DB#1

Introduction

The opioid crisis has been an ongoing public health concern and has raised awareness on all levels of care in the communities nationwide. The Center for Disease Control and Prevention reports at least 130 Americans die everyday from drug abuse.

Competing Needs with Opioid Epidemic

The uprising of opioid drug abuse admissions that have costed over millions due to inpatient treatment, intensive care unit required treatments and outpatient treatments have mounted to 1.94 billion dollars (LaPointe, 2019). Beside the accrued preventable healthcare costs and epidemic that has caused deaths and distressed the emotional well beings of their family members, hospitals are also facing a drug shortage. Soumerai, Kamdar, and Chadner (2019) states the restrictions put on drug companies to manufacture intravenous pain medications due to the opioid crisis has had negative impacts on the patients who are in need of these medications such as oncology patients and end of life needs. Soumerai, Kamdar, and Chadner (2019) further explains that the restrictions on the supply of opioids by drug manufacturers have not improved the opioid epidemic and affects the patients who are in need leading to a suboptimal outcome.

Policies Regarding Drug Shortage and Opioid Epidemic

Currently our policy is to use by mouth pain management such as Toradol, Tylenol, tricyclic anti-depressants, topical therapies and non-pharmacological therapies such as heat, cold, physical therapy and distraction. If the patient is nothing by mouth, the next route would be intravenous pain medication routes such as IV acetaminophen, IV Ketoralac, topical analgesics and others. In situations with acute pain would prompt IV therapies such as IV Ketoralac and Narcotics. Soumerai, Kamdar, and Chadner (2019) have collaborated with their Pharmacy pain management department to produce pain management policies like ours.

Impact of Policy Guidelines for Pain Management

The policies put in place I am now experiencing as an RN in Oncology with overflow is patient satisfaction. Patients feel as though health care professionals are not sensitive to their pain levels and has brought an untrusting relationship between the nurse or Doctors and the patients. I can foresee the patient satisfaction and HCAHPS to decline with the new changes in place. One way to overcome the issue is to provide patient education on other non-pharmacological therapies with pain management.  

By: S. Dahdal

DB# 2

Week 3 Discussion Post 

The nursing role is guided by strong ethical and moral principles that govern behavior in delivering care, and nursing leaders must both demonstrate the capacity to behave similarly and to inspire ethical behavior in others (2018). In my hospital, we have been at capacity for at least three years, despite opening new floors and growing to 514 beds. I choose staffing as my healthcare stressor because it affects both patient and nurse and is the greatest threat to the healthcare industry. With resources being scarce and nurses being an essential resource, in my opinion, the balance between safe, high-quality healthcare and proper staffing has shifted. When organizations state that patient safety is paramount and base their mission statement around patient safety but, do not provide the appropriate amount of nurses, a recipe for disaster is created. Functioning within healthcare organizations where the main goals are cost containment, efficiencies, and effective care significantly impacts the ability of RNs to function as autonomous professionals in keeping with their professional knowledge, ideals, values, and scope of practice (Kelly & Porr, 2018). I am pragmatic; I understand that organizations are under pressure to produce a profit while having to conform to new national objectives. Nurses are struggling with upholding their ethical values and toeing the company line in for fear of losing their job. Open conversation between all disciplines on where the safe changes can be made to better the overall healthcare experience for both the patient and the clinician is the first step in resolving many of the healthcare issues.

Competing Needs for Policy and Effects on Staffing

As a discipline, nursing is grounded in advancing knowledge focused on promoting health and addressing human responses in health and illness (Marshall & Broome, 2017). There are instances when we must step out of our clinical role and express our concerns to the healthcare organizations while considering the business side of healthcare. Currently, we have policies in place that allow for post-operative open heart, Impella, continuous renal replacement therapy (CRRT), and intra-aortic balloon pump (IABP) patients to be at a nursing ratio of 1:1. This policy was recently considered by the administration to be the cause of many of our staffing issues and was brought before the critical care committee for discussion. The committee consists of nursing, surgeons, intensivists, and management; it was a productive meeting and intriguing to hear both sides. The physicians went to bat for their patients and the staff, giving their rationales of why these policies exist and should not be changed. Nursing explained that we have been operating at productivity levels far above average for the unit, standards that are placing nurses in ethical dilemmas with caring for their patients. Management toed the line but was noncommittal. Nursing also brought up the fact that falls, catheter-associated urinary tract infections, ventilator-associated pneumonia, and pressure injuries were also increasing across the hospital. While productivity operating 20% to 50%, depending on the unit, may appear suitable on paper, it is stretching the staff overly thin and hurting our patients, while decreasing morale which has led to an increase in turnover. Administration spoke of the need to cut costs and if there were any ideas from the committee. This idea was well received was increasing the staffing pool; these nurses do not have to be full time and carry benefits. Many nurses are willing to work a shift or two a week, and the opportunity to hire per diem or part-time nurses to fill the void could save the company money over hiring full time or paying nurses to come in for overtime. The administration stated they would run a cost analysis on this idea. 

