While I am aware the health care system and hospitals already face enough problems with budgeting and caring for patients, the inter-hospital politics threaten to disrupt whatever cohesion is still felt by the varying members of the medical community. Nurses, in particular, have an especially hard job, their duties falling somewhere between doctor and assistant, while receiving neither the pay or slack of either. The micro politics inherent in the health care industry can, often, impede the ability of the nurse to maintain a balanced work/life setting, as well as prevent them from caring for the patient in the best way possible. In this summary, I examine several studies about the role of nurses in the health care system, and how they reevaluate my understanding of the practice.
Hospitals are full of politics; personal, economic and social pressures and connections made within the hospital setting (particularly with nurses) can positively or negatively affect the performance of their duties, subsequently having an effect on the health of the patients under a nurse’s care. Many times, I feel helpless and powerless to facilitate any change I may need in order to more effectively do their jobs. In order to get what they need, nurses must learn to play the game of politics; determine how one’s particular hospital setting works, and influence change and get the required materials or policies for the nursing staff (Maslin-Prothero and Masterson, 2002). Through this study, I became very much aware of the strategies and tactics required by nurses in order to get the resources they need – it made me much more invested in empowering my own nursing experience and emboldened me to more emphatically make my points to administrators about my requirements.
In the Ulrich et al. study “How RNs View the Work Environment” (2009), I was made more aware of how other RNs view the industry and workplace environment. The results of that study connects the work attitudes of RNs with the safety of the patients in a way I had not realized before. I did not know the extent to which a nurse having a bad day or being hassled by their peers or superiors could affect the quality of patient care. I am left much more aware of the impact that a poor work environment can have on nurses, as well as what needs to be done to improve it (improved communication, less stressful interventions by doctors and admins).
The Davies study “Political leadership and the politics of nursing” (2004) leaves me with a much bigger understanding of how much inter-hospital politics plays into the nursing practice. A culture of inclusion and exclusion leads to an ‘us vs. them’ mentality among nurses that can segregate them from doctors, keeping them at a distance already. This disrupts communication and exacerbates the kinds of issues that lead to nurse burnout, inter-hospital personal tension, and reduced staff retention. Political leadership is necessary in order for the nursing group to be more fully integrated into the rest of the hospital staff (Davies, 2004). Good nursing leaders must be allowed to be part of the equation as well – “Professional advocacy skills are needed to overcome barriers and to articulate and operationalize new nursing knowledge and standards if nurses are to enact and embed a leadership role” (Sorensen et al., 2008). In essence, I am now well aware of the role that nursing leaders play in the allocation of nurses to their best abilities.
In “Nurse Staffing in Hospitals: Is there a Business Case for Quality?” (2006), I learned it can save more lives to keep RNs available while increasing their hours. However, this can be a slightly more expensive tactic to use, which makes hospital administrators unhappy; the case can be made, however, for quality, where it pays off to spend a bit more money to keep nurses around for longer periods of time with a decrease in adverse outcomes. This made me much more willing to stay extra hours in my own practice, if it means a decided increase in patient care (Needleman et al., 2006).
In “Saving the Practice” (2002), Nelson et al. discuss ways to further best practices in the nursing field – they stress the importance of proper nurse education curricula, and making ‘necessary nursing care’ a priority in hospitals, alongside ‘medically necessary care.’ It makes me much more aware of the gaps that often exist in the utilization of nurses as medical practitioners in their own right, as they are more used as assistants.
Another point of interest in the diminishing of nurse’s effectiveness and morale is the culture in hospitals that supports a normalization of deviance. What this means is that human error is often treated far too casually when it still jeopardizes safe practices. For example, not counting instruments properly could lead to disaster in the future; it is often chalked up to being on autopilot when in the hospital, which is a dangerous thing to admit, let alone participate in. The culture of health care has become increasingly lax on safety behavior, due to an increased level of apathy in nurse culture. This apathy comes about from an increased level of helplessness regarding their jobs. Whether or not they help people during the day, there is always someone they did not help; nurses often feel as though they do more and more work each day for less reward; and their jobs are continually being threatened and marginalized by an increasingly tight-waisted hospital budget. This can leave the nurse feeling apathetic and seeking to merely go about their day, which can lead to the aforementioned autopilot (King, 2010).
There are always risks in human behaviors and choices, but when lives are on the line, people in charge of caring for those lives have to remain as vigilant as ever. Therefore, some solutions must be devised that will help hospital staff work with nurses to get the job done right. Communication lines must remain open whenever possible, and the primary priority must be to the safety and health of the patient, and not personal problems or inter-hospital drama. This can cut down on risky choices that put patients’ lives in danger, and maintain best practices in a hospital setting (King, 2010).
In Goopy’s “Taking account of local culture: limits to the development of a professional ethos” (2004), she talks about how important local culture can be to the implementation of nursing practices. From this, I learned that Anglicized nursing cultures and practices do not have to be the only way, and that we can look elsewhere for innovative ways to treat patients properly. In an Italian hospital, unique social relations occur between nurse and doctor, wherein there is no power in the nurse’s hands, but are a cohesive unit all the same.
