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Boston Globe op-ed: "Nurse understaffing harms patients"

May 12, 2005 -- Today journalist Suzanne Gordon marked National Nurses Week with an op-ed in the Boston Globe. The piece argues that the best way to honor nurses is not through more of the traditional lip service and self-sacrificing "angel" imagery that has often been used to exploit nurses, but through passage of safe staffing legislation like that pending before the Massachusetts legislature, which in her view would relieve the dangerous short-staffing that has driven many nurses from the bedside. The op-ed takes on some of the claims presented by Massachusetts hospitals and nurse executives who oppose mandatory staffing ratios, and although the piece might have done a bit more to counter these, it is effective in arguing that voluntary measures will not be adequate to address the current nursing crisis.

Gordon begins by noting that Nurses Week manages to both "celebrate and compartmentalize" nursing. During this week, health care decision-makers heap nurses with praise for their devotion, while the rest of the year, nurses are asked to care for too many patients as cost-cutting hospitals assembly-line patients through the system, leading to nurses fleeing the bedside due to "burnout and disgust." The piece argues for the pending state legislation supported by the Massachusetts Nurses Association (MNA), which the MNA argues would increase nurse recruitment and retention by limiting the number of patients that could be assigned to any one nurse on specific types of units (e.g. four on medical-surgical units).

Gordon devotes most of the piece to the arguments and alternatives presented by the Massachusetts Hospital Association (MHA) and the Massachusetts Organization of Nurse Executives, both of whom oppose the mandatory ratios. According to the op-ed, these groups argue that there is "insufficient research" for the legislature to determine the right ratios in the different unit settings. The hospitals apparently support public disclosure of unit-specific staffing plans, including staffing levels, so that consumers can shop around. They also support an increased focus on having hospitals apply for nursing "magnet status," a distinction awarded to hospitals that provide nurses with better working conditions and more input into hospital governance. Gordon argues that such "market" and "magnet" measures will not be sufficient because managed care plans typically restrict hospital choice, and in any event, patients cannot protect themselves from bad care "in mid-hospital stay." The op-ed also argues that "[m]ost puzzling of all is that the voluntary staffing levels [the hospitals] agree should be publicized to facilitate patient choice require somebody to make a private calculation, in each hospital, that ratio foes insist cannot be made accurately by the state." The op-ed concludes that deteriorating conditions over the last decade have shown that voluntary measures will not be sufficient to end the crisis and improve conditions for nurses and their patients.

This op-ed makes important points. One of the most notable is that a great deal of the current "nurse appreciation" is at best inadequate and at worst a cover for exploitation that endangers patients. The piece might have done a bit more to explain just how misleading and damaging much of this imagery is, i.e., that nurses are in fact highly skilled professionals who save lives and materially improve outcomes, and that the imagery itself drives the attitudes that make short staffing possible. Likewise, the piece might have briefly explained how nurse understaffing actually harms patients, perhaps through some of the growing research on the topic, or even through anecdotes. No one is better qualified than Gordon to present such information; her powerful new book "Nursing Against the Odds" is full of such detail.

In general, the op-ed may spend a little too much time describing some of the hospitals' arguments, and not enough time rebutting them in a forceful, straightforward way. The piece does not really address the hospitals' "insufficient research" argument, except where it appears to suggest that it is inconsistent for the hospitals to argue for voluntary disclosure of their own unit-specific ratios, while at the same time arguing that the government is unable to set appropriate universal ratios. Whatever the merits of the hospitals' position, it is not inconsistent for them to say that an individual hospital can determine the right ratio for its own intensive care unit this month, but that the government can't set the right ratio for all hospital ICU's in the state forever. Alternative responses to the hospitals might be that the legislation is based on input from nurses with years of experience in the relevant type of unit who are more than capable of determining appropriate minimum ratios, and that in any event there has now been significant research globally on the effects of the inadequate nurse staffing commonly seen today, and the bottom line is that it kills people.

The piece also suggests that disclosure is of little value because of managed care restrictions on hospital choice and because patients can't do much in mid-hospital stay. Gordon's main point here--disclosure alone won't do it--is a strong one, because there are good reasons to believe that health care is one of the fields that is too important and too complex to be left to the market alone. But the actual arguments in the op-ed seem inadequate. The disclosure idea is that members of the public--aided by the same consumer advocates who support this bill, as well as press figures like Gordon--will become aware of such data before they enter hospitals. Magazines and web sites would presumably be eager to gather, organize, and explain such data. Of course, the data would not be up to the minute in the sense that you would know what the ratio would be at the exact time you would enter the hospital. But virtually all health care data is retrospective. People do not know how a surgeon is going to perform tomorrow, only what her reputation is based on past years. Moreover, patients still have significant choice in hospitals; if they did not, the billboard business in major cities would be very different. More broadly, disclosure to the government (reporting) can be a central method by which mandatory requirements like staffing ratios are enforced. In fact, far from being merely a fake measure presented by those seeking to avoid regulation, disclosure and reporting of relevant data can be integral parts of meaningful regulation of the underlying conduct being disclosed. Indeed, pending federal legislation that would mandate specific nurse staffing ratios (H.R. 1222) includes unit-specific disclosure and record-keeping requirements as a complement to the ratios it sets.

The op-ed appears to suggest that a problem with magnet status as a solution to the nursing crisis is that the status will only exist "in a few places." This seems like an argument that magnet status will fail because it will not succeed. Better arguments might have been that magnet status has merely provided a marketable illusion of true nurse empowerment and safe staffing (as the MNA itself has recently argued), and that magnet status is subject to some of the same enforcement problems as hospital accreditation (as Gordon herself argues in "Nursing Against the Odds").

In any case, the op-ed is a timely and worthy way to celebrate nurses week. We commend Suzanne Gordon for writing it and the Boston Globe for publishing it.

See the op-ed "Nurse understaffing harms patients" by Suzanne Gordon in the May 12, 2005 edition of the Boston Globe.