2011
Battle for Ratios at Tufts Medical Center
Work intensification has become one of the major problems in advanced market economies. It is an especially serious problem in health care. At a time of increased preoccupation with cost control and profit maximization, demand for health-care services is growing dramatically. In such a context the pressure for doing more with less becomes overwhelming and irresistible. Nurses have learned that managers who might otherwise have fought to give patients more nursing care and nurses more support on the job find it impossible to resist the pressure to cut, cut, cut. We saw this in the 1990s, when after a decade of denying that nursing cuts were rampant and that this compromised patient safety, Massachusetts General’s Chief Nursing Officer Jeanette Ives Erickson, candidly confessed on an NPR documentary that “we couldn’t cut them fast enough.” That is precisely what is happening in hospitals all over the country and here in Massachusetts.
Over the past decade over 60 studies have documented the connection between nurse staffing and patient mortality, thus failure to rescue and adverse patient outcomes. In my book Safety in Numbers: Nurse to Patient Ratios and the Future of Health Care, my co-authors and I analyzed over 60 studies. Since its publication more studies have come out and have documented this connection. In 2008, an article in the New England Journal of Medicine explored how long it takes caregivers to respond to patients with ventricular arrhythmias. The study looked at 6789 patiens who had a cardiac arrest due to ventricular arrhythmia or pulseless ventricular tachycardia at 369 US hospitals. After identifying these patients, researchers looked to see overall median time to defribilation. Turns out delayed defibrillation (more than two minutes to defibrillation) occurred in an amazing 2045 patients. Of those who had delayed attention, fewer survived to hospital discharge.
We know that patients who are defibrillated immediately – here literally seconds count– do better. These are the recommended guidelines. Yet 30.1% of patients in this study didn’t get care that conforms to the guidelines. Why not? Researchers found a number of things that affected quality of care: if patients were black, if they had a non-cardiac admitting diagnosis, if they were in a small hospital and – most importantly – if they developed problems at night or on the weekend. In commenting on the study, observers noted that the worst time to have a cardiac arrest in a hospital was when units had less staff – i.e. nursing staff on them. If a patient is not hooked up to a cardiac monitor that screams out an alert, they can get into trouble. Nurses are so busy they don’t have time to keep their eyes on the patient enough of the time and thus can’t detect problems and respond to them. This is the classic definition of failure to rescue and another example of why having enough nurses in hospitals – at all times– is so critical.
Then came a study of MRSA in the Lancet that was even more interesting and disturbing. Here again researchers studied one of the most important infection control interventions – hand-washing to prevent one of the worst hospital borne infections. The article made clear that under-staffing and overcrowding are breeding grounds for MRSA. Hospitals that are too worried about rushing patients in and out of their units and that are trying to save money by hiring less nursing and other staff put patients at clear risk for this dreadful infection. The places the study targeted were Australia, where there has been a 40% decreased in public hospital beds, and the UK, Canada, the USA and the Netherlands. In the UK bed reductions have been accompanied by higher patient admissions. Patients are rushed through the system but with less nurses to care for them. When this happens, the indicators for the need for hand washing go up while staff actually wash their hands less. “Transmission of MRSA and other (Hospital Acquired Infection) HAI-causing organisms has been shown to be greater during periods of understaffing, defined by a low health-care worker to patient ratio…” What is more, when health care workers have too many patients, the study showed they washed their hands less because too much hand-washing caused skin- irritation even with new gels. Perhaps the most interesting finding was that too many patients and too few staff leads to what is identified as “organizational fatigue, “ – “which related to overburdening of staff and facilities during periods of high bed occupancy and workload.” It’s what nurses constantly tell me. Yes, they know they should wash their hands but after eight hours on the job, rushing from patient to patient, they just don’t all the time. They are too wiped out to wipe up. So once again, we have proof from all over the world that not having enough nurses and other care providers who have enough time and decent patient loads kills patients and demoralizes nurses.
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Finally,on March of 2011, the New England Journal of medicine published yet another study documenting the connection between nurse staffing and patient mortality entitled just that Nurse Staffing and Inpatient Hospital Mortality. Again the conclusion of this retrospective observational study funded by the Agency for Healthcare Research and Quality. staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients’ needs for nursing care.
