The Impact of the Nursing Shortage on American Healthcare (2005)



last weekend's Virginia festival of the book with face Satterlee author of where of all the nurses gone it's an hour hi I'd like to welcome you to the Virginia festival of the book if you're uh have attended in the past you know there are some things we need to say before we get started I'm going to start with that my name is Joyce Allen and on behalf of Jane's attic bookstore and the Virginia neuro Care Center and the Virginia Foundation for the Humanities which produces the Virginia festival of the book I'd like to welcome you to where have all the nurses gone the Virginia festival of the book is an annual event which promotes literacy and celebrates books the festival emphasizes programs both in schools and in festival venues that are with few exceptions free of charge this festival would not be possible without the help of several hundred volunteers whom we thank for their efforts another way you can help the festival is by filling out the program evaluation you were handed out and return it to a volunteer who will be in the back as you leave or you can place it on the table up here they really do look at these and they try to shape the festival around the responses they get from these evaluations so they're very helpful many organizations make themselves program sponsors hosts and providers of Virginia book programs at this event we'd like to thank Jane's attic and Virginia Nurik hair center especially hundreds of other businesses and individuals have made in-kind and monetary donations if you would like to join them in supporting the festival please stop by the Virginia book information desk at the Omni Hotel or mail a donation to the Virginia Foundation for the Humanities and now it's my pleasure oh let me tell you one more thing after the after phase presentation there will be a reception in the bookstore to celebrate brain Awareness Week and all of you are invited to come to that reception it's my pleasure to introduce phase Satterly I've been a nurse for 40 years June how many of you are nurses how many are in other health care professions and non-medical folks we need you here thank you I'm proud of being a nurse but like so many others I've left nursing and I've left it four times and I keep going back Faye has been a registered nurse for 20 years she's currently serves as cancer services director at Martha Jefferson Hospital here in Charlottesville prior to that she worked in med surg infusion and oncology nursing and Faye tells me that she was born a writer and feels like the luckiest person in the world because there are two things she was born to do writing and nursing who's welcome face sadly and her book where of all the nurses gone thank you for that introduction and I'd especially like to speak to the festival of the book this is just such a wonderful production it's something that Charlottesville has done for years and we are so lucky but it's here so I hope everybody will take advantage and go to lots of the programs this year there are 227 different programs that you can go to in the space of these five days and I'm very grateful that out of that 227 that you chose mine because I would have been really lonely here by myself and as Joyce pointed out I do feel like I'm I'm a pretty lucky person and it's really not very obvious looking at me I'm certainly not wealthy I live by myself because my only child has grown and left home but I think that while many people have to search and search for a vocation for something that really brings meaning to their life I was really lucky to have found two things that bring an awful lot of meaning to my life and the reason that I'm even talking about this is because despite the fact that this room is filled with nursing this is about books so I want to talk to you a little bit just about what that process is like for me I I was born loving words and stories I was very quiet and very shy and in fact I was so quiet and so shy that I was afraid to go to school and I was so afraid to go to school that I had a bottle I don't know what was in that bottle even to this day but it was referred to as my nerve medicine every day as the bus came up the road I would get my tea spoon after a while I stopped getting the spoon out i just opened the bottle and took a swig now I was five years old at that time so I was really very shy and very quiet but because I was so shy and so quiet I had a very vivid life in the imagination and that was probably my favorite life for many years until in first grade I realized that I didn't have to live in that life myself that if you learned enough words you could actually read and not only could you read but you could share your words with other people and that was just like the happiest thing I ever discovered in on seventh grade I had this wonderful teacher who said to me in the middle of the class she was just discussing William Saroyan who really didn't rock my world but it still was a good author and she said in the middle class she just stopped and she goes I think we have someone in this classroom who could write like him they that was like the moment that shaped the rest of my life I was so thrilled that somebody thought that I could be a writer I couldn't imagine anything more exciting than writing in that year I actually lived in a community several miles from the town where I went to school I lived about six miles out in a little country road in that little part of this neighborhood was was referred to as Bethlehem so when she wrote in my yearbook that year this teacher Sally Ryan I hope she's still loved cuz I want to thank her one day wrote in my yearbook to a rising star from Bethlehem well I still have that and I still have my hopes my bestsellers still coming but in the meantime I did find that even though I could do really pretty things with words my plots and my themes were sometimes well infantile so it that continued well into my 20s I'm thinking this is just childish stuff so it's pretty but it's not any good and I decided I didn't really needed to make a living I not only needed to eat I had a child I needed to feed so I had no other alternatives and someone kept insisting that if I just went down the street I