A Day in the Life of an NHS Nurse – How Our Government Is Failing Both Patients and Nurses

Yves here. I am running this post not only to provide a vignette of how the Tories are succeeding in lowering NHS service levels, but also for informed readers to pipe up about staffing levels and patient loads in US and other hospitals.

By Mark Boothroyd,  co-ordinator of the Four-to-One campaign which is calling for the introduction of nurse-to-patient ratios in the NHS. You can sign their petition here. Originally published at openDemocracy

Last year 33,000 nurses left the NHS, 3,000 more than were recruited. There’s a simple solution – resisted by a government determined to press ahead with piecemeal privatisation.

f you take a look at the average daily workload of an NHS nurse, you can see how it would drive any but the most committed to leave the underpaid and undervalued profession.

Average staffing levels in NHS wards means that there are 9 patients per nurse. In elderly care wards the average is 11 patients per nurse. The reality for nurses is it can be as much as 10 or 12 patients per nurse on a medical ward, and 14 to 16 patients per nurse on an elderly ward. The National Institute of Clinical Excellent (NICE) and nursing unions recommend no more than 8 patients per nurse, yet 40% of NHS nurses reported to the Royal College of Nursing (RCN) that they are working with ratios higher than this.

Imagine you’re a nurse with a 12 hour shift. It’s meant to only be 11 hours work because you’re meant to have a one hour break (which you aren’t paid for) but you’ll probably end up working through it. You have 10 patients who you have to help wash, give their medications three times a day, and do a minimum of three sets of observations throughout the day. You also have wound dressings to change for several of your patients, and several need help toileting throughout the day. Some may be bed bound and require full double handed care, requiring another nurse to help you.

You also need to speak to the medical team for each of them to chase up their plans. Several need to be sent for scans, and you need to speak to the porters and x-ray, CT or ultrasound and get them sent down. Dementia patients or those who are falls risk can require an escort so you have to find someone to go with them.

If you’re on a surgical ward you will have a couple of patients on Patient Controlled Analgesia, or epidurals needing hourly monitoring, as well as observations hourly for those returning from theatre, hourly sliding scales for diabetes patients, Naso-Gastric or Total Parenteral Nutrition feeds needing checking and monitoring. Alongside that you’re trying to safely take multiple patients to theatres and radiology which means being off ward for ages, while somehow simultaneously closely monitoring the patients you’ve left behind.

Desperately Trying to Free up Beds

On top of that you will be managing multiple discharges to get patients home to free up beds for the next day’s intake of patients awaiting surgery, and chasing pharmacy for medications. There is barely any time to carry out the essential work of teaching patients about managing new stomas or controlling their diabetes or any of the other essential parts of patient education which are left in the hands of overstretched nursing staff.

God forbid any of the patients become acutely unwell. Then you have to drop everything and spend 2-3 hours managing them intensively, calling the medical or surgical team, the clinical response team, maybe the crash team if they suffer a peri-arrest. Performing observations every 15-30 minutes, administering IVs, taking bloods, deciding whether to inform the next of kin if it’s a serious deterioration or if they are elderly or at the end of life. If you eventually stabilise them you have to go back and catch up on your work for your other 9 patients, who you haven’t been able to do anything for in the meantime.

A study in Australia found that on a busy ward, nurses were making roughly 200 decisions every hour regarding their work. You spend all day every day running from task to task, with barely any time to think.

Documenting Everything – Even When It Was Done Badly

On top of all this you have to find time to document everything about those ten patients; those three sets of observations (as a minimum, more if they become acutely ill), at least one detailed nursing care plan and a follow up note at the end of the shift, noting every time someone was repositioned, every bowel movement, every aspect of personal care, wound care, important conversations you had with the medical team, with patients, their relatives or social services.

There aren’t enough staff to do all the work, but the hospital still requires you to document everything you did to prove you did if (even though it was probably done badly or in a hurry, or maybe not at all).