Again the conclusion of this retrospective observational study funded by the Agency for Healthcare Research and Quality. staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients’ needs for nursing care.
In 1999, we learned that almost 100,000 patients die a year in American hospitals. That’s four times the amount of people who have died in the recent Japanese tsunami, and it happens every year. Recent studies have documented that since the famous IOM study to Err is Human was released in 1999, there has been little progress in reducing harm in American hospitals. In Mid April, of 2010, the Agency for Healthcare Research and Quality, released a report that compared rates of bloodstream infections between 2009 and 2010. The 2010 rate of bloodstream infections, the agency reported, increased by 8 percent in one year, while, in the same time period, catheter associated urinary tract infections had likewise increased (by 4 percent). There was good news, e.g., pneumonias were down.
Perhaps the reason why we are seeing so little progress despite a rash of patient safety innovations has to do with the fact that, all of these innovations depend on having enough bodies at the bedside. If there is not enough staff on the ward to take care of patients, they will not be able to respond to cardiac crises, they will not be able to clean their hands, they will , not be able get off the ward to attend a meeting or take advantage of educational opportunities that would improve patient safety . If there are not enough physical bodies, there will not be enough minds to innovate care at the bedside. Nor will there be enough voices raised to support–or suggest alternatives to–them. If they are taking care of six or seven or eight patients, nurses can’t take the ten or fifteen minutes needed to do the rounds with physicians and convey the critical information on which decisions about medical treatment and nursing interventions should be made. Without this kind of interaction, it is impossible for nurses to become full participants as well as fully respected members of the interdisciplinary team. Without enough nurses, both patients and nurses suffer unnecessarily. I have watched that professionally and experienced it personally as a patient who had the misfortune to be taken care of at night, and on a holiday weekend in a shortstaffed hospital and I am still suffering from a preventable complication that was a result.
Ellen Zane, CEO of Tufts Medical Center insists that she will not jeopardize the financial survival of her hospital by instituting safe nurse staffing ratios. She claims it will cost her hospital $33 million to staff up. My question – one she and all administrators should be forced to answer is : if they can’t afford ratios nurses propose what can they afford? If they can’t afford the appropriate ratios, how can they afford to spend millions on high priced consultants and $4 million on replacement nurses. Indeed, one question for Tufts is how much money has been spent during Zane’s tenure on hospital consultants, like Six Sigma, unnuecessay and replicative medical equipment and futile care? Zane says she is against nurse- to- patient ratios and wants complete management flexibility. Well, guess what, she already has them. In fact, the biggest secret in health care is that we already have total managerial flexibility in Massachusetts and this has, in fact, produced nurse to patient ratios – as in get away with whatever you can ratios.
Ask any nurse manager, and she will tell you that she receives a quarterly budget for her unit. (She does not receive a daily budget that allows her to add more nurses. In fact, nurses are constantly being told they have to leave the unit and go home if a patient is not in the bed) .Knowing how many beds are on the unit, she must allocate that money to pay for staff. This therefore ends up producing a certain number of nurses per a certain number of beds with patients in them. Whether you call it nursing hours per patient day, a staffing grid or ratios, ratios is what it is. In fact, since spending god knows how much to hire Six Sigma, the hospital has produced staffing grids that distinctly document that they have determined nurse-to-patient ratios per unit. These grids also document that, in many instances, the ratios of patients to nurse are going up not down.
The issue here is not whether we have ratios in our hospitals. The issue is whether we want to give hospital executives and managers unfettered discretion to come up with the ratio of patients each nurse will care for, or whether we want to make that process transparent and develop a mechanism to hold hospitals accountable for those decisions.
Although there is no scientific study documenting the perfect number of nurses on particular units, the evidence that better nurse staffing improves patient health is incontrovertible. We may not know what the perfect nurse-to-patient ratio is, but we certainly know what it isn’t. Nurses all over the country are fighting to protect their patients. As a patient, I certainly hope they win.