could go to nursing school I thought it was a particularly terrible idea for the first year of class I still thought it was a particularly terrible idea by the time I got out and I worked my first day I was totally captured how can you not like helping people how is that even possible I wonder why do we keep that such a secret that helping people feel so wonderful and what makes me really say it now is that we have a shortage of Nursing because people perhaps aren't aware of that and perhaps they're not respected for it so I want to tell you a little bit about my experience as a nurse when I went into nursing I started in in med surg nursing I did that for a couple years and I opened an outpatient clinic so I was away from inpatient nursing for about a decade and when I went back to look at it because I became a house supervisor and I had to worry about staffing and how the house work I recognized that the place that I had left was not the same place I was coming back to even though it was the same building and a lot of the same nurses but the nurses were a lot less happy and and that really struck me as as odd I really didn't understand what had happened so I started looking and I think that the problems that I discovered were much more complex than I expected and so I decided that somebody should write a book about it and I think that the best way to give you an idea of what I'm talking about since just describing a complex world where patients are sicker and stays in the hospital or shorter doesn't really help you I'm gonna give you a little look at the day in the life of Karen Karen is a new charge nurse she's been an RN about a year and now she's her first day in charge she walks into the unit finds out there's already been a call in and she has less nurses than she thought and more patients than she thought so this is Karen's little story Karen looks at her assignment and see she has 29 patients three empty beds four nurses and a nurse's aide on patient care she didn't like the math at all instead of a barely manageable assignment of six patients they would each have to take seven with one nurse taking eight seven of the patients were unable to feed or bathe themselves and required total care five were only one day post-op so they would need extra attention to avoid complications three were on isolation precautions requiring that the nurses dawn gown mask and gloves each time they went into the room and one was beginning the alcohol abuse protocol he was the wild card the medications authorized by the protocol could help him sleep through the worst of it or he could become confused and frightened even a little hostile and the staff had its own issues Rachel was a new RN and Lily who was the most experienced was quite a complainer and her complaining could negatively impact the whole unit Karen studied the sheet and tried to decide on the most equitable division of assignments it was nearly seven before she entered the conference room with where Carol the night nurse was waiting to give her report on the current status of the patients the small room was tense Lily snapped at Karen as soon as she walked in seven patients to one nurse it's just not safe you know not the way they are now they're a lot sicker than they used to be a lot more work they get drugs we've never heard and don't have time to look up and Carol of course was quick to feed her fears yeah and then there's the man in 310 who's been wandering into patient rooms all night looking for his garage well look it's gonna be a tough day Karen said Lily I'll take one of yours so you don't have to have seven and I'll take one others so no one has to take eight here's the assignment chief let's get to work she took a deep breath the shift was only eight hours long really how bad could it be she was soon to find out at 7:20 the shift-change report ended and dr. Felton was waiting for Karen I ordered a stat hematocrit yesterday I'm mr. Helmsley and the results aren't on the chart he held it out to her accusingly did you try looking it up in the computer Emma interceded as a space turned scarlet here dr. Felton I'll check for you she said and left them by the elbow to the available computer monitor Elizabeth was whispering and Karen's here are you crazy he hates the computer well it's this the system we use and she goes well I don't want to be around when you break it to him in the meantime Rachel rushed to the nurse's station quick is mr. Turner a DNR I can't find a pulse Karen grab his chart from the rack and skim the order she doesn't say Elizabeth tell the operator to announce a code then call his doctor and find out if we code him or not Rachel grab the cart feet pounded down the hall as code 12 was sounded over the loudspeakers the room filled with members of the code 12 team even as Karen was checking for breath sounds in a heart rate who was this what's his diagnosis is he a full code as the ER physician Joseph Turner admitted yesterday from a nursing home with possible pneumonia Rachel found him without a pulse when she was making her morning rounds and we don't have a DNR order Karen explained the backboard was put in place chest compression started as the Ambu bag squeezed air into his chest the doctor called orders and a nurse from the code team responded by administering emergency meds to the patient's IV line Jim the respiratory therapist spoke up well what was the status before this is he going to have any quality of life if we bring him around I've never seen him before this morning Rachel said me neither said care I was off yesterday the ER physician frowned get his doctor on the phone I just talked to him Elizabeth said as she poked her head into the room he said he hadn't discussed resuscitation with the family he'll call the son and get back to us Jim's face redden he should have done that before he admitted him what is this man in his 80s if he had no quality to his life anyway we should be letting him go in peace clear a nurse call to Sheila as she discharged an electrical shock to the man's chest five minutes past five minutes during which the heart was again shocked more drugs were pumped in and a tube was passed down the patient's throat for breathing Elizabeth's face reappeared the son wants