“Being a Critical Care Registered Nurse myself, I completely understand the stressful conditions that a lot of allied health workers find themselves in these days,” says Richard Manuel, Clinical Operations Manager at Nurses First Solutions LLC. In 2008 he worked as a travel nurse in Miami, Florida with 8 very sick patients from a cardiac telemetry unit on his hands at one time. “Very often employers take it for granted that nurses are battling with a workload much higher than the one they are supposed to handle. Nurse shortage became commonplace and we are expected to do the job that really should be distributed among several people,” explains Richard. The trend in the industry has not been very promising. Not only there is an obvious shortage of allied healthcare workers, there is also a very limited inflow of new specialist into the field.

Shortage of nurses is nothing new; it has been around for years. Except now, with baby boomers nearing retirement age and millions of people getting access to insurance through the Affordable Healthcare Act, the crisis seems more imminent than ever. The survey conducted by National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers  reports that 55% of RN workforce are currently age 50 and older. Meanwhile, educational institutions are failing to keep up with this disturbing statistic. U.S. colleges are struggling to expand their programs and find seats for a large number of qualified candidates.  American Association of Colleges of Nursing reports that in 2011 over 75,000 qualified applicants were refused admission to professional nursing programs.

Yet the most surprising phenomenon among all of this is that despite the existing shortage it has become much harder for new grads to find nursing positions in the past few years.

In 2013 the Wall Street Journal shared with us the story of Sasha Smith, who received a bachelor’s degree in nursing from the University of San Francisco and upon graduation was forced to work as a nanny and live on food stamps. And she is not an exception. The Internet is filled with stories of those with little experience struggling to find a place where they can get started.

“One of the reasons new graduates have difficulty finding positions is that facilities do not have enough staff to train them and need more seasoned nurses to balance the floor’s experience. Another reason would be that hospitals are becoming more strict about only taking in nurses with bachelor’s degrees versus nurses with associate’s degrees,” comments Richard. One more factor that definitely played into aggravating the situation is the recession. Due to the decline in the economy a lot of former experienced nurses returned to work, part time workers decided to pick up extra hours, and the ones who were due for retirement decided to extend employment. In the end, the younger generation had to turn away from the field and find other ways to pay their bills and student loans.

So what is going to happen next, when the financial market finally gets back on its feet, people start feeling less insecure about their future, and time inevitably catches up with those 55% of the nursing workforce?

We are going right back to where we started this conversation: nurse shortage, overworked staff, lower job satisfaction, increased percentage of sick employees at any given time, and of course decrease in the quality of patient care. In other words, if nurses are to care for patients, someone needs to care for nurses.


2013 Survey by National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers – 

2011 Report by American Association of Colleges of Nursing – 

Wall Street Journal “The Myth of Nursing Shortage” –


From a clinician standpoint, health information integrated with computer technology has revolutionized the medical field. The constant diagnostic tests, procedures, and other pertinent patient information reduce the errors and delays for providers. The constant evolvement and updating of newer programs is supposed to make data accessibility easier. Data accessibility also helps decrease the redundancy of duplicating tests and orders which help control cost effectiveness for insurance companies and government spending. When looking at the basic management of health information, one advantage for EMR’s are electronic coding. Coding different diagnosis’ helps track a patient’s medical history. From a government or insurance standpoint, this tracking system provides input to see if a patient with a disease is being treated accordingly or properly managing their care. It also determines if the illness is a chronic condition. By doing so, medical informatics is so important that it can dictate major reimbursements for a facility or a provider. When looking at the disadvantages of an EMR, there are security issues and errors within a computer system itself. If those errors are not properly contained or are not caught in time, patient safety and lives could be in jeopardy.
It is three o’clock in the morning. A seventy-year old male who is on vacation visiting his relatives in New York suddenly develops numbness and tingling on one side of his body while going to the bathroom. He also becomes speechless and is unable to call for help. His shuffling and commotion in the night luckily wake up his family members in the other rooms. They rush to his aid and call 911. Upon arrival to the ER, the doctors ask the son about his condition and history. The son states that his father is here on vacation and all his doctors and medical information is back home in Florida. The son brings in his dad’s pill container that is divided into a seven-day compartment with multiple pills in each compartment. He gives them to the nurse as his father’s home medications. Having an EMR is crucial to healthcare. Not only does it let different providers see into a patient’s health records, but it also dictates their care and treatment accordingly.

Only a small percent of facilities and other health systems have fully integrated into an all EMR format. Meanwhile, only 4% to 8% percent of physicians have implemented EHRs in their offices, where most people’s medical records begin (Goldstein, et al., 2007). When looking at this seventy-year old patient, his life is on the line if his treatment does not go accordingly. His medical records are like lifelines that help piece together answers doctors need for his care. A traditional format to getting patient records in a hospital is a patient has to sign a medical release form. That form is faxed over to the facility that contains his/her information. Once they retrieve that information then it is faxed back to the requesting facility. In ideal circumstances, there is no rush to retrieve the information. In times where a patient’s life is on the line or their care plan is on balance, that information is vital to receive within hours of its request. A fully integrated EMR system would cut the delay. It would save the patient time spent going through unnecessary diagnostic tests.

