2012
Susan Adams for Congress — A Nurse Role-Model
Nurse Adams Runs For Congress
I first met Susan Adams several weeks ago, at a Thai restaurant tucked into a shopping mall in sunny Marin County, California. An Adams-for-Congress supporter had contacted me, by email, about meeting her candidate. My interest in nursing and progressive politics would mesh well, she assured me, with Susan’s impressive personal and political profile as a working RN, nursing professor, and Bay Area activist now serving on the Marin County Board of Supervisors. Before the pad thai even arrived, it was clear to me that Adams is a great role model for nurses in the Golden State (and any state), who want to make their voices heard in the public policy arena.
I had brought along a copy of From Silence to Voice: What Nurses Know and Must Communicate to the Public, a book that I co-authored with Bernice Buresh. I handed Adams the book, over lunch, and the first thing she said (after “thank you”) was “how much do I owe you?” “Nothing,” I replied, “It’s a gift.” Without skipping a beat, Adams informed that that she was now “in politics and can’t accept anything.” Not a book, not a lunch. “You start accepting books and lunches,” she said “and it’s a slippery slope.” So my present turned into a book sale—not a bad deal for an author, but an unintended expense for a citizen politician who, without great personal wealth, has already had to raise more than $160,000 dollars to remain competitive in the crowded June 5 primary field in California’s 2nd Congressional District .
The constituency Adams seeks to represent runs north from the Golden Gate Bridge all the way to the Oregon border. Before redistricting, many of these same north coast voters sent Lynn Woolsey, one of the most liberal members of Congress, to Washington, but Woolsey is stepping down next January. Adams is competing against seven other Democrats and two Republicans in a “jungle primary” that will be followed by a general election in November, pitting the two top vote getters against each other.
One of those opponents is State Assemblyman Jared Huffman. He’s also from Marin and the current front-runner (in fund-raising and the polls), who was just endorsed by The San Francisco Chronicle. Another top tier contestant is Norman Solomon, a well-known progressive activist and writer who shares many of Adams’ views. The second biggest spender in the race so far is Stacey Lawson. She’s a newcomer to politics who is touting her business experience and making a bid for public office backed by her own hi-tech industry fortune in a manner reminiscent of Meg Whitman’s run for governor last year.
Lawson’s wealthy friends have already endowed her with a campaign treasury five times bigger than Adams, whose bid to replace Woolsey was initially encouraged by the Washington, D.C. feminists at Emily’s List. Before Lawson left the business world and moved to Marin, she didn’t bother to vote much (a record of civic activism similar to Whitman’s in the GOP). But, now, Lawson’s fundraising prowess has led some Inside-the-Beltway queen-makers to shift their attention from Davis to her.
That’s a sad commentary on the affection that money can buy in Democratic politics today. Adams is neither new to elected office nor unfamiliar with the survival struggles of ordinary people, including being laid off and loaded up with night student debt. A fourth generation Californian with family roots in rural Mendocino County, Adams got her nursing degree from San Francisco State in 1978. She earned both a masters and doctorate in nursing from the University of California at San Francisco (UCSF), where she specialized in women’s health and maternity.
A single mother of two, Adams put herself through school while working as an obstetrical and gynecological Nurse Practitioner at UCSF hospital. She has also served as a clinical professor, mentoring scores of undergraduate and graduate nurses, medical students, interns and residents. Her nursing practice focused on the problems of chemically-dependent pregnant women, the subject of her doctoral research.
When UCSF hospital merged with Stanford in the1990s, Adams helped organize her facility for the California Nurses Association (CNA) and served on the union committee that negotiated the RNs’ first labor agreement. Unfortunately, the marriage between Stanford and UCSF ended in divorce, leaving Adams among the casualties of its dissolution. Hundreds of staff positions were eliminated and she was one of those laid off (a management decision that, in her case, may have been motivated by her union activity).
Always politically active, Adams served as a campaign volunteer for now U.S. Senator Barbara Boxer, when Boxer, like Adams now, tried to move up from the Marin County Board of Supervisors to a seat in Congress. Gradually, Adams gained experience lobbying on nursing issues in Sacramento and Washington. In the 1999, she decided to run for the state Assembly because “our health care system was broken” and experienced caregivers were under-represented in policy-making circles. “I threw my hat in the ring,” she explained, “so I could be part of the dialogue. After spending only $1,000, I did better some of candidates that raised more than $100,000.”
Even though Adams didn’t win an Assembly seat, many of her friends and neighbors in Marin County encouraged her continuing involvement in electoral politics. Arguing that Marin had a “fractured healthcare system, which wasn’t working for the county’s resident,” she campaigned to become a county supervisor in 2002. “I wasn’t expected to win that race, because a very popular city council member, Paul Cohen, was also running and he had a lot of support and a whole lot of money,” she told me.
