The golden ratios
Reports show understaffing remains a global threat
May 28, 2015 – Media items from around the world in the last six months show that nursing continues to suffer from underfunding, with poor staffing a particular problem. On November 12, 2014, Daily News Egypt ran Menan Khater’s “Alexandria nurses threaten further strikes,” which reported that night-shift nurses at Alexandria University’s Al-Amiry Hospital had gone on strike to protest not having been paid since September. The piece focused on apparent media claims that the strike was responsible for the deaths of two patients. A few days later, on November 16, the Times of India published Sameera Kapoor Munshi’s “Need more staff, say tired nurses at Vashi civic hospital,” which described understaffing at Navi Mumbai’s Vashi Civic Hospital. There, nurses reportedly struggle with nurse-patient ratios of about 1:7 in critical care and 1:25 on the general wards. On April 27, 2015, the University of New Mexico’s radio station KUNM reported that Christus St. Vincent Regional Medical Center nurse Diane Spencer said she had been fired for speaking up about understaffing. Quotes from Spencer explain some specific risks to patients when nurses are understaffed, including the failure to rescue. And on May 28, the New York Times ran the powerful op-ed “We Need More Nurses” about the problem of understaffing in U.S. hospitals by Alexandra Robbins, a journalist and book author. Robbins explored the problem’s financial roots and its health effects, including the intimidation of whistleblowers like Spencer. Then she advocated for better treatment of nurses—“for their sake and ours.”
No response was made
The Daily News Egypt item “Need more staff, say tired nurses at Vashi civic hospital” reports that nurses at Amiry Hospital have gone on strike, but it devotes more attention to the strike’s effects than its causes. And as it happens, one of the nurses’ chief complaints is that the media has prematurely condemned them for the deaths of two patients, without reporting on the reason for the strike. That reason appears to be that they have not been paid for months, despite repeated requests. In fairness, this piece does include that information—but only after the headline “Alexandria nurses threaten further strikes” and four paragraphs of reporting on the effects of the strike. The item describes the alleged patient deaths; the nurses’ complaints that the mainstream media seems to hold them responsible for the deaths even though a police investigation is still underway; and statements by Minister of Higher Education Al-Sayed Abdel Khaleq that the nurses do not have the right to strike and that they will receive “strict penalties” if found responsible for patient deaths. Only then does the piece report that the nurses say they have not been paid since September “as a result of administrative delays” and that they “tried requesting their financial dues in official meetings with the hospital administration on several occasions, but no response was made.” The nurses also reportedly ask “the media to stop framing them as guilty without shedding light on the reasons behind the strike” and say they “will escalate the strike if any personal attack occurs against staff members who are currently being investigated.” The nurses’ statement “also stressed the vital role nurses play in saving people’s lives and that they did not intend to cause the death of any patient.”
This item does eventually get some key points out, especially that the nurses have not been paid, which is no small thing, and that the media should provide more balanced coverage of the strike. In addition, although we understand the nurses’ desire not to be judged responsible for patient deaths based on incomplete information, it might be helpful to know more about why the patients died or how nurses are generally involved in saving or losing lives. And a more prominent statement of the apparent reason for the strike would have been helpful, along with any available context about why the nurses have not been paid. We see no claim here that they have been.
Need . . . more . . . staff
A few days later, the Times of India ran a short item by Sameera Kapoor Munshi headlined “Need more staff, say tired nurses at Vashi civic hospital.” This one is packed with distressing data about understaffing at the hospital. Apparently relying on interviews with nurses, the piece reports that “there are just 176 nurses catering to 350-odd patients admitted in general and ICU wards,” on top of responsibilities those nurses apparently have at 17 other departments. An anonymous nurse explains that the nurses face an “onslaught of dengue and malaria” and that they “don’t have the luxury to go on leaves.” The nurses reportedly sent a letter to the “medical superintendent” describing the various reasons that nurses have left the hospital and urging that a recruitment drive be conducted as soon as possible. The piece addresses ratios directly:
The medically approved nurse-patient ratio in [a] general ward is 1:5 and in [an] ICCU is 1:1. Nurses agree that the ratio is too idealistic but feel that there has to be a balance. “At present, the ratio in the general ward is 1:25 and it is 1:7 in ICCU. If only the administration realizes the seriousness of the issue,” said one of the nursing staff.