When looking at the disadvantages of integrating a full EMR system for the whole country, the first issue that comes to mind is HIPAA. HIPAA laws maintain a patient’s confidentiality while in and out of a facility. Medical records are designed to be kept private and the basis for the law to prevent solicitation from unwanted vendors or providers. All facilities that use an EMR system contain a network security that is constantly updated to prevent hacking and breaching patient information. It is often easier for an individual to dress in hospital scrubs and put on a stethoscope to go through the paper charts and steal vital patient data such as social security or driver’s license numbers. There have been cases where paper medical records, especially parts of them, have disappeared. There was a case where boxes of patient records from a doctor’s office were found in a garbage dumpster (Preventing Medical Identity Theft, 2008) and a case in which stolen medical records were recently found washed up on a Maine shore (Associated Press, 2008b).
There is no single definitive way to protect data but an EMR helps manage that system easier than paper records. Other safety concerns that an EMR may have involve incorrect information transference. One example is if a patient is allergic to penicillin. There have been situations where the clinician and pharmacy did not catch the allergy and the patient received the antibiotic causing an allergic reaction. It is hard to determine if the blame falls on the EMR system or the clinicians taking care of the patient.

There is no sure way to protect patient information. It is always due diligence of the providers and physicians to be advocates for the patient in terms of respecting the confidentiality of their information. While EMR system integration is a work in progress in facilities all over the country, there are still millions of paper documents transferring to medical records as archives. Upon needing those documents, it is hard to determine the importance of the information when it truly matters. An EMR system will help prevent delays and continue to give providers insight into each and every individual patient they encounter. Having that information is like opening an electronic book to their medical past. Along with billions of dollars in healthcare cost savings, EMRs is the future of health and quality care.



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Being the head leader on a unit is a difficult task to manage. Everything flows in different directions and accountability always falls on the nurse manager. Healthcare organizations have come to recognize the importance of nursing input in fiscal planning, and nurse leader-managers in the 21st century are expected to be expert financial managers (Marquis & Huston, 2012). Having a proper balance in spending means using resources timely and wisely to be cost effective. Spending more does not necessarily mean quality care. Throughout the fiscal year, acuity in patient care fluctuates. Directing the assistant nurse managers and the relief charge nurses means working towards the same goals. Emphasis should always be to keep patients and staff satisfied. By doing that there needs to be a thorough plan for the business year.

There also needs to be contingency measures that handle unexpected situations such as staff shortages, spikes in acuity, or equipment needs. Evaluating needs and seeing first hand what goes on during a typical shift both day and night will help address certain issues. Assessing priorities and handling them in an orderly fashion based on highest need is essential. Looking at successes and failures by other units will help create a work plan designed to meet the needs of the floor. Most nursing staff has no knowledge into expenses on the floor’s budget. The more the staff understands the budgetary goals and the plans to carry out those goals, the more likely the goal attainment is (Marquis & Huston, 2012). By being prepare to handle different situations, it helps compact issues that occur throughout the year.

Expenses such as equipment request can be deferred until the next fiscal year. Priorities that take precedence would be to have proper staffing. Nurses often work in high stressful situations and deal with life and death on a constant basis. A survey of nurses in Pennsylvania showed that more than a third reported high levels of emotional exhaustion, a key component of burnout syndrome (Cimiotti, 2012).

With charge nurses requesting additional RN’s for each shift, their request should be accepted if there is funding in the budget to do so. This will alleviate some of the workload on the staff if the ratios are better in number. Expenses that can be addressed now but carried over to the next fiscal year would be the orthopedics conference in August. With some funds left in the budget, the registration fee, which is due now can be paid for and the remainder will be deferred to until the next fiscal year budget.

An area that should be invested is staff development. This would be used for continuing education in order for nurses to get preceptor training. This would ensure that the willing floor nurses are able to advance their roles on the floors as teachers and possible leaders of the unit. The preceptor’s relationship with the new nurse is key to the successful functioning and socialization of the nurse on the unit (Paternitti, 2006). While budget supplies remain strong with 4500 dollars left for the year, fluctuations in patient acuity can alter usage on a demand basis.

Factors that contributed to these inaccuracies primarily fell on nurse retention. Unfortunately these issues are somewhat predicted based on floor moral and acuity. Nurse turnover is a recurring problem for health care organizations (Jones & Gates, 2007). These could be controlled through staff feedback and management involvement with the routine nursing staff operations. By seeing first hand what the nurses have to deal with, this can open the eyes of the charge nurses to see what needs to be done to help improve staff delivery while not compromising patient care.