us to do everything we can Jim the respiratory therapist was growling does he know what everything means it's been 10 minutes and his chest still his heart still isn't beating on its own does he want us to continue pounding on his chest we'll give him a few more minutes the yard doc said and that so the code continued finally mr. Turner's son arrived Elizabeth stuck her head through the doorway mr. Turner's son is here can he come in the ER doctor disengaged himself I'll come out and talk to him how many minutes 20 to continue compressions the doctor followed Elizabeth into the hallway pulling the door closed in a moment he was back we'll call it time of death is 7:56 Jim why don't you go ahead and pull the tube and clean him up as best you can his son wants to say goodbye in the meantime Karen went back to the desk charts with new orders were starting to stack up who's in charge here a surgeon growled I am returning to the desk I ordered a dressing change I'm miss Garrett last night its saturated and making a mess of her bed get it taken care of and then I want you to find the nurse who should have changed it last night and write her up he slammed the chart down on the desk and walked away Karen I need someone to check this blood with me called Donna lily was scowling Karen the pharmacy sent up the wrong drug for mr. Getchell in 306 and they're saying I need to fill out some form to get it corrected I don't have time to fill out a form he wants his medication now well tell him you have to follow procedure we do it to ensure safety and you'll bring it as soon as you can Karen started down the hall after Donna but Elizabeth was calling her name care and mr. Johnson's family's on the phone they want to know how he did last night hey Elizabeth dropped the phone and grabbed at the arms of the patient on the alcohol abuse protocol he was seated in a geriatric chair with an attached tray and it slid down in the chair his chin was on the tray his arms flailed above his head and his bottom hung off the edge of the seat hey I need a little help here Karen asked the patient in the chair where were you trying to go did you need to go to the bathroom mr. Templeton rubbed his head no I was looking for my garage I just wanted to get to the garage do you know where you are mr. Templeton you're in the hospital Karen patted his shoulder well she spoke over his head we need a restraint a waist restraint belt can you pull the paperwork for the restraint protocol and after we get him tied down I'll have to call his doctor for an order its Mathers he doesn't like his patients restrained and I better not say what Karen said at that point the phone rang again it was mr. Johnson's sister upset that she had been left waiting on the phone so Karen took it yes ma'am I'm sorry you were left holding yes mr. Johnson had a good night and is resting comfortably uh-huh yes I'll tell him you called another phone line rang Elizabeth held out the receiver Karen it's Alice that the house supervisor for you but you better hurry because Templeton is trying to slide down under the train again together she and Elizabeth got the man seated properly and then Karen took the call yes how's it going Karen didn't reply did you remember to call the iBank on mr Turner asked Alice the iBank yes we have to call the iBank on every death it's in the procedure book did his family give you a funeral home yet if you know which one I'll call them do you have any idea when you'll get them down to the morgue Karen saw Rachel coming to the nurse's station Rachel does mr Turner son leave yet the supervisor wants to know what time the body will get to morg Rachel look close to tears I haven't even seen all my living patients yet it's 9 o'clock I haven't gotten vital signs I don't know if they've had breakfast how am I gonna have time to fill in all the paperwork for the morgue etc etc a woman obviously frightened approached the desk my husband is breathing too fast he says his chest hurts it's just like when he had his heart attack he needs his doctor now Karen directed than patients nurse into the room for an assessment while she checked his chart for medication that might address chest pain but there was nothing unless she called out find out if he's had these episodes at home and if he takes anything for it she dialed the answering service to alert the physician on call Emma returned to the desk to report that his vital signs his blood pressure his heart rate miss respirations were indeed elevated but five minutes passed and the physician hadn't returned the call so Karen called the answering service again the wife returned to the desk much more frantic this time where is he he needs to do something now and one will give your husband oxygen to make a more comfortable Karen said and we'll we'll get the doctor but five more minutes passed Karen's own vital signs were becoming elevated she paged the nursing supervisor the wife was getting agitated where's the doctor he needs the doctor so the supervisor came to the desk and said do you know whose uncalled because if it's not the physician that is actually taking care of the patient let's call him directly at home get the phone book so they called him at home and Karen braced herself she knew we wouldn't be happy I'm not on call or his first words but he listened to her report and he ordered a stat EKG and nitroglycerin tablets and promised to be there within 10 minutes disaster averted but a new face appeared at the desk obviously disturbed my mother's breakfast is sitting by her bed stone cold no one's fed her or changed her her bed is soaked and smells as if there's more there than just urine what kind of place is this anyway don't you people even care Oh No Karen stared at her blankly as Elizabeth came to a rescue this is mrs. Bedford daughter in 304 I think she's assigned to you today oh no I'm so sorry you're right we've had a couple crises this more and your mother did get forgotten Elizabeth see if him get miss bedford a fresh tray karen shoes burned a trail down the hall noon came and went karen had three pieces of chocolate from a box left by a patient's family as he was discharged she didn't ask what anyone else had to eat because she knew they didn't have time the patient in 