We received a letter to the editor recently from a new nurse who would not give us permission to publish his name out of fear of reprisal from his employer. The letter was in response to an article on functional decline in older adults in our January issue. In the article, Carla Graf underscores the importance of nurses in promoting functional independence in older adults. The letter reads, in part:
The budgeted staff in most hospitals outside of California is not sufficient for assisting and monitoring older adults in activities such as ambulating. Sadly, attention to mobility often is limited to the few moments devoted by the physical therapist, if the patient does not have a family member with whom to walk, and if walking is indeed ordered. It's tough for a day-shift nurse with eight patients. Perhaps all of the expensive medications and other treatments could be replaced with simply getting the elderly patient out of bed as much as possible.
I'm sure many nurses can concur with this and will probably have a similar response to this month's article on bathing patients with dementia by Joanne Rader and colleagues (see page 40). People with dementia can become terrified and combative when bathed because of how this task is approached; some become verbally and physically abusive of caregivers, who sometimes return the abuse. Rader and colleagues outline practical strategies for making bathing safer and more pleasurable, instead of producing anxiety, for people whose perceptions are altered and verbal skills are limited. The article challenges caregivers to think differently about bathing patients. But to think differently is not enough.
Nurses are working too many hours but still can't provide basic care.
This month we feature a study by Alison Trinkoff and colleagues on the extended work schedules of nurses, which can include working more than eight hours a day or 40 hours a week, mandatory overtime, rotating shifts, and inadequate time for rest between shifts (see page 60). They found that a significant proportion of the respondents' work schedules exceeded the recommendations of the Institute of Medicine (such as a maximum of 12 hours per day). More than a quarter of the sample, including half of hospital staff nurses, typically worked 12 or more hours per day; 17% reported having to work mandatory overtime. It has been established that extended schedules in health care workers can lead to an increase in fatigue and error. Nurses are working too many hours but still can't provide the basic care needed to prevent complications, reduce abuse of and by patients, and lower costs.
Something is wrong with this picture. Here are some things we can do to correct it.
Prioritize the basics of nursing care, such as ambulating and bathing patients to prevent complications and promote recovery, as quality improvement endeavors-as exemplified in Transforming Care at the Bedside, a joint project of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement (see http://www.ihi.org). This entails pulling together an interdisciplinary team to examine the problem (for example, the stress and violence associated with bathing patients with dementia); to develop, test, and evaluate creative approaches for addressing the problem; and then to spread the solution to other areas in the facility.
Get rid of mandatory overtime and set limits on extended work hours-as is done, for example, with pilots and operators of public transportation-whether through voluntary action by the employer, union contract, or statute. These practices are not safe and institutions should not be allowed to rely on them to ensure adequate staffing. Nurses who work extended hours by choice should also examine whether doing so is morally acceptable when it puts patients at risk for errors.
I'm concerned that nurses don't feel safe enough to speak out on the factors that affect patient safety. We're not victims. You can advocate change in your institution, or you can leave and find a work setting that wants your commitment to leadership. The choice is yours.