Can Penelope the robot solve the nursing shortage?

January 6, 2004 -- Laurie Tarkan's article in today's New York Times, "Nursing Shortage Forces Hospitals to Cope Creatively," describes fairly well the dangerous short-staffing that has driven the nursing shortage, and predictions that the shortage will worsen in coming years. It also manages to paint a remarkably rosy picture of the present and future, exploring the measures some hospitals are apparently taking to improve nurses' working conditions and benefits. Though the piece is serious and generally seems to reflect understanding of the importance of nurses, it also opens and closes with discussions of health care robots like Penelope that seem to suggest nurses are gabby, shiftless subordinates who could be replaced by more efficient machines.

The article briskly outlines basic aspects of the shortage, including the cost-cutting that has contributed to poor working conditions, the growing evidence of the link between short-staffing and "the rate of medical errors and deaths," California's new safe staffing law, and assertions that many hospitals are now too financially strapped to improve working conditions. The story cites leading scholar Linda Aiken of the University of Pennsylvania for the idea that the high turnover associated with the shortage may have helped Charles Cullen, the nurse who has reportedly said he ended 30-40 patients' lives, move from hospital to hospital without standing out. The article also discusses data about the effects of the shortage, including Aiken's research on the dangers to patients from short-staffing, and the comprehensive recent Institute of Medicine report, which "recommended major changes in hospital culture."

Much of Tarkan's piece suggests that hospitals are already following this recommendation. She gushes that they are "surpassing the creative in dealing with the nursing shortage." (We're not sure that even the Creator could "surpass the creative," but we suppose that for Hospitals, anything is possible.) Tarkan describes how a South Carolina hospital appeals to "young technologically oriented nurses" by offering online auctions that let them bid on extra shifts, which has greatly decreased the hospital's reliance on more costly agency nurses. A Cleveland hospital offers a 9:00 a.m. to 2:00 p.m. "mom shift," child care arrangements and a nine month position with summers off. Many hospitals now offer large sign-on bonuses and better benefits, such as a Maryland hospital's offer to pay 50% of college tuition for nurses' children. Other hospitals offer benefits from "lift teams" to help lift patients to concierge services, and many are increasing their outreach activities. Tarkan concludes that "[a]round the country, using various strategies, some [hospitals] are beginning to see their efforts succeed, leading to lower vacancy rates in nursing jobs, lower turnover and lower mortality rates for patients. In addition, hospitals are seeing higher ratings of satisfaction among nurses and greater satisfaction among patients."

Many of the measures described deserve attention, though some could be considered minor or unsustainable gimmicks that do little to address the underlying issue that the overall treatment of nurses still does not match their level of training and responsibility. And we find it curious that for all the innovation on display, the article does not mention a single hospital that has voluntarily done the one thing nurses have asked for above all else: end short-staffing. Creative is one word; cheaper is another. But the article's final sentence does suggest awareness of what really matters, noting that "[a]side from [all the innovations above], hospitals have begun to address basic problems by ending mandatory overtime, involving nurses in making decisions, listening to their concerns and reducing paper and nonclinical work."

The overall impression of the article is that hospitals and nurses have turned the corner on resolving the shortage, and that the short-staffing and other problems in nurses' working conditions are on the wane. We would like to believe that is the case, but we are not at all sure, as the recent experience of nurses at Philadelphia's Medical College of Pennsylvania and elsewhere suggests.

The real stars of Tarkan's story are Penelope and the Pyxis Helpmate. Penelope is a one-armed robot being developed by Columbia's Michael Treat, apparently a physician, to "replace the nurse who hands the surgeon the instruments, freeing the nurse to give postoperative care." In addition, many hospitals already use the Pyxis Helpmate, a robot that "shuttles medication, meals, lab specimens, supplies, medical records and radiology films around the hospital." Not all of these jobs are proper nursing tasks to begin with, but to the extent robots can safely provide nurses with more time for critical nursing tasks, it does sound promising.

However, we were not impressed with the mistaken implication that a robot could actually replace a nurse in surgery. Nor with the article's lead sentence: "Banter in the hospital operating room may be less lively if the surgeon's assistant is a robot rather than a nurse, but that is of no concern to the inventor of Penelope." Nor with the statement that the Helpmate "saves time by not chatting at the water cooler."

Nurses are autonomous professionals, not physicians' "assistants." Nursing, like medicine, involves critical judgments and sensitive physical tasks of which robots are not (yet) capable. Contrary to the article's implication, during surgery handing physicians instruments is not the main thing nurses do; nurses constantly evaluate the patient's condition and the progress of the surgery, advocate for better surgical practice and initiate measures to keep the patient alive and aid recovery. Thus, Penelope cannot "replace" a nurse in surgery any more that it can replace the surgeon. Moreover, nurses have no more time for idle banter than do physicians who invent helpful robots. We're not suggesting nurses never banter. But these passages do not exactly convey that they are highly trained professionals struggling to avoid burnout because of short-staffing and forced overtime, which--believe it or not--remains the reality for hundreds of thousands of nurses today.

See Laurie Tarkan's article "Nursing Shortage Forces Hospitals to Cope Creatively," in today's New York Times.

Ms. Tarkan does not appear to be available by email, but you may e-mail letters to the editor at letters@nytimes.com