If there were enough staff to do all the work, this level of documentation wouldn’t be necessary. With inadequate levels of staffing, it just become an onerous imposition, and saps what little spare time you have.

By the end of your shift if you work flat out, skip your breaks, cut a few corners and don’t spend too much time doing any of the niceties for patients (the little chats, extra cups of tea, comforting them if they’ve had bad news, and so on) you might have just about managed to do all your care and provided decent, if a little basic care for your patients.

If you have managed to squeeze in most of your documentation you might only leave 30-40 minutes late as you tidy up the last bits of paperwork, check you’ve done all your notes, updated all the care plans, fluid balances, stool charts, repositioning charts and the rest. But if someone became really unwell and you spent 2-3 hours nursing them intensively, you’ll probably be staying behind an hour or two to finish notes, as the only time you’ve really got to work on them is when the next shift has arrived and they can take over all your responsibilities.

How the ‘Market’ Intensifies Nurses Workloads

The effects of years of austerity on hospital budgets, combined with the market mechanisms which allocate NHS funding, are also driving the workload up for nurses. Hospitals receive a payment (a tariff) per patient admission. Hospitals facing budget restrictions and reductions in bed numbers are utilising medical and surgical advancements to improve patient care, but also to minimise time as inpatients. This is done to maximise through flow of patients so they can receive as many tariff payments and maximise their income at times of budget restrictions. They do this so they can afford to pay staff and continue to maintain services, but it drives up nurses workload to an unprecedented level. Whereas 15-20 years ago patients would stay on wards for weeks at a time till they were full recovered, now it’s common for patients to be discharged home as soon as they are stable and not acutely unwell, the remainder of their care being carried out in the community.

Whereas a nurse used to have a mix of acutely unwell patients, and stable recovering patients requiring minimal care, now every patient a nurse cares for is likely to be acutely unwell, meaning their care needs and the workload for the nurse is at maximum every shift. Such a situation creates a horrendous work environment where nurses work flat out all the time, with no downtime or quiet days. It accelerates burnout, and means newly qualified nurses trying to find their feet and develop their skills and resilience are subject to unimaginable pressures and levels of responsibility that they would not have faced 10-15 years ago.

This is why nurses are leaving, and until it changes, they won’t stop leaving.

The Simple Solution

The only way to improve retention and begin to reverse the outflow of nurses from the NHS is to reduce their workloads to a safe, manageable level. This means more nursing staff on wards and in community services.

There is a remarkably simple policy solution to this which has worked well in other countries; mandatory minimum safe staffing levels, enforced in law. This has been implemented in both Australia and California, in response to concerted protests by nurses and their unions.

There is a consensus for this across nursing unions and the nursing workforce. The RCN, UNISON and Unite all call for mandatory minimum safe staffing levels across NHS wards, and surveys of nurses show 90% in favour.

What is stopping the government adoption of this policy is the impediment it would pose to cutting and privatising the NHS, and the demand it would create for increased funding to pay for the staffing. But it is absolutely necessary if we are going to see the continued functioning of the NHS, and the survival of nursing as a viable profession. For this reason all nurses and their unions have to become more active and aggressive in campaigning on this issue, for the wellbeing of ourselves, our patients and the NHS.

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  1. XXYY

    I was hospitalized for several weeks earlier this year after a traffic accident. I live in California, and heard from several nurses who had come to the state after nursing in other parts of the US. Almost every one said they would never be a nurse anywhere else because of California’s mandatory staffing ratios.

    The nurses were obviously still working hard, but not to the point where care deteriorated or became a joke. This is where we want to be.

    This is also a story about how effective and activist labor unions can make things better not only for their members, but also for society as a whole.

    1. Dave

      Level 1 trauma center ICU nurse here, major inner city hospital in an economically challenged area of Philly.

      EVERY day I work I am thankful I am in a union hospital, and being unionized is the only way to avoid these horror stories on patient ratios.

      Even in a 2 patient to 1 nurse ICU setting there are days I come in where I am stuck in one patients room for hours and have to rely on other RN’s to cover my other patient. I read this article and am aghast. There is no way to provide safe competent care with those ratios, period.

