If I let myself think too much about the dumpster fire of American Healthcare, I get overtaken with a wave of hopelessness that’s heavier than anything I’ve carried before. For today, I’m going to set that weight down here so I can enjoy a Saturday off of work, without the guilt of feeling like I could be doing more. We all could always be doing more, but sometimes we need to be okay with enough.
I am enough. I am enough. I am enough.
Take a load off
I graduated nursing school 13 years ago, as the US was coming out of the Great Recession. Nursing jobs were scarce because single-income families were becoming a thing of the past, and middle-aged nurses were returning to the workforce as their spouses were losing their corporate jobs (at least, that’s the story as I remember it). To get a job as a nurse, you had to already work there, know someone who worked there, or be one of the first 10-20 applicants when the position was posted. “New Grad” was not a selling point — a novice nurse wasn’t nearly as appealing as a nurse returning with 10+ years of experience. In short, I spent a lot of my time applying, and none of it interviewing.
I’ll save my “I can’t guarantee the job will be here when you get back” for another day. The heaviest weight in my mind is the quickly-evaporating pool of qualified nursing candidates. I’m worried about the future of Healthcare (capital H).
The Institute of Medicine warned nurses back in 2010 in the Future of Nursing report to monitor the workforce and heighten our practice. A lot of nurses took heed and became APRNs — professional advancement is huge, and there is/was a need for them. But now, the best bedside nurses are migrating toward primary care or other specialties, leaving the frontline increasingly sparse.
If we were warned in 2010, you’d think we’d have our shit together at the beginning of the COVID-19 pandemic. Maybe we were getting there? I don’t remember feeling like we did. Healthcare-capital-H seemed to forget about the other part — monitor workforce data to anticipate/alleviate needs. Maybe they thought watching the turnover rate was the way to go. How many hires are leaving within the first 1, 2, 6, and 12 months? Sure, this is relevant, but it doesn’t tell the whole story. They should have been asking: Why is our turnover rate __%? Where are the nurses going? What can we do to make bedside nursing more desirable as a long-term career, instead of a stepping stone to anything else but this?
And here is the can of worms I always hesitate to open. But I’m doing it here, so maybe some extra eyes can help me unbundle it. And help me figure out where we go from here.
Now that’s Quality
Nursing, in the grand scheme of things, is a continual work-in-progress. We’re a newer profession, led by The Lady with the Lamp back in the mid-1800s, and always tasked with keeping up with modern medicine and technology, and modern patient care needs and preferences. I’m sure someone in research can calculate the difference in nursing before and after the Recession, and leading up to and after the Pandemic. Before the Recession, nurses documented on paper, patient records were in binders, and if you weren’t home when the phone rang, the answering machine would take a message.
And then, BOOM. Technology and The Patient Experience exploded.
Mobile phones, electronic medical records, patient satisfaction surveys tied to Medicare reimbursement, and fancy new ways to measure outcomes flooded Healthcare. We had this new ability to measure almost anything. And if you can measure it, you can change it. I’m not going to dive in too deeply for the sake of brevity, so let’s just say Healthcare is measuring everything. Turnaround time for labs, transport time for tests, door-to-needle for interventions, falls-per-patient-day, occurrence of infection, outcomes of codes, preventable injuries, deaths, and so on. Where are they getting most of this juicy data?? Why, the electronic medical record of course! Who’s entering all this helpful data into the EMR?? You guessed it, bedside nurses.
I’m going to pause here for a nod to my other Healthcare colleagues. There’s plenty of data entry from physicians, aides, therapists, etc. and I don’t mean to discredit the mountain of work they are also trapped under. I’m hoping that these other professions, too, will see this as a glimpse through the lens of a nurse, and help me figure out our action items. (Another pause to note that I’m focusing on acute care “hospital” nursing in my generalities here, as that’s where I spent my first 10 years in the profession. Outpatient, home health, skilled nursing facility, and every other realm of care can hear and notice that this echoes everywhere). We’re all in this together, but we’re so busy with work there’s no time to dig our way out.
So, are you following me so far? A lot is/was being asked of frontline healthcare workers (specifically bedside nurses) to capture an accurate clinical picture of the patient in the EMR via their documentation. And when a metric was abnormal — too high, low, stagnant — it was someone’s job to fix it and show that it worked. That’s (a very abbreviated explanation of) quality in Healthcare.
