Nursing Notes

April 9, 2011

Prevent Readmissions With Discharge Planning

With The Joint Commission looking at “revolving door” admissions, it is time for everyone to get on board and start working to prevent readmissions.  Being readmitted benefits no one.  The patient feels like their health has become unmanageable and they are frightened.  The family becomes convinced that they cannot handle the needs of the patient safely.  The hospital, once a safe haven, becomes a scary place.

We have to work “better” not harder at discharge planning.  We need to be looking at the patients’ needs and desires as much as possible.  Just getting patients out of the hospital is no longer acceptable.

The article below is long, but well worth your time.  Only part of it is below, so please do click over to finish reading.  This is from one of my favorite sites, Health Leaders Media, where you will find many other great articles dealing with various issues in today’s nursing.


Rebecca Hendren, for HealthLeaders Media , April 5, 2011


Discharge planning is a process that should begin as soon as patients are admitted to the hospital. In a perfect world, healthcare team members, patients, and families communicate and work together to move patients quickly and safely to home or the next level of care.

In reality, discharge planning can be fractious. Older adult patients and their families face many choices about where to go and often disagree on the best course of care. Communication among caregivers can be far from ideal and communication between patients and families can be fraught with disagreements.

As hospitals battle readmission rates, more attention is being paid to discharge planning. Lori Popejoy, Phd, APRN, GCNS-BC, assistant professor in the Sinclair School of Nursing at the University of Missouri, has been studying the discharge planning process around older adults and recommends hospitals pay more attention to the decision-making process with these patients.

Popejoy, who has years of experience with care of the older adult before entering academia, recently published a study, “Complexity of Family Caregiving and Discharge Planning,” in the Journal of Family Nursing. I spoke to her about the problems nurses face as they work with older adults and their families, the challenges faced by healthcare providers as they discharge older adults from the hospital, and the healthcare transitions faced by elderly people and their families following hospitalizations.

Popejoy says that our understanding of discharge planning and how patients make decisions is quite simplistic. We usually think about conversations between physicians and their patients or between physicians and families. In reality, dozens of people are involved in any decision. So she examined interactions between healthcare team members, including nurses and social workers, and older adult patients and their families. She wanted to understand how these diverse stakeholders come together to make a single decision about leaving the hospital and where they are going to go. She wanted to understand how much participation in decisions patients and families want the healthcare team to have and what actually happens as decisions unfold.


“Every participant comes to the situation with their own values, their own beliefs, and what they want to get out of it,” says Popejoy. “What stands out for nurses or social workers is their overall concern for patient safety. Their input into the decision making process is to find the most reasonable choice and the safest choice.”

For older patients, most just want to go home. Some recognized they were too weak and were willing to go somewhere else, but for them, it was to be a short-term stay where they could get stronger and then ultimately go home.

For families, safety is important, but also the issue of ‘I want my parent to be able to live the life they want to live,’ says Popejoy. “For a spouse, it’s a whole different ball game—they just want their spouse to go home with them.”

Within child-parent relationships, some want their parents to live with them; others recognize that their lives are too complicated to handle a parent at home who is functionally unable to care for themselves. Some can handle a short-term stay, but not one for the long term.

Popejoy says that hospitals need to figure out who the key players are who can influence decisions. “Listen to older adults and find out what they want, but also listen to the family and what they can do,” she says.

She cautions decision makers are often not available during Monday to Friday business hours. Although most organizations know this, it can be difficult to get good information across the week, not just during traditional work days. Discharge planning and communication may have to be done via conference calls or during off hours.

Another important thing that leaves healthcare teams in difficult positions is the idea of autonomy.


“In the United States, we value autonomy and your independence above all…[read more]

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March 31, 2011

Many don’t take prescriptions because of cost

Here’s an article from Reuters that I read and scratched my head about.  As a nurse I have known that this is a major problem for many years.  I know that patients will take medication if it “works” ( ie.  they get better), they will take it if they feel they need it and it is not too much trouble to acquire, and they will take it if they can afford it.  So, what’s the deal with this study at this time?  With healthcare costs sky rocketing, it seems that someone in charge has finally seen the light.  Maybe we can prevent some of the catastrophic illnesses by starting earlier in the cycle and intervene at a time when medication alone may be able to prevent further bodily damage.  What a thought.

