September 29, 2007, 1:59 am

I Say, “Why Not?”


So that’s my problem!

I’m awake, but my liver bile is still asleep!

Who knew?

Isn’t “liver bile” redundant?

I wonder what’s in those Carter’s Little Liver Pills?

An exhaustive search of Wikipedia the internet shows that Carter’s is still sold as Carter’s Little Pills and is made of Bisacodyl.

AKA Dulcolax.

Seems it wakes up more than just your liver bile!


What the hell was I thinking when I signed up for ten semester units???

I told myself I would take classes slow and easy and enjoy the process. Of course, the first chance I get I sign up for pretty near full time units. I always do that.

Now I work nursing, I study nursing and I blog nursing. I’m a nursing machine!

Somehow that didn’t come out right…


I believe that as long as nurses are employees of a hospital and not private contractors they will not have power in an organization.

I started to brainstorm ideas. After the shock of having my brain still functioning after three hours of Statistics, I asked myself…

How could this be done?

What if nurses started their own staffing companies? Companies that the nurses themselves would own.

I’m not talking registry here. I’m talking a company that contracts with a hospital to provide unit staffing. Any unit. Any floor. Long term. One year, perhaps more…


I’ll use the emergency department as an example. Suppose I brought together a group of nurses with experience in emergency nursing. All of them CEN certified with ACLS, TNCC, PALS and ENPC certifications. We form a company – just for fun we’ll call it “EmergiNurse, Inc.”

EmergiNurse, Inc. contacts Hotel Hospital and says, “For ‘x’ amount of money, we will staff your department full time for the next year.” That includes charge nurses and a manager.

If an EmergiNurse is sick, another EmergiNurse will take their place. The hospital doesn’t worry about providing health insurance, benefits, sick leave, vacation or scheduling. They don’t have to worry about paying overtime. Twenty-four hours a day, seven days a week there will be enough EmergiNurses in the department to staff the floor at least at minimum staffing levels. More staff if the acuity is up. Less if the acuity is down. We adhere to all hospital policies regarding Joint Commission requirements and patient care/procedures.


For a price. We contract with the hospital to provide nursing service on a unit for a set fee. One fee negotiated for the year. If the census drops the fee stays the same. If the census increases and more EmergiNurses are needed, the fee stays the same.

We would provide documentation of all licenses, certifications, inservices and competencies. We would provide the health insurance, vacation, sick time, educational leave and malpractice insurance for ourselves. We would pay ourselves a set monthly salary.

None of this clock punching, standing by the time clock waiting for the minutes to pass before you can leave without getting docked in pay. We are professionals. We show up and we work. If we finish our work before change of shift is over, we leave. If the unit is quiet, we decide whether to leave or staff in case of admissions. If we have to stay over one day, it’s not a big deal and we don’t quibble over 20 minutes of overtime. We set our own schedules.


We are professionals who own our own practice, and we own the company. If we make money we keep it. We aren’t going to lose money because the hospital still has to provide for nursing services to the patients – they would be paying this money anyway. They don’t have to worry about union contracts because they are not our employers. We would manage ourselves, bound only by hospital policies and state laws regarding breaks and overtime. We hire only the best nurses who meet our high standards. Magazine readers, internet surfers and all ’round lazy attitudes need not apply.

We would be paid for our service and not have our professional services hidden in room fees and miscellaneous hospital costs.

Look, doctors do this all of the time. They contract with hospitals to provide care for the patients. Yes, that generates money for the hospital but the hospital is going to have to provide nursing care no matter what for those patients.

So we make it easy for them. They are still paying (big time – nurses don’t come cheap), but with less administrative hassles to deal with.

Imagine hiring a nursing company to staff your facility.

Travel nurses do it as individuals. Registries do it per shift.

Why not entire units?


  • Sean

    September 29, 2007 at 6:30 am

    I’ve been saying the same thing for ages: that nurses need to be contract workers, rather than employees. Usually, my statements are met with uncomfortable laughter, or just a strange look. I think the idea is obvious and perfect! But, a lot of people would have to get on board. But, like you said, travel companies have been doing it for ages.


  • Jenn

    September 29, 2007 at 6:49 am

    I think it’s a brilliant idea. I’ve done staff nursing, travel nursing, and agency nursing. I definitely felt more empowered doing the travel and agency nursing. And got paid nearly twice as much as a staff nurse too.

  • kmom

    September 29, 2007 at 8:52 am

    My nervous concern is that the ones in charge of the contract nurses (those negotiating with how much the hospital would pay for our service, and how much the individual contract nurse would in turn be paid) would feel the need to make a profit for themselves/the company/the “stock holders” like so many other businesses have done.
    So there would still be the temptation to staff with fewer nurses.
    It is a fear aligned with the sometimes more experienced nurses eat instead of nurture the new ones.
    Now, Kim, I would for sure work for you. But I have encountered some pretty mean Nursing Supervisors before….
    Of course, it couldn’t be worse than what we have now!
    So, after you get done with the course work you are doing now, what about going into business management? 🙂

  • Eric

    September 29, 2007 at 10:32 am

    The key to making it work as well as you envision is, as you state, the nurses having the equity.

    I’m not intimately familiar enough with the business of nursing, and I don’t know how much margin you can build in the services, but as the business growth slows, and you want to make MegaEmergiNurse, Inc. a larger entity, the challenge will be finding funds to grow the business without diluting the partner’s equity.