      There is only one downside to the union, it does protect some damn incompetent nurses who should find another career.

  2. marieann

    As a retired RN in Canada…..yes this is how it was except we only had 5-6 patients, but this was 14 years ago.
    We always had a mix of RN’s and RPN’s but that ratio was changing around the time I left. The RPN’s were taking on much more responsibility with full care for their own 5-6 patients but ultimately the RN was responsible if a patients condition deteriorated, she had to take on full care of the RPN’s patient.So you could start out with 6 and end up with 8

    Working overtime was the norm.

        1. marieann

          Yes you are right. Though perhaps if we had been rocket propelled we could get our work done without overtime :)

          Just before I retired the RPN’s were taking on much more responsibility, like patients that were usually assigned to RN’s.

          I am friends with 2 RPNs who took early retirement rather that go through the quick classes the hospital provided.

          1. RMO

            A Canadian here: the last time I was in hospital for treatment (aside from emergency room visits) was 1993 after a motorcycle accident. I assume that back then things were probably better than even 14 years ago but I was impressed by how hard the nurses worked, how high the quality of care they gave was and how friendly they were. The workload I saw then struck me as being pretty heavy so the notion of it being what, twice as heavy? Three times? – for the NHS nurses now seems downright diabolical.

  3. Jack White

    The article on nursing is accurate. One of the better contract negotiations is schedule control: no more than seven eight hour shifts or five twelve hour shifts in a row, no more “doubling back”, changing from nights to days without 48 hrs off, etc. Nursing management writes schedules they couldn’t pull themselves. Unions save nurses and preserve nursing. Our union (1199NM) won daily overtime, so one could chart at the end of shift on time-and-a-half. In the future there’s some room for robotics I think. May the robot chart? Can the robot assist the patient up in bed? Could the nurse wear a bodycam linked directly to Center for Medicare and Medicaid Services and the loathsome Joint Commission on Accreditation of Hospitals? (sarc)

    1. SD

      Thanks for this insight on what’s at stake in these kinds of negotiations. As you may know, we currently have a number of labor disputes here in Massachusetts between nurses and hospitals. There may even be a ballot question this November about it.

  4. James T. Cricket

    I can’t believe this has attracted only 5 comments so far, whereas the story about Elon Musk’s Tesla has hundreds. A story like that seems to draw in the sycophants, who haven’t commented before on Naked Capitalism and never will again, but who are ready to defend Musk’s honour and declare that “it’s hard to deny he’s a visionary”, while stories about real human beings go almost unnoticed. My best friend of the moment is becoming a nurse in Australia. I wonder if she knows how much work and responsibility she is committing to in order to earn her space on planet earth for her and her children. We could say anything in these moments and no one will care because few people will see it. Elon Musk is an idiot. Jeff Bezos is a stupid bastard. Ordinary persons, like nurses and teachers, are undervalued and underpaid. Don’t worry, none of the reactionaries will venture into this comments section to make stupid objections.

    If people could go through life without making a difference on planet earth, that is, leaving it more or less as they found it, this would be better a bigger advantage than most of the visionaries promise, I think.

    1. Jeremy Grimm

      I’m not sure how to comment to this post. This post describes the nursing in the NHS but it fits what I know of nursing in the U.S. Having worked at a couple of hospitals while in college and having dated a few nurses I find that what it argues is consistent with what I’ve heard through many sometimes heated conversations with nurses.

      Nurses have been underpaid, undervalued, over-worked, and frustrated for a long-time. Can something be done to fix things? The post closes with several excellent proposals for making vast and reasonable improvements to the work-life of nurses while improving the quality of their work and doctor and patient satisfaction. So — underpaid, undervalued, over-worked, and frustrated for a long-time — and there exist excellent proposals for making vast but reasonable improvements to their work-life — What about school teachers? What about most jobs now days?

