Higher Workloads and Fewer Nurses? Not a Recipe for Patient Protection and Affordable Care.

flying cadeuciiIn further celebration of Nurses Week, it’s worth discussing this TIME article about the “Killer Burden on Nurses” under the Affordable Care Act.

The point I’m raising and highlighting here is not meant to be political or partisan, but really one about nursing workloads, management decisions, and what’s right for patients.

We’ve seen recently that American healthcare spending is UP about 10%(the biggest increase in spending since 1980) – mainly due to newly insured patients getting care. The point is to get people care and treatment, but maybe the law should have been called the “More People Getting Healthcare Act?” That’s a noble goal.

From the TIME article, an opinion piece written by a nurse from California:

“… I worry that the switch may compromise the quality of the care our patients receive.”

The nurse talks about patients who are sicker due to not getting good healthcare previously. These patients require more attention and more nursing time.

In any workplace, the staffing levels should be set based on the total workload. Using “number of patients” is not a good basis, since the acuity of patients (and the resulting workloads) aren’t equal. Not every patient is the same.

Hospitals, due to other industries, do a really poor job of “industrial engineering” work that would establish the right staffing levels based on workloads.

Staffing levels are often set based on:

  • Budgets (how much money is available, instead of what the workload demands)
  • Benchmarks (if every hospital is similarly understaffed, we have a race to the bottom)
  • BS (who knows — wild guesses or staffing based on what we had before)

I fully realize that hospitals are more complex work environments than a car factory. It’s relatively easy to determine the staffing levels for a car factory because the work is very repetitive and pretty predictable.

But, if a hospital sees that nurses are having trouble getting their work done… if patient safety and quality really came first, they would react by ADDING staff, at least in the short term.

Sometimes, saving money by keeping staffing levels low might cost us some larger amount down the road. But, the short term costs of increasing today’s labor costs are very known. The potential savings is a prediction and is not guaranteed. It’s a hypothesis and a bet many leaders are not willing to make.

So the nurse complains:

“During that shift, one of my other patients said, “You must be busy. I haven’t seen you all night.” My heart sank. He was fine physically, but I could tell he needed someone to talk to for a few minutes. Unfortunately, I had to get back to my diabetic patient. Preventing her blood sugar from dropping took priority over spending time with my lonely patient. Unfortunately, there were no extra nurses to care for my other patients.

In fact, executives at my hospital recently proposed reducing our inpatient nursing staffThey note that the number of patients admitted for overnight stays has decreased in the last few years.

This new burden is falling heavy on the hospitals and staff. Nurses are working harder than ever with fewer resources.”

The full name of the law was the Patient Protection and Affordable Care Act. I’m pretty sure that overburdened nurses is NOT the way to safer patient care and better outcomes.

We need to, in many cases, add people to a process to make sure it can be done properly. If that’s not possible, we HAVE to reduce waste by improving processes and improving systems. If patients are to be protected and costs are to be reduced, we HAVE to free up time… that can have the same effect (more nursing time) as adding more nurses would have… but that’s the only affordable and sustainable way to get there… through Lean, waste reduction, and process improvement.

Our patients and nurses deserve it.

Mark Graban (@MarkGraban) is a consultant, author, and speaker in the “lean healthcare” methodology. Hes is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Innovation and Improvement Services for KaiNexus. Graban blogs regularly at Lean Blog, where this post originally appeared. 

10 replies »

  1. Higher workloads and fewer nurses leads to voluntary nurse turnover. Turnover is predicted when workloads are combined with little autonomy, insufficient team work, and other resources, and when work comes to be so challenging physically and mentally that nurses feel they are too busy to deliver high-quality patient care. The increased job complexity causes situations of minimized control from recurrent adjustments in patient orders, increased patient acuity, and frequent transfers, admissions and discharges. Research has shown that overdue tasks and involuntary overtime was related to the likelihood of nurses voluntarily leaving. Voluntary nursing turnover increases the amount of stress and workload on the remaining nurses and adversely impacts their optimism and well-being. This can result in the decline of nurses’ psychological health and a decrease in job satisfaction. An increase in nurse turnover lessens the productivity of the nurses remaining who are required to orient and educate new nurses. Extreme turnover escalates work disputes, lessens consensus and structure and decreases functioning of the nurses that remain. Interactive relationships and social stability are disordered when nurses are constantly coming and going from organizations. Nurses that are satisfied contemplate leaving due to an increase in stress and pressures of the work environment.

