“Patients die because nurses are too busy”

Press items report deadly nursing shortage on both sides of the Atlantic

A study of European hospitals shows that missed care due to nurse understaffing has increased death rates, according to an August 2017 article in The Times (U.K.). And a February 2016 piece in The Atlantic describes a critical long-term shortage in the United States.

August 24, 2017 – Recent news pieces indicate that nursing shortages continue to take lives in Europe and the United States, with worrisome prospects for the future. Today health editor Chris Smyth reported in The Times (U.K.) that a new study of 300 hospitals in nine nations had found that every 10% increase in nurses skipping key care tasks led to a 16% increase in patient mortality. The article had strong quotes from lead study author Jane Ball of Southampton University. She said that the study increased concerns that nurse understaffing was causing higher patient mortality and that rates of missed care were dangerously high in the U.K.’s National Health Service (NHS), where nurses said they were unable to carry out about one third of the tasks they believed were necessary. The piece reported that unions like the Royal College of Nursing had seized on the study to argue that the U.K. government had failed to hire enough nurses to meet patient demand. The article might have included more detail. And in a February 2016 article in The Atlantic, Rebecca Grant examined the nursing shortage in the United States. Her comprehensive, data-heavy report explained that “due to an aging population, the rising incidence of chronic disease, an aging nursing workforce, and the limited capacity of nursing schools—this shortage is on the cusp of becoming a crisis.” The piece included some insightful quotes from nursing leaders and scholars, who explain how these factors have come together to form what University of Pennsylvania nursing professor Julie Sochalski calls a “perfect storm.” The piece also told how poor nurse staffing threatens patients and nurses themselves, as well as some ways in which the shortage might be addressed, particularly through nursing education. The Atlantic piece could have done more to make clear what nurses must actually know and do to save lives; why nurses struggle to get adequate funding and scope-of-practice rights; and the qualifications of the piece’s expert sources. Still, both reports have helpful material. We thank those responsible.

Patients pay the highest price

The perfect storm

Patients pay the highest price

The short report in The Times has the better headline: “Patients die because nurses are too busy.” Just seven words, but powerful and accurate. The piece explains that the new study published in the International Journal of Nursing Studies was based on data for 423,000 patients in 300 hospitals in nine nations, including 31 hospitals in the NHS, and surveys of 27,000 nurses about “13 basic care tasks.” The research reportedly focused on the 1.6% of patients who died within 30 days of surgery and the results of the surveys regarding what care the nurses said they did not have time to do. According to the Times piece, the researchers found that “for every 1.3 tasks missed, death rates rose by 16 per cent,” or to put it another way, “every 10 per cent increase in nurses admitting that they skipped tasks such as checking vital signs and giving medicine on time increases death rates by 16 per cent.” Nurses in the NHS apparently said that they did not have time for about one third of the tasks they felt were needed. The piece includes several good quotes from Jane Ball, “who led the study at Southampton University.” 

If there are not enough registered nurses on hospital wards, necessary care is left undone and people’s lives are put at risk. These results give the clearest indication yet that registered nurse staffing levels are not just associated with patient mortality, but that the relationship may be causal. … We are not running with sufficient nurses to keep patients safe. … If you had a drug that was associated with a 16 per cent higher risk of death because of the way it was given, you would want to reduce that. We are running with a level of risk that needn’t be there. 

The piece adds a little more detail from Ball, who reportedly says that recent increases in the number of NHS nurses have not matched the increase in patients. The piece adds, perhaps relying on Ball, that there has been a “slump in applications for nursing degrees and a dip in EU arrivals since the Brexit vote.” The article also notes that unions have seized on the findings “as nursing vacancy rates run at 10 per cent,” quoting the Royal College of Nursing’s (RCN) Janet Davies:

This research puts beyond doubt that patients pay the highest price when the government permits nursing on the cheap. Ministers cannot ignore further evidence that the lack of registered nurses leads to people left in pain for longer and a higher risk of not recovering at all. Pressure is mounting, staff are pulled in every direction and important things are inevitably missed.

