How many nurses does it take to care for a hospitalized patient? No, that’s not a bad version of a light bulb joke; it’s a serious question, with thousands of lives and billions of dollars resting on the answer. Several studies (such as here and here) published over the last decade have shown that having more nurses per patient is associated with fewer complications and lower mortality. It makes sense.
Yet these studies have been criticized on several grounds. First, they examined staffing levels for hospitals as a whole, not at the level of individual units. Secondly, they compared well-staffed hospitals against poorly staffed ones, raising the possibility that staffing levels were a mere marker for other aspects of quality such as leadership commitment or funding. Finally, they based their findings on average patient load, failing to take into account patient turnover.
Last week’s NEJM contains the best study to date on this crucial issue. It examined nearly 200,000 admissions to 43 units in a “high quality hospital.” While the authors don’t name the hospital, they do tell us that the institution is a US News top rated medical center, has achieved nursing “Magnet” status, and, during the study period, had a mortality rate nearly 40 percent below that predicted for its case-mix. In other words, it was no laggard.
As one could guess from its pedigree and outcomes, the hospital’s approach to nurse staffing was not stingy. Of 176,000 nursing shifts during the study period, only 16 percent were significantly below the established target (the targets are presumably based on patient volume and acuity, but are not well described in the paper). The authors found that patients who experienced a single understaffed shift had a 2 percent higher mortality rate than ones who didn’t. Each additional understaffed shift carried a similar, and additive, risk. This means that the one-in-three patients who experienced three such shifts during their hospital stay had a 6 percent higher mortality than the few patients who didn’t experience any. If the FDA discovered that a new medication was associated with a 2 percent excess mortality rate, you can bet that the agency would withdraw it from the market faster than you could say “Sidney Wolfe.”
The effects of high patient turnover were even more striking. Exposure to a shift with unusually high turnover (7 percent of all shifts met this definition) was associated with a 4 percent increased odds of death. Apparently, patient turnover – admissions, discharges, and transfers – is to hospital units and nurses as takeoffs and landings are to airplanes and flight crews: a single 5-hour flight (one takeoff/landing) is far less stressful, and much safer, than five hour-long flights (5 takeoffs/landings). Continue reading “Nurse Staffing, Patient Mortality, And a Lady Named Louise”
Filed Under: THCB, The DC
Tagged: Artificial intelligence, Mortality, NEJM, Nurses, Nursing
Mar 23, 2011
If you have been at your nursing job for a while, you’ve probably almost forgotten.
Forgotten what it was like to come in to the healthcare system you now work for and realize there are hundreds of new protocols for you to learn and adhere by as a nurse. After years of routine, you now go about your day as if you actually have some choice in the way you give care.
At one point you probably did. I was not around during this age of nursing. The age when we had autonomy. Freedom to practice. Freedom to be innovative.
Today, I am somewhat saddened by the current state of the nursing profession. Don’t get me wrong: I LOVE what I do. I am so thankful for the opportunities set before me.
But whatever happened to “nursing judgment”? Or “nursing decision”?
I can’t tell you how much recently I’ve heard the phrase, “It is hospital policy that…” “You can’t do that, it is protocol that…”
I understand the need for protocols. They help us in the case that something goes wrong and the hospital gets sued. Did the nurse adhere to the protocol? If not, they will be subject to disciplinary action and take the fall. If something goes wrong and there is no protocol, the hospital can say in its defense: “There is now a protocol in place.”
Maybe a less cynical need for protocols: promote and regulate evidenced-based practice among nurses. Evidenced-based practice was developed for a reason: it brings good outcomes and protects the patients.
Even so, to me it seems we are being protocoled to extinction.
Continue reading “Nurses: Protocol -ed to Extinction?”
Filed Under: The DC
Tagged: Checklists, Nurses, Nursing, Protocols, Sarah Beth Cowherd
Mar 10, 2011
Last week, we highlighted an unintended consequence of the Affordable Care Act: it will dramatically worsen an already gaping mismatch between the demand for and the supply of physician services in the US. Put simply, there aren’t enough white coats out there to care for 32 million Americans who will obtain health insurance coverage for the first time as a result of the new law. It’s not even close.
We also speculated that the recommendations made by the American Association of Medical Colleges to address the burgeoning crisis will not work. The AAMC wants Congress to increase the number of Medicare-funded medical residency training slots—essentially, to increase the pipeline for new physicians. This isn’t a bad idea except that Congress is gridlocked on a good day, bitterly divided on all things health reform, and in no mood to enact spending programs of any sort.
That brings us to an alternative solution, proposed recently by the Institute of Medicine. In a report titled, The Future of Nursing: Leading Change, Advancing Health, the IOM concluded that the best way to meet the coming tidal wave of demand for medical services is through a sweeping expansion in the roles and responsibilities of nurses.
Reasoning that nurses are cheaper and quicker to produce than doctors, the IOM recommended the implementation of incentive programs which would assure that 80% of nurses have a bachelor’s degree within 10 years, and that 10% of such nurses enter advanced degree programs. It recommended further that nurses should assume central roles in redesigned, team-based care systems, and that regulatory and institutional obstacles, including limits on nurses’ scope of practice, should be removed so that advanced practice registered nurses (APRNs, including nurse practitioners) can practice more freely. This includes increasing their power to prescribe drugs.
