Should Patients, Families, & Advocates Know @ Staffing Shortages and Staff Turnover?

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Customer service training often includes instructions for staff when patients or families have complaints or concerns about care.

  • “My husband needs his pain medication.  We put the call bell on a half hour ago.”hoyer lift
  • “I’ve been waiting an hour to talk with the nurse about the swelling around my IV.”
  • “HELP! My mother just fell off the toilet.  She was waiting and waiting and  decided to try it herself.”

Carefully worded training instructs staff to apologize to patients and families and go get help, but never tell them that “we are short of staff”.  This approach puts patients, families, and staff in a difficult and unsafe predicament.  Staffing influences care in many ways such portrayed in this blogpost about overmedication on a dementia unit.

I have a friend and colleague who is an oncology nurses, (an excellent one) and she and I have differing opinions about this.  She believes telling patients and families about shortages is inappropriate because it would increase stress and worry for patients.  I can see her point, and yet think, if it is true, patients and families have a right to know.   They would have realistic expectations and be empowered to increase family support, seek treatment elsewhere, or hire an advocate.

In many healthcare settings there is a big gap between what we say we can do, what we should do, want to do for patients and what we humanly can do.  I don’t want to add stress to patients and in general don’t approve of caregivers complaining to patients about organizational problems. However, uncovering, discussing, and addressing truths about staffing and workload expectations will help to get us on the same side in terms of seeking solutions.  Shouldn’t  consumers and providers  be on the same team? And shouldn’t consumers  be informed?

A recent study at Johns Hopkins  suggests that Patient Satisfaction Surveys may misleading as reported by Kaiser Blogger Jordan Rau in, Patient Satisfaction May Not Be A Good Indicator Of Surgical Quality”.  I think this is because there is an imbalance of focus on hospitality and perception rather than engaging consumers and frontline staff to build better systems.

What would happen if staffing patterns became transparent to patients and families? This could be by verbal report on a given day and/or by posting information about ratios of caregivers to patients, turnover, sick-calls, and back-up staff coverage policies (protocols for  and effectiveness of) replacing sick workers etc).  Progressive organizations such as Magnet Hospitals might use this information to promote exemplary patient safety and staff recruitment records.     Organizations that are chronically understaffed may have to address staffing and related issues such as morale and turnover.  Both seem like positive outcomes.

What do you think about making staffing patterns transparent?

BB closer Headshot 1-13 CherationsBeth is an organizational development consultant, medical improv trainer, and author of Confident Voices:  The Nurses’ Guide to Improving Communication & Creating Positive Workplaces.  For bulk orders contact beth@bethboynton.com

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11 Responses to Should Patients, Families, & Advocates Know @ Staffing Shortages and Staff Turnover?

  1. I agree with transparency. In the ER (my field), we have patient surges from time to time. This is often misinterpreted as understaffing when it is more “over-arriving.” When staffing for expected volume, a surge does not translate to understaffing, which implies intent. Patients may need their expectations re calibrated during surges.

    If a leader knows what it takes to manage a certain population and applies less staff intentionally, this is improper (perhaps unethical) understaffing. This is a common Monday happenstance in many high volume ERs across the US since it is predictably 20% busier on Mondays and staffing is often not commensurately increased.

    It is not right for a department director to be told by the C-suite “we are immediate rolling out a 20% cut in budget, cut staffing immediately.” Such dictums are enigmatic of a myopic, frantic or uninformed administration.

    The determination of whether safe care can be provided with less staff has to be verified and then introduced with a safe action plan. If there is clearly a lot of non productive activity (often correlating with how much time personal smart phones are spend out of pockets during a shift), then there certainly is justification and it’s time to crack the whip.

    When fiscal realities mandate a paradigm shift to a more efficient care model, there needs to be a formal change plan: stakeholder involvement in process redesign and then significant staff retraining.

    But … back to the question. Yes, the patient deserves an honest explanation and an apology when their expectations were not met.

    • Excellent points Tom. To some extent surges will always be part of healthcare delivery. And functioning at this pace all the time is not healthy or safe. Sometimes I wonder if leaders see a productivity level at a peak and think we can or should be able to sustain it. I bet burnout and errors are far more costly than safer staffing. Also, a little non-productive time may be reasonable, but how much? This makes staffing tricky, but as you note some surges are predictable to some extent. Cost-effective strategies include delegation skill training, inspiring and hiring staff with initiative, instilling a clear and consistent vision, and being honest with limitations. At some point budget cuts may mean we can not do some things and considering this should be part of strategic planning. But, maybe we can get creative about using families and volunteers too. One challenge of staffing decisions is to figure out what we can control and predict and what must emerge. What excites me about medical improv is that I believe it will bring out the best in emergent behavior. Beth

  2. Ina says:

    I agree with the problem of shortage of staff as many years ago I experienced a problem when was in the hospital to deliver a baby. It does cost more for a hospital to employ more people but for a patient a nurse and the care taking staff are the people who take care of them and if they are not available at the right time, then it is a major problem.