This piece is good as far as it goes, including some core findings of a powerful study on the deadly effects of nurse understaffing, as well as some good quotes by the lead researcher and a union leader. But it would have been better with more detail. To its credit, the piece provides the name of the nursing journal—not something we can take for granted. But in giving Ball her quotes it fails to state that she is a nurse with a PhD and vast experience researching these issues, potentially leading some readers to wonder if she is even a nurse. Likewise, Janet Davies is not just someone from the RCN, but the chief executive and general secretary. More fundamentally, the piece might have included more detail about the current research findings and about past findings in this area over many years. Some of those findings come from the work of Linda Aiken of the University of Pennsylvania, a co-author of the current study; her research has long made clear that poor nursing staffing increases patient mortality. The short piece also does not do much to explain the causes of understaffing. And calling the 13 care tasks measured “basic” is problematic; at least some of them are not simple, and they are important to patient survival, so terms like “key” or “critical” would have been better. Still, on balance the piece is helpful.

The perfect storm

In an odd reversal of the Times item, Rebecca Grant’s Atlantic piece is comprehensive and thoughtful, but it has a highly distorted headline: “The U.S. Is Running Out of Nurses.” Grant begins with a brief description of her own experience with the nurses who cared for her mother for two weeks in an ICU, five years earlier. She says they “checked on my mother—and us—multiple times an hour. They ran tests, updated charts, and changed IVs; they made us laugh, allayed our concerns, and thought about our comfort. The doctors came in every now and then, but the calm dedication of the nurses was what kept us together. Without them, we would have fallen apart.” 

No surprise, then, that Grant finds “alarming” the prospect of a U.S. nursing shortage driven by the aging general and nursing populations, the increase in chronic disease, and inadequate resources for nursing education. The nation’s three million RNs are the largest segment of the health care workforce, but Bureau of Labor Statistics figures indicate there will be 1.2 million vacancies between 2014 and 2022. The main cause is the Baby Boomer generation, whose aging will lead to a huge increase in those 65 and older, and a corresponding explosion in the need for health care. Grant notes that analyses suggest about 80% of those older people have at least one chronic condition, and most have more than one. On this point, the piece quotes “Julie Sochalski, an associate professor at the University of Pennsylvania School of Nursing”—which is good except for the failure to mention that she is an RN with a doctorate. Sochalski describes the aging population and the increase in chronic disease as “the perfect storm driving demand for nurses.”

Ensuring there are enough nurses is a problem. The nursing workforce is aging, with about one third reaching retirement age in the next 10-15 years. Pam Cipriano, president of the American Nurse Association, notes that many nurses started at a time when there were fewer career choices for women, and now that cohort is starting to retire. And while there has been a recent increase in new nursing students and graduates, the nursing education system remains a bottleneck. An American Association of Colleges of Nursing report says U.S. nursing schools “turned away 79,659 qualified applicants from baccalaureate and graduate nursing programs in 2012 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.” Cipriano emphasizes the faculty shortage, which is hard to address since most nursing faculty positions require a doctorate. Sochalski suggests that in some areas, a key barrier is a limited number of clinical opportunities for newer nurses. Cipriano agrees that employers can be reluctant to hire such nurses, but when they do, there is a vast drop-off in experience from the nurses they replace, and employers “have a responsibility and a burden to ensure that new nurses can maintain expertise and wisdom at a patient’s side.” The piece consults Ed Salsberg, a health workforce researcher at the George Washington University School of Nursing, who suggests that recent efforts to make the health care system more efficient and reduce hospital readmissions may reduce demand for nurses. He notes that so far, the Affordable Care Act has not greatly increased demand because most of the newly insured are younger and healthier. 