So, after a few minutes of head scratching, I realized that it is a good thing for someone to finally be looking at this issue in a quantitative and measurable way.  Maybe this is how we effect change in our system.

I know that my niece, the doctor, always chooses her medications to prescribe based on the $4.00 list at the local pharmacies so her patients can be sure to get the treatment they needed when they came to see her.  Maybe others should not be so influenced by the drug reps to prescribe the newest, most expensive drugs on the market.  Who knows?  Just my thoughts on this topic.  What are yours?

Please go to the site and read the entire article, then come back here to let me know what your thoughts are on this topic, won’t you?


By Alison McCook

NEW YORK | Wed Mar 30, 2011 11:52am EDT

NEW YORK (Reuters Health) – A significant portion of people – perhaps as many as one in five – don’t take drugs a doctor has prescribed because they can’t pay for them, according to a new survey of people visiting an emergency room.

“I think this is a wake-up call,” study author Dr. Karin Rhodes of the University of Pennsylvania told Reuters Health.

Among a group of more than 1500 people who volunteered to complete a questionnaire, more than 20 percent said they had previously not taken a prescribed drug on account of the price tag.

It’s an issue that many doctors aren’t aware of, noted Rhodes, and the system needs to address it. “Patients need to be asked ‘can you afford your medications?’ and they should get help to pay for them.”

A number of studies have shown that people with chronic health problems, including high blood pressure, diabetes and heart disease, commonly fail to take their medications as prescribed.

Other reports have shown similar rates of so-called “nonadherence,” although the actual estimate tends to vary depending on the exact questions researchers ask, according to Dr. Jae Kennedy of Washington State University, who did not participate in the current project.

One recent study found that 22 percent of prescriptions written for 75,000 Massachusetts patients were never filled. And in another, people were less likely to fill “dispense as written” prescriptions (See Reuters Health report, March 25, 2011).

Some people go to the trouble of filling the prescription, but never pick it up. Looking at information collected from 5 million Americans over 6 months, a study late last year showed that just over 3 percent never retrieve their prescriptions from the pharmacy, and were more likely to abandon expensive medications.

During the current study, 21 percent of the 1506 participants said they had previously not taken medications because of money concerns. Another 5 percent said they were worried they might not be able to pay for drugs.

The researchers, who published their results in the journal Academic Emergency Medicine, considered both groups to be “at risk” of nonadherence with future prescriptions.

Looking at the responses to other questions on the survey, Rhodes and her team found that people were more likely to be at risk of nonadherence if they had money issues – for instance, they worried about money, didn’t have enough food, reported housing problems, and had inadequate health insurance. But they were also more likely to be at risk of nonadherence if they smoked, used illegal drugs, or experienced domestic violence, as either the victim or perpetrator.

“I think (nonadherence) goes along with people who have difficult, disorganized lives,” said Rhodes.

Nonadherence has consequences, she added – one problem, if left untreated, will create others, such as when untreated high blood pressure hurts the kidneys. Research shows that people who don’t fill prescriptions or take medications as they’re prescribed are more likely to get sicker, and become hospitalized, said Kennedy in an e-mail.

“Nonadherence is a widespread and serious public health problem.”…..[read more]


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March 18, 2011

Fun Friday Video

Filed under: Nursing — Shirley @ 9:30 pm
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Let’s have just a little humor today, okay?  This video is funny but true.  Let me know if you enjoy it as much as I do.


October 21, 2010

Technology Monitors Nursing Performance

BALTIMORE - JANUARY 15:  Beds are prepared in ...
Image by Getty Images via @daylife

I read this article with much interest.  I guess things really are terribly different between med-surg and psych in that I was lost pretty soon after I started reading this.  At a psych hospital, no one considers your expertise or training when making assignments.  You are simply a cog in the wheel and you get your patients assigned for whatever reason the charge nurse wants to use.  In my experience, the rationale for assignments usually goes like this–I like you, so you can have so-and-so; I don’t like you, so you can have the SOB in room ???; I don’t feel like working too hard today, so I won’t take many patients today; I’ll give you all the difficult patients because you made me look bad last week; etc.  Where in this process is my expertise taken into account?  I did complete the reading of this article and I have to say that this hospital in Midland, TX seems to be very forward thinking and modern in its approach to nursing care.  What do you think?