312 lost his dentures starting a frantic search until a family member acknowledged taking them home the nursing supervisor visited the desk to tell Karen that someone would need to work a double shift to help cover the evening intravenous infusion pumps alarmed coal bells chimed phones rang doctors left orders can try to explain diagnosis medications or tests to anxious family members she fielding complaints and tried to soothe those in pain and just as the evening ship was preparing to go in for report just as Karen was beginning to believe that they might finally be finished mr. Paulson's daughter demanded to speak with her she was familiar with mr. paulsen it was his ninth day in the hospital with a diabetic foot ulcer are you the charge nurse karen nodded and attempted a smile that went unanswered my father is mr. paulsen in room 315 he's leaving tomorrow but he'll probably be back dr. Holloway thinks that he needs a to have his toe amputated and then she reached into a bag and pulled out of tin dad wanted me to give these to the nurses there chocolate chip I made them fresh this morning Karen could barely contain her surprise well thank you how nice I'm sure everyone will appreciate them he wants to make sure that if he has to come back he can come here again Karen melt all the right words and walk back to the conference room she laid the cookies calmly down on the table looked up at the next shift of nurses awaiting report and burst into tears the evening charge nurse reach for a cookie huh just another day in paradise she said I'll point out that's the nurses in the room because I'm sure many of you have lived that day but so let me ask you a question why do you think we have a shortage now after reading something like that after hearing something like that and imagining if that goes on day after day the answer seems obvious but it really isn't nearly as obvious as it would seem on the surface the simplest answer really and since I typed and very large print I can finally take my glasses off the simplest answer really is one that that requires no blame no finger-pointing it is simple demographics the fact is that women who have up till this point made up 95% of the nursing profession women have found that in the last 20 years they suddenly have choices they never had before so whereas I thought I could be a nurse or a teacher or a secretary and I really wasn't that good a typist the girls today the women young women today and the young men have unbelievable opportunities available to them so that gives them all kinds of choices that maybe some of us baby boomers weren't thinking of then the other thing is of course us baby boomers those who are fit in nursing for a long time are slowly starting to leave nursing and and it's a lot of that is because of the physical nature of the work and it's really hard to stay in nursing until you're 65 it you certainly don't find many people who can do that on an inpatient unit they only can do it if like me they get to sort of slide into an administrative role but otherwise it's very difficult to do such physical work and stay at it until you're 65 but the other problem is that just as US baby boomers are leaving nursing we're also getting old enough to need nursing and there's a lot more of us than those who came before us and the fact is the very profession that we work in the very professional it's done such a great job keeping people alive and doing so well with making diseases that used to be fatal now chronic we have a lot more people living who are living with chronic long-term diseases and that means they need nursing care that's the simple answer but the second answer probably I think revolves most around respect and respect comes in many forms not the least of which is compensation and I think this was in 2000 there was an article with when people just were starting to rumble that there was something going on that people weren't entering nursing schools at the rates they had done so and they're starting to be alarmed that maybe they were going to be less nurses and maybe not enough and there was an article in our very own daily progress and someone was quoted as saying and III unfortunately this quote was etched permanently into my brain that when you accounted for inflation since 1983 nurses had actually lost money now that's a pretty scary thing when you consider how much more complex the patients are and therefore how much more sophisticated Nursing is so that's one little piece of respect but another piece of respect is a sense of power and at the time that I was writing this book which was 2001 in 2002 and I will say that I think things are really starting to change pretty radically but I think that one of the biggest issues about respect is not feeling like you have any power and nursing as a profession certainly has historically not been a profession that felt like they had power not even any power over their daily the daily way that they work that was always dictated by orders from a physician or by somebody else who designed their space who didn't know anything about clinical work but designed a space that made sense maybe to an architect and maybe didn't work very well for the people who are actually working in that space so I think a lack of power was is definitely a big deal in our sadly I would say that in our American society right now and there's no one to blame except ourselves and that's all of us that's the greater number of people is that with our huge emphasis on technology on the bigger and bigger house on the bigger and bigger car there is no respect given to people who choose a career just out of altruism and for as difficult as Nursing is as rewarding as it also is it certainly takes altruism to want to go into the profession and as a society it sure would be nice to be able to think that we could once again really pay respect pay homage to that kind of sense so that sort of tells you why not enough people are entering the profession but keeping them there is a whole different issue and keeping them there is more like Karen stay there they're more inclined to leave because they have days like Karen's because the work is so physical because the public and I'm not going to discount my own self the public