Continue reading “Physicians, Nurses and the Coming Transformation of our Health System”
Filed Under: OP-ED, Physicians
Tagged: Nurses, Nursing
Nov 11, 2010
The recent City of Ontario v. Quon decision has had a mixed reception among privacy advocates. Though many are disappointed that employees’ privacy rights have once again been narrowed, some have discerned helpful dicta in the case. However, I worry that, whatever the drift of thought among swing justices, economic imperatives and cultural shifts will mean a lot less privacy in the workplace of the future. Health care in particular offers a few interesting bellwethers.
As an opinion piece by Theresa Brown explains, maintaining proper staffing levels in hospitals is becoming increasingly difficult. Surveillance systems are offering one way to address the problem; work can be performed more intensively and efficiently as it is recorded and studied. But such monitoring has many troubling implications, according to Torin Monahan (in his excellent book, Surveillance in a Time of Insecurity):
The tracking of people [via Radio Frequency Identification Tags] represents a . . . mechanism of surveillance and social control in hospital settings. This includes the tagging of patients and hospital staff. . . . When administrators demand the tagging of nurses themselves, the level of surveillance can become oppressive. . . . [because nurses face] labor intensification, job insecurity, undesired scrutiny, and privacy loss. . . . To date, such efforts at top-down micromanagement of staff by means of RFID have met with resistance. . . . One desired feature for nurses and others is an ‘off’ switch on each RFID badge so that they can take breaks without subjecting themselves to remote tracking. (122)
Like the “nannycam” employed by many a wary parent, the nurse-cam may be seen as a way to protect the vulnerable. It may also increase the accuracy of evidence in malpractice cases. On the other hand, inserting a tireless electronic eye to monitor what is already an extremely stressful job may create many unintended consequences, or deter people from going into nursing altogether. Even advocates of pervasive surveillance recognize these difficulties. Continue reading “RFID Tags for Nurses. Then Everybody?”
Filed Under: Uncategorized
Tagged: Frank Pasquale, Nurses, Nursing, Privacy, RFID
Jun 27, 2010
Doctors like to assert, maintain control and continuously patrol over their territories; at least some do. In a recent post on THCB, “Nurseanomics” by Maggie Mahar addresses the heated debate over the difference between a doctor and a nurse. Mahar takles the question that Legislators in twenty-eight states are dealing with. Should a nurse practitioner (NP) with an advanced degree provide primary care, without an M.D. being in charge? But another pressing question that needs to be addressed is: Should nurse practitioners be called doctors (DNP)? (DNP is a Doctor of Nursing Practice.) That is the question that I will address here. I reached out to the medical community to get their reaction. It’s not surprising that the immediate response of some doctors when asked if nurse practitioners should be called doctors (DNP) is “No!” evidenced by Dr. Stangl’s comment.
“NO! Nurse practitioners should NOT be called “doctors” because they are NOT! While many NPs do an excellent job of handling certain types of problems in certain settings, they do not have near the depth or length of education that physicians do and should be credited for what they Do have, which is their nursing background and expertise.” Susan Stangl, MD
Take a look at this comment that appears in THCB:
“An NP has mostly on the job training…they NEVER went to a formal hard-to-get into school like medical school,” wrote one doctor. “I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpinning principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive. HEY NURSIE, IF YOU WANT TO WORK LIKE A DOCTOR…THEN GET YOUR BUTT INTO MEDICAL SCHOOL AND THEN DO RESIDENCY FOR ANOTHER 3-4 YEARS. NO ONE IS PREVENTING YOU IF YOU COULD HACK IT![his emphasis]”
Continue reading “Nurse Practitioners – Doctors?”
Filed Under: The Insider's Guide To Health Care
Tagged: Nurses, Nursing
May 12, 2010
Twenty-eight states are now engaged in a heated debate over the difference between a doctor and a nurse: Legislators in these states are considering whether they should let a nurse practitioner (NP) with an advanced degree provide primary care, without having an M.D. looking over her shoulder. To say that the proposal has upset some physicians would be an understatement. Consider this comment on “Fierce HealthCare”:
“An NP has mostly on the job training…they NEVER went to a formal hard-to-get into school like medical school,” wrote one doctor.
“I have worked with NPs before, and their basic knowledge of medical science is extremely weak. They only have experiential knowledge and very little of the underpinning principles. It would be like allowing flight attendants to land an airplane because pilots are too expensive. HEY NURSIE, IF YOU WANT TO WORK LIKE A DOCTOR…THEN GET YOUR BUTT INTO MEDICAL SCHOOL AND THEN DO RESIDENCY FOR ANOTHER 3-4 YEARS. NO ONE IS PREVENTING YOU IF YOU COULD HACK IT!” [his emphasis]
Fortunately, not all physicians exhibit the same degree of rancor. Some support the movement. Another reader notes the commenter’s emphasis on just how brutal med school can be: “The anger reflected in the previous comments reveals not only the writers’ ignorance of scholastic achievement required of Nurse Practitioners, but mainly their fear that NPs will not be under physicians’ control…Many older doctors’ schooling and experience was conducted in punitive ways, sacrificing self esteem. It seems that anything less, isn’t sufficient.”