Salsberg reportedly points to growing regional disparities in the availability of nurses, with an increasing number of states in the South and West experiencing marked shortages. The piece quotes Vernon Lin, an author of a 2012 study on that subject and “a professor at the Cleveland Clinic Lerner College of Medicine.” (Lin is a physician, as the piece should have stated.) Lin says that in his experience, there have been a surprising number of nursing vacancies even in “sunny southern California.” Grant goes on to explore more regional differences, which may relate to especially aged patient populations or scarce nursing educational opportunities; Lin says nurses tend to settle where they attend nursing school. And of course, poor and rural areas have more trouble recruiting than do “urban magnet hospitals.” The piece focuses on Rapid City, South Dakota’s Regional Hospital, where new chief of nursing Lori Wightman has to close a certain number of beds every day, citing patient safety and “standards of practice for what nurse-to-patient ratios should be.” The piece explains:

Those standards can represent the difference between life and death. When nurses are stretched too thin, they have less time and energy to devote to each patient. Overworking leads to fatigue and burnout, which threatens the quality of care and increases the incidence of error. Past research has found links between insufficient nursing staffing and higher rates of hospital readmission and patient mortality. Higher patient loads are also linked to higher rates of nurse turnover, which can be costly, disruptive, and potentially harmful to patient safety. Conversely, more and happier nurses can mean better care and better outcomes.

The article says hospitals may also ask nurses to work more hours, which of course raises safety concerns, or may use travel nurses, who are expensive. Wightman explains that, in addition to good pay and working conditions, attracting nurses depends on assuring them that they will be able to practice to the full scope of their licensure. She refers to restrictions on South Dakota nurse practitioners compared to some nearby states, and she suggests national licensure as a possible solution. 

Lastly, the report addresses issues related to nursing education. It cites the Institute of Medicine’s 2010 “Future of Nursing” report, which advocated for higher education levels for nurses, especially increasing the numbers of bachelor’s-prepared nurses. But Salsberg suggests that could exacerbate shortages, and he argues for the importance of associate’s degree entry to the profession in rural areas. The piece points to campaigns aimed at providing support for nurse educators. The report closes with remarks from Cipriano, who says the ANA is lobbying Congress to increase funding for Title VIII of the Public Health Service Act, which provides grants for nursing schools and repays student loans for nurses who work in facilities with critical shortages. She notes that “when you adjust for inflation, we’ve seen a 30 percent decline in that money since 1971.” Grant concludes: “There will always be a need for nurses, the medical professionals that make otherwise harrowing experiences bearable for patients and their families.”

This is a generally comprehensive overview that makes many good points about the shortage, exploring causes, effects, and possible solutions. In several ways it makes clear the key role nurses now play in health care and that they must play in its future. Grant’s initial description of what nurses did for her family is good as far as it goes. She conveys the nurses’ dedication, close attention, and psychosocial care, and she mentions a few basic-seeming tasks (“ran tests,” “changed IVs”). But the passage fails to convey the knowledge and skill nurses have. The later paragraph about the life-or-death importance of nurse staffing goes some way toward addressing that. So do the descriptions of nursing education (the need for doctoral preparation to teach, the desirability of a bachelor’s to practice), although those still fail to give specifics about how nurses save lives. The piece’s reliance on nurse experts like Cipriano is good, although it does not always adequately identify their qualifications. Nor does it clearly alert readers when they are getting information about nursing from sources who are not nurses, like Lin and Salsberg. We would not call nurses “medical” professionals, which evokes physician practice; a better term would be health professionals. (Nurses practice nursing, not medicine.) And the piece omits public undervaluation of nursing as a key factor in the shortage and in scope-of-practice barriers. On balance, though, the piece is a fairly good introduction to a complex public health crisis. We thank those responsible.

See the article “Patients die because nurses are too busy” by Chris Smyth, posted on August 24, 2017 on the website of The Times (UK).

See the article by Rebecca Grant “The U.S. Is Running Out of Nurses,” posted on The Atlantic‘s site on February 3, 2016.