is becoming larger and heavier and that also makes the work more physical because regulatory agencies have created more and more paperwork and more and more documentation requirements because there's new frightening infectious diseases that nurses fear bringing home to their families and because and because public expectations have grown out of proportion with the possibilities now when I say that I think it's important to really point out what I mean and and I think that it's because we've made such great strides in medicine because we have cures for cancers that used to always kill people because we can we can take care of heart disease we can which somebody in and out after they've had their chest cracked in four or five days I mean it's just amazing what medicine has done however the the downside to that is that it's given people the expectation that any problem they come with can be fixed and I think we're losing sight of the real truth which is sure I'm till the next problem comes because one of them is going to take you we are all still mortal and I think that that becomes a harder and harder truth to accept in a society that gets that puts more emphasis on materialism and at the same time finds miraculous cures for many diseases so um I can talk now about the potential cure for the shortage or where we are now or how things are in Charlottesville or about the process of writing a book but um since you all have been so gracious and I've just been talking and talking I would be really happy if instead you told me what you'd like to hear about so does anyone have a question yes I know you said things that are lacking but are we making any progress do you see any solution you address if you have in your book at all is nursing I have known to young women recently she wanted to go into nursing and had a terrible time getting into schools one of them got in in is is actually doing okay the other one even though she wants to be a nurse and is it is that what I would call an average student and an incredibly motivated young woman is not in cannot get into nursing um that has been a huge issue and it's especially a huge issue right now about five and six and even a decade ago that many years ago people started actually closing nursing schools but at the same time the the people who are teaching nursing schools are the same baby boomers they're also retiring or they're finding with their education that they make more money by doing something else so after a while of doing the teaching and of working really hard they find a profession that makes it a little easier for them and gives them a little better compensation I think that nursing itself is really looking hard at the problem and trying very hard to get more people masters prepared who are capable of teaching and that does take time the same way that it takes somebody you know the four years to get through nursing school in the first place even if you have people who are nurses now if there are BSN it's going to take them another couple years to get that master's and we also need doctorate prepared nurses I think the reason that the tide is starting to change is because compensation has definitely gone up I mean I think everybody can testify that certainly it's not what it was in 2000 I think that's changed radically I think that it can change a lot more and it will but I think that nursing for the first time has stopped being in the 1950s and has gotten a little more radical in California it is the nurses Association the state Nurses Association that was so rabble-rousing that they actually forced the government to mandate a ratio a nurse to patient ratio now there's a lot of people who think that's a bad thing I personally thought it was a great thing because I don't want it to stay that way I don't want there to be mandated ratios I want nursing to be able to choose what's the best kind of ratios I want the health care system to really make good decisions about that but nonetheless it proves the power of nurses and for that reason I think it was a wonderful thing yeah I was cheering a mind now of course Arnold has has changed that because this year it was supposed to go it went to they mandated a 1 to 6 ratio and this year it was supposed to in 2005 dropped to 1 to 5 ratio but for economic reasons Governor Schwarzenegger kind of nixed that and moved it to I think 2008 he changed it anyway but even if that seems like a loss I don't think it was because once once that nurses association was able to make that move all over the rest of the country people have been starting to do the same thing again I don't mandated ratios is the answer but it proves they have power and once you have power you can start to change things internally yourselves and I think what's what you see in the country too when I just before I have to send in the manuscript for the last time I went to look and see how many magnet hospitals are were in the country and the magnet certification just indicates that the hospital is really nurse focused they're really looking at doing the care with shared governance so that the nurses themselves are making intelligent decisions about how to do care what's the best mechanism how does it fit for them how does it work and there was only whoa there was something like thirty at that time now that was in 2002 do you know what the number is now now we're up to a hundred and eight and this is a lengthy process it takes about three or four years just to even think about it and then try to go ahead for the application so that tells you something as well and and we have on these great researchers now Linda Aiken is one of the the marvelous researchers who has actually come out and done studies that prove that if you have more nurses to the paid to the patient ratio so her ratio was a one to four I even hate to announce this but for every every patient more than four that a nurse had their risk of death within 30 days of discharge and that's because of all the important things that a nurse does that you can't that's intangible it's all that assessment all that looking all that teaching all of that stuff means that their chance of death within 30 days of discharge went up by 7 percent for each patient greater than for that