Nurses routinely work shifts as long as 12 hours. The overtime laws were designed to prevent hospitals from adding mandatory overtime on top of those lengthy shifts. An article on Renal Business’ website quotes one of the study’s leaders, Carol Brewer, as saying, “The laws seem to be accomplishing their objective.”

At issue in the study was the extent to which those laws or regulations had actually affected the workplace. Researchers examined NLRNs’ self-reported mandatory and voluntary overtime hours, as well as their total work hours to find the answer.

They found that in the states with rules governing mandatory overtime, NLRNs were 59 percent less likely to work mandatory overtime than their colleagues in unregulated states. (Not all states with overtime rules prohibit mandatory overtime; some simply limit total work hours). Overall, 11.6 percent of nurses said they worked mandatory overtime in a typical work week, averaging 6.1 hours of mandatory overtime.

In addition, in the states regulating overtime, NLRNs worked an average of 50 fewer minutes per week than their colleagues in states without overtime regulations.

Researchers anticipated that caps on mandatory overtime might lead to increased voluntary overtime, thus defeating, to at least some degree, the purpose of the restrictions. But the data demonstrated no relationship between mandatory and voluntary overtime hours. Nevertheless, more than 50 percent of NLRNs reported working voluntary overtime in a typical work week.

“While safety is the principal objective of caps on mandatory overtime, the laws probably also have a positive effect on nurse retention,” said Kovner. “Nurses have lives and families outside the workplace just like everybody else, and they probably prefer to have a schedule they can rely on. One way to make their jobs and lives more manageable is to avoid mandatory overtime, which should lead to nurses staying in their jobs, and indeed, in the profession longer. That’s particularly important in light of the looming nursing shortage. Every nurse who stays in the profession is one fewer nurse we need to recruit.”

“It’s important to policymakers to understand the impact of the remedies they devise for particular problems,” said Bae. “In this case, the states developed caps on mandatory overtime with safety issues in mind, reasoning that fewer mandatory overtime hours would translate into fewer hours overall. What we learned in this study is that it’s working. The tool is effective. Other states with similar objectives can follow suit and expect similar results.”

The RN Work Project is the only multi-state, longitudinal study of new nurses’ turnover rates, intentions and attitudes―including intent, satisfaction, organizational commitment and preferences about work. To date, researchers have learned that more RNs work in hospitals than any other settings early in their careers―nearly nine in ten (88.3 percent) work in hospitals six to 18 months after being licensed and 78.8 percent work in hospitals 31 to 54 months after licensure. The study has also revealed that nearly one in five (18.1 percent) new nurses leave their first employer within a year of starting a job and more than one in four (26.2 percent) leave within two years. Nine in ten of those who leave stay in the nursing field.

Subsequent studies will determine why nurses stay in or leave their jobs, what influences their first job choice, how the job settings they work in vary over time, and whether they move in and out of nursing.

The Robert Wood Johnson Foundation focuses on the pressing health and healthcare issues facing our country. It’s the nation’s largest philanthropy devoted exclusively to health and healthcare and works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, measurable and timely change.

The mental health and optical workers were protesting the effect of staffing shortages on their patients as well as proposed cuts to health and retiree benefits. The walkout was the second in two months, and the fourth since negotiations between Kaiser and the National Union of Health Care Workers began in 2010.

Leighton Woodhouse, spokesman for the National Union of Healthcare Workers, said the mental health and optical workers were happy to have the nurses’ support.

“The nurses have advocated for years around safe staffing and this is an issue of safe staffing,” said Woodhouse, speaking from the Kaiser medical center in Los Angeles. “It’s also about cutting union benefits and this is where there is trade union solidarity around the fact Kaiser is making billion in profits there is no cause” to propose cuts.

Kaiser officials said more than 66 percent of the nurses crossed the picket line and came to work on Tuesday and accused the nurses who honored the strike of violating a “no strike” clause in their contract, which runs through 2014.

“We are pleased that so many of our nurses made the decision to continue providing our patients with high-quality personalized health care and to honor their contract,” Kaiser officials said in a statement.

Representatives from the nurses’ union say earlier court rulings support the nurses’ right to strike in sympathy with other unions and contested Kaiser’s figures. The union said between 80 percent to 95 percent or more of nurses honored the strike, depending on the facility.