2011
Potential Nurses Strike in Massachusetts
This morning I woke up to an op-ed in The Boston Globe penned by the president CEO of the Massachusetts Hospital Association Lynn Nicholas and entitled “Massachusetts Nurses Association (MNA) , the target of the attack — has long favored in Massachusetts and nationally. What’s so interesting about this article is that it adds a new twist to the hospital industry’s long-standing opposition to any kind of positive government regulation of nurse staffing in hospitals. The article has been prompted by the fact that the MNA has been engaged in negotiations with Tufts Medical Center centering on safe staffing issues. Nurses at Tufts have filed over 520 reports of incidents that have compromised patient care and have been begging the Medical Center and the legislature in the Commonwealth to deal with patient safety issues through contractual provisions that guarantee safe staffing as well as legislation around nurse-to-patient staffing ratios. In response MHA CEO Lynn Nicholas drags out the same old arguments against safe staffing and adds some new ones to the mix.
Let me say before I begin to analyze Nicholas’ arguments, that I am deeply concerned about patient care in Massachusetts and elsewhere in the nation. I spend most of my time talking to nurses, nurse managers, and patients, and what I hear both in Massachusetts and elsewhere is not reassuring. The worst news comes from hospital managers, who report — when they talk in private that is — that staffing in their institutions is getting worse not better. I spoke to two managers recently who told me that they spend almost all of their time trying to find nurses to staff their units and that the supply of experienced nurses is very limited, yet their hospitals won’t let them hire any new grads –thus assuring that the pipeline that produces experienced RNs is steadily flowing. One manager told me she has a 23 bed unit and is only allowed to staff for 18 beds. Another, who supervises an oncology unit has seven patients to one RN — in California, the benchmark for nurse staffing in the US, the ratio is 4 to 1. These managers reported that they feel ill when their cell phones ring because they know someone is calling them to find more staff if someone reports in ill or takes a personal day. That is the message they deliver in private. In public, they risk firing if they express anything resembling their real concerns. In fact, a Kentucky hospital recently fired a nurse manager because she’d launched a safe nurse staffing cause on Facebook which attracted 25,000 followers.
We should remember one thing when nurse managers speak out against safe staffing. Under American labor law, managers have no rights at all in the workplace. They are the ultimate example of the “employee at will.” They can be fired on the spot without just cause and have no recourse against employer retaliation. If an employer, like Tufts for example, fires them because they express their true concerns about patient care, they have no legal remedy and unlike staff nurses who join together to protest unsafe conditions, cannot take their case to the National Labor Relations Board. Although I have great respect for nurse managers, I believe that their employment status under American labor law makes it difficult, if not, in instances like this, impossible, for them to speak up protect patients. As the case in Kentucky shows, when nurses become managers, their hospitals take the position that they now represent the interests of the institution, rather than the profession or patients, and that they cannot take positions that contradict those of their institutions.
Yet, one of the positions that Nicholas articulates is — again a typical one –that staffing ratios make it impossible for nurse managers to assign appropriate levels of nursing care to patients and that staffing ratios represent a cookie cutter approach to patient care by denying managers flexibility to staff appropriately. This could not be farther from the truth and Nicholas must know this (if she doesn’t, we are in big trouble). Staffing ratios establish a maximum number of patients a nurse can take care of, not a minimum number of nurses per patient. If, as nurses allege, Tufts is asking nurses to take care of 3 patients in its ICU (a terrifying thought, since ICUs should be staffing 2 to 1 or 1 to 1) nurse staffing ratios of 2 to 1, would not prohibit the hospital from assigning three nurses to one patient if the patient needed help. Staffing ratios don’t preclude using aides to help nurses care for patients, although they would preclude aides from replacing RNs when an RN is the only appropriate caregiver. Hospitals lose no flexiblity in providing higher levels of nursing care to patients — which is what we, as patients, should be concerned about. Nor do staffing ratios, as Nicholas contends, impede managers ability to staff with veteran rather than novice nurses. If Nicholas and her colleagues are against government mandated staffing ratios in principle, one should ask them if they also favor eliminating the rule that we need two pilots in an airplane flight deck or 1 flight attendant for every 50 seats in an airplane. Do they also think we should permit state licensed family day care providers from caring for more than six children — of which only two can be infants? Let’s be consistent here, if you argue against staffing ratios in hospitals that take care of the sickest patients, then you should also be against them on airplanes or family day care homes — not to mention on fire engines and in schools.
