Want to keep ER nurses from leaving? Focus on patient safety instead of satisfaction.


I have been an emergency physician for 12 years.  I have had the opportunity to learn from and try to emulate an impressive number of amazing clinical physicians.  These doctors seemed god-like at first, but as my training and career progressed, I realized that they were mostly teaching me through their own experiences.

One of my favorite teachers had a humbling saying:  “Good judgment comes from experience.  Experience comes from bad judgment.”  It was his way of trying to get me (and all of the residents) to learn the lessons of his own mistakes.  Experience is an incredible teacher — perhaps the best teacher of all.

In almost a decade at my current job in a busy suburban ED, I have watched countless talented and experienced ER nurses come and go.  At first, I asked them why they were leaving.  Now, I ask them why they stayed as long as they did.  Over the years, our ED has seen a drastic increase in acuity, a steady increase in volume, and a decrease in staffing levels.  Is it any wonder that nurses leave after a few years in that environment?  The phenomenon isn’t unexpected at all.  It isn’t an unsolved mystery.

An ER is a great place for a new nurse to start working, provided he has good preceptorship.  One can learn an incredible amount, develop competency and confidence with various types of patients, as well as become a member of the team in a busy American emergency department.  There is great satisfaction in becoming competent; not long ago, I experienced that thrill as a physician.  But competency only sustains a worker for so long.  The hours, the demands, the endless negative reinforcement, the dwindling support, the feeling that one is not meeting one’s own standard when it comes to patient care, all wear each and every nurse down.  They wear down so much that they leave to work somewhere else.  All of them do: every single one.  I have seen seemingly unbreakable people with seemingly unbreakable spirits leave because their spirits were broken.

Experienced ER nurses leave because their work environment sucks.  Maybe you care, and maybe you don’t, but one day each of us will hope and pray we have an experienced ER nurse who isn’t overwhelmed and overburdened.  I know I will.  I want one who can listen to me, focus on me, and has seen patients with my disease process at least a thousand times before I roll through the door.  I want an experienced ER nurse because I have seen experienced ER nurses save lives, spot serious problems masquerading as benign ones, and prevent errors before they happen.  Who wouldn’t want them in their corner?

American health care now focuses on patient satisfaction as a marker of quality care.  Numerous studies have shown this practice to be unfounded, yet it continues.  It continues because it is easier and cheaper to provide pedicures, gourmet food, and valet parking than increase the number of FTEs.  Numerous studies (like this one spearheaded by Dr. Linda Aiken) and articles (like this one by Alexandra Robbins) have shown the increased morbidity and mortality in hospitals and wards where nurses are required to care for an excessive number of patients.

Until we are able to shift the focus from patient satisfaction to patient safety, health care workers will continue to rearrange deck chairs on the Titanic.  Pedicures, valet parking, and great food are boons for wealthy folks who aren’t terribly sick.  Trouble is, American emergency departments care for three types of patients: the really old, the really sick, and the really poor.  A really sick, really old, or really poor person will be turned away from anywhere but the ER.  Not every American is really old or really poor, but there is a good chance that sooner or later, every American will get really sick.   When that happens, trust me when I say that the valet parking and pedicure won’t matter.

Show me a hospital with better nurse to patient ratios than its competitors, and I will show you a hospital I will choose for my care.  It’s that simple.  As health care workers and patient advocates, we need to create a push to make this information public and important.  It is one of the few true markers of quality, yet it is being completely ignored so that administrators can continue to make millions.  Isn’t it time to acknowledge that maybe the little girl shouting, “The Emperor isn’t wearing any clothes!” may be right after all?

Thomas Paine is an emergency physician.

Image credit: Shutterstock.com

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