“The nurses understand that yes, we have a contract and we’re grateful that is the case, but we think all of our co-workers deserve the same rights and benefits we do,” said Deborah Burger, president of the California Nurses Association and a staff nurse at Kaiser Santa Rosa.

Kaiser prepared for the strike by rescheduling elective procedures, relying on nurse managers and bringing in replacement nurses.

Image courtesy of FeatheredTar via Flickr

In one North Carolina clinic, a safety team implemented a new system stressing anonymous reporting and no punishment for making a mistake. The facility saw an uptick in the number of reported errors in two and a half years, with the number of submitted reports from both nurses and doctors rising from from 5 to 216. After collecting data and analyzing the results, the team was able to change clinical practice that addressed three-quarters of the errors’ origins.

Hospitals generally have a grading system for errors, which includes potential risk to the patient from the error. The higher the risk of harm to the patient, the more careful monitoring the error triggers. In cases where errors are more severe, additional training of the clinician may be warranted, but hospitals still emphasize that this is not a punishment. A clinician may simply be lacking a skill-set for a given area or may have learned how to perform a patient care standard incorrectly. There may be several reasons behind an error and sometimes reinforcement of a safety standard is all that is needed to prevent future errors.

One hospital in Dayton recently has been telling nurses to stay home rather than come in for scheduled shifts. Some of the nurses at this hospital lost up to a third of their regularly scheduled hours during the holidays, according to this article.

The problem is that there are fewer patients coming in — 10 percent fewer than usual. That plus a 1% vacancy rate for nurses means that there are currently more staff than are really needed.

That vacancy rate for nurses is the lowest that it’s been in several years, according to Deborah Mals, the vice president and chief nursing officer at Miami Valley Hospital. “This is going to be short-lived,” she said.

The Ohio Hospital Association said the vacancy rate statewide for nurses was 4 percent in 2010, the most recent year for which data was available. That’s down from 6.2 percent in 2009 and is down considerably from previous years when the statewide vacancy rate was in double digits, OHA spokeswoman Mary Yost said.

Kettering Health Network said the overall vacancy rate for nurses at its hospitals is under 5 percent, but said there are still opportunities available for nurses in emergency, maternity and some other departments.

“We are still actively pursuing experienced nurses,” said Bev Morris, KHN vice president and chief human resources officer.

The Dayton Daily News contacted Good Samaritan Hospital after receiving a tip that nurses there were routinely told to stay home.

Good Samaritan’s Garman said the use of flex time is a “last resort” at the hospital. “It is unfortunate, and I certainly would like to know who got the last-minute call. It should not be a last-minute call.”

Garman estimated that of the 700 or so Good Samaritan nurses who work outside of the hospital’s emergency department, the majority have had scheduled hours canceled either voluntarily or involuntarily in recent weeks. Some nurses who didn’t get to work their hours were “on-call,” and therefore received a small fraction of the pay they would have received had they worked, she said.

The use of flex time hasn’t been as common for nurses working in critical care or the emergency department, Garman said.
While long used, flex time has become a more prevalent practice at hospitals statewide, said Gingy Harshey-Meade, chief executive officer of the Ohio Nurses Association, which represents registered nurses.

“From an economic standpoint, it’s a very bad thing for the nurse,” many of whom are single parents trying to support families, Harshey-Meade said. “How long could you support your family if your weekly pay was diminished by a third?”
Harshey-Meade said consistent use of flex time is not the best way to run a hospital.

“It’s being used as a staffing solution as opposed to (hospitals) knowing their markets,” she said.

Garman said that since she became chief nursing officer in September, she’s been working on a plan to help nurses get their budgeted hours. The hospital’s administration has taken a close look at its vacancy rate (currently 6 percent); departmental staffing; and its contract and agency staffing, she said.

“Employees are an extremely important asset to us,” Garman said.

Harshey-Meade said reduced reimbursement rates by the government for health care services also are likely a factor in nurses being told to stay home. But Garman said those reduced reimbursement rates have played no role in Good Samaritan’s use of flex time.

“It’s totally driven by volume and acuity,” or the severity of patients’ illnesses or injuries, she said.

Educators say that it’s not that the nursing school students don’t need to know as much as they used to, but that “the amount of essential data has exploded.”