You can find this and other great nursing articles here.


HCPro’s Advisor to the ANCC Magnet Recognition Program® , October 19, 2010

Midland Memorial Hospital in Midland, TX, recently changed its process for tracking not only online training but demonstrated proficiencies among its nurses. The change has resulted in a real-time information tracking program that has helped not only with tracking training, but documenting growth of its employees for its ANCC Magnet Recognition Program ® (MRP) journey.

Jenny Delk-Fikes, BSN, RN-BC, clinical excellence manager with Midland Memorial, explains that previously, e-learning was tracked online, while checklists for demonstrated proficiencies were tracked in paper format—leading managers to have to look in multiple locations, in multiple formats, just to figure out what their staff knew and how well they knew it.

This has been much improved with an all-electronic system.

“The first thing we did was get a system that met our needs,” says Delk-Fikes.

They needed a centralized component that gave the hospital real-time access to knowledge skills and critical thinking skills of the nursing staff.

“We need to know when something is new and when it has changed. We need to be able to communicate those changes in real-time,” says Delk-Fikes.

The previous system had a delay, because the learning management system, while it was a good program, did not have all the necessary components in one place.

“We needed an integrated competency system that could support the practice model,” she says.

With the new system, managers could look at their staff as a whole to determine who the right person is for the right patient. Previously, managers would literally have to look in three locations to assess staff competency.

Midland Memorial went with a system called Decision Critical, a 360-degree learning and evaluation system.

This new system actually allows them to track input from the staff as well, at times tracking downward trends early.

“Our staff knows performance is low before our data even shows it,” says Delk-Fikes. “We want them to be able to communicate that with us.”

The facility also wanted a system that could demonstrate skills in practice—are the lessons being taught then put into practice?

Finally, they needed a system that could capture professional development inside and outside the organization.

“We have a lot of people who are very active in their professional organizations,” says Delk-Fikes. “They’re attending conferences, doing training certification classes, things that are not deliverable through a computer system that you want to track. We want to know if you are an ED-trained nurse working on the oncology floor, because if a head trauma is transferred to our unit, you’re the best provider to work with that patient. It’s all in the individual portfolios.”

The first delivers the knowledge component of nurse education.

“Here’s the content, now take the test,” says Delk-Fikes. This is the basic component of demonstrating that information has been given and taught, but does not yet demonstrate competency in the field.

Communicating comfort level

Next up: a check list going over everything in a given area of practice that is important for nurses to know to drive up performance, adhere to standards of care, and provide safer and more beneficial healthcare.

“This is essentially your peer evaluation,” she says. “We need you to work on X proficiency, but you did Y efficiently. The individual can communicate what they feel they need to work on in the self-assessment component, and there is also an annual needs assessment.”

This one-two punch of assessment is key to success of the program. A nurse can identify their own strengths and weaknesses and ask for additional training or help in the latter.

“They might tell you, I’m good at IVs, at foley catheters, and at restraints., but this list includes tracheostomy care, and I haven’t taken care of a tracheostomy patient in three years, so I’m going to say I’m average,” says Delk-Fikes. “I have the knowledge but not the skill.”

The program pulls in everything the nurse has accomplished, needs to work on, and has not done yet, she says.

This level of communication also helps design methods for training. If the nurse needs help learning or re-learning tracheostomy care, why not send them down to the cardio-pulmonary unit to shadow a more experienced nurse to pick up those skills? When managers are going through nurses’ files, they aren’t bouncing from source to source—the educators and managers can see each nurse’s self assessment, their annual assessment, and all of this can be used to plan upcoming education events.

It also means that educators can identify how great a need certain training requires. How many nurses identify themselves as not proficient in a given task? How many have been identified by their peers as needing additional training?

“If one nurse says she’s not comfortable with tracheostomy care but the majority of her peers are, I’m going to loop her through cardio-pulmonary to increase her knowledge,” says Delk-Fikes. “But if the whole unit says it’s a problem, rather than looping them I’m going to bring the education to them on that floor.”

