Changing how the world thinks about nursing

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In juggling your hectic business schedule prior to your stay here at Ritz Memorial, did you forget to pack one of those little essentials, like toothpaste, shampoo, or a nurse? If so, our concierge is pleased to provide them with our compliments.

September 17, 2005 -- Today the New York Times ran a so-so piece by Alina Tugend in the "Your Money" part of its business section about the apparent trend toward hiring private nurses to compensate for hospital short-staffing. The piece shows that short-staffing is a problem that could endanger readers' health, focusing on the need to have someone around to spot obvious problems like respiratory failure and to help patients to the bathroom. And it relies heavily on several nursing leaders, who provide sensible advice on how to avoid the worst effects of short-staffing, including investigating nurse staffing ratios in choosing a hospital. However, even acknowledging that the piece's focus is practical advice rather than policy, it falls short in key ways. Despite its length, the piece fails to note the link between short-staffing and the nursing shortage, does not ask even in passing whether we really want to continue our apparent slide toward a Victorian era health financing system in which only the affluent can afford nursing care, and fails to explain what nurses can do that unskilled "companions" cannot. The piece's failure to appreciate the full nature of the staffing crisis is captured in its headline: "Going to the Hospital? Don't Forget to Pack a Nurse."

Taking a conversational approach, Tugend notes that she was skeptical several years ago when a friend was advised to hire a private nurse when undergoing major surgery--was this more "baby boomer excess?" Did the friend really need someone in addition to the regular nurses at her "beck and call?" But the more recent experience of a relative, whose sister happened to be at her hospital bedside to alert nurses to the patient's respiratory failure, helped Tugend realize that 24/7 attendance by a "relative, hired nurse or companion" might not be such a luxury. She quotes American Journal of Nursing editor Diana Mason, RN, Ph.D, as noting that Mason had hired a private-duty nurse for her sister-in-law when she was hospitalized for an operation a few years ago. Indeed, almost every "medical authority" Tugend spoke with had done something similar, though she notes that the need to do so depends on the illness and the hospital, especially its nurse:patient ratio. The piece notes that this is a result of the worsening nursing shortage, explaining that recent studies have shown "how dangerous it is to load too many patients onto one nurse." It notes that California enacted mandatory nurse staffing ratios in 1999, and that 18 other states are considering similar laws. Mason, who serves on the Center's advisory panel, notes that private nursing is "alive and well" despite the pressure to improve staffing.

The piece goes on to offer practical advice for those considering a private nurse. It notes that a companion who is "not medically trained" costs about $15-22/hour, whereas a "private-duty nurse" costs $35-75/hour. Tugend says it's a good idea to ask "your doctor's opinion" of hospital staffing, though she provides no quote from any physician in the piece. She also advises checking whether a hospital is a Magnet facility, and finding out nurse:patient ratios and other relevant information, which may be available online. She includes a quote from American Nurses Association president Barbara Blakeney, RN, MSN, who urges readers to simply ask the hospital about the ratios, and if they won't provide the information, "then find another hospital." The piece discusses specific ratios, noting that the right number depends on how sick the patients are and the nursing skill mix, though it reports that Mason says there should be no more than six or seven patients per nurse on a post-op floor, and no more than two per nurse in the ICU. (We believe there should be no more than four patients per nurse on a post-op floor; Dr. Mason told us that the piece's quotation of her was not completely accurate, as she had indicated that a ratio of 1:4 or 1:5 was good, and that 1:6 or 1:7 was pushing it.) Tugend relates her efforts to get her sister-in-law's hospital to disclose their staffing. She did not tell the hospital that she was a reporter, and had trouble, though she eventually reached a floor nurse who said the ratio was about one to five and that they would be glad to provide a list of agencies that supply nurses and companions. Blakeney recommends finding out about the relevant training and experience of agency nurses. The piece notes that not every patient needs a "highly trained" additional person; the need may be simply for a "companion" who can "offer water, help to the bathroom or simple reassurance." The piece quotes the head of a New York area agency that provides nurses and companions as saying that it can be helpful to have "someone" to make sure "Mom" does not slip and crack her hip. The piece ends by warning that not all hospitals are welcoming of additional personnel, quoting University of Pennsylvania nursing professor Jean Whelan, RN, Ph.D, who notes that when she was in a clinical setting there was "a certain resentment" of such persons, but that she "loved it at night" when there was "one less patient to worry about."

The piece deserves credit for highlighting some effects of short-staffing today. It does not question whether readers might try to improve staffing by actually asking their government to take steps to change the underlying situation. Is there any basic problem with an increasingly stratified, unequal health care system, where only the affluent can afford adequate care? Moreover, as with other articles that fail to clearly explain the link between short-staffing and the shortage, most readers will likely conclude that short-staffing exists because of the shortage, and not that the managed-care driven short-staffing of the 1990's was arguably the biggest immediate cause of the shortage.

Of course, the piece is primarily intended as practical advice, and there's no doubt that readers have to take the world as they find it today. Most of the practical advice in the piece is valuable.

Even so, the piece never really quite overcomes the sense that nursing consists mainly of being at someone's "beck and call." It does note how much more expensive nurses are than unskilled companions, but does not really explain why that is. We hear short-staffing can be "dangerous," but not why, other than a simple need to have a competent adult check on critical patients often, which a family member can also do. Not everyone needs extra skilled help, but why not? In fact, nurses save lives through skilled monitoring, action, education and advocacy that no lay person could begin to do. The piece also fails to convey that given today's increasingly complex care systems, plugging in even skilled supplemental nurses--while it may be the best option available to a patient right now--is unlikely to be an adequate or cost-effective substitute for having a sufficient number of nurses who are part of a hospital unit's regular team. Likewise, though hospital nurses might appreciate the help on a given shift, it is not clear that an increasing reliance on private-duty nurses is in staff nurses' long-term interest. Nor does this piece reflect awareness that there is controversy over potential solutions to the staffing crisis, including between supporters of California-style mandatory ratios and those who, like the ANA, favor market-oriented measures to put more information in consumers' hands. Likewise, we get no sense of many nurses' ambivalence over the Magnet program. In keeping with Times practice, the piece never informs readers that Mason or Whelan have Ph.D's, though the paper is careful to attach "Dr." to the names of physicians each time they appear.

Finally, we realize that the headline's notion of "packing" a nurse must have seemed cute to someone at the Times. But obviously the image suggests that nurses are a bunch of simple, fungible objects to be plugged in here and there, like just another piece of durable medical equipment.

We thank Ms. Tugend and the Times for a piece that, though flawed, provides important information for patients confronting today's nurse short-staffing.

See the article "Going to the Hospital? Don't Forget to Pack a Nurse" by Alina Tugend in the September 17, 2005 edition of the New York Times.

 

 

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