The piece closes by noting that “even deputy municipal commissioner J Sinnarkar acknowledged that there is a shortage.” He reportedly said that “until the government decides to recruit, we have instructed the medical department to employ staff on contract.”
This item fits an impressive amount of dismaying information about nurse staffing into a small space. It gets into specific ratios and makes clear how short-staffed the hospital is, although the apparent concession that safe ratios are “too idealistic” seems unnecessary. It may seem idealistic to wish for such ratios in a cash-strapped clinical setting, but it’s still a good goal. The ratios listed here are grossly unsafe, and research shows that patient outcomes are much worse with that level of understaffing. The piece might have mentioned that research or at least what can happen when there are too few nurses, like a failure to rescue, and missed care.
The University of New Mexico radio piece is “Nurse Says She Lost Her Job For Speaking Out.” The NPR affiliate reports that nurse Diane Spencer was recently fired after 18 years at Santa Fe’s Christus St. Vincent Regional Medical Center. Spencer’s union has filed a complaint with the National Labor Relations Board alleging that the firing was in retaliation for her advocacy for better staffing ratios. The piece itself includes a fair amount of that advocacy:
Spencer has said that staffing levels at the hospital are set by accountants—not medical professionals. She’s testified as an expert witness for the state Legislature for the last three years about how running health care workers ragged negatively affects patients. “For nurses, we’re not able to give pain medicines in a timely fashion,” Spencer said. “We’re [not] able to ambulate the patients to prevent blood clots in their legs or blood clots in their lungs or pressure sores. People do not get fed as they should. They don’t get toileted as often as they should. All of those things are very important when people are trying to get healthy.” She said being short-staffed increases the chances of what’s called ‘failure to rescue.’ “If you are not with a patient frequently enough, you do not see the early signs of a patient deteriorating,” she explained. “If you don’t see those and catch them early, then the patient gets a whole lot sicker than they should have.”
The reporter closes with what happened when she asked Spencer whether patients should be going to the hospital: Her “eyes filled with tears” and she declined to comment. The piece says Spencer “just wants her job back,” although it seems clear that is not all she wants. Indeed, the piece describes a news conference in front of Santa Fe’s City Hall at which her union’s lawyer Shane Youtz links her firing to her persistent advocacy, noting that she had received “extremely good” evaluations until she started testifying for better staffing at the state legislature.
The report includes some additional context, noting that union members allege that New Mexico hospitals like Christus St. Vincent “run on staffs that are too small in order to pinch pennies.” It consults Delma Delora, a “nurse and patient advocate in sports medicine” at the hospital. Delora says staffing has continued to be a problem even after a recent union contract required the hospital to meet certain staffing levels; evidently the hospital has been paying fines for its failures to meet those levels into “the Nurse Education Fund.” She also says the problem exists statewide. In response to all this, Christus St. Vincent reportedly issued a statement saying that data from the state Hospital Association shows that medical / surgical staffing at the hospital is better than at most of the state’s large facilities, and that “staffing is only one factor in patient satisfaction.”
This piece includes a good deal of strong and helpful advocacy about why better nursing staffing is needed–as well as what can happen to a nurse who decides to pursue that advocacy in the current environment, in which nurses remain undervalued and vulnerable to retaliatory action. Spencer’s quotes are especially helpful in explaining exactly why nurses are so critical to patient outcomes. And the widespread failure to understand that fact is, of course, the key underlying cause of the understaffing many face now. Undervaluation drives both understaffing and the challenges nurses face in resisting understaffing. The piece also brings out how understaffing affects nurses, although more might have been said about the risks to the profession itself, which include burnout and a loss of the profession’s strongest, most skilled and conscientious members.