Midland Memorial has shared governance with a multidisciplinary team they turn to for when they encounter practice issues. For example, if they were to discover they are not hitting their benchmarks for Foley catheters based on CMS guidelines, they bring this issue to the council to update how this information is going to be rolled out to staff.

“In our old system, I worked with every council, key departments  like quality management, infection control, human resources, and said, we are doing 32 annual training modules,” says Delk-Fikes.

These were just testing knowledge. That’s a significant amount of time, she says.

“Our employees were spending four to nine hours completing each of these,” says Delk-Fikes.

They needed to find a more efficient way of handling training. Non-clinical roles now have 22 training modules required, and clinical still have 32 on hire, but 24 annually.

“When we reevaluated we looked at more effective learning,” says Delk-Fikes. “We moved things off the checklist or added depending on need.”

Regulatory requirements

They also pulled in the requirements for NIAHO (National Integrated Accreditation for Healthcare Organization) standards in order to align their required training with the standards (the organization is DNV accredited). But they also looked beyond their own standards for best practices.

“We still look at The Joint Commission because they also have wonderful practices. We put everything we were doing under the appropriate categories,” says Delk-Fikes. “If a regulatory agency says okay, you need to provide training on, for example, confidentiality and ethics, we need to know how to demonstrate that.”

To show all the components they engage in annually is great, but how does it align with the standards? You need to be able to demonstrate that.

Nursing excellence documentation

Midland Memorial is seeking ANCC Magnet Recognition Program® (MRP) status. They need to be able to track and trend their nursing education to show progress. With the new system, they are able to drill down, whether it’s an organizational problem they want to fix, or a performance issue they want to improve.

“If our scores are stagnating at 88 or 89% and we want to do better, we can do that,” says Delk-Fikes.

The way a critical care unit nurse is trained is completely different from a pediatric nurse. Under the new system the organization can document the progression of each nurse in accordance to their unit’s requirements.

“One of the things about this system that we’re using is that, for MRP’s requirements in the area of innovation and technology and nurse organization-wise performance, this actually is your Source of Evidence,” says Delk-Fikes. “If you want to show nurses are growing professionally, you can pull it from this program.”

Previously, it was a challenge to simply show how many certified nurses were on staff at a given time. Now, a nurse manager just has to look at a given nurse’s portfolio to see whether they have been CPR recertified, for example. Is the nurse a certified medical interpreter? That is in the portfolio as well.

Nursing levels

Midland Memorial Hospital uses “levels” to describe each nurse’s skills and training: beginner, novice, and expert.

At orientation they are given the on hire checklist. Evaluations are done six months to a year out, allowing time to acclimate and grow into the culture of the facility. By the end of the first year, nurses begin their competency-based assessment.

After reaching the expert level, nurses start getting into individualized growth plans. They enter preceptor roles, take on mentoring tasks, and help train skilled nurses in areas where there is a knowledge gap.

But before reaching that level, there is quite a climb—and that climb is ever changing. Expert level nurses cannot stagnate—there are always new things to learn. If, for example, 10 new requirements arise for experta, they must become proficient in all of those requirements before being considered an expert/level 3 nurse again.

In fact, most of the time, nurses are considered advanced beginners. Nurses are paired in training with the appropriate trainer—a beginner is not handed over to an expert to shadow at first, but instead are paired up with a novice/level 2 nurse who can bring them up to their level of training first.

This article was adapted from one that originally appeared in the November 2010 issue of HCPro’s Advisor to the ANCC Magnet Recognition Program®, an HCPro, Inc. publication.

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September 8, 2010

Nursing videos about the shortage

Filed under: Nursing — Shirley @ 2:45 pm
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June 24, 2010

Patient discharge planning receiving more attention

It has always seemed to me that discharge planning was forgotten or simply ignored in the past.  Patients came in, got treated, signed papers and got copies, and they left the hospital.  I always wondered if my patient really understood the correct way to care for themselves at home.  There was a time when home health was available and utilized more, but abuse of that system has curtailed that avenue for the most part.  Home health is still available, just not as readily.

My patients are the mentally ill, so discharge planning is even more important, but at the same time my patients may or may not follow through.  I often worry about patients after they leave the hospital because I know in my heart that they will be back soon.

It’s great to see a push in this industry to have an adequate discharge plan in place and to involve the entire team in this process.  The patients can only win in this situation.