  3. Kenny Hopkins, CPhT says:

    Yes I think they should be told about, at least ,being short staffed. The families need to be told that this is one reason they are not checking on the patient as frequently as they would like. I have seen first hand a hospital that had enough nurses, etc. to staff the floor, and they checked on the patient almost to being annoying. The nurses need enough help so they can check on the patients enough so the families feel like someone cares. If you are short staffed, and I have experienced this first hand also, sometimes it seems like no one cares. The patient is the reason we are there and they need and deserve all the attention we can give them.

  4. I actually suggested this at a the recent MSNA meeting in Portland. I said that when there are delays, errors or other problems, and staffing is short, that the truth should be told. Nurses absolutely should tell the patients that they are short staffed and let them know how many other patients they are caring for that day. We have covered up and made excuses for facilities that do not staff appropriately for years. Unless patients know the truth, we as nurses are taking the fall for everything that goes wrong! And we are not giving our patients the truth or being transparent. They may see the importance of having a loved one stay with them to help with simple tasks and advocate for them. A nurse sitting at the same table with me at the conference said “OH NO, We cant do that!” My response to her was WHY NOT? She didn’t answer, but I think the answer was fear and intimidation.

    • Good for you, Kathy! Being honest creates a path where consumers can help fix the problems….and breaks down the idea that we should be keeping secrets…..or the “Us-Them” mindset. Keep on doing your awesome work!!!
      Beth

  5. Beth,
    Great post and great questions. I agree that patients and families need to know when there is short staffing. This kind of transparency is so important, not only to incite more patient/family engagement in care but to ward off negative criticism toward nurses. You’ve heard it, I’ve heard it. Patients and families complain that their needs aren’t getting met fast enough and some believe that nurses just don’t care enough or would rather chat with one another rather than respond to call buttons. If patients/families know the reason their nurse isn’t coming quickly to respond to a patient’s needs, then that tends to reduce frustration, increase understanding and hopefully increase motivate to get in there to help.
    The main reasons I explain in both my books what nurses are up against is because of the need for this kind of transparency and to sensitize patients/families to the hardships nurses are going through, not because of their design.

    • Absolutely, Martine and thank you for your comments. This will go a long way to decrease a blaming mentality and increase collaborative problem solving. Your book, “The Take Charge Patient” is such an awesome resource for increasing engagement and responsibility of patients and families. Moving towards better care with empowerment is one of the most hopeful concepts I see for improving healthcare.

  6. I think that anything that might build bridges of better communication with consumers of healthcare is a good thing. Public perceptions still see medicine as an infallible profession where too much is expected from providers. When things go wrong, there is devastation, lack of trust and total communication breakdown. When patients and families find out about things like under-staffing and turnover, they are shocked by such revelations. Wouldn’t it be better for the healthcare industry to just lay out the facts up front? Perhaps that might even encourage better patient engagement and participation by patients and their families, and bring home the art of listening to them when they voice valuable concerns. We can no longer assume as consumers of healthcare that everything is perfect and the odds of poor outcomes are rare. In such a complicated and expensive system, it is logical to expect staffing shortages, high turnover and lack of continuity of care. Yet, the public is still oblivious to what the term patient safety even means, nearly 20 years after I personally realized it was an issue and have been advocating ever since.

    • I agree, Jen and thank you for your comment. If we aren’t truthful in defining problems, how can we ever work together effectively to solve them? I can understand hospital or other Healthcare leaders may worry about liability and expenses of staffing. But, not being honest about limitations sets staff and patients up for all sorts of problems ranging from inconvenience to catastrophe. I think there are all sorts of possibilities that can emerge with respectful dialogues be consumers, staff, and leaders. As you suggest, better patient engagement and participation by families! Best to have the dialogues outside of a patient’s vulnerable time w/ illness or injury…maybe that is part of what we need to consider. Engaging consumers BEFORE there is a problem. Nevertheless, I think we are missing out on co-creative problem solving by empowering all stakeholders with the truth!

      • pete mcewen says:

        Of course the patient has the right to know.The NHS is a public service. The patient is not a commodity and the delivery of healthcare is not commodity production.The
        transformation of patients into : consumers,stakeholders, customer, whatever, is a consequence of neo- liberalism applied to the public sector.Everything is reduced to
        and described in terms more appropriate to the Mall.
        The delivery of healthcare and the relationships that take place there; is a political and moral debate.

What are your thoughts?