-stress, physically, intellectually and emotionally demanding job, and that’s why I think the ratios are so critical, so that when people go to work they are reassured that they won’t have more than five patients, or more than two in the ICU. That may be a heavy load, but it’s better than it used to be.
Copyright © 2010, The Los Angeles Times
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