Why are those nurses hogging so much of the hospital budget?!
March 25, 2011 -- Recent press reports have highlighted the continuing debate over adequate nurse staffing in U.S. hospitals. A fairly good March 16 piece in the St. Paul Pioneer Press was among those reporting that a new study published in the New England Journal of Medicine had found that nurse understaffing at the Mayo Clinic significantly increased the risk of patient mortality, and that high patient turnover had an even greater effect. Christopher Snowbeck's report also provided helpful context, noting that nurse staffing levels have been critical factors in recent labor disputes between hospitals and nursing unions. And today, the Boston Globe ran business columnist Steven Syre's piece about the "conundrum" hospitals face in trying to balance costs with the growing awareness that having fewer nurses threatens patients. It seems that nursing payrolls are the biggest single "expense" hospitals have. This piece also provides a pretty balanced look at recent labor disputes in which nurse staffing has been a key issue. But the writer seems puzzled about why nursing salaries are such a part of hospital budgets. No one says: "Yes, nursing salaries are a big factor because hospitals exist to provide professional nursing care, not to house physicians or machines. And nurses are not just 'expenses'; they create most of the value that hospitals provide." That basic reality might have been helpful for readers to know. In any case, we thank those responsible for these two pieces.
Too few nurses
The St. Paul Pioneer Press report has a good headline: "Too few nurses, greater death risk, Mayo finds: Study certain to stir debate over hospital staffing in wake of Twin Cities nurses strike." And the article does a fairly good job of laying out the basic aspects of the study "Nurse Staffing and Inpatient Hospital Mortality", which examined staffing at the Mayo Clinic's Rochester hospitals over a four-year period (2003-2006) and found that nursing staffing levels "met or were close to targets" about 84% of the time. For the study, being "close" to the hospital-set target means that units were not short more than eight of the target RN hours. However, it also means that even at the elite Mayo Clinic, which admitted 200,000 patients during the period studied, units were short by at least one nurse 16% of the time. The article notes that other studies have looked at nursing staffing at much greater numbers of hospitals, which critics say has the drawback of not controlling for variations in other aspects of care quality.
The new Mayo Clinic study found that patient mortality increased when nurses were under-staffed. The researchers, in analyzing data for patients in the first 30 days after admission, found that only about one third stayed in units that had no significant short-staffing under the study's "one nurse per shift" definition. About 35% of patients "experienced at least three shifts where staffing targets set by hospital management weren't met." The study found that "a patient's risk of death increases by 2 percent per [8-hour] hospital shift when units are understaffed with registered nurses." And the risk of dying increased for a small number of patients "by about 25 percent because they happened to experience between 10 and 14 under-staffed shifts during just five days in the hospital."
The Pioneer Press reports that the Mayo study identified a second major factor in patient mortality: "high-turnover shifts," where "demands on nursing staff increased with a high number of admissions, transfers and discharges." The piece does not reveal how much turnover was required for the study to consider it "high," but it says that while about 40 percent of the patients studied managed to escape such shifts, about 13 percent of patients were exposed to three or more high turnover shifts. The study found that each high turnover shift increased the risk of death by 4 percent.
The report quotes the study authors explaining that this finding underscores the importance of "flexible staffing practices" that "facilitate shift-to-shift decisions." And it says that hospitals "welcomed the study" because this "need for flexibility" was a key argument they made in "last year's contract negotiations with unionized hospital nurses in the Twin Cities." The article also describes a one-day strike last year by nurses at about a dozen area hospitals with nurse staffing the core issue, presumably the same dispute. The piece quotes Lowell Taylor, a professor of economics at Carnegie Mellon University, as saying that the effect of turnover shows why (in the piece's words) "it might be difficult to write nurse staffing rules into contracts and state laws." Taylor:
What this shows is that other factors matter -- such as the turnover of patients -- that are subtle and would be difficult to mandate in clearly specified work rules.
The piece notes that Taylor "has studied a California law that mandates nurse-to-patient ratios," but does not note that a 2010 "working paper" by Taylor and other economists found no evidence that the California law had improved patient outcomes. Nor does the article explain that a 2010 study by nursing scholar Linda Aiken and colleagues found that if the California ratios were applied in Pennsylvania and New Jersey, they would have saved the lives of hundreds of patients. The piece does quote Carol Diemert of the Minnesota Nurses Association as arguing that staffing rules should (and so presumably can) be written in ways that allow for patient turnover. Diemert also underlines the core findings of the new study:
What we're seeing from this study is that on a day-to-day, shift-to-shift basis at an elite hospital, they're not meeting their own standards. They're one whole nurse short per shift. . . . When you're down one nurse, it has an impact.
The piece also says that "nurse union officials" noted that the study supported the points they made in last year's contract dispute, with union official Deb Haugen stressing that the fact that (in the piece's words) "about 16 percent of all shifts documented in the study fell short of staffing targets suggests a lack of accountability on the part of hospitals."
