Rising acuities and shortening lengths of stay (LOS) continue to challenge the nation's nurses and hospitals. Patients are ushered in and out of units at a fast pace that makes staff nurses work to keep up.
Daily turnover because of admissions, discharges, and transfers on a typical med/surg unit can range from 25% to as much as 70%, according to Barbara Farrell, RN, MS, MJ, director of quality and innovation for the American Organization of Nurse Executives (AONE).
"A nurse working a 12-hour shift can see three patients turn over in one bed on one shift," she says. "The nursing care that's required to tune patients up and get them discharged or transferred within that short period is incredible."
Technological innovation and a reworking of traditional nursing roles and admission processes are helping some hospitals to better address the constant admit/discharge "churning" in their units and the tough demands it makes on nurses' time and energy.
One success story is at Rush-Copley Medical Center in Aurora, Ill. The organization uses the admission nurse role, which is helping to streamline the time-consuming admission process and improve nursing and patient satisfaction.
"Staff nurses can't always drop what they're doing to run in and admit patients, and we don't want patients to sit alone in a room and wonder what's going on," says Becky Runkle, RN, BSN, an admission nurse at Rush-Copley. "Admission nurses do whatever we can to speed along the process."
Admission nurse positions are filled by highly experienced RNs, usually over the age of 45, who are dedicated to promptly greeting new arrivals and completing the admission process. This includes completing a full history, physical and safety assessments, medication reconciliation, and all necessary forms, including advance directives. They also can call physicians for orders, if necessary, and they have the time to hunt down and review patients' admission histories.
"The admission nurses are very thorough and can get more in-depth because they have more time to be one-on-one with the patient and family," says Karen Scheid, RN, BA, BSN, OCN, a staff nurse in the Rush-Copley Cancer Care Center.
Before the advent of the admission nurse role at Rush-Copley, it was not unusual for staff nurses who were trying to complete an admission to be interrupted four or five times to attend to other patients' needs, says Scheid.
"We found that the rapid churn in and out of our med/surg units made it difficult for staff nurses to complete a full admission history so we could develop a good plan of care," says Judi Bonomi, RN, MSN, MS, OCN, director of inpatient nursing. And in-house surveys revealed that experienced nurses were planning on leaving their units because they felt they could not keep up with the pace. Press Ganey surveys found that patients were dissatisfied as well, according to Bonomi.
Rush-Copley Medical Center is collecting data to measure nursing turnover and nursing and patient satisfaction as related to the admission nurse role and process. Bonomi believes the objective data will support her subjective observations so far.
"Admission nurses say they offer patients a better experience because they can give patients their full attention," she says. "They like the role because it allows them to stay at the bedside and gives them a setting to use their expertise."
A way to go
Hospitals also are attempting to decrease the toll of churning by streamlining documentation with electronic data collection systems such as electronic medical records and personal digital assistant devices (PDAs). But technology still has a way to go, say Farrell.
"Hospitals try to fix things with new technologies, which may not meet the needs of nurses," she says. "The old and the new are not always matching up."
Direct care nurses are key to the development of effective and efficient electronic documentation systems that do not waste nursing time with unnecessary or redundant citations, according to Carol Watson, RN, PhD, president of the AONE.
"If you're not involving frontline nurses in decision-making about how those documentation systems are built, you can't build a good system that decreases the documentation burden," she says.
Don't skimp on staff
Despite the challenges in developing electronic systems that actually reduce the time nurses spend on documentation, patients are reaping some benefits from the technology and science boom that resulted in decreasing LOS. These include less invasive procedures; fewer complications; less exposure to pathogens; and a quicker return to family, work, and lifestyle.
"Decreasing LOS can be a good thing for patients, but you have to have the staffing for it," says Isis Montalvo, RN, MS, MBA, manager of nursing practice and policy for the American Nurses Association. "When you are performing more activities in a shortened period of time, you need to have better staffing and more resources to render the care that is necessary."
Unfortunately, recruitment and retention remain a challenge, and healthcare organizations have stepped up by implementing strategies to optimize the work environment to increase both staff and patient satisfaction. Strategies include obtaining Magnet status and initiating the Transforming Care at the Bedside program, which is led by the Institutes for Healthcare Improvement, the Robert Wood Johnson Foundation, and the AONE. This program teams up nurses and staff to rapidly identify, test, and implement their own ideas to improve patient care on their own units.
"Hospitals and organizations are recognizing that nursing decision-making and autonomy and involvement are very important in a time of shortened LOSs," says Montalvo. "Ultimately, when you have the resources, including adequate staffing, it has a direct impact on satisfaction and better patient outcomes."
The good old days of longer stays
The changes brought on by short LOS and quick turnovers make some nurses and patients long for the "good old days" when longer LOS gave them more time to develop close relationships with patients and families.
When baby-boomer nurses began their careers in the 60s, 70s, and early 80s, it was not uncommon to have patients stay in the hospital for treatment for 10-14 or more days. Things began to change in 1983 when the federal government created diagnostic related groups (DRGs), a system that classified patients into groups with similar diagnoses that are expected to need similar hospital resources and LOS.
"DRGs partially impacted LOS, but the changes in technology really were the driving factor in decreasing it," says Watson. "For those who have been in nursing for many years, it changed our relationship with patients. For younger nurses, that's all they know. It's a generational difference based on what your frame of reference is."
The younger generations of nurses, reared on technology and massive accessibility of information, may appear to be better equipped to deal with the rapid assimilation of assessments, data, and orders that is required with short LOS and quick turnovers. But even for Generation X and Y, there is a limit to what can be digested and implemented, and information and process overload can take a toll.
"New nurses are feeling the same frustrations that more experienced nurses are feeling," says Farrell, adding that this can eventually lead to younger nurses leaving the profession.
But today's healthcare environment also has created new career choices, such as the admission nurse role at Rush-Copley Medical Center, for nurses who want to take a step back from the grind. Positions, such as those in case management, home health, hospice, and palliative care, can give today's seasoned nurses the time they need to develop longer, more intimate relationships with patients and families.
"Our admission nurses cherish the opportunity to get to know the patients," says Bonomi.