      Although associated with documentation and paperwork the increased level of control exerted over nurses was not specifically mentioned in the post. With that exertion of control comes increased responsibility. The post doesn’t mention liabilities. I assume this reflects a contrast with the U.S. One liability for nurses in the U.S. goes beyond just losing their job — they will lose their profession if they lose their nursing license. And of course the financial liabilities from suits could prove far more damaging.

      Nursing is among the few remaining professions that still have and get support from functional unions. That the nursing profession is in such straits seems telling for the situation of others in the workforce. That the nursing profession is in such straits when healthcare issues have become so prominent among national concerns seems telling for the situation of U.S. political and economic processes. Something is badly, badly broken in the U.S. political and economic processes which have brought us to this juncture.

  5. sharonsj

    This should link to the article on the cost of elder care insurance. I think of elder care insurance as a complete scam. If you miss a payment, the entire insurance disappears, along with all the money you’ve paid into it for years. And even when you have it, it doesn’t cover much.

    As usual, health care in this country is a complete joke unless you are rich.

  6. Kevin

    I had a skirmish with stomach cancer that landed me in the hospital off and on for 7 months in 2015.

    My respect and admiration for Nurses is second-to-none. They performed duties and assisted me in ways that my own mother would have demurred…I’m talking disgusting, middle of the night emergencies – all performed with the utmost respect and warmth. I was, and still am – in awe of them.

    It is a disgrace we live in a society where people who provide these services are treated less than CEOs and Politicians who are clearly inclined to do harm, the exact opposite of nurses.

  7. Synoia

    The British love their NHS. Corwin will win on this subject alone, as he reminds the British that the NHS was a creation of the first Labor Government after WW II.

    The recession or depression following Brexit may also be an opportunity to roll back the Thatcher initiated neo-liberalism. Certainly Germany’s monster balance of payment surplus will cause another European War. One cannot escape one’s history, and the EU appears not as a solution to this as was hoped in the 1950s.

    The collapse of Carillion is a very clear refutation of the “robber baron concept” of the private sector can “do things” at less cost. It cannot, because of the costs of executives and the cost of profit. But the concept, like all exploitative enterprises of ruling classes, will not die quickly.

    Remaining and New “Carillions” will whip their workers unmercifully for profit extraction. Bankruptcy is an integral exit strategy to the business model, because the savings and obligations promised after extracting profit and executive pay are ephemeral.

  8. paul

    This is all part of the plan.
    As far as the westminster government is concerned, the NHS does not have problems, it is the problem.
    The current health secretary , who owes his fortune and position entirely to patronage and the public purse,coauthored a pamphlet aiming at, amongst other things, the privatisation of the NHS (p 76 onwards). One of the authors,Hannan, considers the NHS to be ‘a sixty year old mistake’.

    Note that this problem is largely found in the English NHS, Health is devolved in Scotland and is not experiencing nearly as many of these problems because the SNP are committed to the idea of a national health service and have shunned private sector expertise such as that offered by tax exile richard branson and his ilk.
    Its not hard to see which is producing the better results (unless you watch BBC Scotland)

  9. SD

    I don’t have insider’s knowledge, but I do know from having followed the nurses’ ongoing contract negotiations with Berkshire Medical Center in Pittsfield, Mass., that the issue of patient ratios is at the center of that dispute. Originally, the nurses, who are organized under the Massachusetts Nurses Association (our nurses union), wanted fixed nurse-patient ratios written into their new contract. They’ve since backed off that demand–after stiff resistance from the administration, and a one-day strike followed by a five-day lockout in October 2017–and are now simply asking that a charge nurse with no assigned patients work every shift to manage the workflow and provide assistance where needed. It doesn’t seem like an unreasonable demand, but the two sides have been at an impasse for months, and a federal mediator has been working with them since last March. There will likely be a referendum item on the Massachusetts ballot this fall that could ultimately force the legislature to set minimum safe staffing levels in specialty areas like the ICU, maternity wards, and psychiatric wards. BMC, unsurprisingly, has a bloated administrative tier with salaries well into the high six figures, which is ludicrous for a small hospital like ours. It shouldn’t require a brute force solution like a referendum to set reasonable staffing levels at hospitals, but this is where we are.