  2. Lisa, very well said! I have been a nurse for 8 years and I can relate to this nursing issue. I agree with your last paragraph regarding nurses need TIME! Nurses are pulled in many directions throughout their shifts and what nurses really want is TIME to simply provide exceptional care to their patients.

  3. And now, the business community discovers “the desire of nurses to widen their scope of practice” and be nurse-attendings.

  4. “Nurses….and doctors…need TIME. Time to think. Time to Listen, and Time to Care.

    Now how does that get factored into the budgets today?”

    Well put.

  5. Thanks for the post, and interesting comments on an issue that is not new. I have been an advanced practice nurse for decades and the staffing issue has never been adequately addressed within the industry. We have the evidence that appropriate staffing leads to better outcomes. Lean and other strategies to improve the work environment itself can help improve the ability of the RN to provide good care, but these strategies alone will never lead to the outcomes we seek.

    Consumers and clinicians alike need to press the envelope on this issue because there is no substitute for the knowledge and analysis needed at the the bedside 24/7. Nursing practice requires constant evaluation of the physiologic status of every patient. Most inpatients in the last decade come with multiple needs and several diagnosis, very few are like the one described in the post.

    Patients and families are grossly underestimated and undervalued by the industry as a whole. The new law has simply speeded the implosion that has been underway for some time now. Patient centeredness and the new buzz word patient engagement have become marketing phrases but the infrastructure to support such concepts is not in place. Nurses….and doctors…need TIME. Time to think. Time to Listen, and Time to Care.

    Now how does that get factored into the budgets today?

  6. Her article made me laugh. I did my MPH research in California in the early 00’s when there was a big fight over the state”s nurse staffing ratio law (I wrote 10K words about it then, I won’t replicate those now!). The rich, rich irony is that this woman has been a nurse since 2007, *after* the law was enacted, providing patients with more staffing. The law has also stemmed the hemorrhaging of RNs from California which, before the law was implemented, ranked 49th in the country for the number of RNs per capita.
    When I was nursing in the 90s, our staffing was much, much lower when I worked in a similar facility as hers.
    The problem is not Obamacare, the problem is the way hospitals nickel and dime nursing care and always have, in part because they know they can burn out their staff and there’ll always be someone to step into their white shoes. I had Directors of Nursing admit as much to me during my research.
    Hospitals put nurses into an “expense” line, they should be thinking about nursing care as “investment.”

  7. I agree John. I’m not a fan of the ACA, but I think some of these changes may have been coming even before the ACA. The problem is there will be a critical increase in patient load as mentioned in the blog. I think one major downfall of the ACA in my opinion was not looking ahead to manpower in terms of all providers, nurses and docs included. Who do they think is going to take care of all these new patients?
    I would also like to know the impact of the quality measures, EMR, etc. activities that don’t relate directly to patient care, but take up time of the provider.

  8. The seems to be across the board. Management’s preferred solution of the hour appears to be “hey, ok. let’s-plug-in-a-nurse-practitioner” or “let’s try hiring some scribes” ..

    I’d like to see a courageous EMR company or healthcare system put some serious effort into quantifying the impact the ACA is having on front line health care workers. We’ll learn a lot about what’s really going on …

  9. “More People Getting Healthcare Act?” That’s a noble goal.

    More People Getting Insurance Act, not necessarily healthcare.

    My wife is a radiologist in a fair-sized hospital in the Midwest. The administration is laying off many regular full-time techs and nurses and hiring newbies and part-timers to save on benefits. What you get is limited
    continuity of care, and an influx of unexperienced nurses. What does this lead to? Poor patient care.
    I have a moderate sized private practice office. We do everything we can to keep our staff, they are critical to the smooth running of our office and proper patient care and satisfaction. Even if we could save money by laying off and hiring temps or newbies, we’d lose in the long run due to screwups and upset patients and clients. It’s not worth it.
    The problem is business people are running hospitals, not medical people.

  10. I’m hearing frightening things. Lots of studies out there on the ACA’s impact on doctors and patients. Almost nothing on how nurses are being impacted?