“There are too many drugs now, too many interactions, too many tests, to memorize everything you would need to memorize,” says Ms. Eland, a specialist in uses of technology. “We can’t rely nearly as much as we used to on the staff knowing the right dose or the right timing.”

Five years ago, most American hospital wards still did not have electronic patient records, or Internet connections. Now, many provide that access with computers not just at a central nurse’s station but also at the patient’s bedside. The latest transition is to smartphones and tablet computers, which have become mandatory at some nursing schools.

“We have a certain set of apps that we want nursing students to have on their handheld devices — a book of lab tests, a database of drugs, even nursing textbooks,” says Helen R. Connors, executive director of the Kansas University Center for Health Informatics. Visiting alumni, she says, are shocked to see students not carrying physical textbooks to class.

But technology carries risks as well. So much data is available that students can get overwhelmed, and educators say that a growing part of their work is teaching how to retrieve information quickly and separate what is credible, relevant and up-to-date from what is not. (Hint: look for the seal of approval of Health on the Net.)

They also worry that students rely too much on digital tools at the expense of patient interaction and learning.“There’s a danger that having that technology at the point of care at the bedside creates a misperception that students don’t need to know their stuff,” says Jennifer Elison, chairwoman of the nursing department at Carroll College in Helena, Mont.

“I get worried when I hear about nursing programs that want to replace the person-to-person clinical experience with increased hours with simulation,” she says. “We hear sometimes that it feels to patients that the computers are more important than they are.”

The article also talks about the privacy issues that arise when a smart phone is always at the ready. Four students were expelled from nursing school when they posed with a human placenta (ew) and posted the photos on Facebook. Ms. Ellison ends the article by saying, “(T)his is a generation that immediately hits that send button.”

The organization, called the CARE Centre for Internationally Educated Nurses, has been around for about a decade.

Even nurses who have had a complete education and plenty of experience have had to start four-year training programs all over again once they relocate to Canada. CARE is doing something about that. “You can easily go back into nursing within one year or two years,” said the organization’s Domine Reutayisire in this article on CBCnews.ca.

Tambudzai Kasiyamhuru came to Canada two years ago from Zimbabwe. She spent 16 years there working with AIDS patients.

She came to the CARE centre in Windsor “so I can quickly write my examinations and quickly get a job here in Canada,” she said.

Kasiyamhuru currently volunteers at Hôtel-Dieu Grace Hospital and she has two part-time jobs elsewhere.

“There’s a high probability that I can get a [full-time] job as soon as I finish my exam and get my license,” she said.

Marie Wood worked all over the world as a nurse for the British army, and later in palliative care in England. She even earned a medal from the Queen. But that didn’t help her navigate the bureaucracy of Ontario’s College of Nurses.

“I was emailing back and forth with the College of Nurses and getting nowhere. They were always [telling me] it takes time, but as soon as CARE came along, they seemed to pull up their braces, so to speak, and get on with things,” Wood said.

Wood volunteers at Hospice while working on her accreditation.

Both women plan to write their exams in May, far sooner than they could have done arranging it on their own.

Nurses in demand
Rutayisire said there are jobs in Windsor for nurses.

“There is quite a bit of demand. We do have two big hospitals and we have nurses who work in long-term care facilities as well, and community nursing. So nursing is in demand all the time,” Rutayisire said.

There’s still a need for more nurses in Ontario. The Ministry of Health plans to create another 500 positions this fiscal year.

So it’s not quite “Goodbye to the nursing shortage” yet, though it certainly seems to vary by region. This is an innovative way to address the problem.

Ambulatory care nurses work in a variety of settings, including primary care clinics, outpatient surgery centers, federal and state correctional facilities, home health settings, schools, dialysis centers, hospice facilities and community health centers. Any non-hospital setting where a patient walks in and walks out may be defined as an ambulatory care center.

The skills needed by an ambulatory care nurse differ from a hospital-based nurse. Triage, delegation and emergency management are all different in a non-hospital setting. Because of the economic downturn and many patients losing their insurance, an increasing number of people are afraid of incurring high bills by going to the hospital and instead show up at their doctors’ offices presenting with life-threatening situations such as heart attacks and strokes. Therefore ambulatory nurses need to know how to advise patients in a multitude of situations.