    1. Alan

      One thing in US to look for is nursing Magnet status. Studies show higher nursing satisfaction and better patient ratios. Takes sbout $ 2 million to achieve I’ve read. Have seen reports of abuse whereby once it is achieved management abandons the reforms to stop spending the money and reverts to high patient/nursing ratios. Another saying money saved by better outcomes offset that. I’m not sure our ratios here but thought we had at least guidelines for ratios which Magnet apparently requires. We are Magnet. I asked nurse I work with if we are still Magnet and he said “oh yes, that’s why I’m getting my bachelors at 55”. Must be Have bachelors to work in a Magnet. Interestingly perception out there is its easier to recruit MDs to Magnet certified hospitals as well. Will ask nurses about ratios but believe it is part of the required package. Only 7% of hospitals are Magnet in study below. Staffing ratios are better.
      …”When California hospitals are excluded, we found the number of patients per nurse in Magnet hospitals to be significantly lower than in non-Magnet hospitals (t = −5.29, P < .001)…”

  10. Arizona Slim

    I had relatives who were as Tory as they come. And they loved, loved, LOVED the National Health. They couldn’t understand why we Americans put up with the joke of a health care system that we have.

    1. Altandmain

      That’s the sad part though – I don’t understand why economic conservatives think that the free market when completely unregulated is better. It often leads to worse service and costing at higher prices.

      Not to mention, employees often lose out. The reason why of course is the profit motive.

      1. Mike G

        Because their real definition of “better” is “generates more profits for elites”.
        The ego gratification of working employees into the ground is a bonus.

  11. Wukchumni

    Some years ago when friends became newly minted RN’s, they could work at a regular hospital you or I might be admitted to for $34 an hour, or work at one of our many prisons for $51 an hour.

    Viva! our prison industrial complex!

  12. templar555510

    I’m a Brit aged 68 . The NHS has existed for my entire lifetime. The everyday reality for us Brits is that when we go to the doctor, or turn up at the Accident and Emergency Department whatever treatment we need we will get it , no questions asked and no money demanded. So we don’t live in fear of getting sick simply because we might not have insurance to cover our treatment, or have sufficient funds if we don’t have cover. The particular issue addressed by this piece is an issue, but it is not as simple as a patient to nurse ratio. That issue is largely to do with inadequate funding. The wider issue is one of ward management in the neoliberal era, by which I mean that patients have been relabelled ‘ customers ‘ as though it were a choice to be in hospital in the first place. My wife is a former nurse back in the sixties and seventies when it was a vocation that could be entered at age 16 without much in the way of academic attainment, but with a motivation and attitude thought to be appropriate to such a task as nursing which in those days included cleaning the wards, emptying bedpans etc. Now I know this is the twenty first century and things have moved on, but the essential skills of nursing remain the same – the foremost , beyond any medical knowledge – being empathy with sick people . Sadly in the corporate managerial mind such skills are of little or no account as they can’t be measured on a job application form, or in the pretend market funding model. Our present Health Secretary Jeremy Hunt is neither better nor worse than his predecessor . He is a simple-minded politician of no particular distinction who will be forgotten a few years from now. The failings are systemic, but they could be changed ( not overnight admittedy ) by a change in the political ideology that prevails and has done for thirty years now that the NHS can and should be run like a business .

    1. kate

      Well worth mentioning jeremy hunt is virginia bottomleys cousin,
      now Baroness Nettlestone in the Lords. She lobbies on behalf of the private health sector via her directorship of BUPA.