Here’s an article from the Patient Safety Monitor about this topic:

Discharge planning has been an often neglected time in a patient’s hospital stay, which is likely one of the main reasons 20% of patients return to the hospital within 30 days, reports The New York Times. Several new programs have taken root to reverse this trend and ensure that patient care at discharge is a focal point to prevent patients from returning to the hospital.

Two of these programs, Project BOOST (Better Outcomes for Older adults through Safe Transitions) and Care Transitions Intervention, are leading the way. Project BOOST is a creation of the Society for Hospital Medicine and provides interested hospitals with a toolkit of standardized forms to streamline the discharge process. Care Transitions Intervention is out of the University of Colorado Denver’s School of Medicine, with funding from the John A. Hartford Foundation and the Robert Wood Johnson Foundation.

I wrote about the Care Transition Intervention program a couple of years ago in Briefings on Patient Safety. At that time, this project was a newer take on how to manage the handoff process for patients being discharged from the hospital. It also gave rise to the notion of a “transitions coach,” a similar concept to that of the “patient navigator” I posted about last week.

Has your facility taken part in any program that focuses on patient discharge as a means of preventing rehospitalization?


About the Author: Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books, webcasts, and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals ( and manages Patient Safety Monitor (, of which this blog is a part. Contact Heather by e-mailing

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June 7, 2010

Noise levels can be hazardous to patient safety

Filed under: Nursing — Shirley @ 2:51 am
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Image by peasap via Flickr

My hospital is very loud all the time.  It’s really an issue.  Some of it is the type of patient we have, some of it is the staff forgetting that others are sleeping, part of it is the actual routine of patient care and rounds.

My last overnight stay at a hospital was full of loud noises and I got no sleep at all.  That can’t be a good thing.


Hospitals are noisy places, and the increase in technology-based care has only added to the volume, according to an article in The Boston Globe. However, some hospitals are trying to reduce noise levels through unique building design and internal programs in an effort to not just make patients happier, but to improve their safety and potential for healing.

Studies have shown that patients heal faster when noise levels are lower, encouraging longer sleep periods with fewer disruptions. Additionally, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey asks patients whether the areas around their rooms were kept quiet at night. Part of providing patient-centered care means taking into account what patients want from their care, and working with them to ensure these conditions happen during their time at the facility. Having a quiet room is often ranked highly.

In addition to building new hospitals with materials that are more sound absorbent, some facilities are instituting certain hours of the day that are considered to be “quiet hours” for patients, with limited interruptions. Although these types of activities are challenging to schedule, they can be worthwhile to increase healing time for patients. Other strategies include instituting noise monitoring technology to alert staff members to noise levels.

Is your hospital partaking in any of these noise-reducing activities? Here’s the full article from The Boston Globe.

This is from the Patient Safety Blog

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March 9, 2010

Nurse to patient ratios: lies, damned lies, and statistics.(Legislative Updates)

This is an old article, but I want to publish it here just to show that this problem has been going on for quite some time and still is no further along towards any resolution.  I am sure that if the hospital administrators had to work the floors as nurses, there would be a fast action, but since that will never happen I expect little to no headway to be made along the lines of mandated nurse-to-patient ratios.

Nurses will just continue to get frustrated and burned out and drop out of nursing altogether and we will continue to hear about the “horrible” nursing shortage.  If the nurses who currently hold RN licenses were to all come back to the profession right now due to better staffing and nurse to patient ratios, would we even still have a “nursing shortage”?

This article just lets you know that we have been fighting this battle for a long, long time.


By Lillian Gonzalez | August, 2007

The data is in. The fewer patients assigned to nurses, the better the patient outcomes. So why does Nevada, particularly Southern Nevada, have high nurse-to-patient ratios?

Some argue that it’s all about the money. After all, it is logical that fewer nurses caring for more patients could yield higher revenue for hospitals. It can also ensure a cycle of repeat business by way of “frequent flyers.” For example, a male patient is hospitalized to get a knee replacement. Because his nurse has ten other patients, the nurse is unable to adequately protect him from acquiring an infection. Thus, the patient must stay an extra few days for antibiotic therapy. He is rushed out of the hospital because of the HMO factor and receives little to no discharge teaching because the nurse is putting out fires for the other nine patients. The patient returns a week later with a bowel obstruction because he didn’t understand that the pain killers he took home could cause constipation. So much agony could have been avoided if a nurse had had the time to adequately address his needs during his first admission.