In Clarke’s “Failure to rescue: lessons from missed opportunities in care” (2004), I was made much more cognizant of the often superfluous role nurses are shoehorned into in a hospital setting, making them glorified maids and assistants, and not medical professionals. “Without concrete data, nurses contend with characterizations of nursing work as ‘invisible’, as consisting mostly of routine tasks none of which are particularly dependent on skill, and the profession finds itself at a distinct disadvantage in arguing that patients need close attention from highly educated nurses” (p. 67). I have felt that in my own experience, but I had no idea it was such a widespread phenomenon – it is clearly an attitude that must be curtailed in order to utilize nurses properly.
According to studies, “Interoccupational conflict and competition continues to be a feature of the health care system” (Kenny and Adamson, 1992). Between many different positions (particularly nursing assistants and registered nurses) a feeling of competition and disenfranchisement can often occur, leading many on either side to resent the other for performing what they feel are ‘their’ duties. There is a great dichotomy present between those who wish to make a name for themselves in the medical profession, and those who wish to serve the overall team and their patients. Often, patients can recognize these tensions, thus lessening their faith in the people assigned to care for them. This can hinder treatment and care, and lead to negative experiences on all sides of the patient/medical professional transaction.
Staffing shortages are a significant problem that contributes to the disenfranchisement of nurses in a hospital setting. This problem is made even worse when staff retention becomes an issue – many nurses can become irritated or fed up with the conditions at a hospital and leave; alternatively, burnout can occur which leads the nurse’s performance to fall to the point where they must be fired. In order to prevent this, inter-hospital micro politics must be smoothed up as much as possible. This is up to the nursing managers, who are meant to lead the nursing staff in their interactions throughout the hospital. It can be quite costly to train and hire new nurses, making it ever so important to retain whatever trained nurses remain on staff, no matter the cost (Duffield et al., 2010).
In “Nursing Work Life in Acute Care” (2004), Brooks et al., examine how nurses often evaluate their work life, and their satisfaction with it. Its finding, that “Nursing job satisfaction, turnover, workload, staffing issues, skill mix, communication, autonomy, rewards, recognition, and empowerment remain problematic” comes at no surprise to me, and only seek to confirm my suspicions that dramatic changes in the field need to be made (p. 275). This is furthered by findings made by Fitzgerald et al. (2003), who determine that Australian nursing is full of “activities that were not regarded as important by staff when interviewed….while relatively small amounts of time were observed to be spent educating patients or communicating with relatives of patients” (p.326). This is a misuse of skilled staff that needs to be corrected.
Many political reasons and work environment factors exist for nurses to quit their jobs; four main ones are organizational, interpersonal, structural and professional. In the case of organizational, a nurse can have a problem with having too little or too much of a workload, or having incompatible schedules with their home and family life. With interpersonal issues, a nurse may be clashing with other nurses or doctors to the point where they cannot reasonably work at the hospital anymore, at least around those individuals with which they are having personality clashes). Structural issues include the environment of the hospital itself, the physical layout – some aspect of it that makes them uncomfortable. Finally, professional issues involve nurses taking umbrage with the way things are run at the hospital – the quality of care, or the autonomy (or lack thereof) encountered by nurses working at that facility (Duffield et al., 2010). I have had many of these issues throughout my nursing career, and as such it can help articulate my concerns to classify them in this manner.
In order to control these factors and prevent burnout, many things can be done for nurses in a hospital setting. Empowerment of the nurses can go a long way towards making them feel important, at home and appreciated; it can dramatically increase their job satisfaction. Greater flexibility with their schedules can prevent burnout, as they are less likely to work too many hours at a time, thus exhausting them and making them miss their home or family life. Also, improving relations between peers and supervisors can help the nurse feel more at home and accustomed to the environment of the hospital (Spence Laschinger et al., 2009).
In conclusion, nurses in a hospital setting are disadvantaged in a number of ways. There is a culture of exclusion and segregation that the nurses take part in, wherein each segment of the hospital staff tends to stick together and treat the others as adversaries. Proper nursing management and hospital workforce change can bring about the changes necessary to lessen tensions between peers in hospitals, prevent burnout in overworked nurses, and increase job satisfaction to the point where staff retention is increased exponentially (van der Weyden, 2004). This can create a hospital culture where the greatest number of people can be helped by a willing, satisfied workforce of nurses and other healthcare professionals. This has informed my understanding of the micro politics in hospital settings by showcasing the rampant poor behavior and lack of understanding that is present among medical professionals of all types (doctors, nurses, administrators); in order to create a proper sense of community and a streamlined means of patient care, all departments must work together to smooth over inequalities in the system.
According to Clarke (2004), “Nurses talk about the sense of peace that comes from knowing that details of care have been attended to, whether patient outcomes are good or not, and of lingering
discomfort when they leave work with unfinished business.” In my own practice, there have been many instances in which I did not feel as though I was doing enough to help my patients. Often, I would get in my car, start the ignition and be halfway down the road before realizing that a patient had asked me to do something, but in my rush to take care of other patients, or because someone had asked me to cover for them, I did not address that need. I would hope that another nurse was caught by them and they saw to that request; however, I would end up feeling bad that I was not the one to take care of it.