that nurse had now as that information reaches the public reaches even healthcare the people in health care want to do what's best and when those kind when they have researched prove it that's when the changes will happen I think we're in an incredibly exciting time to take nurses and nurses who have always lived in this very matriarchal society where you had one little head nurse and she sort of ruled all the chicks to go from mac and and was ruled by all the physicians when you go from that kind of a model to a model where the nurses are actually looking at is this the best way to treat this patient in this situation they still have the orders from the physicians as far as what medications as far as what kind of treatment but they're choosing the best way for their work to actually happen that's pretty exciting so I think those changes will bring about more changes and will make it so there's more space for people to come into the profession but until we get more trainers trained it's hard to keep the schools open and at least to keep the space is open you might have the school there but they may have cut down from you know 150 slots to a hundred slots because they just don't have enough instructors you know that that's such a huge issue I think if you're gonna look at anything that really has kept nursing in the position it's in it's the way that we pay it's the way the insurance recognizes the way that Medicare the way that all the big payers recognize a physician does a procedure they have a charge and maybe the hospital where they're working has a charge but there is no charge no recognition of all the care required to that nurse and I can only hope that will happen and I and I think when you have nurses associations when you have groups of nurses who understand what matters and group together and feel like they have power then things change and that's one of the things that you really change yes sir talk to us after you finish that passage which is very very interesting exciting you've now been talk a little bit about the solutions and about the things that would make a difference in your book since I have a read your book do you talk about those things in your book yes I try but if I was gonna write the book again I would write it differently one of the reasons I wrote it the way I did was because I was discovering things myself I was offended by what I was seeing I was offended once I started digging deeper to see what was happening to nursing I don't think that I was totally aware what was going on and maybe wasn't totally aware of how the profession was viewed so once I started digging I was kind of hurt and and um I have no idea where I'm going so you help me again see this is what happens to us baby boomers just as we get older and older one question that one comment you made was very interesting to me was the whole question of expectation the expectation of the hospital the patient the family and everybody involved and I think that what are the problems doesn't that relate to the issue of respect when somebody has an expectation that's totally out of reality that how can you then bring that person back but that's even like you're being negative you can bring that person back if you have the time to address it and I I think that's the single largest issue I think it's the single largest issue for physicians and that's their biggest complaint is that they don't have the time to spend one of the examples I used is that you have a 19 year old who comes into the hospital and he has appendicitis the surgeon naturally says sure I can do or scopic appendectomy and take care of this this youngster he's gonna be done he might be out that afternoon he might be out the next morning but he could be walking out that afternoon then you've got a 75 year old who comes in with the same problem surgically it's the same thing it's still a laparoscopic appendectomy but the problem becomes that you're looking at a system that just had a little more age to it so some of those parts are a little more worn out than the 19-year old parts so that it tends to you do something simple but complications occur and and that's the the generation or that's the group that you're more likely to see complications for seemingly simple things and it's very hard for a physician to explain to someone without taking a lot of time about why it is much more risky for mr. Jones than it is for his grandson to have the very same very simple procedure if that helps but I do remember your question now I did talk about solutions but but one of my issues when I really looked at this as I was trying to think of what what started this what made this all happened so I was looking at it from everybody's perspective so I did it from the nurses perspective I did it from an administrators perspective I did it from the doctor perspective and I did it from the perspective of the public and tried to look at how they perceived what had happened and and of course the the persons who did the worst in this whole deal is the public they are the most unsuspecting all these changes occurred and they were the ones least able to understand what was happening so I think they all suffered for it but especially the public we at least had consultants we we were told what was happening to healthcare by somebody came in and and told us what was happening to healthcare but I think that wasn't what was happening for the public so for instance if you had when I first started nursing I was on earth somebody would come in for a total hip they would come in the night before they walked in they walked up and down the hall all night they probably smoked while they walked up and down all night and they had a high old time everybody talked to you know but he was still your patient but he was totally able to take care of himself then he'd be in for at least a week by the time he left he was back to walking up and down the hall smoking and and having a high old time so you were taking care of a patient where you had plenty of time to explain to him all the ramifications of that hip but in if you now cut that down to three days you have less time to explain it to him you have less time to practice with him on his new hip so he's in and out now it's