What Could Be Wrong with the IOM Committee on the Future of Nursing?
I have great respect for the IOM and am sure that the folks on the committee that is exploring the future of nursing have excellent intentions. But here’s the problem, if you check out who is on this committee it includes only high level management and corporate representatives. One of the people on the committee is John Rowe, who is the former CEO of Aetna. According to researchers on health care overhead and administrative costs, Rowe — a former geriatrician –earned more than $200,000 a day as CEO of Aetna. I did the math and turned that into an hourly wage — assuming that Rowe worked a ten hour day — and came up with guess how much he earned each hour? Over $18,000 an hour. Is anyone on earth worth that? So one man earned, in say three hours, more than the average nurse makes in a year. I am sure Rowe is well-intentioned, but like the traders on Wall Street who are now guaranteed bonuses without regard to performance, such corporate compensation without regard to how an insurance company like Aetna performs for its subscribers/patients strikes me as a disqualifier for someone talking about the future of nursing. Aetna was obviously very profitable for Rowe, but like other insurers it routinely denied sick patients needed services, forced them to wait for hours on 800 lines, and routinely denied coverage because of preexisting conditions.
Check out who is on the committee. There is no staff nurse representation . No union representation even though unions make up the majority of nurses who belong to an organization within nursing. More to the point, IOM recommendations tend to be exclusively voluntary. I am therefore dubious that this committee, well intentioned as it maybe, will be able to grapple with the serious issues that face the profession. What are some of those issues?
Well of the most crucial ones is work intensification — i..e nurses are constantly asked to do more with less, while their CEOs seem to be rewarded for doing less with more. Today, I was reading an article in the New York Times about Wall Street firms guaranteeing bonuses to traders — even if they lose money for a firm or client. Seems that Wall Street firms — who have done so much to advance our well-being economically and otherwise — are so eager to attract talent that they will tell traders they are assured say an extra $100 million even if they screw up. Yet, our society, which supposedly values and trusts nurses is not willing to even guarantee a nurse a day’s pay. Nurses all over the country come to work only to be told to go home when there aren ‘t enough patients. Or they’re told not to come in on a scheduled day and take a sick, vacation or personal day instead. Is this the way we treat a valued professional? When I cancel an appointment with my massage therapist less than 24 hours in advance I have to pony up the entire fee for the hour I missed. But RNs with years of educaiton and experience are supposed to live on air and altruism. Will the new IOM committee consider this?
What about the way that hospitals are racing patients through the hospital bed via computerized bed tracking programs. Nurses all over the country are complaining that the moment the patient comes into the bed, what concerns their management is not what happens when the patient is actually in the bed, but how quickly the nurse can get the patient out of the bed. It is critical to consider how this corporate focus on through-put impacts nursing practice. “The moment the patient arrives, we have to estimate how quickly they will be discharged,” one nurse told me recently. What is most important to her managers, she said, was the patient’s exit not what happens to the patient when he or she is in the hospital. Of course, discharge planning is a crucial part of any attempt at patient management. But if or when planning for the discharge seems to overshadow planning and delivering exquisite care to the patient before they leave the hospital, then something is very wrong. Yet nurses on the ground say this is precisely what is happening. I am curious to know whether the IOM will look into this.
Perhaps the most distressing thing we see in all this is how the mechanisms of the factory assembly-line are invading health care. Strategies to intensify work — to get nurses to do less with more –defeat nurses’ attempt to maintain a professional practice. Although all of these assembly-line strategies come neatly packaged in the rhetoric of patient-centered care, it is clear that efficiency, defined in classic economic terms as how few inputs can produce a particular output so that the cost is cheaper, often compromises patient outcomes. Moreover, the industrialization of nursing work also compromises nurses’ sense of job satisfaction and ability to maintain professional standards. Those who consider themselves to be nursing leaders talk alot about professionalism and professional integrity. Yet many of the policies they promote Taylorize the work and deprofessionalize the worker. Moreover, they convince working nurses that management is not merely not on their side but actually against them. When a computerized bed utilization system was introduced in her hospital, one new nurse– who’d only been out of nursing school for a couple of years– had this to say. “They (hospital management) hate us. Why do they hate us?”
I’d like to hear from working nurses about these work intensification issues and also let me know what you think about all this. Do you have experience with new computerized systems? Do you feel that your workload has increased with the introuduction of computerized systems? Do you feel supported by management?
If you’re a manager how do you feel about what I’ve said?