    In some businesses, where the gross margins are *very* high, you can do it on cash flow. But growth of staffing companies has usually been done with cheap credit or private equity investment. Cheap credit isn’t so bad if the debt service is reasonable and you can make the note payments while still returning decent returns to the partners. But cheap credit may not be an option.

    The *moment* you take on outside investors that aren’t the working nurses is the moment that the system breaks down, because they’re going to want a certain rate of return and the ability to sell their stake at a profit in three years.

    Toss up some notes with what the spread is between what the nurses make and what the hourly rate paid by the hospital would be, and we can make some educated guesses.


  • JohnS

    October 1, 2007 at 1:23 pm

    Use California numbers: A beginning RN gets $40/hr base (just got this number from a recruiter in the SF Bay Area last week), 1 year experience $42, + shift and other differentials.

    Rule of thumb is, up to a point (the point used to be around $100K for office people) the overhead for an employee is 100% of base salary.

    That’d be $84/hr to meet staff costs (wages + benefits), minimum, since the prospective staff is more experienced than that.

    What’s the value to the hospital of taking all the administrative problems away?

  • dancern

    October 1, 2007 at 2:42 pm

    Hmmm. Some agencies are already nurse-owned, but the employees are still nurses, so what really changes?

    I read really good stuff about nurses contracting services in professional practice groups and having self governance in the business plans, so that nurses operate the same ways that physicians do in medical staff organizations. Is that what you mean?

    There\’s some blogging about that, too.

  • Markie

    October 1, 2007 at 4:28 pm

    Interesting. I’ll have to see what else is out there that’s been tried/done. I’m curious if that model would work in the real world.

    Neat idea!

  • Jo

    October 1, 2007 at 8:35 pm

    That’s a fantastic idea! I would do it too. AND I would feel better being a Nurse, working for Nurses rather then a bunch of suits who have no idea what nursing actually entails.

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  • Max

    October 2, 2007 at 9:59 am

    As someone who has been in the staffing business for 10 years, and nurse recruitment for the last 4, I wanted to see if I can add to the conversation here.

    You see this model all the time for physicians in the ER (see CEP and MedAmerica). The challenge you run up against is the same as the hospitals have. Enough qualified, motivated nurses to staff all their shifts at a rate that keeps them out of bankruptcy.

    I think that especially in California, we have seen that giving nurses more money (equity in this case) does not equate to better care. And as in any outsourcing solution, the administrative hassles don’t go away, they just get shifted onto someone else. In this case, they go to the nurse who is no longer practicing at the bedside and is now administering the nursing function including staffing.

    And the only way to make this work is to charge enough to at least break even. In the staffing world, take the base pay and add between 20 and 30 percent for benefits, taxes and SDI. For some experienced nurses at the highest pay step and with maximim benefits I have heard of as high as 40%. That is your break even. If you need to make a profit you have to mark up salaries at least 50%, and remember that is only if you are covering nurses who are actually working at the facility. Not those who are administering the program.

    I agree that nurses are eductated, dedicated professionals who are not always treated that way, but the outsourcing model probably does not get you what you are looking for.

  • Chris (CAK)

    October 5, 2007 at 6:26 am

    Kim, I have just found your website.
    Courtesy of Grand Rounds.
    I remember taking the coursework that forced me to ask the same questions you are now asking, during my master’s pgm.
    The people who have responded, using percentages, break-even points, equity, etc. are right-on, I believe. You would need a business plan, also mentioned by one responder. This is heady stuff.
    Staffing adequately for contingencies is a headache on any nursing unit. I have thought that one of the nursing units I have staffed was suitable for a plan like you are proposing–but not all units.
    Where I work, this alternative is in place: a “float pool” of nurses to enhance flexible staffing. It is an elaborate plan. And the nurses themselves are NOT the focus of this plan
    –adequate, safe staffing is the focus. So sometimes you get cancelled and you lose some pay. If valuing nursing is the top priority, then this is NOT the plan for you. This plan, however is a good compromise most of the time.

    To me, the ideal is an extremely small-scale operation where a small group of nurses contracts directly with a manager of a nursing unit. Or with individual patients (for home care, for example). As soon as it becomes BIG, it requires a lot more organization and it requires an administrator/organizer; tax forms; files to document competencies; faxes, phones, an office (some overhead anyway). Benefits is another huge headache born of bigness. Dealing with insurance companies, claims, explanations of benefits, etc. is huge, to me.

    If you can manage all this, then you, too, are in the “business” of medicine, and nursing has veered away from its most essential caring mission. Medicine-as-a-business is a huge distraction from caring, in my experience. Blessings upon those who can meld and merge the two goals.

    I have a neighbor who is aging. He needs some monitoring of his blood pressure, weight. Nothing big. It looks as if he needs a “private nurse” to do this minimal monitoring. I am thinking of contracting with him directly–nothing in between me and him. I have also considered contracting directly with my son’s pediatrics practice to offer to jump-start the medical home model . . . However, my job that keeps the household running is bedside nursing for the largest private employer in my state, which happens to be a huge healthcare org with 24,000 employees, 24 hospitals, etc.

    I regard your ideas as idealism, in the best sense. If anyone figures out a way to make this work, I’m in. Show me the model, and I will pass the word.

    I sometimes think that nurse’s unions have the MOST influence/power with respect to getting nurses to be recognized as professionals. Perhaps it would be a nurse’s union that could make these ideals work . . .

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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