March 29, 2024

Dear Interested Readers,

 

Reflections On Nursing

 

This week’s letter is shorter even than last week’s letter. I am making progress, but sitting in a comfortable position for the time required to do work is a challenge. I have appreciated the many expressions of goodwill that have come my way. Words of encouragement and even caution are treasures for me.

 

I was pleased to receive an encouraging email this week from Eve Shapiro, who is a regular reader. I have known Eve since 2016. I “met” her by email while she was co-writing The Patient Centered Value System: Transforming Healthcare through Co-Design with Dr. Tony DiGioia. I was pleased to write the preface for that book. Don Berwick wrote the forward. I met Tony, a very active orthopedic surgeon at UPMC, on one of his trips to Boston where he was collaborating with the IHI on patient-centered care.

 

Given the many times Eve and I have spoken by email over several years, it amazes me that we have never spoken in person! I can’t blame that reality on the pandemic. I think it is a function of geography. Eve lives in Maryland in the DC metropolitan area. As you know, I have become a hermit in New Hampshire. What amazes me is that having a wonderful friendship without ever meeting in person is possible.

 

I think that two things have drawn Eve and me closer together. The first “connector” we share is a passion for improving the experiences of getting and giving healthcare. Our second connection was the accidental discovery that we both considered the same man, Professor Jack Russell, to be our best teacher ever.

 

We both took every class that Dr. Russell offered at our universities. Dr. Russell was a charismatic English professor who taught with the intensity of a March Madness basketball coach. I first met him in 1963 as a freshman at the University of South Carolina. I was in Dr. Russell’s advanced placement English class at the moment we learned that President Kennedy had been shot in Dallas. Eve met Dr. Russell many, many years later when he was her professor at the University of Maryland. It was amazing to compare the similarities of our experiences with him

 

If you thought it was strange that I said that Dr. Russell taught with the intensity of a basketball coach, there is an explanation. His father was “Honey Russell” who among many things was the first coach of the Boston Celtics(1946-1948), and is enshrined in the Basketball Hall of Fame. I never knew much of his father’s story until long after I last saw Dr. Russell even though his dad was inducted into the Hall of Fame in 1964 while I was still attending his course in English literature. Years after I last saw him, he wrote a book about his dad, Honey Russell: Between Games, Between Halves.

 

Eve reports an identical student-teacher relationship with Dr. Russell years later at the University of Maryland. It is amazing to me that Eve made the connection. She picked up on our connection through Dr. Russell from a little comment in conversation or a few words in one of these letters about Dr. Russell’s influence on me. She quickly made the connection that my Jack Russell was her Jack Russell.

 

After last week’s note about my hospital experience, Eve was quick to write me. 

 

Hi Gene,

How are you feeling now? I was sorry to read about how long it took to get you a room and the pain you endured on the third day after your surgery. 

It sounds as though your surgeon was terrific, though. I hope your long-term outcome is good. No question, you needed this surgery.

I can’t help wondering, why all the traveling nurses? And did the fact that everyone came from somewhere else have an effect, positive or negative, on your care?  

When I interviewed the many nurses I did for my book Joy in Medicine?, I was struck by how many of them were either burned out or worried about burning out given their working conditions: too few staff being assigned to way too many patients, working too long hours (often without notice that this would be the case on any given day), and being so loyal to one another that they endured intolerable and unsafe conditions (for themselves and their patients) rather than leave their colleagues “in the weeds.” They also told me about hospitals not hiring replacements for nurses who leave in an effort to save money. Better to hire traveling nurses who may have no benefits, no loyalty to their colleagues at a given hospital, and no common culture? And even with traveling nurses, is the nurse: patient ratio adequate? Are patients safer?

I’m sure you’ll be thinking and writing about things like this for a while, and about many other aspects of your surgical and care experience. I look forward to it!

Be well, my friend. I hope you get stronger each day,

Eve

 

I wrote back to Eve and told her that she had presented me with the subject for this week’s letter. Imbedded in Eve’s letter, there are comments that can be turned into a list of significant unknowns that raise questions that are getting little attention about the total impact of travel nurses on care  It may be true that we must “fix” nursing before we can ever expect to consistently deliver care that is patient-centered, safe, efficient, effective, timely, and equitable. The fact that care delivery in many rural and small-town hospitals is becoming increasingly dependent upon travel nurses suggests that we must begin to understand the why, how long, and at what cost travel nurses will be a part of the future of healthcare.

 

Last week was the first time that I have had any personal contact with travel nurses. As a hospital system board member, I had been impressed by the huge, budget-busting cost of dependence on travel nursing. I don’t have accurate data on current costs, but as a board member of Guthrie Health, I knew that an average cost of about $300 per hour for each of our travel nurses was adding tens of millions of dollars of expense. The rapid increase in nursing costs was a budget buster that negated the benefit of many cost-saving efforts.

 

The high hourly cost of travel nursing is a combination of several factors. First, salaries had to be increased to entice nurses to come to rural, small-town, and even inner-city hospitals to fill critical roles. Contracts often include housing considerations. The agencies that manage the recruitment, licensing, and many of the employment details are also paid fees that approach the hourly nursing compensation. There is not much literature to reference in an attempt to answer questions about travel nursing that should be critical in our attempts to improve healthcare. Before things evolve much further, we must understand how travel nurses impact the cost of care, the safety of care, patient satisfaction, and access to care.

 

Eve raised the following questions in her letter.

 

• Why all the traveling nurses? 
• Did the fact that everyone came from somewhere else have an effect, positive or negative, on your care?  

• How many of them were either burned out or worried about burning out given their working conditions?– too few staff being assigned to way too many patients, working too long hours (often without notice that this would be the case on any given day), and being so loyal to one another that they endured intolerable and unsafe conditions (for themselves and their patients) rather than leave their colleagues “in the weeds.” 

• With traveling nurses, is the nurse-to-patient ratio adequate? 

 

I can add a few more questions about the impact of travel nursing. With those questions and any that you might want to send me, we can try to learn more about this “solution” which may eventually be a bigger problem than the problem of a nursing shortage which it was meant to solve. I can see the necessity of giving greater consideration to the underlying political, geographical, professional, and organizational problems that have created the need for travel nurses.

 

Perhaps if we better understand the origin of our increasing need for travel nurses and the full impact of travel nursing on patient satisfaction, safety, cost, efficiency, safety, and equity in healthcare delivery we would first be appalled and then perhaps find new enthusiasm for developing care pathways that fully appreciate the importance of nursing in our effort to improve outcomes while eliminating burnout and moral injury on the road toward returning joy to the practice for all of our healthcare professionals. 

 

Strange

 

It’s strange to get a foot and a half of snow during “Holy Week,” the week of “Opening Day” and Easter. Why shouldn’t a late snowstorm shatter Punxsutawney Phil’s prediction? Back on February 2nd, Phil saw his shadow and that should have meant that the ice would be out of the lake and the roads clear by mid-March and that is not true. When I came home from the hospital nine days ago there was no ice on my lake and almost all the snow had melted. By Monday morning the lake was covered again with a thin blanket of ice, and we had the largest dump of snow this winter. 

 

The return to winter doomed any plans I had to test drive my “Rollator” walker outdoors. This week’s header is the view from the easy chair in my bedroom where I have spent much of my week. I am very excited that my Easter will include a visit from my new grandson. He is now nine weeks old. I hope that your weekend will be a pleasure. If you are a skier, I can attest to the fact that there is snow up north.

Be well.

Gene