The relationship that ambulatory care nurses develop with their patients takes place over a long period of time. Due to the short, but more frequent interactions with patients, nurses may see the same patients over the course of many years and come to know other members of the family as well; something a hospital-based nurse doesn’t always have the opportunity to experience.

The Affordable Care Act is bringing change to the model of ambulatory care nursing. More nurses will need to coordinate care, manage chronic diseases and use telehealth technology. Patient volumes are expected to increase as more patients have access to care and home health care becomes more prevalent. Patients will look to nurses to help them navigate the new care models that are based on care teams.

More jobs for ambulatory care nurses will open up as hospitals hire fewer nurses and outpatient services become the basis of more patient care. Management of chronic diseases will need fewer hospital-based interventions as treatment becomes more sophisticated.

In the past, new graduate nurses were not able to obtain jobs in ambulatory care settings due to a lack of general knowledge, but that rule is changing.

It lays out a three-pronged approach to reduce personnel costs for nurses; a new approach to nurse overtime, use of supplemental labor such as from nursing agencies or from an in-house nursing pool, and focusing on retention efforts rather than going through the time and expense of finding and hiring a replacement.

The “Effective use of Supplemental Labor” section discusses the need for nursing agencies, as well as how alternative supplemental labor sources can help with costs:

Many healthcare leaders routinely budget for traveling or per diem nurses, but much of that may be unnecessary, says Hunt. Although there are reasons to use supplemental nurse labor, daily census demands shouldn’t be one of them, she says. Supplemental labor is expensive, she adds, so these nurses should be used to address seasonal volume increases, medical leaves, or to fill in during large training initiatives such as ICD-10.

“I do believe there is a place for supplemental nurses; it’s how you use them. If there are usually four nurses on a shift and you need to use one to replace a member of the unit or add one to address an exceptionally high census, then they work well because you have enough of your core nurses there who know the workload and who know the organization to be able to support this external staff member,” she says.

Hunt explains that hospitals and health systems that rely on supplemental nurses may be overlooking a greater issue—miscalculated productivity that is masking a full-time staff shortage.

Hunt says nurse managers will staff according to a core number to meet the average daily census. “What some nurse leaders are experiencing is that they feel short-staffed, though the productivity level looks to be at 100%,” she says. However, the productivity level fails to account for the quantity of overtime nurses may have to work to accommodate patient volume that is your average daily census, or the use of supplemental nurses. Using overtime and agency nurses comes at a premium rate to the hospital and drives up cost, she explains.

“What it comes down to is nurses are highly skilled at care, but they haven’t been taught the language of finance. Many nurse managers don’t have the level of understanding needed to watch for this type of disconnect,” says Hunt.

For instance, Hunt points to a unit she recently worked with in which the nurse manager’s unit was demonstrating 100% productivity. This unit had 12.5 FTEs on the roster, but routinely required 16.4 FTE to meet the target number of worked hours. By comparing the actual number of FTEs to the number needed as exhibited by the productivity target, the case to increase the number of staff on the roster becomes apparent. This plan will decrease the use of overtime and higher-dollar temporary labor.

“In the short-term, there will be extra cost to hire additional staff due to orientation costs; but in the long-run, it will be labor at an hourly rate, not a premium one. Plus, it provides a safer environment for the patients because the unit has a stable team,” she explains.

In addition to ensuring each unit has enough full-time nurses to meet the daily patient demand, Nash’s Ohio facility found another way to bypass supplemental labor when the need called for more nurses. The organization created a nurse labor pool by making a network of part-time staff, full-time staff, and cross-trained nurses.

“There are good reasons to use supplemental staffing, but it’s also expensive. By establishing this pool when we have a staffing shortage, we can get the right nurse, at the right time, at the right price,” Nash says.

With the ongoing nursing shortage, Polly Davenport, RN, FACHE, CEO at Ochsner Medical Center-North Shore, a 165-bed acute care hospital on the north shore of Lake Pontchartrain in Slidell, LA, says using an in-house nursing pool can keep tenured, more experienced nurses with invaluable skill sets from leaving the facility altogether.

“Although these seasoned nurses want to slow down and retire, you don’t want to lose these experienced nurses; they have knowledge that the newer nurses can benefit from,” she says.

Many organizations will pay more to in-house pool nurses because of the experience and expertise they bring, says Davenport. These nurses are usually willing to cover multiple clinical areas in the hospital.

