A Numbers Game


Nursing, it seems, is a numbers game. We take our patient’s blood pressure and convert a handful of numerals into a clinical condition. We decipher a body temperature to establish the presence or absence of infection. We utilize the height and weight of a human being to properly dose medications that, without meticulous calculations and crosschecks, could easily prove to be lethal. Our numbers game is one where the winners and losers face the highest of stakes, yet despite the importance of these facts and figures, we at the bedside are pummeled with numbers of a very different variety.

Patient satisfaction scores. Nursing sensitive indicators. Measures and metrics and series of statistics are thrust upon us thanks to a healthcare system that seems to have shifted from patient-centric to metric-derived. Deep down at the bedside, one mustn’t only be familiar with the quantity of fluid that is removed from a patient’s continuous dialysis machine: we must also be certain to make family members feel welcomed and comfortable – not because that is the decent and humane thing to do, but because scoring a nine out of ten points will earn an institution the desperately sought-after reimbursement it hopes to secure. I cannot blame the hospital systems and healthcare powerhouses who wish to grow and expand in the name of a medical pay-for-performance structure: if left without a means for financial stability, they will be bought out, shut down, or reorganized by the neighboring system nearby. A hospital is a business, and business is all about the bottom line. At what point, however, do we draw the line?

So while we make every effort to toss caution to the wind and save lives come hell or high water, we nurses must think twice about our capacity to care. We mustn’t make the excuse that our patient is too unstable to be turned or repositioned – foolish be the nurse that fails to document this cardinal sin of the profession! Rather, we lower the head of our open-chest patient’s hospital bed and ever so gently tilt their torsos to avoid getting a slap on the wrist or a note in our file. Better dead than bedsore? Not quite, but some moments it feels this way. We remove the dreaded urinary catheters in patients who damn well may need one, if for no other reason than to prove the point that it will eventually go back in anyway. We scrub the hubs on our central lines like they’re grimy grout on a bathroom tile, hawking others to blame should the patient develop an infection. We back-prime and we buddy system and we desperately stick for any vein we might hit to keep the germs at bay. And instead of risking that our patients should fall, on those especially busy days, we keep them tucked away in bed – rigged with alarms and running with fright, like Pavlov’s dogs, when that bed trigger sounds.

It’s a numbers game, this nursing life, even when things don’t quite add up. Some days we are spinning, running in circles and muttering a prayer that we’ve done all we can for our patients while appeasing the system. Some days we are tempted to leave that stupid freaking catheter in for just one more hour, so we ourselves can have a moment to scarf down a snack and take a bathroom break in peace. Some shifts we feel the guilt that creeps up from the pit of our stomach when we know that we pushed an emergency drug without wiping down a line, because we fear the wrath of consequence despite saving a life. Some days, we just don’t give a damn whether our patient’s husband’s brother-in-law is a doctor, because him flaunting medical knowledge and spewing out jargon won’t change how we deliver care. Truth be told, some people will never be satisfied anyway: so we can “yes ma’am” and “no sir” and apologize for inconveniences while offering grievances all the live long day and it still won’t help our monthly averages or our quarterly scores or our annual totals that someone reports.

Nurses don’t do our jobs for the numbers. We don’t work through lunches and cry with patients and code until our hands bleed because of our scores. In fact, we do all of these things – and so much more – in spite of them. Nursing has always been a numbers game: one life saved; one last breath; one moment to see a patient hug his or her family again. I love my job, and I go to work every day hoping to give, learn, and grow in some capacity through the work that I do: but some days, I can’t seem to make sense of the calculated risks. Today, it seems that the mathematics have become more complex, yet what we need in this profession doesn’t need to feel like calculus. It’s a matter of simple addition: more staff; more stuff; and more time for direct patient care. Nursing is a numbers game: when you subtract competent and effective nursing care from the equation, the end result is always zero. A business cannot be a business without a profit, but a hospital will never be a hospital without its nurses.

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  1. Sonja-you capture a perspective that is so incredibly valuable! I am old enough to have watched loved ones rely on the medical profession in their final days. They had wonderful people with them, and those who are lucky enough to have you to care for them are lucky indeed. Your writing is smart and insightful and asks us lay people to think differently. Thank you. I look forward to being continually enlighten by you. Kathi Love

  2. As usual I am blown away by not only your knowledge in your profession but also how you speak your mind and the truth as if you are reading the minds of those that read your blogs. I feel bed side manner is so important no matter if you’re a nurse, dr, or an assistant running aroun to help clean the rooms and change the bed sheets. As a person who has been on both sides of of the medical field, I have worked with Drs who made me cringe with the way they spoke to their patients as well as the staff that huffed and puffed when they had to get off their seat and cell phone to answer a question or actually do their job. I’ve also been a patient where I have received good care with nurses and Drs that made me feel calm and as if they really cares to hear me ask them questions continuously for reassurance without rushing out the door or cutting me off. Sad to say my most recent time as a patient is one that will be taken to the higher authorities because not only did the people who who cares for me at my visit not comply with the hippa policy that I so stand by and pray they do as well as professionals as I sign my name on those papers for my privacy, just to find out that a relative in the filed at the hospital I went to was told I was going to the hospital and not only either went through my file to see why I went and what the outcome was, but also had a nice sit down gossip session with the dr and nurses that took care of me that day. Had a few laughs at my expense and then all that was discussed and discovered by this person than told their child everything that was said and the assumptions of how I had gotten what I had. Things like this make me sick and now will hinder me from ever going to that hospital again and make me think twice now with a little less trust when I sign those papers and be live them when they say ” what is said in this room doesn’t leave this room “. That’s sad. And something I take very seriously and will be dealt with when the time is right. I just thank Gos their are people like you in this profession that stay true to what you learned and abide by the rules you are given and do so with a smile on your face and kindness to all you see as if they are one of your loved ones. Thank you for being you.

