If We Add More Nurses and Nurses’ Assistants Will We Make More Money? Why This is the Wrong Question for Healthcare Leaders

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Budget decisions in in profit-driven healthcare are generally made based on an investment mindset, “If we spend money here, how much money will we make?”  

This creates a problem for staff nurses in hospitals and nursing homes and nurse leaders who are advocating for more staff especially in chronically understaffed units.  The problem is that administrators want to see objective signs of increased productivity and nurse leaders may be held accountable for proving added value of added staff.

BUT, wait!  Increasing staffing won’t necessarily increase ROI because so much is going on underneath the radar.  Patient advocates and healthcare consumers will be more empowered if they understand some of the hidden issues that this presents for staff nurses and nurse leaders.  It is critical to understand these three points if we are going to staff hospitals and nursing homes with enough RNs, LPNs, LNAs/CNAs to provide safe, quality care not to mention customer satisfaction and job morale.

1).  Many of us who work in direct care are working as fast as we can.  When we don’t have time to do things right, we may take short cuts or develop workarounds.  We don’t talk about them, because we are not supposed to do them.  But we do develop habits.  I learned a lot about this from working on a recent Root Cause Analysis, (RCA) project with Bob Latino, CEO of Reliability, INC.  “Normalization of Deviance”  is a term that comes from analyzing the shuttle launch catastrophe and basically is when we do things the wrong way and nothing bad happens so we keep doing it until something bad does happen.  You can learn more about this in our RN Medication Error video we just released.  One of the first things that should happen when staffing is increased is that we stop taking short-cuts!  But since they are invisible, investors may wonder, how is this impacting the bottom line?

2)  Also, many, in fact almost 90%, of the errors that occur in healthcare are not reported.  In the April, 2011 issue of Health Affairs, the leading journal of health policy, published 3 articles with staggering updated statistics about preventable medical errors, (aka adverse events, aka sentinel events) in the USA.  Medical errors, according to resources in this issue, are ten times more frequent than hospitals and US regulators are reporting and each year:

  • 187,000 deaths in hospitals (other estimates as high as 400,000)!
  • Occur in 1 out of every three hospital admissions
  • 6.1 million injuries in and out of hospitals
  • An estimated cost of 17.1 billion in 2008
  • An estimated social cost of 393-958 billion in 2008

The hope would be that any staffing related errors will decrease when we have enough staff.  But how will we know since we’re not really talking about them in the first place?

3).  Many nurses and nurses assistants I have worked with over the years do not take meal and rest breaks as they should according to human needs, labor laws and organizational parameters.  Organizational leaders will often post signs about the expectation and reprimand staff when they don’t take breaks.  Some resort to punching out for breaks but not taking them, i.e. going back to work.  Some of us call this “Pseudo Lunch”! This problem is complicated and there are individual and organizational factors that contribute, but my point in this post is that at least some of this behavior occurs because the workload staff are assigned can not be done in the right way in the time allowed.  So increased staffing is more likely to allow staff to have the time to take meal and rest breaks.  Again, increase staff will be a big budget line with no obvious ROI!

Progressive and compassionate leaders understand that adequate staffing will help the bottom line because there is less liability and overall better quality and safer care.  Less wasted resources, less staff turnover and less re-admissions are all benefits from adequate staffing but not necessarily easy to see.


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4 Responses to If We Add More Nurses and Nurses’ Assistants Will We Make More Money? Why This is the Wrong Question for Healthcare Leaders

  1. Meg Helgert says:

    I work in a small clinic and staffing can be an issue if someone calls in ill for the day..what I see as a huge problem are the poorly trained medical assistants coming out of these 3 month programs making huge medication errors; unable to take blood pressures with even the proper cuff size; then (let alone) them offering medical “advice” or better yet; not know how to draw labs; not understanding how and why to spin blood..and worst of all..absolutely no training and better yet; no agency is monitoring them; they are not on anyone’ radar screen for licensing; most are not licensed or certified by any state agency.
    Now that’s a liability and cost dollars every single day.

    Meg Helgert FNP
    Portland OR

    • Beth Boynton says:

      Hi Meg,
      Thanks for your input! Do you find yourself ever in situations where you are supposed to be monitoring staff and preventing medication errors? How does it impact your workday? Harm to patients and liability, although both potentially very costly seem like they could also stay off the radar too easily.

      Poorly trained medical assistants and lack of oversight is scarey. Somehow, it seems organizations can save (or make) more money by hiring less qualified staff and not monitoring their work effectively. There is probably someone, like a Charge Nurse, ARNP, or Physician who would be held accountable if something goes wrong, but realistically workloads, time, and perhaps unclear expectations make me wonder just how effective s/he can be. Then something goes wrong and we look at the problem in isolation. Why didn’t S/He do more to supervise. We don’t necessarily look at the underlying organizational factors.

      I recently collaborated with Reliability Center Inc. to do a Root Cause Analysis of a medication error by an RN. It is not exactly the same topic you are describing, but it does help highlight some underlying dynamics i.e. organizational culture, systems and management responsibility. You might find it useful: http://www.youtube.com/watch?v=ESrTr08fLB4

  2. If more staff are added, there may be less litigation and liability expenses … just ask former state trooper Matt Whitman. He writes “that, by the grace of God, an observant nurse who just happened to walk by my room when I stopped breathing, called a ‘Code Blue’, and that ultimately saved my life. I would have been just another statistic if it wasn’t for that nurse.” – http://wp.me/p1JikT-f6

    • Beth Boynton says:

      Thank, you, Micheal! (And Matt!)

      I absolutely agree!

      You might enjoy any of these youtubes that raise awareness and promote discussion about similar issues:

      Interruption Awareness: A Nursing Minute for Patient Safety

      Why is Communication So Hard for Healthcare Professionals?

      RCA Analysis Of RN Medication Error

      Happy to have you in the loop and look forward to your insights,

      Take care,

What are your thoughts?