So are high nurse-to-patient ratios about the money? Or is it unavoidable because of the highly publicized nursing shortage? Let’s get right down to the stats.

The American Hospital Association (AHA) reported in April 2006 a national registered nurse deficit of 118,000 RNs “to fill vacant positions nationwide.” (1) In the December 2003 issue of Health Affairs, distinguished nurse researcher, Peter Buerhaus, published interesting statistics supporting our nation’s increased dependence on “foreign born” nurses. (2) However, this same data appeared to indicate a surplus of 600,000 registered nurses in the U.S., not working as nurses. A surplus of 600,000 nurses could well eliminate the AHA’s reported 118,000 deficit.

When questioned by email about this surplus, Buerhaus responded, “There are roughly 500,000 individuals who are licensed to practice as an RN in the U.S. today, but who are not currently working.” He then speculated that perhaps many of these nurses are retired, too old to work, independently wealthy, or have chosen to stay home with children. But nurses working in the hospital trenches of Nevada, where some of the highest ratios in the country exist, need not speculate why Nevada has the worst shortage of nurses in the country. To them the reason is: burnout.

Another argument challenging ratio enforcement is the hypothesis that ratios would be impossible to meet and would therefore cause hospitals to shut down. But according to Deborah Burger, President of the California Nurses Association, where mandatory ratios are in full force, “After many dire predictions about closing hospitals and wards by the California Hospital Association, there were in fact NO hospital closures let alone unit closures in California due to the ratios law. It is not just my wishful thinking but actual facts reported to the Department of Health Services.”

Did California have an abundance of nurses to support mandated ratios? Before ratios were imposed, California ranked last in numbers of nurses per capita and Nevada ranked second to last. Today, California has increased its numbers of nurses per capita, now leaving Nevada in last place.

The California Nurses Association has embraced nurses is Texas and other States to help them achieve mandated ratios as well. In a report by The Texas Observer, “Even Schwarzenegger’s office has acknowledged that California’s law has produced some benefits. For one thing, it’s lured thousands of nurses back to work, easing that state’s shortage.” (3)

How did the California Nurses Association manage to beat the odds and attain ratio legislation? Ms. Burger reports, “Since we left the ANA [American Nurses Association], we have accomplished more in the last 12 years than in the previous 50 years with ANA. Since then we have put forward safe staffing legislation (ratios and whistle blower protections) in Illinois, Maine and Texas. In all states, ANA has opposed the bill, but we are moving forward because nurses (just ask any traveler who has worked in California recently) know this will make a difference.”

California has set the standard for hospital nursing care. There, medical-surgical nurses are assigned a maximum of five patients, while here in Nevada it is customary for nurses to have twice as many.

So the next time someone offers statistics supporting a particular view, recall what Mark Twain said, “There are three kinds of lies: lies, damned lies, and statistics.”




Lillian Gonzalez, BSN, RN

Las Vegas Agency Nurse

Here’s the link to the original article

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February 14, 2010

Costs on rise, nurses protest staffing changes

I am a staunch supporter of some type of national nurse-to-patient ratio to be enacted.  I feel this way because I know what it is like to work a shift with too many patients and not leave at the end of your shift.  I know what it is like to wake up from a dead sleep to call the unit to make sure I did (or did not) do some task because I was so busy during my shift.

That said, I have to now say that the following article does not surprise me in the least.  I read articles each and every day that describe the effects on health care of all the budget cutting going on.  I know that hospitals really are a business and are always looking for ways to save money (read increase profits).  I knew it would not be long before “nursing costs” were under scrutiny and new and novel means developed to decrease those costs.

Granted, these nurses have been working with fewer patients than the norm.  Granted, these nurses are well paid.  However, it sets a really dangerous precedent for this hospital to increase nurse-to-patient ratios as a cost-cutting tactic.  What do you suppose will happen to that same hospital when it cannot find or keep nurses at the bedside?  Hospitals cannot operate without nurses, period.

Is there no other way to save money and increase profits besides increasing patient loads?  Surely there are some intelligent and creative people out there with better solutions to this problem.