Conclusion

The future of healthcare is all about change and trying to adapt to the environment (2009). More importantly, the future of healthcare is dependent upon nursing leaders being able to communicate the needs and concerns of nursing professionally. At every level of the healthcare ladder, nurse leaders must make their voices heard. Open lines of communication with management and administration, being active in professional organizations, growing our young nurses, we must take the extra effort to show pride in fighting for what is ethical for our patients and ourselves. On the policy level, it would be helpful to re-open the discussion on formulating legislation regarding optimum nurse staffing levels (van Oostveen, Mathijssen, & Vermeulen, 2015). Florida staffing bills usually get squashed before there is ever a vote on them. If at an organizational level, our needs are not being met, we must take on the fight at the next level. No patient should have to incur any additional pain, injury, or expense due to an organization failing to staff their hospital adequately. 

By: D. Boag

DB# 3

The pressure by the Institute of Medicine (IOM), to have 80 percent of nurses holding a baccalaureate degree (BSN) or higher is a competing issue affecting the nursing workforce, resources, patients, and development of policies. The factors that affect the nursing workforce, patients and resources available are in conjunction with each other. Some of these factors are the aging population including the nursing workforce, nurse burnout, and lack of educational support (Haddad & Toney-Butler, 2019). Currently, the US has the highest rate of people living over the age of 65 in history. (Haddad & Toney-Butler, 2019). Most people living over this age have more than one sickness or disease process they are dealing with, requiring advanced skills, education, and knowledge to treat this population.

The nursing workforce is aging along with the baby boomers. Since 2012 over 60,000 registered nurses (RN), who are baby boomers have retired. It is estimated that over 1.5 million nurses who are in their late 50s and 60s will be retiring by 2030 (Buerhaus, Auerbach, & Staiger, 2017). Though most of these retiring nurses only have an associate’s degree in nursing (ADN), because of traditional nursing qualifications, there is a substantial amount of nursing knowledge that these nurses have gained from years of experience. The demand for increased knowledge and care for the elderly patient client, and loss of experienced nurses may decrease the quality of care patients receive (Buerhaus et al., 2017). Most of these senior nurses also serve as mentors, leaders, and role models because they have learned how to effectively collaborate with physicians, administration, and the whole interdisciplinary team to provide safe and quality patient care (Haddad & Toney-Butler, 2019).

Nurse burnout and staffing ratios may also affect the development of policies. The restructuring of healthcare plays a huge part in the stress put upon nursing. Pressure by the IOM, for nurses to further their education, is causing push-back from nurses. A qualitative study about the barriers for BSN completion showed that nurses are pressured about the requirements to completing a BSN, while juggling working full time to receive benefits, and taking care of a family (Duffy et al., 2014). One nurse stated in the study that “It is a lot to ask when you’re working 12 hours shifts, and have to make sure there is still food on the table, most of us do not think going back to school is worth it, especially when there is no significant pay raise.” (Duffy et al., 2014).The RNs noted pressure about the requirement to complete a BSN while also working as an RN, regardless of family and other related factors. This added pressure is a leading cause for nurse burn-out when having too many responsibilities, in such a short period of time.

Lack of educational support because of facility shortage, not enough classroom space or clinical sites and budget restraints are barriers to nurses pursuing higher education (Altman, Butler, & Shern, 2016). Not enough nurses are going back to school to pursue a higher degree because they simply do not have financial support, are being turned away because of schools budget cuts or do not see higher compensation for going back to school (Altman et al., 2016). It is the ripple effect that is greatly affecting the future of education and nursing future.

