Internal Bleeding

St. John's Mercy Medical Center alienated their RNs when they turned to less experienced caregivers to save money. Now they're paying for it.

Overall, is patient-focused care working? "We have teams that are at different points in their evolution," Crain says carefully. "The creation of the PCA role was a consolidating of some of the other tasks that folks assisted the nurses with: traditional nurse-assistant tasks, some of the phlebotomy.... It was an attempt to have the majority of the patient's care needs met by that group of caregivers."

She sees the shift as a way for nurses to become less task-oriented and more managerial. "It is our responsibility to participate in the care by using our critical-thinking skills, analyzing the data and helping to certainly provide the care for patients but also direct the care." Do the nurses have enough time with their patients to give -- or direct -- quality care? "I do believe here that the nurses -- I personally monitor staffing here on a very consistent ongoing basis, and I believe that our staffing patterns and ratios are absolutely adequate," she replies. "There may be isolated situations here and there, but the nurse-to-patient ratios are better today than they were in '93-'94, because the folks that are left here are sicker."

Maybe she means the ideal ratios -- because if the actual, current ratios were that good, St. John's wouldn't be looking to fill more than 150 RN vacancies, plus almost 90 PCA posts, and they wouldn't have created more than 110 new RN positions in the past year. They're struggling to rebound, especially because the average daily patient census is up to 528, a 7 percent increase since 1995.

Peggy Palermo, a critical-care nurse at St. John's for 15 years, says the ratios are misleading anyway, because nurses are doing more secretarial work, lab work and housekeeping work. "You can't spend any time doing patient teaching or preventive treatment," she notes, "and we don't keep charts and records the way we used to, noting every detail or warning sign. We don't even have time to fill out incident reports when something goes wrong." You also have to measure ratios on the bad days, not just smooth them into an average, she adds, because "there's no longer any nursing staff to pull in. We're below skeleton."

Crain swears the overall turnover rate hasn't increased, and the overall level of nursing experience hasn't dropped significantly. A few months ago, she distributed a video detailing recent recruitment efforts. Was it convincing? "I suppose if you hadn't been at St. John's for a while, it might have been," acknowledges Herbert. "But all these things have been said before. During the MONA campaign, they staffed up too, but afterward, things deteriorated again."

Thacker worries about inexperience, noting that 21 of the 48 RNs on her floor have been there for less than a year. "We've had nurses taken out of training because of staffing necessity. And those fresh out of orientation are training new orientees." Prade says "in peds (pediatrics), if you've been there a year you're an old-timer. In mother-baby, we had one girl who said, 'I've only been there a year and I'm orienting new people.'" (Those new people, incidentally, start at $12.68 an hour; long-timers at the top of the pay scale make $24.12 an hour.)

"Certainly new nurses do require training," concedes Crain, pointing out that the hospital has excellent educational programs. "We all started as a new nurse at some point." That's slim comfort, though, to those who depend on them. "There has been a mass exodus of some really good nurses," notes a physician. "We have a lot of new faces, relatively inexperienced, taking on the patient care."

The other training issue involves nurses assigned to "float" to a shorter-staffed area. D.J. Gross works in the mother-baby area, a happy, cheerful unit that's "probably the best-staffed in the hospital. It's the PR area, and we have an excellent department. But we get pulled to the NICU or peds or gyn.... You need to know where things are; you need to know the routine. With a contract, we could specify that we want adequate training, so we don't endanger any patients and run the risk of losing our license. It's just a very uneasy feeling you have when you are taking care of someone and you are not really sure what you are doing."

Prade, who's in the NICU, says, "They will pull in a maternity nurse who never really did babies. We try to give her the easiest cases, but there are times those babies are actually getting sick and that nurse doesn't know how to pick up the subtle signs." Conversely, when Prade was "floated" to pediatrics, she found herself taking care of "a 13-year-old, two days post-op with a spinal fusion. I am so far out of my league here."

Crain points out that "there was a time when nurses floated to multiple areas." (Granted, patients were less sick in those days.) "Now we are structured into care centers, groups of similar patients; we have identified and established networks that nurses float to, to ensure that the competency they need is appropriate for the needs of the patients." In other words, if you're a neonatal nurse you should already know how to take care of that teenager with the spinal fusion.

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