When dealing with patient acuity, a proper balance is needed to maintain the sanctity of the floor. Acuity has been increasingly used in an effort to control rising cost of patient care through tools designed to dictate appropriate staffing levels (Shaha & Bush, 1996). Nursing leaders have to deal with budgets and design them accordingly to meet the needs of the patient while maintaining proper patient ratios. Changes in healthcare reform are drastically causing nurses to deal with more work and responsibilities on a regular basis.

Once again, these changes can cause imbalances with staffing from nurse turnover. A way to maintain proper acuity according to classification systems is to assign each patient with a proper level. Assessing needs, workload, and complexity are tasks that will fall on the charge nurses from each shift. They will carry out this assignment every time a patient reaches the floor. A simple way to approach this would be to classify each patient with point system. The UK model rates patients from a one to four (Hurst et al., 2008). A patient with a score of one point would be a patient who is minimally dependent on the nurses. A patient who scores four points would classify as one that is completely dependent on the nursing staff. When making assignments for each shift, balancing the acuity according to the points system should help distribute the workload on each nurse.

Strategies in motivation would start off at the leadership level. A transformational leader is a manager who is committed, has a vision, and is able to empower others with this vision (Burns, 2003). This leader is committed for the long term and cares for the people during the change. For this situation, a transformational leader would communicate to the staff that this is not going to be an easy process but will work together in making it work. A transformational leader empowers others. This means that this leader would motivate and encourage he assistant managers to come up with ideas of how the floor changes can be done. Taking feedback from the staff and empowering them to new areas of innovation will help change the culture of the floor in a positive way. A transformational leader looks at the effects and identifies common values. This leader encompasses acting as a mediator and champion and exerting control over complex situations (McIntosh & Tolsen, 2009). One way to keep staff moral high in times of high acuity would be to know the floor point balances. If all nurses have more than one or two patients with a points classification system of a level four, then management should step assess the budget to see if a stat nurse or an extra nursing assistant would be feasible to help out the floor. If that is not possible then even something as simple as a free lunch can go a long way.

With the government becoming strict on hospital reimbursement, quality patient care has become the constant initiative towards meeting goals. Signed in 2010 by the president, the Affordable Care Act went into effect on June of 2012. Section 3014 of the Affordable Care Act focuses on quality measures for patient improvement while in the hospital. Aligned with the Centers for Medicare and Medicaid Services, this ensures that hospitals will meet the goals with establishing their core measures. Under HCAPS scores, departments are graded on the work given and the patients that were discharged provide feedback on their hospital stay. The categories graded are hospital cleanliness, staff responsiveness, environmental noise, physician communication, nurse communication, medication/discharge information, pain control, and willingness to recommend.

A structure that is implemented as a tool to improve consumer satisfaction around the country is hourly rounding on patients. This initiative tool was designed to meet the needs of patients on a constant basis with around the clock attention. Nurses involved in hourly rounding protocol are finding their shifts less stressful, their time more productive, and their patient safety and satisfaction scores hitting all-time highs (Leighty, 2006). This would not only fall on the nurses to fulfill but also on the unit manager, charge nurses, therapists, case managers, and even the doctors to perform. The phrase, “Is there anything else I can do for you before I go?” should become a common phrase within the floor itself. Another tool that can be implemented on the floor would be daily care plans. These care plans can have a list of a patient’s up to date hospital status such as medication list, doctors on their case, therapy, and procedures. These can be distributed by the nurses with a brief explanation of their care and answer any questions the patient or family may have including education. If a patient is going to get discharged within the next few days, a quick survey to the patient or family can be passed out. The goal is to answer any issues or concerns while the patient is still the hospital. By meeting these goals before discharge, it hopefully will reflect upon patient surveys scores that are sent out after they are home.Those scores in each category are graded from a zero to one hundred percent and are calculated monthly on a year round basis to see which areas need improvement. The overall goal is maintain a ninety and above in all categories. Our system has become a pay for performance system. The work the nurses do in regards to patient care reflect back on the facility and its budget if satisfaction is not met.

By assessing the needs on the floor based on priority, the budget requests will be met in all areas. Personnel and overtime accounted for areas of the budget that were inaccurate. Accountability for why these areas were inaccurate was partially due to workload and patient acuity leading to nurse turnover and a decrease in patient care. This cycle then puts remaining floor nurses to work overtime causing the overtime budget to decrease. Patient acuity can be distributed using a point system assigned to each patient. By assessing each patient and assigning the proper points to each nurse, it will hopefully distribute the workload to the staff as a whole. Having a transactional leader who is open and receptive to the staff will open a forum of communication on the floor. Answering questions and taking feedback will hopefully create an environment that empower each employee to take initiative and create ideas that will help the floor and improve patient care delivery. Getting staff involved to help improve patient satisfaction will reflect on survey scores that ultimately will dictate hospital reimbursement. Promoting hourly rounding and distributing care plans on the unit should become a structure used on a daily basis as quality measures of improving hospital stay. By fulfilling all these tasks, the unit manager should have a strong cohesive unit aimed at retaining staff and achieving the overall goal of promoting quality patient care.



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