The other part of quality Healthcare is the Patient Experience. Turns out, we can measure that, too! If you’ve consumed any healthcare services in the last decade or two, you’ve likely received a survey inquiring as to your experience in that setting.
Did everyone treat you with respect?
Always?
No?
Bonk - points deducted.
Did they explain things in a way you understand?
Always?
No?
Bonk - (Should’ve had a V8).
The article linked above explains the purpose of the surveys better than I can (You can’t read my mind, and I’m fighting the urge to explain myself in every sentence). The original intent seems genuine, and I understand where they were coming from. Logically, I get it. Healthcare is a business, and their customers are always right. And they need to know what they can do better, so they can count on your business next time.
But those surveys have led to a shift in focus from beneficence - do good; do what’s best for the patient — to — do whatever it takes to get these metrics to improve (I’ll save my dive into patient surveys and the opioid crisis for another day).
For now, let’s just say Healthcare is missing the point.
Where did all the good people go?
Before the pandemic, bedside nurses were gently migrating, drifting, growing, into new ways of advancing their practice. They practiced for a few (five-ish?) years at the bedside, then progressed to roles in education, leadership, specialty, or advance practice.
Now?
They’re escaping. Fleeing the bedside in droves.
Nurses with 6 months of experience are turning around and signing up for grad school before they’ve even gotten their feet wet. All paths of advanced nursing education are built on the foundation that the students are bringing in at least a few years of clinical experience. But those colleges might not be too discerning, since they’re charging tens-of-thousands of dollars in tuition and fees, some of which will be reimbursed by the Healthcare companies themselves. Yum, money! And nobody is there to advise nurses on their career path, because they’re all too busy to mentor anyone.
I feel the need to point out that I love new grads, they come with fresh ideas and the latest knowledge, and they are such eager learners. They are bravely joining a profession that is running into the dumpster fire of Healthcare, and I don’t want to discourage people from signing up. We need the help!! But, if your intention in going to nursing school is to immediately sign up to be an advance practice nurse 6 months after graduation, I caution you to please please consider whether or not you have the solid clinical experience to do so safely.
All Do Well
So where was I going with all of this?
Healthcare is a mess, nursing and healthcare workforce shortages are reaching critical mass, and at some point (now) I need to just put it down and say FUCK IT. I shouldn’t feel guilty for putting down the weight. For figuring out how to alleviate my own suffering. I shouldn’t carry the weight of work on my day off, when I wake up in the middle of the night, when I’m up with the birds at 4AM and the worries come flooding in. I “should” all over myself, but it’s increasingly difficult to put it down and leave it. Counseling, medication, numbing, tuning out, hibernating, escaping… plenty of modern ways to cope in a disaster.
Do you ever get the urge to yell at someone. Point a finger and say “YOU created this mess, YOU clean it up”. “You” who? Healthcare executives? CMS? Private insurance? The wealthy? The greedy?
Placing blame will get us nowhere.
We’re all in this mess together. As a worker, as a consumer. This problem affects us ALL. Even on a day off.
What’s built out of greed is bound to collapse…
Wookiefoot said it better than I ever could in their song All Do Well.
How can we in Healthcare work together to plug the hole that’s flooding our boat, without making new ones? I got on here to put the weight down. I put some of it down, but sometimes it feels like I can’t keep up with the fire hydrant of worries. I feel better thinking that someone might read this and think “Oh Jess, you idiot, the solution is so simple! Don’t you know you can just…”.
So I’m going to crank up some tunes, like a salve on my burnt up pandemic heart. I’m going to let the worries subside, or force them out. I’m going to go easy on myself. I’m going to let this post be what it is, and hope that strangers on the internet are kind. I’m a tangential storyteller and I rambled quite a bit, so thanks for sticking it out with me. I’m going to put this out there. My early morning act of bravery.
I am enough. You are enough.
Enough.
~Jess
P.S. This Wookiefoot photo is from Spotify, and if you haven’t listened to their album “Writing on the Wall” — it’s time. It’s become my pandemic soundtrack, and along with Bo Burnham’s special “Inside”, defines my experience over the last 2-ish years.