The reasons I cannot give all of my care are many and complicated. Much of it is time and energy; there are just not enough hours in the day to manage that level of care for the number of patients I have to deal with. What’s more, a lot of the medical and administrative red tape prevents me from getting a patient something they requested. Also, the sheer number of patients asking for the same things repeatedly can wear on me, and so I perform mild triage on whose needs and requests are the most pressing.
I have seen many instances in my medical practice where “staffing is clearly inadequate to provide even a minimally safe level of care to patients and others where there are insufficient qualified professionals available to deal with foreseeable complications of the treatments being carried out” (Clarke, 2004). In my practice setting a few weeks ago, I realized that I had to order more of a certain type of medical equipment – our previous machines were starting to break down, and it was obvious that we needed new ones. Seeing as our budgets are getting tighter, however, it then became quite a struggle to bring myself to ask the administrative staff for the money to free it up. I knew the administrators’ feelings on spending money we did not have to, to the point where we run machines to the bone, until they are nearly falling apart.
When I finally brought the issue up to the administrator, he was somewhat receptive, though not entirely gracious that I was the one that was requesting it. I am not sure whether it was a lack of time or because of the request for more money the hospital did not have, but he seemed somewhat cold to my urgings to get new equipment. The amount of paperwork and red tape that we both will have to go through will be tremendous, and that likely contributed to his reticence to hear my demands.
It is true that “Nurses rarely challenge the structures within which they work and do not tend to address issues such as inequality that may determine health status, permiate health care structures, and that can constrain nurses’ ability to deliver health care” (Maslin-Prothero, 2002, p. 109). For one, there are many individuals (such as myself) who do speak up when policy changes need to be made. At the same time, nurses can become entirely complacent and defeated in the face of such struggles, and consequently shut up about the problems they face. They know or realize (or sometimes falsely believe) that their problems will not be addressed, as they are considered ‘little people’ by the doctors and other administrators of their practice setting. So, in a way, the extract is sadly true, but that needs to change. Nurses must be willing to stand up for the care of their patients and of their fellow nurses, and put forth the effort to make changes happen. Otherwise, the system of politics within the hospital system will continue unabated.
I have thought often about what is used to silence the voices of nurses, even those methods that are not spoken out loud. There is a semblance of casual sexism that can often take place in the hospital, wherein women are nurses, and as such ‘not real doctors.’ What’s more, a mini class war often rages between doctors, administrators and nurses, holding nurses back from feeling heard as medical professionals due to their perceived ‘diminished’ status below doctors. Nurses often feel marginalized as a result.
In terms of time management, it seems as though the doctors and administrators manage the time, when really it is largely up to the patients and their demands. Intake and existing complement of patients can dictate how much time is spent on each patient, and how many hours are logged in a given work day in general. Autonomy is largely a myth when it comes to nurses; they are largely often at the mercy of the patients, doctors and administrators in terms of their time and responsibility. When any of these three groups say ‘jump,’ nurses must do so immediately and with gusto. Greater autonomy would allow nurses to meld their schedules to the real needs of patients.
There are many more nursing assistants nowadays, many with a unique set of skills that sometimes eclipses that of real nurses. While it is a boon for more hands to be available in a hospital setting to work, it can often upset the natural pecking order of a hospital, especially those with experienced nurses already on the payroll. In essence, I believe the political aspect of the debate boils down to money – it is often much cheaper to hire on nursing assistants than it is to get nurses, and they are often more skilled than some nurses. As a result, it is cheaper labor for inexperienced, yet educated nursing assistants, something which threatens many experienced, established nurses.
A new model that emphasizes an increased participation of nursing assistants will, naturally involve a backwards involvement of RNs. This does present a problem, as the vital assessment duties of RNs will be diminished, leaving little room for proper determination of a patient’s problems. The influx of nursing assistance can lead to more unprofessional behavior among bitter, disenfranchised nurses. This can often speak to a territoriality that occurs often in the medical profession, just like any other – often, nurses will show solidarity at the expense of other groups like the nursing assistants (Goopy, 2005).
The thought of having nursing assistants replace RNs due to their lower cost is frightening to me, and indeed sounds like blackmail. It basically smacks of asking nurses to take pay cuts, lest they be replaced. Everyone understands that the health care system is facing severe budget cuts every year, but one thing that must not be compromised is quality of care. At the same time, lowere accountability is something that some nurses desire – “This situation raises an interesting tension insofar as the nurses seek independence and recognition through their ability to be acknowledged by both their nursing peers and the doctors as ‘good’ (competent and capable) nurses and at the same time seek to maintain their identity as assistants” (Goopy, 2005).
It can most definitely be described as a Band-Aid to the budget problem; sure, nursing assistants cost less, but they might cost more in the long run if RNs are kept out of the loop and cannot do their proper jobs. Mistakes and errors made by inexperienced assistants can cost the hospital more than the potential savings of an assistant, which is something to bear in mind. I would barely be able to see a future as an RN if I were forced to be paid assistant’s wages to do more work, as it does not provide a solid motivator for nurses to perform well.
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