“They are typically very flexible individuals, flexible in the hours they work and the locations in the hospital they will cover. There is a price differential; agency nurses … do cost more than in-house pool, but you’re paying the RN rate plus the agency who has their own costs to cover,” she says.

Evidence is starting to come in regarding whether they make a difference, and the news seems to be pretty good.

Nurse.com has an article explaining a new study out of the University of Pennsylvania School of Nursing, the first of its kind:

They studied more than 16,000 nurses working at 316 hospitals in four states and found that “implementation of an EHR may result in improved and more efficient nursing care, better care coordination and patient safety,” wrote lead author Ann Kutney-Lee, RN, PhD, a health outcomes researcher, and co-author Deena Kelly, RN, MS, a fellow at Penn Nursing.

At the same time, the authors wrote, “it is important to note that having a basic EHR was associated with better outcomes independently of nurse staffing, indicating that they both play an important role in quality of care.”

Nurses in hospitals with fully implemented basic EHRs were significantly less likely to report unfavorable patient safety issues, frequent medication errors and low quality of care. These findings suggest that the level of detail available in the EHR may allow for more comprehensive unit transfer reports and discharge summaries to outside healthcare providers.

Recent estimates have reported that only 12% of U.S. hospitals have a basic EHR system in place, the authors noted, but that is likely to change under the Health Information Technology for Economic and Clinical Health (HITECH) Act. Beginning in 2011 under HITECH, Medicare and Medicaid began to offer federal incentive payments of $2 million or more to healthcare providers and hospitals to use EHR technologies.

“With the passage of the HITECH Act, EHRs are rapidly becoming part of the daily practice of the bedside nurse,” Kutney-Lee said. “Nursing administrators should be fully engaged in the process of EHR adoption and implementation to ensure effective use and success in creating seamless transitions for patients throughout the healthcare continuum. The degree of support from nurse leaders for the EHR will affect the success of this technology’s implementation and, as a result, patient care.”

I was a bit surprised to see that only 12% of hospitals currently are using Electronic Health Records. It’s encouraging that they are making a positive difference.

An article on Nurse.com explains:

These savings come from the adoption of electronic standards that will help eliminate inefficient manual processes and reduce costs.

The provisions will allow healthcare professionals to “spend less time filling out paperwork and more time focusing on delivering the best care for patients,” HHS Secretary Kathleen Sebelius said in a news release.

A May 2010 study in the journal Health Affairs found that physicians spend nearly 12% of every dollar they receive from patients to cover the costs of filling out forms and performing other unnecessarily complex administrative tasks. The study found that simplifying these systems could save four hours per week of professional time per physician and five hours of support staff time every week — time that could be better spent on patient care.

“As a nurse, I know the importance of giving healthcare professionals time to focus on patient care,” CMS Acting Administrator Marilyn Tavenner, RN, BSN, MHA, said in the news release. “The less time a physician has to spend on paperwork is that much more time that can be devoted to patient care. Having standardized procedures across the healthcare industry can only lead to lower costs and greater efficiencies all around.”

The rule — formally known as the Adoption of Standards for Health Care Electronic Funds Transfers and Remittance Advice — adopts streamlined standards for the format and data content of the transmission a health plan sends to its bank when it wants to pay a claim to a provider electronically (through an electronic funds transfer) and to issue a Remittance Advice notice. Remittance Advice is a notice of payment sent to providers that may or may not accompany the payment the provider receives.

For example, when a provider submits a claim electronically for payment, a health plan often sends a Remittance Advice separately from the Electronic Funds Transfers payment. The disconnect between the two makes matching up the bill and the corresponding payment difficult or sometimes impossible for the provider. The rule addresses this issue by requiring the use of a trace number that automatically matches the two. The new tracking system should allow healthcare providers to eliminate costly manual reconciliation.

Future administrative simplification rules will address adoption of a standard unique identifier for health plans and a standard for claims attachments, as well as requirements for health plans to certify compliance with all HIPAA standards and operating rules.

All health plans covered under HIPAA must comply with this regulation by Jan. 1, 2014.

I wonder a bit about the savings estimates — could they be over-optimistic? But the quotes about allowing nurses to spend more time on healthcare and less on paperwork make a lot of sense.