Faculty shortages are one of the main drivers of California’s chronic nursing shortage. There aren’t enough trainers. Add to this the age-old “solution” of importing nurses from other states and countries to meet the shortfall, and you get a fairly accurate picture of a nursing training system which is missing a few moving parts.

The new bill to create training places for nursing doctorates is a slightly muted response to a very difficult situation. There are 18 nursing colleges in California, but only 3 would be offering doctorates. The reason for this relatively small drop in the bucket isn’t clear, but what is crystal clear is that California, like the rest of the nation, has had the same ongoing problem with training policy concepts.

It’s a very strange situation, when demand is so high, and core business demands reinforcements for front line people, that the training paradigm has been on the back burner for so long around the nation. In industry, training is actively supported by business.

In medicine, everyone is expected to battle their way through the fees structure, a dysfunctional health care sector, and make a career. There’s a fundamental contradiction in the way medical training is managed.

Try this as a vision of cohesive training policies, nationally:

1. Doctors are produced at great/absurd expense and in relatively small numbers. That process has done precisely nothing to improve any aspect of health care, and simply exacerbated the problems.

2. Despite the demand for places in nursing colleges, and the huge productivity improvements that training more nurses would bring, not much is being done to provide more places, except for a vague, and apparently slow-moving, unimplemented idea of letting the community colleges do the basic training.

In a supermarket, if there are a lot of customers, the average checkout person can yell for help and a floor manager will get someone else on another checkout. The health system apparently hasn’t advanced to the stage where it’s able to recognize that it doesn’t have enough staff to operate day to day business.

This is truly lousy training policy management by employers. Why aren’t they screaming for more training places, when they obviously need them? Health sector managers are supposed to have had some form of business training, even if it’s only at crayon level. Evidence supporting the theory that they understand training policy issues is not particularly noticeable.

The holes in the import of health care workers approach are well known. The failure to support sector demand through US-based training has been catastrophic, and if anyone thinks there’s a money angle, it’s largely cosmetic. The amount of money spent fixing the problem with cheapskate approaches could have been halved by providing a working training program.

The good news is that California often leads the way in legislation which creates working solutions. The nurse/patient ratio has been law in California for years. Establishing at least a pilot program of nursing doctorates will show the other states how it’s done.

With any luck, in ten years, the other states will get the message, and a professional cadre of nursing doctorates will be able to help train the next generations of nurses.

It’s a long way around the mulberry bush for nurses. Everything seems to require industrial action. The latest episode is in Duluth, where 1300 nurses and two Minnesota hospitals are engaged in a tussle over issues related to workplace safety. Minnesota previously had a major issue over nurse/patient staffing ratios a couple of months back.

The problem is that these types of issues, which are also based on OHS law as well as best practice and common sense, seem to be incomprehensible to some parts of the health sector. There are no gray areas here, just an assessment of situations which seems to differ with a sort of bovine regularity. If nurses say the sky is blue, someone in the health sector will say it’s beige on principle.

It’s a matter of opinion where this “hate the employees” motif comes from, but wherever that may be, it should go back where it came from. Does anyone seriously imagine that nurses have nothing better to do with their time than invent issues? Aren’t there enough?

If a fireman says your house is on fire, most people pay attention. If a nurse with a string of qualifications says there’s a medical problem, a debating society is created. Spreadsheets are waved like holy crucifixes as if warding off vampires.

How many mindlessly conforming, corporate-brainwashed idiots does it take to run a health sector? Hospital nurses would like to know. So would the public. “Another day, another headline about a malpractice lawsuit” is the usual fare. It may have escaped the notice of the hospital boards, but sick people are dodging bullets in Mexico, rather than risk exposure to the American health care system. They’ll travel for days. There’s a character reference.

While all this happy camping is going on, every nursing issue, particularly related to the workplace, turns into an expensive dance around the maypole. The very people trying to inform management of real issues which are decimating the health care system on a daily basis are the last people to be even considered as sources of information.

Is that a “good outcome?” Is that “dynamic management?” Or is it a farcically obscene waste of time and money?

There is a way of dealing with workplace problems. Most people paid over $500,000 a year aren’t taught this, so I’ll explain:

1. Find problem.
2. Inform management about problem.
3. Management fixes problem.
4. World does not end.

This is called “efficiency”, and it’s not actually illegal, just unfashionable.

The theory upon which management science is based is that management actually does something, like what it’s paid to do, when it needs doing. This concept exists for a reason.