  3. Taryn:

    As ALWAYS, I appreciate your support and encouragement. Your candor shows a tremendously difficult issue surrounding the healthcare profession at every level that needs to be addressed. Sadly, there will always be “bad apples” in every group and throughout each profession. I hope that in the future you and your family members receive the most kind and compassionate and COMPETENT care, heaven forbid they should need it. I’ll keep your story in mind every time I enter a patient room.

    xo Sonja

  4. True words and feelings. I’ve been a nurse for 37 years, the majority of the time working in the hospital setting at the ICU level of care. My overall experience leads me to believe that healthcare and nursing practice is cyclic. After a few years we will switch our priorities to something else. Remember, “pain is the 5th vital sign”? I am hoping this present cycle transitions into another cycle soon, as experienced Critical Care RN’s and Critical Care Physicians, are leaving the bedside in large numbers. First time in my career we are hiring large numbers of GN’s into our Critical Care Units to fill the void. And then they only last the length of their contract, 2 years. Inexperienced RN’s and inexperienced physicians in the critical care setting. Are our patients really getting the best care possible?

    1. Ellie —

      WOW! 37 years! Sounds like you’ve got all of the knowledge and insight to help describe just how much has changed (and how much has remained the same) in this profession! My hope is that we are able to create a role at the bedside for those like myself with a few years under our belts where we can feel equally capable of thinking critically and acting accordingly AND monitoring the numbers, data, and trends. It’s an interesting time to be a member of the nursing clan, indeed! xo Sonja

  5. Nice – well written, poetic, packs a big bedside punch. If you’re open to feedback, I’d cut that last sentence – second to last is the clear winner.

  6. You are so right. It is a numbers game.I’ve been in this game for 29 years as a step down nurse. The number of nurses leaving the bedside because of all the extra demands is scarey. Nothing can replace the human touch that we all give. May we all find a balance we can live with.

    1. Susan —

      First of all, I’m blown away buy your level of experience and commitment to the profession! I agree with you — a balance is the key to ensuring that nurses and patients are taken care of! We cannot have quality for one without advocacy for the other! xo Sonja

  7. It has become a numbers game because we have let it become so. We, as a profession, have not demanded a seat at the table with physicians and hospital administrators when it comes to core nursing issues…patient/nurse ratios, support staff, shift length, work-life balance, compensation, and so much more.

    1. Mark —

      Thank you for your insight and feedback. I happen to agree with you: it is not enough to complain about something, we must make an effort to do something to incite change. I agree that being active and vocal members in policy and administration not only in hospital but nation-wide is the only way improvements in these areas can be seen.

      If I might ask, do you have any suggestions? ANA and other groups is a good start, but I often wonder how to pack a larger punch on an individual scale.


  8. Sonja, I am thrilled to read your blog. I have been a bedside RN for 30 years. I worked with Mothers and Babies and then sicker and sicker infants until I reached the NICU. I finally quit (in lieu of being terminated) because I refused to work when I was sick or exhausted. I then took a 6 month sabbatical at the cost of my retirement funds. I am so very happy I did. While I did not give my ALL to nursing, I gave the best I had every minute I worked. As a young nurse I always worked overtime and did so until the last 5 years. Then I stepped down to only 3 days a week. I was still exhausted and demoralized and it became even worse.
    I have reentered the workforce, but not in nursing proper. I could not do that again. My sanity is too important to me. The most fantastic comment a manager put in an evaluation was “Sara is a persistent patient advocate”. Damn right I was!! That carried me through for several years, but finally even that was not enough. I pride myself on never having a central line infection or a VAP due to my care. Those were the kids I took care of only once or twice because they had primaries
    . In the background and often in the foreground were the anxious parents. Or you had the parents who didn’t listen and inadvertently harmed their little ones. I saw young Mothers who were not even ready to acknowledge their pregnancy deliver a 24 week baby. These young women had severe bonding issues that NO ONE ADDRESSED, but we forced these women to “nest” with their very fragile baby before taking it home. Some of them “made” it. Some did not and to loose that infant after all our hearts and souls went out to it was beyond sad. It was unnecessary.
    I do know that the only way we can salvage this crisis is to care for our nurses in all their life stages. When I knew I was no longer appreciated I gave up. Not to my patients, for they were the reason I was there, but I gave up caring about the hospital I had given 15 years to.
    This “modern” healthcare is a travesty. I cannot support it through my presence and my efforts. Thank you for putting things into words, and words not just spoken at the nurses station or lounge. Good luck with your efforts

    1. Sara —

      Thank you for your poignant and candid response. It genuinely is a shame that the shift in our system has lead to movement out of the bedside, HOWEVER I am so proud and inspired by your level of self-awareness and ability to put yourself first. Please take a few moments to read my latest letter entitled “Drowned: Nurses Under Water,” which I have submitted to government and nursing institutions. I have no doubt, given your experience and passion, you will relate. Sending lots of love your way! xo Sonja

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