  13. roxan

    The HMOs resulted in shrinking staff all through the 1990s. Everywhere I worked soon changed to half staff, then quarter staff or less. Hospitals routinely give RNs 13 med-surg patients. Officially, you have five! In psych hospitals that were designed for two nurses and four aides, I was usually the only nurse and had two aides, sometimes just one. Once, my aide took the keys (we were short of keys too) and accidentally left me locked in with the patients. After taking care of my 40 patients, I then went to another building with no nurse assigned, and poured meds for another 40. Often, they had no insulin and other essential meds. In nursing homes, I went from 25-30 pts to 40, 50 even 60. At night, even in large buildings with 300+ patients I might be the only RN, functioning as building supervisor as well. When I moved down South, I found 60 to 120 was routine! Instead of pushing the cart from room to room, the patients gathered in a circle around the cart and nurses sort of tossed their pills at them. You can imagine what sort of care patients got. There was never time to do all the wound care. The last nursing home I worked in, declared overtime would result in termination, so everyone clocked out on time, and went back to do two hours or so of free labor.

  14. The Rev Kev

    Nurses can never be paid enough for their work that they do. How much again do we pay millionaire athletes as we watch them hit, punch, kick or throw balls to each other?

  15. Bukko Boomeranger

    You wanted comments about nursing in other countries? I’ve had the privilege to work as a nurse in two U.S. states and two non-American countries (Australia and Canada.) The latter pair — great! Mandatory staffing ratios of no more than four patients for each nurse. That means we get to spend more time with patients instead of dashing in to give a medication or change a dressing, then running off. California, where I worked for three years on a cardiac ward in San Francisco, also had mandatory 4:1 ratios due to a law passed by the state legislature. Arnold Schwarzenegger tried to negate this LAW by his own executive fiat, and we members of the aggressive California Nurse’s Association (our union) used to picket against him when the double-family cheater showed up to speak in town. We won, ultimately.

    When I was a nurse in Florida, there were no ratios. Bosses could lump us with however many patients they wanted. Nursing homes were the worst. We wound up doing a crappy job because we couldn’t keep up. That meant that old folks were left lying in their own urine and faeces for longer than they should have had to, because we couldn’t get to them in time. People waited for pain meds longer than necessary too. And we weren’t as able to stay on top of changes in their medical conditions if they started going bad. Plus, it’s never good to have your nurses and aides be stressed and unhappy when they’re dealing with you as a patient.

    Even in Cali, work was stressful because there is SO much documentation required in the U.S. medical system. The post caught a flavour of that with the NHS stuff. Every minute spent on papers is one less that’s spent with patients, for sure. The documentation isn’t being done for the benefit of the ill people. It’s to protect against what I call “imaginary lawyers from the future.” If you don’t document to cover your arse, the hospital is worried it might get in trouble from some future lawsuit. Ignore the patients today in favour of lawyers from tomorrow. Crapification!

    In contrast, Canada’s system required a lot less form-filling, and Australia is even more streamlined. It’s kinda sloppy here, to my American mind, but patients seem to live as long and outcomes are good. I don’t get the (justified) complaints about how patients felt ignored like I did in the U.S. either. No wonder we have so many nurses here from the UK and Ireland, to say nothing of the usual crew of Filipinos you’ll find everywhere. Oz is a glorious place to be a nurse. And a patient. Except for that whole sickness and fear of death thing with the latter…

  16. PressGaneyMustDie

    In most parts of the country except the overheated real estate markets, hospital nurses make good pay relative to the local cost of living. I work in the suburbs of an over-heated market & do well. I know I am blessed but the reality of most bedside care is fraught with personal & professional peril. I was attacked more as an emergency nurse in 9 years than I was attacked as a bouncer in college in 4. I have rolled on the floor in an ICU with a family member with a firearm and with a emergency department patient. Most nurses are fine with their pay, the problem is nurse staffing-staffing-staffing-staffing, patient safety & working conditions (yes, and staffing). Analogy: the mechanic who fixes your transmission can screw up in his/her job but will not face criminal liability but the nurse who screws up her/his job faces criminal prosecution & threats to the license that allows them to make their living. The US healthcare system is so amazingly inefficient in outcomes but delivers profit to right players the way it is designed to do. The stories I could tell but anonymous journalism isn’t safe in today’s surveillance state. Unless Yves & I can work out a way. I have stories.