I strongly agree with all of your comments and share your concerns. Working as a staff nurse and also a national speaker buts me in a unique position. As a staff nurse,my workload continues to increase weekly – small additions to the workload e.g. this week we now have to get a key from one pyxiss and then go to another pyxiss for PCA Dilaudid and then return the key! 3 steps for a med that 80% of our post op patients use. Management does not intervene – they don’t see the effect. The bottom line is money. Even hand amputees are discharged as shor stay patients in less than 24 hours. Because changes like thse are insidioius and small, and nurses work so hard, they often don’t see the cumulative effect of numerous busy-work.
That said. Let’s lobby now to the IOM to include front-line nurses and managers in this forum – even if it’s just recommendations.
Appreciate your advocacy! Kathleen
I think your idea is a good one, lobbying is really necessary. the committee should include some kind of staff nurse representation. I’d like to hear from other people on this, please write in.
The IOM committee has announced three public meetings that should provide an excellent forum for the expression of concerns:
• Future of Nursing Forum: Acute Care
October 19, 2009 – Los Angeles, CA
• Future of Nursing Forum: Primary Care, Community Health, and Public Health
December 3, 2009 – Philadelphia, PA
• Future of Nursing Forum: Education
February 22, 2010 – Houston, TX
This page has contact information for the commission as well as subscription information for the listserv for committee updates.
As an advanced practice RN (CNS) I was involved in setting up a stroke program for a large HMO. Many of my recommendations involved un-popular ideas such as making all newly admitted stroke patients a 1:3 RN to patient ratio. My rational was based on the workload (numerous studies; CT, MRI, MRA, CTA, vascular ultrasound, etc). These numerous studies mean that each RN must go with each patient to many locations in the hospital. What we call “road trips.” When each RN must transport patients 4 to 8 times a day, there is little time left for doing all the other work such as medications, charting, teaching, and on and on. The bottom line, RN’s were very stressed, and patients did not get the care and attention to detail they needed. As a result, “patient satisfaction scores dropped.” This got the attention of senior leadership, but they still didn’t see that the problem was the RN not having enough time to do the job right. They wanted to know what was “wrong with the RN’s?” Did I mention that we also had 7 different RN managers in two years for the new stroke unit? No consistent leadership.
I am an ER nurse in a large level one trauma center. We have recently been implementing computerization in stages. I have to say that I felt very supported regarding this process. There were so many trained hands around to provide technical help that we were nearly tripping over each other. I never felt left alone to figure out my own way, making the transition seamless and easy.
It has now been over a year. I always give myself a year to adjust to change, figuring that angst has more to do with transition than the actual change itself. And I have to say that I feel more like a bank teller than a nurse, especially in triage. I even try to joke about it with my patients when I have to wait for the system to reboot.
Our bed management and tracking system has also made me feel less like a nurse. Too many times a day I hear, “Why is that patient still here?” And I feel the need to defend myself, yet again. I am tired of running against the clock that ticks faster than I can think.
Don’t get me wrong. I love technology. At home, I use my blackberry for a phone, listen to podcasts on my iPod and read books on my Kindle. My laptop has become my best friend. Is my life at home easier? No, but I can say it is enriched. At work? Not so much. Technology feels more and more like a burden I don’t want to bear.
I feel so old when I say nursing is moving a direction I don’t want to go. I’ve been a nurse for 12 years-wanted it since I was 13 years old. And now, I just don’t know. It’s so impersonal and overwhelming. And now, after reading this blog, I understand why I am so miserable.
Thank you Suzanne for your insight,
Wow, these are great comments. I especially like the one about the computerized bed system. Yes computers are great, but the real question is, in what context are they used and what imperatives and mission do they serve. Lorettajo Kapinos and the other nurses I talk to highlight what seems to be one of the main imperatives of too many hospitals today — get the patient out. The question too many administrators and managers seem to be asking or seem to be forced to ask is, as she says, “why is the patient still here?” The response seems obvious — because the patient is sick. The real question that should be asked is “What can we do for the patient while he/she is here?”
As a staff nurse on a busy general surgery floor, I can tell you that the need to discharge patients more quickly has become a more “urgent” issue from our supervisors, who have had it handed down to them from their supervisors. Women who have mastectomies are now discharged the next day. People can have complex vascular bypasses/repairs of their aorta and be out in only 2 days! Of course, with the vascular patients, you spend the first 12-16 hours after their surgery doing hourly neurovascular checks (which requires an RN) and also hourly vital signs. Sometimes, I come in the day those patients are discharged, and think to myself, “but all of that work that I did, now I have to start over with another patient!”. You can see how nurses can easily get burned out. Not only that, but in the last 3 years, I have seen an increasing number of patients “bounce-back” i.e., return to our floor because they have developed a complication which could have been prevented with a little more time to teach them how to prevent it, or they come back simply because they were never really ready to go home in the first place! So then the patients return for another 3-5 day stay, when maybe, they could have just stayed an extra day in the first place, the return stay could have been prevented! Add up those costs!