The theory that all workplace issues have to turn into soap operas, for some reason, is not a management science principle. Hospitals should set standards of management practice in relation to workplace issues, (in the case of workplace safety, there’s a few libraries full of laws which may provide some insights) and make sure those standards are maintained.

If anyone wants to save money, start by listening to nurses and stopping the endless incidents which are costing the sector a fortune.

In what must surely be one of the most roundabout series of events in history related to whistle-blowing, two Texas nurses have finally been vindicated after a long hard battle and losing their jobs.

The nurses sent an anonymous letter to the medical board providing information in support of allegations that a doctor was endangering patients at their county hospital. The doctor got the local sheriff to investigate the letter, and the nurses were dismissed. They were also charged with a felony, “misusing government information.”

The nurses filed a civil suit alleging breaches of whistle-blowing protection provisions and their constitutional rights to free speech and due process. The county has now agreed to settle. The doctor has since been charged by the Texas Medical Board with a series of extremely serious alleged breaches of professional medical practice.

The nurses should never have been charged with anything. There’s a natural contradiction in the fact that nurses who have access to this type of information by definition, could be accused of “misuse” of that information in the course of discharging what are actually professional obligations.

The charge of felony was also seriously off target. It is not a felony to proceed with a prescribed procedure which is actually the only avenue available for those wishing to deal with malpractice. What were the nurses supposed to do, put an ad in the paper?

The fact that the initial letter was written anonymously says volumes about the culture in this case. Why, exactly, was that considered necessary? It’s technically an incorrect procedure, but it was also obviously a result of concerns about repercussions. That’s entirely inappropriate in cases where people’s lives may be put in danger.

Any management system in which intimidation or threats are used to defend against allegations is suspect by definition. That seems to have been a factor in sending an anonymous letter when the allegations would have actually benefited from the signatures of two experienced nurses who could reasonably be expected to know what they were talking about.

This is all too common in the health care system, and it must end. If someone reports a robbery, you don’t arrest the person making the report. If nurses report actions which could cost a hospital millions of dollars, you don’t blame them for reporting it.

Which reflects worse on hospitals:

(a) Failure to appreciate the significance of information

(b) Lack of action on information

(c) A purely defensive response to a situation which could completely trash a hospital’s reputation and in some cases get it closed down

(d) Apparent incomprehension of the potential for extremely expensive, damaging statutory and civil actions related to matters raised by whistle blowers

(e) Ineffectual cover-ups which can’t protect hospitals against facts and make them look that much less credible

With any luck this incident will at least create a healthier perspective for the nation’s hospitals to appreciate how valuable whistle blowers are to the sector in preventing major disasters.

Whistle blowers are not the enemy. The sooner that’s realized, the safer the health sector will be for hospitals, patients, doctors and nurses.

The hazards of being a nurse can be grim. Ms. Jean Law, nurse at Baptist Medical Center South, went to her hospital’s emergency room with a fever of 104, and was given pain medication. The infection was so virulent that when the mistake was discovered several hours later, it was already too late. To stop the spread of the infection, procedures were carried out to remove tissue.

Nurses will recognize the issues, and the problem: sepsis. It is not alleged that the infection was acquired in the hospital environment; in fact there’s been no public mention of possible sources.

The problem for nurses is working in an environment where these incredibly dangerous infections are well known. The dreaded, deadly Golden Staph is the best known, but there are plenty of others, including this one, eventually diagnosed as Strep.

Matters are not improved by the fact that the standard Rapid Strep Test can be done in 10-15 minutes, which would have been appropriate in this case. Strep, like Staph, is one of the more common disease risks for anyone in a medical environment, and these tests really should be compulsory when any kind of fever is present in a health care worker.

(For those wondering, even a non-necrotic Strep infection feels like getting put through a blender or several. If you’re a health worker experiencing serious fever, start by being suspicious of the possible causes.)

All nurses will feel deep sympathy for Ms. Law’s situation. The problem is that not much seems to be being done about the presence of these murderous organisms and the ongoing risks, even when diagnosis is effective. They’re a risk to everyone in a hospital, patients and staff alike. The highly resistant strains of disease pose a constant threat.

It is unacceptable in the 21st century that this almost medieval situation should be tolerated at all. It’s like having a pack of mad dogs roaming the entire health sector. Post operative infections are hardly a new revelation, and Ms. Law’s tragic case, wherever it was sourced, is a good indicator of the risks for even healthy people.

This is an endemic environmental situation, and it’s not good enough by any standards.

Nurses spend long hours in environments where these infections are literally part of the landscape. The net amount of effective action on this subject so far amounts to precisely zip.

This situation must change:

There must be compulsory Rapid Strep screening of health workers for these deadly infections in any medical situation where fever is present.