hard enough for nurses to try to cram in all that teaching in this little compressed time but for the public who's the ones left going outside it's even harder I think so I think the payers the payers are going to be the real crux but unfortunately who do you think the payers are it's us so we have to decide also what we're willing to pay for and I think that one of the ways we have to decide what we're willing to pay for is to decide to have a dialogue about something that no one wants to talk about which is when is enough enough when is just because you can it's not necessarily right to continue and I'm not gonna I'm not gonna give my my perspective on that debate I'm just saying we need to have that debate some decisions need to be made people especially need to come into healthcare understanding what it is they personally believe what do I want I know what I want I've tried to tell my only child what I want so that when that time comes she doesn't have to make a horrible decision that goes on for days and days and days she can make a decision and we can all feel good about that decision and everyone in the public when you have the capability to do this many things everybody in the public better make those kind of decisions for themselves just for themselves you don't have to decide for the guy next to you just know what you want and make sure you tell the guy next to you so he can make that decision when you come in yes you spoke a lot about the issue of power and you also have said now that if you had to write this book you would be saying different things I'm interested to know if you can chronicle a little bit about what the process of researching and then writing the good did for you personally and have that impacted your life Reese still working in the institution yes my book yes well I thought it was pretty amazing I because I never really entirely thought of myself as a nurse because I really always thought of myself as a writer and that's a person who works over here by themselves you don't need power so so I don't think that I felt that same sense of not having power but once I started really looking around at the staff and realizing they felt that and really started checking around the country I I researched country and I got nurses who told me they worked with a 1 to 10 ratio how do you even do that I don't know how you'd even see all 10 of them before you go home so I was appalled at what I found but but I also think that it was it was very empowering for me personally it was very empowering to write it down and to actually have an agent say yes I like that idea and to have a publisher say yes this is very timely I think we should put it out that was very empowering but but I think that I also found with the bad stuff I found that a lot smarter people than me had already figured out this problem and they were already working on it the Linda 8 of the world were already doing this research that was inspiring us all to say yes here is a tangible reason why nurses are so important so I think if I was writing it now I would I try to focus I try to focus I'm a little ad D so I like going to all those different different areas but I would try to focus more just on what Nursing feels like and what it what it feels like to be in nursing right now at Martha Jefferson we started right about the time that I was writing the book we were working on a shared governance model and and the really cool part about doing it was that we took two years to roll out the plan because slowly slowly started getting people used to the idea that we were gonna change the model by that they were accustomed to we're a very lovely Community Hospital we had people who you know liked liked a certain role they were comfortable they'd been in that role for a long time so you don't just change that culture without doing a lot of preparation work and now that it's unrolled then it's been in place for about eight or nine months is that right people are so excited I can't even tell you what it feels like to walk down the hall it is so different plus using some of that research from my own unit I was able to ask for a budget so that we would have a 1 to 4 ratio that's an exceptional ratio by the way I just thought I'd point that out and the rest of the hospital for medical surgical is still one to five which is a really good ratio but because we're also aware of it now we all really are militant about it we all try to protect the nurses I mean it's a very different place and it feels so much better I can just imagine what people did five or six years ago who suddenly became Magnet status why they got all of the nurses in the area I mean they get nurses and they retain them because no one wants to leave those facilities because they just are so much more nurse friendly there's so much more collaborative the team is the nurses and the doctors and the physical therapist it's a whole team and not only this group over here and this group over here so if I answered that anyone else is in the indus description of the work and having colleagues which would you have the running commentary of what actually happens you get a sense of the the importance of leadership and you also get offensive of what each person faces when they're in a crisis mode and without founding caddy I have to say that I had this sense that I wanted how many people qualified for al-anon it felt like you know there is there was there was some sort of and that's not meaning negative but there's some sort of person that would could enjoy rising to the occasion now I'm not I'm just you don't need to answer there I'm not a nurse that's not a criticism but it I think it does you do feel that there's there's nurses that to have to quit because they haven't make a choice between being in a masochistic kind of environment right and you have to quit not because you aren't a good colleague and you're not a good professional and you don't function well but it is you put yourself in a position of being harmed every day either by by the system but also by colleagues and the question of course it comes to me that's only hinted at is where are the children most nurses that that I know end up single moms or our single moms who stick it out you know it's it