Nerrissa Shurtluff and others gathered outside Tufts Medical Center in Boston. Nurses from Tufts and Boston Medical Center protested what they say are dangerous changes to staffing.
Nerrissa Shurtluff and others gathered outside Tufts Medical Center in Boston. Nurses from Tufts and Boston Medical Center protested what they say are dangerous changes to staffing. (Wendy Maeda/Globe Staff)

By Liz Kowalczyk Globe Staff / February 12, 2010
Tufts Medical Center says it has found a way to trim the high cost of nursing while improving care, but the plan prompted a protest yesterday outside the Boston hospital by nurses, who say it is an example of the intense cost-cutting pressure on hospitals statewide.

But they said cost was not the primary reason for the change, adding that they want to improve care and working conditions for nurses. The hospital is bringing on 35 technicians to free up nurses from unskilled jobs like transporting patients to imaging tests and tracking down missing meals, so they can focus on monitoring vital signs, giving medications, and providing essential patient care.

“Our nurses will be working smarter,’’ said Nancy Shendell-Falik, Tufts’ chief nursing officer, who said she believes patients could get more, not less, attention from their nurses. She said a consultant hired by the hospital found that nurses at Tufts – and, by extension, other Boston teaching hospitals – care for fewer patients than is typical for similar hospitals elsewhere in the country.

But many nurses are upset by the changes. They say that requiring nurses on the hospital’s medical and surgical floors to each care for five patients, most of whom are extremely ill, is dangerous. Tufts nurses have traditionally cared for three or four patients on regular floors. In intensive care units, Tufts is assigning two patients to each nurse in most cases, up from one, but can increase the number of nurses if patients are especially ill.

“Nurses are overwhelmed,’’ said Barbara Tiller, a nurse at Tufts for more than 20 years. “They are behind their entire shift. Patients slowly deteriorate now, and no one picks it up until they’re in a crisis mode.’’

The Massachusetts Nurses Association, a large union, also organized a protest at Boston Medical Center yesterday, which plans to increase the number of patients assigned to some nurses from two to three. Hospital administrators said that they are assigning patients who are not as ill to those nurses and that they hired the same consultants as Tufts, who said nurses in intermediate care units nationally usually care for three patients.

“Of course, cost is included in our decision, but we have to be responsible about patient safety first,’’ said Lisa O’Connor, vice president of nursing at BMC.

The union also bought newspaper advertisements yesterday criticizing the changes at the hospitals.

“We understand that everyone is in a budget crisis,’’ said Lisa Sawtelle, a nurse at Boston Medical center. “We will not complain about the money we bring home. But they’re making it more and more difficult for us to do our job at the bedside.’’

Soaring hospital costs statewide are under increasing scrutiny. Medical costs in Massachusetts are growing more than 7 percent annually, driving up insurance premiums and threatening to bankrupt businesses. Last month, the attorney general’s office found that the increases are largely driven by higher prices charged by hospitals and doctors, and Governor Deval Patrick proposed legislation Wednesday that would allow the administration to review and reject medical provider rates.

At the same time, some hospitals, including Tufts, have been at a financial disadvantage because they get lower reimbursement rates than their larger competitors with more market clout. Boston Medical Center, too, is struggling with cutbacks in state funding and has sued the state over the issue.

Nursing always has been a huge expense for hospitals. Administrators who testified at hearings held by the Division of Insurance last month said labor accounts for up to 70 percent of their costs, of which nurses are the largest component.

Massachusetts nurses have enjoyed some of the highest salaries in the United States, which is typical of states with strong nurses unions. The average salary for a nurse in Massachusetts was $79,000 in 2008, up from $57,000 in 2003, and second only to California, said Judith Shindul-Rothschild, a nurse and professor at Boston College. Massachusetts nurses also enjoy some of the best working conditions in the country and are among the most highly educated, she said.

The Advisory Board Co., the Washington, D.C.based consultants hired by Tufts, found that Tufts nurses have lighter workloads than average. Tufts nurses typically have cared for 3.7 patients each on regular medical and surgical floors, while the national average is 4.5 for teaching hospitals and 5.7 for all hospitals. The company, however, also found the hospital had lower than average numbers of support staff.