There must be a concerted effort to permanently rid the hospitals of such incredibly dangerous organisms.

This is more than OHS; it’s life or death.

Finally, reducing the cost of home health care is more than a dream. The biggest home health service in the country, the Visiting Nurse Service of New York, (VNSNY) has clocked up an astonishing $150,000 of annual savings on deployment of Optimum Lightpath telecommunication systems for patients.

It’s hard to imagine a more appropriate setting for this type of system. New York’s high density home health issues are well known, and if ever there was a place for cost-effectiveness to be proven, this was it. VNSNY was already highly internet based. It wanted to introduce a new system for its 140,000 patients which would provide 24/7 coverage and VOIP access.

The VNSNY clinicians are typically mobile device dependent, so providing direct access for patients was the critical step to meet all requirements. In one quantum leap, VNSNY eliminated the need for an expensive physical call center, and upgraded patient communications.

You may have heard some mutterings about these systems in the past, and certainly the mobile versions, but this is a fully operational telecommunications system, in place and obviously working in the top echelon of the sector. The ramifications for home health care are enormous. This is a full health care system, including secure data uploads and communications with doctors, the whole package of primary care capabilities.

The communications problems for home health care systems are as demanding as they are costly:

• Patients need access to services at all times.
• The access through old style communications systems creates multiple steps between parties which may cause problems in response efficiency, particularly in emergencies.
• The overheads on these systems create massive cost drains on the budget.

That $150,000 may be an underestimate, if they’re talking about operational costs, and not the cost of housing a new physical system. The cost of that sort of system alone can hit a quarter or half million quite easily, in the setup stage. (In New York, it’d probably cost a lot more, particularly if you’re going to include things like furniture, windows, space, etc.)

This is good business practice, as well as good health care. There are obvious applications throughout the gigantic US home health care sector. Home health nurses will be only too aware of the potentials of these capabilities to save lives and drastically improve their ability to provide prompt, effective care.

You could do the relative costing merits of this type of system on a calculator, if you’re running a home health operation and finding that working in a plodding, museum-like environment while trying to provide health care has its drawbacks. These systems are working well, wherever they’re in operation, and are now considered best practice in the nursing sector when people can get their hands on them.

VNSNY is a major league, reputable organization which works in an extremely cost-sensitive, just plain tough business environment. The fact that it’s chosen this option should be a real wake up call to the sector.

A very circular, and very unproductive, argument is now bubbling around the relative merits of state “nursing compacts” involving 24 states, which recognize the nursing licenses of other states. This was brought on by USA Today’s pointed article in relation to various nurses who committed offenses in their home states and then went on to commit alleged offenses in other states. At least one patient death was involved according to USA Today.

In theory, the state boards are supposed to notify the National Council of State Boards of Nursing, but bureaucracy isn’t the most reliable of all methods. Records have also been found to be missing (what a surprise) and in short the machine doesn’t necessarily work in all cases.

The National Council of State Boards of Nursing responded, referring to the relatively few nurses cited in the article and stating that the millions of nurses on its records perform their jobs honorably.

There are a few facts to be filled in at this point:

1. The few cases cited hardly qualify as an exhaustive check on these types of problems.
2. The issues raised refer to large gaping potential holes in a system which really doesn’t need any more problems.
3. The shortage of nurses could be a great breeding ground for more problems.

According to USA Today, 10 states have disciplined “three or fewer” nurses in the last decade. The most enthusiastic optimist would consider this to be an unusual number, to say the least. The most experienced nurses would consider it ridiculous.

The general appearance of this situation is that yet another cockamamie do-nothing administrative system doesn’t work. This looks like a sort of bureaucratic Nirvana, where all problems are somebody else’s, and if a few patients die, there’s a policy around somewhere which can be sent to the funerals as a mark of respect.

For nurses, blessed with working with unreliable, untrustworthy people in the workplace as a result, the enthusiasm is somewhat less obvious. Real nurses have to clean up the various disasters created by offenders and a management system which may or may not condescend to deal with the issues when reported.

Before the health care system became a sort of holiday camp for people who like playing office in between lawsuits, the expectation was that professional standards would be met. Now, the absolute certainty is that they won’t. There was once an expectation that administrators would do their jobs, too, and that’s not noticeably doing the rounds with the nurses any more, either.

The solution is obvious. Put senior experienced nurses in charge of the Boards. They’ve got more qualifications than the average administrator, and even know what wards and patients look like. More importantly, they can tell the difference between real nurses and this other variety.