Continue reading “Nurseanomics”
Filed Under: Maggie Mahar, The DC
Tagged: Nurses, Nursing
Apr 22, 2010
THCB reader CARISSA PILLOW, an RN, is one of many readers who objected to the tone of the satirical post “Let’s Pay Nurses Minimum Wage.” Carissa writes:
“Dear Mr. Angry, I just wanted to take a moment to express my sincere disappointment. Yep, I’m a nurse. Yep, I got it, you were trying to be funny, with some witty satire. Yep, I see that you were trying to point out how backwards it is to pass legislation “outsourcing” nursing. But, by making a funny funny post, what you did was perpetuate the ongoing misconception of what a nurse does. You describe nurses as a group of butt wiping, overpaid babysitters with skills the equivalent of retail clerks. And while yes, in my 13 years of nursing experience I have done my fair share of butt wiping and babysitting, my daily work involves so very much more than the public understands. So let me clarify my job description for you and for the American public that you have misinformed. In my career I have: Sat by a patient as the only person in the room while they met their maker, and provided dignified post mortem care for them; Given a 40 year old wife the news that her husband had suffered a massive heart attack and was recovering from a cardiac cath procedure that saved his life for the third time; Told a hospitalist the orders that she needed to write for a patient suffering from Diabetic Ketoacidosis; Helped countless doctors sort through the diagnostics on their patients and helped make critical decisions in their patients’ care; Provided critical information to doctors during their patients’ sudden onset of cardiac dysrhythmias; Run countless codes; Prayed with families and patients prior to some very frightening surgeries; Packed countless gaping abdomenal wounds; Given countless doses of Morphine, Zofran and Insulin; Spotted critical errors and omissions in care and brought them to the attention of the doctor responsible for immediate correction; Informed families of impending brain death of their loved ones; Continue reading “Commentology: Dear Mr. Angry”
Filed Under: Uncategorized
Tagged: Carissa Pillow, Nurses, Nursing, Patients
Mar 30, 2010
The nursing profession takes a certain dedication to love. After all, most office jobs don’t involve standing for 12 hours at a time, scarfing a bite of lunch between “clients” or handling gallons of bodily fluids on a daily basis. But for years, nursing schools lured students with the promise that they would be snapped up by prestigious hospitals upon graduation, remunerated for their hard work with good pay and enviable job security.
And they were right – until now, that is.
It’s a paradox straight out of “Freakonomics:” Even though California still faces a shortage of nurses, up to 40 percent of nursing school graduates will be unable to find jobs, according to the California Institute for Nursing and Health Care.
The recession set off a domino effect that has caused California hospitals to virtually stop hiring newly-minted nurses. The Institute estimates only half as many nurses will be hired this year as in 2008.
It’s all thanks to Botox, healthcare reform and other people’s husbands. Continue reading “No Country For Young Nurses”
Filed Under: OP-ED, The Insider's Guide To Health Care
Tagged: Nurses, Nursing
Feb 19, 2010
In a report this week, Nursing crisis looms as baby boomers age, CNN Money repeats a well-known story: there are unlikely to be enough nurses to take care of people as they age. Nursing schools can’t keep up with the demand and trouble awaits. We’ll face a shortage of 260,000 RNs by 2025, we’re told.
I don’t really believe it’s such a big deal.
There are two good solutions to the problem, and they aren’t mutually exclusive:
- Increase the recruitment of nurses from abroad
- Substitute technology for labor Continue reading “Welcoming immigrants and robots to fill the nursing shortage”
Filed Under: Uncategorized
Tagged: David E. Williams, Nurses, Nursing, Technology
Dec 30, 2009
Earlier this month, ProPublica and the Los Angeles Times published an investigation detailing the failure of the California Board of Registered Nursing to investigate and discipline nurses accused of misconduct in a timely manner. An examination of all disciplinary cases from 2002 to 2008 found that the board took an average of more than three years to investigate and close them — while the nurses accused of wrongdoing continued to practice without restriction. The day after the story was published, Gov. Arnold Schwarzenegger replaced most members of the board, and its longtime executive officer resigned the day after that.
The fallout has continued. There have been a slew of follow-up editorials and articles in California newspapers. One, in the Los Angeles Times, said of the governor's response: "This time, he acted to protect patients, but where was the gubernatorial outrage when the state Board of Chiropractic Examiners, which included several of Schwarzenegger's friends, was accused in a state audit of similar failures to put consumers first?"
Another, in the San Francisco Chronicle, suggested that "Schwarzenegger shares a measure of blame too: his imposed work furloughs will slow investigations, and his administration should have been on the problem earlier."
Continue reading “After Nurses Investigation, Scrutiny Turns to Other California Health Boards”
Filed Under: Uncategorized
Tagged: California, Nurses, Nursing, ProPublica, The States, Uncategorized
Jul 24, 2009