Nicholas goes far beyond the usual hospital arguments against staffing ratios. In this article, she adds a new twist. That is pitting other hospital employees against nurses. She suggests that nurse are trying to hog the limelight when it comes to patient care and are implicitly ignoring the contributions of other hospital workers in the care of patients. She also implicitly suggests that if hospitals do better on nurse staffing they will have to fire nurses’ aides, ward clerks, patient sitters and so forth. Particularly in this economy — you know the one that pays hospital CEOs in the high six to seven figures and lower level employees in the low twos. If is refreshing to see a hospital association CEO worrying about the very employees hospitals have been jettisoning as they outsource everything that isn’t nailed down in a hospital room or corridor. This is a brilliant new tactic in the staffing debate but an old one when it comes to fighting against progressive change. Of course, other hospital employees are also critical, why they should be paid more and why many of them also need protections against excessive workloads.
Every hospital employee — from the janitor to the RN to the lab tech — needs good pay and decent working conditions. When nurses fight for their patients, they are not fighting against other hospital workers. They are setting a precedent that other workers should follow and engaging in a struggle other workers should support. Most importantly, it is a struggle all patients should support. We are the ones whose lives are on the line here. As someone who suffered a hospital injury after surgery because of problems of nurse staffing I know about this from personal experience. As someone who has written a book about safe staffing, entitled Safety in Numbers: Nurse-to-Patient Ratios and the Future of Healthcare, I have studied this issue for years. Over 70 studies confirm the relationship between quality patient care and nurse staffing. Indeed, the latest just came out. It’s entitled “Nurse Staffing Levels and the Quality of Care in Hospitals,” and appeared in the New England Journal of Medicine on March 17, 2011.
2011
Check this one out — Why Hospitals are the worst places to be when you are sick
This sad but all too true article just appeared on the Huffington Post
http://www.huffingtonpost.com/judith-johnson/health-care-reform_b_817892.html
2011
Great Example of Team Intelligence In Action
Building Team Intelligence (TI) — the capacity of people to learn, think,reflect, and act together — has been a major focus of my research for several years now. In fact, I am writing a book with an airline pilot and medical educator on the aviation safety movement and how it changed aviation culture. The book – Come Fly With Me — considers what those working on quality and safety in health care can learn from the aviation safety movement.
As my colleagues and I have been working on our book, we have been looking at examples of similar transformations in health care settings. We now know that safety –whether in an airplane or an operating room — depends not simply on technical proficiency but on team work and the development of team intelligence. Last week, I saw an impressive example of Team Intelligence in action at the University of Toronto, in Ontario where I had the privilege of learning about the work being done by the University of Toronto’s (U of T) Faculty of Medicine’s Wilson Centre for Research in Education and its Centre for Interprofessional Education . The work these two centres are doing both on their own and in collaboration is fascinating.
Although many Canadian health care researchers had long been interested in promoting inter-professional education and practice, their efforts got a huge boost after the Romanow Report on Building on Values: The Future of Health Care in Canada that was released in 2002 . The Romanow Commission, led by Roy J. Romanow, considered the future health of Canada’s Medicare System. One of its key recommendations was creation of initiatives that would promote Interprofessional Education for Collaborative Patient-Centred Practice (IECPCP). The Canadian federal government took on this challenge by setting aside millions of dollars to fund Interprofessional Education and Practice in Canadian schools of medicine, nursing, pharmacy, dentistry and other health professions. In Ontario, the government added to that federal effort by setting aside money to fund both inter-professional education and practice .
The University of Toronto, with its Wilson Centre and Centre for Interprofessional Education, is at the heart of these efforts. The director of Wilson Centre is Brian Hodges, a psychiatrist who wrote the clinical commentary for Chloe Atkins amazing book My Imaginary Illness: A Journey into Uncertainty and Prejudice in Medical Diagnosis published by our series The Culture and Politics of Health Care Work at Cornell University Press.