Or is this going to be another situation where something that wouldn’t be tolerated in a Third World country is fine in the US?

Time, sadly, will tell.

In what may be very good news for nurses, HealthStream Inc has signed an agreement with the American Nursing Association for the provision of continuing education courses online. This could be the beginning of a much more efficient, and definitely far more responsive, approach to nursing training needs.

Nursing training is now perhaps the most important single employment issue facing the profession and the health care sector. Last year, 40,000 people were turned away from nursing training simply because of the antiquated training system’s lack of places. This was a truly bizarre event, in which a sector with a well known demand for large numbers of new trainees to meet future demands simply couldn’t cope.

Apart from some belated muttering about using community colleges to take some of the overflow, not much else was said, and less has been done, about this very pressing issue. As usual, the net effect has been “too slow, too little”, and “too late” is becoming a real possibility.

This is no longer the 20th century. Modern nursing is apparently stuck with an education concept which hasn’t budged since 1940. Even the idea of taking advantage of the huge online education system, a multi-billion dollar industry which is now educating the rest of the world, doesn’t appear to have filtered through to the health care system until now.

HealthStream and the ANA have created a very good working paradigm for a whole range of nursing training issues. Let’s put it this way: If fully qualified professionals can do ongoing education training online, why can’t new trainees?

The sole requirement of nursing training is to meet licensing requirements. An accredited nursing college must be the trainer. There are no other specifications.

It is ridiculous to expect the nursing colleges to somehow find so many extra places. It is equally absurd for the colleges not to use their online facilities to handle the academic training and free up physical space for practical training.

The online option also:

• Creates its own audit trail, and cross checking capacity for educators and trainers.

• Reduces real cost for training colleges.

• Provides a very wide range of electives, modules, and training options in all professions.

• Is far more suitable in some situations for busy working nurses trying to get their second or third degrees (particularly those doing extra shifts).

With any luck, HealthStream and the ANA have cracked the code for getting something done about the training impasses, which have become major bottlenecks. Continuing education is the best possible showcase for what online training can achieve.

Hopefully, the next generations of nurses won’t have to wade through the bureaucracy and comatose levels of health sector apathy to get their training.

A nursing home patient called 911 to alert authorities to the heat problems in Baltimore’s Ravenwood Nursing and Rehabilitation Center. As a result, the state ordered evacuation of the facility’s 150 patients.

The patient may have saved many lives. This could have been a very deadly situation. Temperatures in the facility’s rooms were measured at 93 degrees. The Center had been using room air conditioners to attempt to deal with the heat, but patients reported that they weren’t effective. (Not too surprising, because room air conditioners can only serve a small area, and in larger buildings they’re usually inadequate.)

The state Department of Health and Mental Hygiene is currently looking at the failure to report conditions potentially harmful to patients as required by law. The obvious issues created by a patient making a report have called into question the efficacy of these reporting requirements.

The nursing angle in this story refers what appears to be an equally inadequate process. On learning of the situation, the Department contacted local nursing homes and the Health Facilities Association of Maryland. Staff from other facilities were tasked to go to Ravenswood and assess the situation.

The Department clearly did everything it could, as soon as it could, but this situation highlights a gaping procedural hole in the system.

Consider the logic:

1. Ravenswood has obviously been caught short by the heatwave. It does what it can, but it’s the wrong option.
2. The Department apparently lacks direct means of monitoring situations like this.
3. Third parties are required to drop everything and come to the rescue, which fortunately they did.
4. Dangerous heatwaves have been common for at least a decade. Public health warnings are common around the world.
5. There’s no major mystery about the possible health effects of heat stress on vulnerable patients. They’re a primary risk group.

The actual result, however, was caused by the fact that none of the obvious precautions were taken. There was apparently nobody on site at Ravenswood able or willing to make a report. The reporting system therefore had no hope of working.

What, exactly, is wrong with having some qualified nurses checking up on these well-flagged seasonal public health issues?

Not wishing to criticize the Department, because it did the best it could with what it had in the emergency, but wouldn’t things work a bit better if these problems didn’t happen? This procedure isn’t working, didn’t work, and can’t be trusted to work in future.

The net cost to the state of Maryland of a few nurses making sure public health regulations are being complied with is likely to be a lot less than the cost of large numbers of lawsuits for medical negligence. Nurses are trained to make these judgments, and having a few onsite to deal with dehydration, kidney damage and treating the related conditions of heat stress wouldn’t hurt, either.

The economic issues of health care can only go so far. Prevention is a primary medical process. That applies to health regulations, too.