In the end, policies need to be set forward to address the issues mentioned to support higher education. One way to address this is by creating a policy that brings together retired RNs and less experienced nurses so they can learn the tips of how to handle management positions, team building, budgeting, and leadership roles (Buerhaus et al., 2017). Another policy that can help is establish more financial assistance programs for nursing who have families or simply cannot afford to go back to school. Certain hospitals provide tuition reimbursement for pursuing a higher educational degree. When incentives are provided for higher education such as tuition reimbursement, better pay differentials for obtaining a higher degree, and greater opportunities for advancement, nurses feel more appreciated and willing to go back to school and make a difference (Altman et al., 2016).

By: C. Davis

DB#4

A new analysis from U.S. federal government actuaries say that Americans spent 3.65 trillion dollars on health care in 2018 (Sherman, 2019) Healthcare cost is skyrocketing and there is tremendous pressure for cost-cutting in hospitals in the United States, the hospitals trying to have minimum staffing levels necessary to ensure the safety of patients and nurse. staffing problem gets worse with baby boomers and as demands in health care grow, staffing also impacts nurse-patient ratio and nurses burnout and quality of patient care.

Staffing and Burnout

Staffing directly impacts patient quality of care. Nurses are the majority of labor cost in the hospital. Staff shortages, an aging population, and with the increased patient volume all the time leads to more chaos. Nurse staffing is crucial to control cost in the long run for hospitals. staffing crisis leads to other major problem in nursing nurses burn out, issues with retention, dissatisfaction, high tune over, poor quality of care, negativity, aggression, and much work-related illnesses. Our hospital has code purple 3 out of 7 days, our staffing is based on budget, patient acuity, and nurse-patient ratio. Inadequate nurse staffing linked to higher readmission, higher mortality and it leads to hospital-acquired conditions which are costly for hospitals e.g. falls,  pressure ulcers, CAUTI, central line infection, etc.

Understaffing endangers nurses and patient alike. also, it impacts hospital turn over and hiring of more agency nurses  and temporary nurse staffing  which  causes resentment among permanent nurse for the pay changes with agency nurse and staff nursing, understaffing issue leads to mandatory overtime, dissatisfaction and high turnover as per Association of Nurse Executives (AONE) turnover account for 21 percent of total cost on an average one nurse turn over cost $10k , also have hidden cost for training  new nurse, along with loss of productive hours, it is  hard to recruit and retain nurses. shortage of staff leads to high nurse-patient ratio, errors in documentation, medication errors,  poor patient care and overall it impacts patient, nurse, and hospital. Agency nurse and temporary nurse, even with good pay still not providing a good quality of care like hospital own permanent staff RN, as they are not familiar with the policy, protocols, and standards. Productivity reduces, due to additional burden on hospital staff nurse to train the agency nurse. The AONE reported four out of 10 nurses planning to leave their current position in the next three years, this will create false ballooning of nursing shortage (Gordon, Moss, Kirtner, & Rees, n.d.).

Nurses feeling fatigues, dissatisfaction, negatively impact hospital operational costs by sick call, going to prn basis, negativity at the workplace, impact other coworkers, patients, and work-related injuries, medication errors and errors in documentation (Miller, 2019).

Staffing and Policy

Policies are placed for the safe patient handling, staffing policy is for 12hr /shift without accurate nurse-patient ratio.   The epidemic of staffing crisis leads to American nursing association(2015),  campaigning for regulations and campaigning for state staffing laws to have hospital nurse-driven staffing committees to match the skills and experience of staff, mandate nurse-patient ratio and disclose staffing level to the public or to the regulatory body. This changes should include the intensity of patient needs, no of admission, d/c and transfer during a shift, level of experience, unit layout, and availability resources like ancillary staff technology, etc. This regulation help nurse to have a safe ratio, better staffing and it is evidence-based, may help with cost saving for the hospital.

Due to high patient turn over med surge nurses on average taking 8-10 patient /day. Discharges must be completed within one hour. Observation patient should be discharged in 23 hours and admission should be completed within 1 hour after the patient arrives on the floor.  All this leads to more patient admission and high nurse-patient ratio. Staffing policy is there but how accurately it is implemented? we are short of staff for more than 5 yrs. due to turnover for manager and directors, it is hard to find a solution for staff till they get acquainted with the system During pick season that is during the month of November, December and January hospital hiring more agency nurses. A recent survey shows nursing burnout rate is higher at my hospital, leaders hired PCT for non-skilled task delegation to reduce the burden on nursing for ADLs, pending survey to analyze the result.

By: H. Bhatt