Go ahead, baby, fear the Reaper
Alexandra Robbins’s strong op-ed in the New York Times is headlined “We Need More Nurses.” She’s not talking about the “nursing shortage” in the well-known sense of a lack of nurses to fill open positions; she’s talking about the understaffing that continues to plague many U.S. hospitals. And perhaps the most striking thing about the piece is the accompanying hand-drawn image, an overhead view of rows of 36 somewhat indistinct patients in their beds, with only one apparent caregiver but eight black-clad Grim Reapers among them, all going about their business. Robbins’s op-ed is yet another in the journalist’s campaign to promote her new book, The Nurses: A Year of Secrets, Drama, and Miracles With the Heroes of the Hospital, by placing pieces about elements of the book in a remarkably wide group of mainstream publications.
Robbins starts with the experience of Molly, who worked at a large metropolitan hospital where emergency department (ED) nurses were regularly assigned 7-9 patients at once, “when the safe maximum was generally considered four,” and just two for critical patients. Molly was given 20 patients “with non-life-threatening conditions.” Robbins describes several of the ED nurses “crying in frustration…scared because their department was so understaffed that they believed their patients — and their nursing licenses — were in danger, and because they knew that when tensions ran high and nurses were spread thin, patients could snap and turn violent.”
Pulling back, the piece says that “inadequate staffing is a nationwide problem,” noting that no state except California has required specific minimum staffing ratios that apply to the entire hospital. (Massachusetts does now have such ratios for ICUs, and the Australian state of Victoria set hospital-wide ratios before California did.) Robbins refers to the “dozens of studies” showing that worse nurse staffing ratios mean more deaths, more adverse events, and longer hospital stays. She notes that the Center for Health Outcomes and Policy Research “found that if every hospital improved its nurses’ working conditions to the levels of the top quarter of hospitals, more than 40,000 lives would be saved nationwide every year.” And a survey of nurses sponsored by the Massachusetts Nurses Association (MNA) found that 25% of respondents said “understaffing was directly responsible for patient deaths.” The piece notes that nurses are often “punished for speaking out,” citing the New York State Nurses Association’s report that Jack D. Weiler Hospital of the Albert Einstein College of Medicine had recently “threatened nurses with arrest, and even escorted seven nurses out of the building, because, during a breakfast to celebrate National Nurses Week, the nurses discussed staffing shortages.” The hospital disputes that. Deborah Burger, co-president of the union National Nurses United (NNU), reportedly says intimidation is not unusual and nurses have been “blackballed” for speaking about staffing.
Robbins links these problems to the “push for hospital profits.” MNA spokesman David Schildmeier attributes it to the “unrelenting emphasis on boosting [hospital] profit margins at the expense of patient safety.” And Judy Smetzer of the Institute for Safe Medication Practices says many hospital administrators ignore the studies and fault individuals, rather than the system:
When they’re understaffed, nurses are required to cut corners to get the work done the best they can. Then when there’s a bad outcome, hospitals fire the nurse for cutting corners.
The piece says that “nursing advocates continue to push for change,” citing a recent grievance filed by NNU against Tampa’s James A. Haley Veterans’ Hospital alleging that the facility fell well short of the minimum staffing levels required by the Department of Veterans Affairs. And Robbins herself urges readers to “insist” that hospitals treat nurses right, noting that they are “the key to improving American health care” and “unsung and underestimated heroes who are needlessly overstretched and overdue for the kind of recognition befitting champions.”
This piece is generally great, explaining in detail the nature of the staffing problem nurses face and why staffing is so important to patient outcomes and the health care system, such that nurses are “the key to improving American health care.” The op-ed also highlights the intimidation that nurses who speak out can suffer, echoing the issues raised in the earlier KUNM piece. Mostly all we could suggest is more detail, for instance the piece might have included more on the effects of understaffing on the nursing profession, which go beyond nurses’ everyday fear and distress to serious burnout and higher turnover rates. And the language near the end about “champions” seems a little odd—champions of their patients? But on the whole, the piece is an effective and powerful call for the public to value nurses and address their urgent concerns.