2011
Team Intelligence — language is a good place to start
I have spent a lot of time watching doctors and nurses and other health care workers and professionals function in hospitals and other health care settings. The very first thing that impressed — or rather depressed — me when I first went into the hospital over 20 years ago was how little real communication there was between doctors, between doctors and nurses and between doctors, nurses and other professional or non-professional staff. Very few had what I have come to think of as Team Intelligence. What I noticed then and what I still notice when I go into hospitals is that there’s an awful lot of action but very little interaction. A lot of activity but not much interactivity. And how could there be when people function not just in silos but in heavily armed fortresses where they spend much of their time defending themselves against what they conceptualize as invading armies. (If health care workers and professionals only occupied silos, we’d be in better shape and it would be easier to re-form the system. Silos after all aren’t fortified.)
The inter and intra group relationships are really disturbing. The nurses who I write about are very focused on how poorly doctors treat them, but they rarely consider how they treat lower level staff — the cleaners, and LPNs and aides and so many others who make the hospital or other facility world go around. When my mother was dying in a nursing home, in 2002, I spent nine days at her bedside in a vigil after she refused to eat or drink. I watched the RNs treat the LPNs brusquely and rudely and the LPNs return the favor when they talked to aides. These aides are referred to as “nurse extenders,” as if they have no occupational identity of their own. And this term is used by people who dislike being called “physician-extenders.”
Nurses have all sorts of other ways to put each other down. Four year university degree nurses view themselves as “professional nurses,” and seem to dismiss the skill and competence of nurses who have gone to two year schools because they are just “technical nurses.” Enter the advanced practice nurse, who views her or himself as way above the two year or four year RN because he or she can prescribe and diagnose and is thus advanced. Consider the language here. You have different skills than a direct care RN — but you are an advanced practice nurse. So what does that make a veteran, expert, registered nurse who has spent 30 years honing her craft at the bedside? Is she inferior, retarded, delayed — all words that the thesaurus tells us are the opposite of advanced. I know now NPs, who refuse to even use the word nurse, or who don’t want to be viewed as “just a nurse.” How can these NPs, work effectively with RNs (which by the way an NP must become if he or she is to become an NP or APRN) if they have so little respect for the job and the person in it?
If nurses don’t respect one another, how can they expect doctors to respect them? If nurses put down one another, how can they expect doctors not to put them down?
And then let’s look at how docs treat each other. Over the years I have heard doctors — who nurses think to be the ultimate team players who stick together through thick and thin — belittle one another shamelessly. A surgeon I know commented dismissively that oncologists are just “hand-holders,” and don’t “do anything” for their patients. An internist insisted that my friend the gyncological surgeon wasn’t really a surgeon because she only did a limited number of operations. Another friend told me she’d heard an internist comment dismissively about an orthopedic surgeon who’d just had brain surgery — “oh, he’s just an orthopod,” like he didn’t really need a brain.
Junior doctors are afraid of attendings, afraid to point out problems in patient safety because they will be reamed out because they don’t know something that they couldn’t possibly know because they are novice/learners. They are afraid to admit to mistakes when we know that the way we learn is by making and learning from mistakes. In my work with doctors and nurses, I have seen a lot of tension and conflict result from the fact that the physician-in-training is trying desperately to get a nurse to help him or her cover up a mistake just before rounds (and just at nursing shift change) because he’s afraid to get reamed out by the attending. Rather than acknowledging the need for help (which he or she is not supposed to do because doctors give orders to, not ask for help from –nurses) the doc becomes demanding just when he or she should explain the problem and ask for assistance. Some nurses who think they know all about physicians misinterpret the physician-in-training’s actions and chalk it all up to those damn doctors who don’t appreciate nurses. While some doctors don’t, in this kind of case, the conflict between the novice doctor and nurse is generated by intra-group dynamics.
We talk a lot about teams in health care. And God knows patients like myself need them. But we’ll never create genuine teams unless people in health care do a lot of mental redecorating. How you think about the person who works next to you, the language you use to describe their role versus your’s is a great place to start.
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