1. Simpson, Kathleen Rice PhD, RNC, FAAN

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No doubt everyone reading this column knows someone who has been laid off or facing mortgage foreclosure. With job loss comes loss of health insurance, thus hospitals are now caring for more uninsured patients. Reimbursement has decreased for many patient conditions. Hospitals and healthcare systems have lost millions of their investment dollars, affecting their financial safety net. Nurses have seen their nest eggs dwindle, and some who were preparing for retirement are now planning on working longer. While banks and mortgage institutions have received billions in bailouts, the healthcare system is left to do more with less, absent significant government assistance. As the healthcare industry suffers, this financial crisis has direct implications for patient safety


While it would seem that nursing is a recession-proof profession, this is not so for all nursing positions. As with previous economic hardship affecting healthcare, leadership and education positions are the first to go. Nurses in non-direct care positions are being laid off, including nurse managers, directors, educators, clinical specialists, mentors, quality professionals and risk managers (many of whom are nurses). As positions for members of the nursing administrative and education team are eliminated, the basic infrastructure for keeping patients safe is being dismantled in many hospitals.


Many staff nurses are now on their own for keeping current with the latest standards, guidelines and clinical protocols. Annual updates on critical clinical skills that are the foundation of safe care during labor and birth such as fetal monitoring, labor induction, perioperative care, and medication safety are being eliminated in many hospitals. There may be no one left to develop new policies and procedures and provide education for implementation. There may be no one left to follow up with case review and critical events or coordinate root cause analyses (the need for which will likely increase as unit staffing, ongoing education, and opportunities for case reviews suffer). Orientation hours have been cut and new graduates are facing shorter fellowship programs, and in some cases, no formal fellowship program at all. As a result, their patients will be receiving care from nurses who are inadequately prepared for their new role. Without adequate preparation and support, these new nurses (our future) may burn out early and leave the profession entirely. Funds for conferences (both tuition fees and nonproductive time to attend) have been dramatically reduced. Many hospitals have eliminated all nonproductive education hours from their budget indefinitely. Financial support for specialty certification has been dramatically reduced. Nurses may no longer be able to afford membership in professional organizations or journal subscriptions. In this context, nurses will be challenged to obtain critically needed ongoing continuing education required to promote safe care.


All of these factors have contributed to a stressful work environment in which errors and omissions are more likely to occur and a decrease in conditions that are conducive to safe care. Further, nurses experiencing financial strain at home as their spouses lose their jobs may be stressed as they carry out their patient care duties on the unit. It's easy to say, "Leave your troubles at the doorstep when you come to work," but it's another thing entirely to make that happen every day, especially when you are worried about paying your mortgage and grocery bills. We need to be sensitive to how the financial crisis may be affecting our coworkers as well as our patients. This crisis will pass as have all others; we each need to do what we can to make a positive contribution in the interim to keep mothers and babies in our care safe during these stressful times.


Suggestions for Maintaining a Safe Care Environment with Limited Resources


* Be as generous as you can with your time and money in offering support to those in financial crisis.


* Be especially sensitive when caring for patients who are uninsured.


* Work with social services to obtain assistance for patients who need extra support.


* Offer to pick up extra shifts if staff nurse positions have been cut and staffing has suffered.


* Be creative in seeking educational opportunities that don't require significant funds


* If you can't afford journal subscriptions or new textbooks, use the hospital library resources.


* Offer to present an in-service education program on an important clinical topic.


* Convene a group of staff nurses to review and update unit policies.


* Start a unit journal club.


* Develop and participate in systems for self-scheduling and self-governance.


* When asked to help with a process usually assumed by the leadership team or nurse educator, take the opportunity to do so.