you get your one career choice for nurses is to be the stay-at-home mom instead of having to work because she's got a spouse or being able to make a choice about what are my heart attacks and a lot of times that the nurses who do work have a young child that they're also trying to take care of their emotional and physical needs up and I can just I can just feel the pain as you're talking about these women trying to take care of their patients take care of their patients families and take care of their you know their professional responsibilities I can just imagine what it's like when they get called and say we'd like you to work a second shift and they're on the phones trying to arrange childcare they're trying to fund it or their sister can pick up their child it's a daycare and they're trying to find out you know all of these and I know that supervisors have to work with this kind of strategy and I don't know if this is addressed in the book well one of the things especially enforced over time I would like to say publicly we have never done that at Martha Jefferson nor will we ever but where you find if you look at the country and sort of look at where nurse unions have evolved that's why it's because of things like enforced over time and if you talk about that I think I think to be a nurse requires a special person I do believe that I think you have to really enjoy you have to get a lot of a lot of back out of helping people you have to feel like you're on a mission that you're doing something good and that feels good and I think that in its purest form that's that's absolutely wonderful but I do agree that the that it snuck up on us that it became so difficult and when I say it snuck up on us I mean in the last ten years it changed so it wasn't that it was always that hard it's that when the payers made the day's short when the patients were able to live longer with many more complicated diseases it became more complicated so it snuck up on us not that it was there when we went into it negative or the where the wounds are but I think it speaks to the difficulty then in making clear political and personal decisions when you're in such a bind about how to conduct yourself you're between being exhausted having so many other responsibilities and and in need of a job you know the nurses to ask a different question we've had these banners at University of Virginia for example proclaiming top 100 hospitals is there any opportunity in the future for nurses to evaluate hospitals that make it so that does of us who are using these facilities now this is for a good nursing care Edith and I have a good well I think that we already have that we already have that choice and where you already see it is who has low turnover and as well staffed and who isn't well we have three patients come in asking what's your nurse to patient ratio before they come they want to know that black people are internet savvy and they they come in and they the one thing about the public right now is you might not even know your next-door neighbor you might not you know we don't have barn raisings people live in isolation when you come into the hospital you expect all your needs to be event by one poor nurse you know everything you expect her to meet all your needs when you don't even know your next-door neighbor or you know you're getting all your needs met on the internet right now but you expect someone to take care of you well and you know society has a bunch of very strange issues right now in this business strategy I do wonder about child care and how nurses are are there 13 cooperative or some sort of how I got into them and to work with very young children interestingly enough it was when my children before they were born I my first employment when I was going to college was in a day care center at place called Crawford long walk from Atlanta Georgia and the only people and the only people who could leave their children there were are mmm and we kept those children for all for two shifts now not the mid not the last shift but we put those child children in pajamas I was 19 years old but those we had a ratio in there of one worker for every four children and so you know it we sort of replicated the need and running and met the need now maybe it was a recruitment process but where are the children in this community of nurses for care that's right I think that's a question I can't even answer but someone in the back did have a question I wanted to know why the CNAs absolutely never recognized for our what you do I would if we did not have CNAs nurses couldn't make it with a one to four ratio III don't think you can one of the things about a magnet hospital that is so cool one of the things that's so great about chair governance is the idea that you really start looking at your whole team you don't just look at you you start looking going wow every other person on this team is important to get in the work done and I think frankly I think there's no one more important than the CNAs because they do what I used to love to do and can't do any longer don't know but what they're taught in the books you know and I feel like we we all recognize I'm seeing all you can pay more than will be absolutely and I think that I really think that we're moving in a better direction where we're really gonna recognize all members of the team in a better way and I know I know that we are working on that in my hospital I know in my own unit we're trying to make a big emphasis to make sure that every member of that team is appreciated especially because they they work so hard I think um I could wrap up it unless someone else had a question um I I certainly appreciate your attention I really appreciate your all coming and I hope that you'll do other stuff with the festival of the book do other stuff with Nursing but definitely go and see some of these other things that are at the festival of the book and thanks for not going to see Malcolm Gladwell tonight but thank you very much face Adderley at last weekend's virginia festival of the book she's been a nurse for 20 years where have all the nurses gone is her first book for more information on the festival visit VA book dot org

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