    1. gale.in.the.night

      Press Ganey code status- DNR!
      Shrewd unit managers will devote resources to bolster patient satisfaction scores. What this looks like is hiring LPN, RNs and SW to phone recently discharged patients in order to get better metrics. Also, to reduce readmissions by encouraging outpatient follow ups and prescribed meds. Better scores means better chance of quarterly bonus. This is new where I work but it has been effective at rasing scores.

  17. RBHoughton

    My suspicion is that government revenue is falling and the great capitalists are applying pressure on officials to reduce public welfare on the grounds that people are free-loading and need to be treated more harshly. There may be some free-loading but there is also a torrent of profiteering by both pharmaceutical and equipment providers. Some hint of the hardening terms of life is apparent in greater reported crime, both against property and crimes of anger.

    1. Lambert Strether

      > reduce public welfare on the grounds that people are free-loading and need to be treated more harshly

      Let’s not forget that treating proles harshly doesn’t really need any justification. Plus, it’s fun!

  18. Eustache De Saint Pierre

    I was privy to three days of care on a cardiac ward & witnessed two day teams plus the skeleton night staff, day after day work a 12 hr shift with the utmost of expertise & as mentioned when needed, the required TLC.
    Around twelve nurses during the day, ( mainly female ), who automatically & expertly dealt in perfect teamwork with any arising situation. At the end of their shift they would basically collapse in a collection of chairs as the next shift took over.

    We live in a world where killers are called ” Special Forces “.

    1. cnchal

      We live in a world where killers are called ” Special Forces “.

      It’s a marketing gimmick. Calling them “Killer Forces” might arouse a conscious. Can’t have that.

  19. markodochartaigh

    I started work at the county hospital where President Kennedy was pronounced in 1986. At that time nurses on the floor would have about 14 patients, it was best to start out with a full load because admissions and discharges take longer; and often it was one RN and one LVN for 25-30 patients. Requiring a Bachelor’s for floor RN’s is, in my opinion, a stupid tactic pushed by nursing administrators who want to “increase respect” for nurses but who themselves have very little or no floor experience and thus administrate the job which they cannot themselves do. I worked with many LVN’s, Diploma RN’s, and Associate Degree RN’s who were as good or better than Bachelor’s RN’s. Anecdotally the stupidest mistake which I ever saw kill a patient was committed by a Master’s Degree RN, who was immediately made a Head Nurse after the patient’s death.
    I started around $8.00 an hour in the Big D, RN’s from the same small town Texas college where I graduated often went to tiny hospitals in tiny towns making $4 to $5 an hour, those hospitals closed in Reagan’s ‘Murica of the 80’s. One payday in the late 80’s our checks were short and we were informed that we were now classified as management and would no longer be paid overtime. We also were not paid anything at all if we stayed less than one hour overtime, and in a teaching hospital virtually every nurse stays at least 15-30 minutes over in the mornings,we obviously were not allowed to stay the whole hour. For all the libertarians, in a red state without a union, you cannot sue your employer if the employer is large and politically powerful, so take your libertarian stone and go slay your own Goliath. The cognitive dissonance was amazing, even when I pointed out to most Texas nurses that we were being stolen from on each check, the Texas nurses would respond that they didn’t like unions, that we would have to pay a union to represent us, that unions weren’t a “godly thing”, etc. Of course very many nurses were from overseas, especially Kerala, it was difficult for the hospital to recruit American nurses. At that time about one third of the total income of the hospital was taken off the top for administration. The hospital had been run by doctors and nurses but by the late 80’s management of the hospital was taken over by Administrators. Of course Modern ‘Murican Administration™ Theory teaches that if you can run a McDonald’s, you can run a hospital. In 2005 when the hospital started to pay us overtime suddenly all sorts of meaningless end-of-shift tasks which were mandatory became “why are you doing that, clock out now!” tasks. Like in all authoritarian systems money is important, but control of the employee is almost as important. I took my pension in my 29th year because I was afraid that after 8 years with a Democrat in the White House there would be another swing to the right and red state public pensions are obviously a target; no, we don’t also qualify for Social Security from the same job. I phone banked and canvassed for Bernie and then Hillary and I’m glad for the time I put in trying to educate an ignorant electorate and motivate an apathetic electorate. But the same ignorance; by administrators on how a hospital functions, by nurses on the benefits of a union, by the public on what quality care really is, I see infecting much of the voting public who are easily baited by every flashy red herring even as they are unwilling to try and educate themselves on real issues. Can a democracy survive an ignorant or apathetic electorate?