It is unclear whether the new Tufts plan or the consultant’s findings will lead other hospitals to assign more patients to their nurses.

Karen Nelson, a nurse and senior vice president of clinical affairs for the Massachusetts Hospital Association, said the deciding factor will be whether the hospital is able to maintain good results for patients.

Shindul-Rothschild cautioned against comparing nurse-to-patient ratios in Massachusetts with national averages, because they may not account for differences in patients and because they do not indicate if the state’s higher concentration of nurses leads to better care.

“Yes, maybe we have higher ratios,’’ she said. “But you can’t look at those in isolation of patient outcomes.’’

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February 13, 2010

Nursing Certification Has Many Rewards

I have been a nurse for 20 years and all that time I have worked in the same specialty.  It has just recently become a goal of mine to obtain certification in my specialty.  I will get no pay increase for it, I will get no additional pat on the back, but I will feel more professional.

With the current dialogue going on about what should be the “entry level” requirement for educational status in nursing; whether BSN should be required to sit the NCLEX or not, certification could easily fall through the cracks while the fight ensues.  My thought is that certification is something you do for yourself and in doing so, you do something for your patients and their outcomes.  Not everything we do as nurses is about compensation, or at least I hope it’s not.  Sometimes we do something simply because it is the right thing to do.  Certification is the right thing to do.


There are a myriad of advantages to becoming certified in your field of nursing.  I am a Certified Occupational Health Nurse Specialist (COHN-S) and find that certification has many rewards!  Here are a few reasons to consider:

BENEFITS YOUR PATIENTS: According to the American Association of Critical-Care Nurses (AACN), nursing certification has been linked to better patient outcomes.  Certification is credited with a reduction in medical errors, among other benefits.  If I listed no other reasons to become certified, this one should be enough!

ACCOMPLISHMENT: Becoming certified in your field is both a professional and a personal accomplishment.  Most certifications require extensive studying and experience to initially attain the certification.  Once earned, you carry with you a keen sense of accomplishment as a certified nurse. You are seen by uncertified peers and management as a level above.

CAREER ADVANCEMENT/PART 1: Earning your certification advances your career, and creates opportunities that otherwise may not be available to you.  For example, with my COHN-S certification, I am eligible to apply for case management positions.  Although I have never done case management, one requirement (just to be considered) is either a Case Management or Occupational Health certification.  Nurses certified in specialty areas earn an average of $9,000 more per year than their non-certified peers (Mee, CL. Nursing 2006 salary survey. Nursing. 2006, Oct; 36(10):46-51).  Mee also reports that certification increases confidence and job satisfaction.

CAREER ADVANCEMENT/PART 2: With current job market challenges, certification places you ahead of the competition when applying in a new organization or for promotional opportunities in your current workplace.  Hiring authorities view certifications as a mark of excellence and a sign of commitment to your field.  Additionally, hiring personnel understand you have gone the extra mile to earn your certification. Don’t believe me?

“Nurse Managers surveyed by the American Board of Nursing Specialties (ABNS) overwhelmingly prefer to hire certified nurses because certification attests to an individual’s proven knowledge base and documented experience in a given specialty. In fact, 90% said they clearly prefer to hire certified nurses.” –

SKILL AND KNOWLEDGE: Even though you may have practiced in your field for years, there are aspects of your professional area you may not be familiar with.  For example, when studying for the COHN-S, I learned all about OSHA chemical reporting programs that I have never worked with.  Studying for certification can familiarize you with other paths in your own specialty area that you never knew existed.

KEEPING ABREAST OF THE LATEST CHANGES: Nursing certifications require a lot of continuing education to maintain the certification.  This consistent education validates knowledge, keeps a nurse abreast of the latest changes in his/her field, and enhances patient care.

To participate in discussions regarding continuing education programs and certificates, go to our  Continuing Education forum.

About the Author: Sue Heacock, RN, MBA, COHN-S and author of the recently published book – Inspiring the Inspirational: Words of Hope From Nurses to Nurses.  Sue is a Certified Occupational Health Nurse Specialist and has worked in a variety of areas of nursing including pediatrics and research. Before entering the nursing profession, Sue worked in human resources and equal employment opportunity.

Click here to read more on Sue Heacock.

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