“But nurses have an 85% approval rating and people responded to my message that electing a health care provider could help us create a healthier community and a healthier planet for our families.” Adams won the race, much to her surprise, and she has been re-elected to the board of supervisors twice since then. In the decade Adams has served on the board, Marin County has built a health and wellness campus in San Rafael and Novato. “We have clinics all over the county now. We used tobacco settlement money for the San Rafael site and it provides comprehensive services in partnership with non-profit providers, including primary care, mental health services, and dental care.” Patient visits have jumped from 10,000 annually to more than 100,000 a year now. Says Adams: “This means we are definitely filling a need.”
Adams is particularly proud of a new county program that
“has diverted almost 200 non-violent, mentally ill offenders into treatment rather than jail and reduced recidivism by 85% and psychiatric emergency room visits by 50%.” Most of these former offenders are now gainfully employed and paying taxes again, she observes. On the county board, Adams also cast the deciding vote that launched the Marin Clean Energy Program, which addresses climate change by encouraging green job creation. Working with other county supervisors, Adams helped obtain $25 million in federal funds for non-motorized transportation projects.
As a result, Marin is now one of only four counties in the country to receive federal demonstration project money for non-motorized pathways (i.e. walk-able and bike-able commuting routes). Another program she helped initiate and facilitate is the nationally recognized Marin Medical Reserve Corps. “In our county today,” she explains, “we have a few hundred healthcare professionals trained in incident command who are ready to jump into action in the event of disaster. When we were faced with a flu pandemic, we had the whole county vaccinated within a week or two, receiving national recognition for this as well.”
Although several of Adams’ opponents in the 2nd Congressional share her progressive views about single-payer health care, she believes that her hands-on experience in hospitals and leadership role in public health makes her the real expert in the race. After all, how many other 2nd district candidates can boast of “delivering hundreds of babies as a nurse”—a track record that, according to Adams, insures that she’ll “deliver for us in Congress.”
“You’ll be my boss,” she tells the voters of the north coast,” not Wall Street, millionaires, or corporate donors.” With women holding less than 17% of the seats in Congress, she also hopes “to bring more common sense and collaboration to the table” in Washington. At the very least, at a time when right-wing Republicans are targeting feminist gains on many fronts, it certainly wouldn’t hurt to have an outspoken RN and grandmother of four fighting to protect women’s reproductive rights and access to health care, including contraception.
Win or lose, Susan Adams is the kind of nurse that many patients have been glad to have at their bedside and in the delivery room. She’s a credit to her profession—a living, breathing affirmation of the RN’s duty to be a “patient advocate,” in the broadest and best sense of that term.
(For more information on the Adams campaign, see www.SusanAdamsForCongress.com)
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2012
Ask Me If I Cleaned My Hands
I just wanted to alert people to a new article I did for JAMA, which appeared on April 18, 2012 in the journal. It’s entitled Ask Me If I Cleaned My Hands and recounts my experiences with hand hygiene when I was a patient getting surgery several years ago. I can’t print the entire article here but you can find it by linking to the url above. I can quote from it a bit. So here is a bit from the beginning. I hope you will read it and think about some of the ideas in it. I was pleased that it was cited as one of JAMA’s 50 top viewed articles in April.
So here is an excerpt:
SEVERAL DAYS AGO, A FRIEND, WHO IS A MEDICAL EDU-
cator in a residency program at a medical school,
told me a tale. She was accompanying an intern as
they trailed alongside an attending physician who was
seeing patients in an out patient clinic. He
examined three patients in a row and did not clean his
hands before or after examining any of them….
This is about all I can show you, but article makes some suggestions about how to really make patients a part of the hand-hygience process. And believe me, the solution is not to expect patients to ask their doctors and nurses if they have washed their hands. We just won’t do it. It’s too scarry.
In fact, I wonder how many physicians and nurses have ever had patients ask them if they have cleaned their hands? I would love to know if that ever happens.
I hope people find the JAMA article of interest.
2012
The Trouble With Smiles
Nursing has been infected with smilitis. Go into any hospital, and check the pictures on the walls. Hospitals often use pictures of nurses to promote the institution. Trouble is, the nurses are always smiling. Doctors look serious, with serious looks on their face, because they know something serious. Nurses, on the other hand, are used to convey an impression of coziness and comfort. Although patients actually find comfort in the fact that the people who are taking care of them actually KNOW what they are doing, hospitals and a lot of nursing organizations seem to ignore this and focus on the sentimental value of the nurse.
Check out nursing websites and what you often find are hearts and smiles. Like for example, Johnson and Johnson’s Campaign for Nursing’s Future. Smiling nurses greet you on every page.
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.
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