  20. Altandmain

    My god – the Tories in the UK are trying to Americanize the NHS.

    Here’s the recommendations for where I live (Ontario, Canada):

    The Auditor General indicates
    that RN workload is heavier in Ontario than what international best practices recommend.
    Although Ontario does not have mandated nurse-to-patient ratios as in other jurisdictions,
    research has established a best practice ratio of 1:4 (one RN for every four patients) in hospital
    medicine and surgery units.

    The Auditor General found that at the community hospitals they visited, nurse-to-patient ratios
    are as high as 1:6 during the day and 1:7 during the night shifts on medicine and surgery units.
    In fact, the auditor’s survey of large community hospitals found that nurse-to-patient ratios for
    medicine units are as high as 1:9 for overnight shifts. Lack of funding was the reason hospitals
    gave for these extremely high patient ratios.

    It seems like austerity is the bane of the middle class. It’s a form of class warfare, IMO.

    What I am interested to know is why is healthcare so expensive in the US, yet the ratios seem to be even worse than they are here in Canada (and as you can see from the above passage that we have a problem, although it seems the NHS is even worse off). Judging by the anecdotes above, the nursing to patient ratio in much of the US must be truly awful in many places.

    The PDF is from the Nurse’s Association, so yes you do expect there to be some bias there, but I think it is worth discussing if this may pay for itself in part.

    RN staffing is associated with a range of improved patient outcomes: reduced hospital-based
    mortality, hospital-acquired pneumonia, unplanned extubation, failure to rescue, nosocomial
    bloodstream infections, and shorter length of stay.
    Indeed, as the auditor identified, comprehensive research shows “that every extra patient
    beyond four that is added to a nurse’s workload results in a 7% increased risk of death.”

    Research has also developed costing models related to cost savings realized from interventions
    and treatments related to avoidable adverse events that would no longer be required. One
    study, for example, has demonstrated that higher RN staffing decreases the odds of
    readmission of medical/surgical patients by nearly 50 percent and reduces post-discharge
    emergency department visits.

    Given that the workload is certainly beyond 4, the fatality rate is probably higher than it should be.

    What a disaster neoliberalism has wrought. Ultimately the culprit is that our rich are hyper-greedy. That’s the real root cause of this crisis.

  21. J C Durr, DDS, JD

    The great lie of any country from Cuba to Switzerland, to the USA, to The Netherlands is that any country can afford the health care that its citizens demand. For all of those who think that “the government” should assume all costs live in an Orwellian haze. The Netherlands bolted from an NHS delivery system at the end of WWII while the English did not: the Dutch have a vastly healthier population than the English. As for the USA, my home, there is so much systemic corruption in the health industry starting with the legal and regulatory envelope, the demands of the nursing world, while a spark, does not really provide an insightful window into the complexities to the delivery of health care in the post industrial world.

    1. Lambert Strether

      > The Netherlands bolted from an NHS delivery system at the end of WWII while the English did not

      You’re wrong on the history for the UK. The NHS was established only after WWII, as a make-good, if you will, to the working classes of England for having died for the nation in their hundreds of thousands a second time.

      > the Dutch have a vastly healthier population than the English.

      And Australia (single payer) does vastly better than the Netherlands:

      So I’m not sure what point you’re trying to make, here, other than a proof-by-example that facile country comparisons are to be avoided?

      –Lambert Strether, Blogger, School of Hard Knocks


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