Most human beings, and particularly those in the health sector, would agree that when it comes to politicians in the workplace, the best option is “Don’t encourage them.” Politics tends to be about as useful as a singing dialysis machine in real world medicine and is considered more obstacle than obstetrician in terms of achievements, real or imaginary.

So the current situation involving California gubernatorial hopeful Meg Whitman and the California Nurses Association is a not-very welcome reminder that there are other disaster areas in the world outside the health sector. Ms. Whitman (R) is strongly anti-union and has focused attention on incumbent governor Brown’s “allowing” state workers to unionize.

The state unions have reacted to Whitman’s position, which includes laying off 40,000 state employees, and have been running ads against her. The nurses have created the “Queen Meg” character, which has been dogging Whitman for some time, portraying the billionairess as an ogre. Whitman has responded with a somewhat selective website highlighting the wages of the nursing union executive and various tactics to undermine the campaign and various personalities in the union.

The merry sitcom world of U.S. politics, in short, is bubbling, shrieking and seething along nicely in California.

The problem with this wholesome family fun is that while people are dying like flies and/or going to bullet-riddled Mexico for cheaper treatments, not one single word appears to have been uttered, at any point, on the subject of the state’s health issues.

Although the general progress of the health sector in terms of returning to the standards of the 12th century has been good (it may even be possible to achieve pre-tool use levels of medical practice in coming years), maybe there’s more to health care than individuals. There may even be a reason for the existence of medical professions.

Could it be, perhaps, that this trillion dollar sector exists for some purpose other than the electoral process? Is it possible that the tens of thousands of sick people in the state aren’t really theatrical props in the great Punch and Judy show formerly known as American politics? Maybe there’s some sort of management required which doesn’t come out of a packet?

If so, the California health system may be on the verge of a cataclysm. Someone might accurately cost a band aid, for example, or stumble across the idea that patients may require some form of horizontal surface upon which to rest. Unlikely, admittedly, given recent history, but the threat of relevance sometimes even intrudes on politics.

So let’s see some policy and some issues addressed. I think it’s fair to say that if anyone wants the health sector vote, those votes have to be earned. Even political scientists and spin doctors should know enough domestic science to know that blue sky isn’t part of this sector.

So start saying something worth hearing.

The long, bitter health insurance battle of last year produced an interesting side effect. The new laws, which come into force on September 23, preclude many of the outs used by insurance companies to avoid incurring extra costs on policies, or to rescind them altogether.

The administration has also stated that it wants to deal with another phenomenon: Gouging. There is an average 20% rise in the cost of health insurance premiums for new policies. This is an interesting statistic, because there are recent indications that the ongoing price rises across the board are affecting hospital inpatient numbers.

People are literally being priced out of the health care industry, so demand for elective surgery and other services is falling off. An enchanting little practice called rescission, which involves canceling policies for paperwork errors, real or expedient, has also meant people can lose health care coverage at the whim of the insurers.

That, in turn, means some hospitals are actually closing units. The new laws may force a rethink of these high premiums and the related practices that are forcing people to forgo health care.

The rising premiums are no joke even for existing policyholders. One case cited included a 40% increase in premiums. In other countries this behavior by any industry would be illegal, effectively a cartel. The efforts of the health care insurers, combined with rampaging costs, have been the main drivers behind price rises for decades.

The ultra-destructive cost factor has flowed on to employment, resulting in “down skilling” jobs, reducing the number of nursing positions, and the endless restructuring which has been largely responsible for the chaotic state of health care employment.

Now the good news: If the gouging of health insurance customers ceases, and medical coverage becomes viable, the sector will stabilize, allowing more work to be done by hospitals and creating more jobs.

This, in turn, will require health care providers to establish workable structures to cope with the new influx of patients able to afford health care services. That will help the bottom line, and ensure some flexibility in otherwise fossilized employment policies.

Good news isn’t easy to find in America’s venal, insane, hopelessly outdated health care system, and this may be the first ray of light to a system that does what it’s supposed to do.

There are alternatives to the current situation, just for the record. These extremely uncompetitive prices do create opportunities for new forces in health care in the US marketplace. Foreign health insurers, who charge a fraction of American insurance, could walk in and take over the industry with almost no opposition from the overpriced cartels. This could operate like travel insurance, a go-anywhere policy motif, and insured people could even opt for treatment in other countries.

Hospitals, which have healthy markups of up to 175% of actual costs for procedures, might even shave some of those margins. That would reduce the net cost of treatment, and provide some real options for patients beyond the current “be sick or be broke” scenario. That would definitely help revitalize the sector, create jobs, and improve quality of life for sick people.

A dream worth having, perhaps?