This is a fairly balanced presentation overall, with both sides having a chance to express their views of the study, and most of the experts consulted here are nurses. But it might have been better to explain just what critics of minimum staffing mandates mean when they seek "flexibility" as a way to manage turnover issues. Do they mean that mandates should not specify an exact number of nurses who must work in a given unit, thereby permitting the unit to respond to high turnover with more nurses? If so, that would seem to be a red herring; we have never heard of a staffing rule that required a maximum number of nurses who could work in a given unit, and it's pretty hard to imagine any nursing advocate asking for that. Staffing mandates are minimums, not maximums.
Or do the critics mean that hospitals must have the "flexibility" to draw nurses from other units, potentially causing those units to drop below a target staffing level? It's possible to ensure that there are enough nurses in the hospital to respond to high turnover events and maintain adequate staffing everywhere. But it may require that potentially affected units have additional nurses, or that there be a pool of qualified nurses available to respond to such events when needed. Since this study suggests that high patient turnover is twice as deadly as understaffing overall, some might argue that the focus should be on addressing staffing issues during a high turnover.
Discharges and Admissions
Discharges and admissions are extremely time-consuming for a nurse. Typically, nurses are burdened with both a discharge and an admission at about the same time. The inevitable effect of doing a good job on a discharge and admission is often that the nurse's other patients do not receive the care they should. And if a nurse has a turnover of two beds in a shift, other patients may be lucky to see that nurse once. It seems clear from the results of this study that discharges and admissions should actually receive a higher value in evaluation of nursing staffing (i.e., they should count as more than one patient), and the nurse's other workload should be adjusted accordingly. Arguably a properly staffed unit can respond to high turnover without drawing nurses from elsewhere, and a unit that cannot do so cannot be called adequately staffed.
One flaw of the Pioneer Press article is that it does not explicitly say that a key factor in disputes about nurse staffing is money. Good care requires nurses, and nurses must be paid money so they can support themselves and their families. But with recent efforts to control health care costs and the longstanding undervaluation of nursing, funding has been hard to find. In fact, it's not clear that adequate nurse staffing would cost much more money, because research shows that nurses save money when they have the staffing to prevent costly adverse events and shorten hospital stays.
Another unexplored issue is the apparent assumption that the Mayo Clinic's staffing targets reflect good staffing. The study compared shifts in which the Clinic met its targets to shifts in which it did not. But nurse understaffing can occur even if hospitals are meeting their targets, because those targets often do not reflect an understanding of the role that nursing care actually plays in patient outcomes. Alternatively, the targets may not reflect a willingness to staff nurses in accord with their role in rescuing, educating and advocating for patients. The article does not tell us what the targets were.
The piece also quotes one of the study authors, Mayo Clinic nurse Marcelline Harris (right). That's good, but the piece just calls her a "researcher," and fails to note that she is a nurse, with a doctorate, or even to clearly indicate that she was involved in the study, much less as the principal investigator, as she was. Maybe we can't blame the newspaper too much, since Harris's own Mayo Clinic bio only refers to her "PhD," and buries her nursing expertise in her educational background. (Her new University of Michigan School of Nursing bio at least lists that "RN" after her name.) So readers will probably not understand from this article that graduate-prepared nurses conduct important research like this. Harris's quotes are generally good:
Hospitals need to know what staffing is needed to care for their patients and then take actions to make sure those staffing levels are achieved. Your risk of mortality increases with increasing number of shifts that are below your (staffing) target. . . . Largely, managers are taking a lot of responsibility to meet those targets. When patients started to have three or more shifts with below-target staffing, that is when we started to really see this risk increase.
Harris is also quoted as saying that (in the piece's words) "some degree of under-staffing is difficult to avoid in hospitals . . . because nurses sometimes call in sick and the number of patients needing care can change unexpectedly." Of course, that's fair enough, but it seems to assume that hospitals are staffing at the edge of their apparent needs and they lack safe and effective systems to respond to unexpected needs, which is not so much a law of nature as it is a practice driven by cost concerns.
The piece closes with a short summary of "key findings" in both major parts of the study, which it signals with the headings "Not enough nurses" and "High turnover." This is an effective way to bring the piece back to its powerful bottom lines. We thank the St. Paul Pioneer Press.
Why are player salaries such a big expense for the Red Sox?
Steven Syre's business column in today's Boston Globe focused on the mysterious tension between controlling hospital costs and actually paying nurses to do their work. The column is headlined "Nursing a conundrum" (what would headline writers do if the word "nursing" could not be applied to any unskilled tending?).
The column presents nursing mainly as an "expense" and fails to convey that nursing occupies such a big part of hospital budgets because hospitals exist to provide skilled nursing care--even though nursing has long been buried within the "room and board" charge on hospital bills, a damaging distortion of nurses' true role that has attracted amazingly little attention. Still, the piece actually does a decent job of outlining some of the basic issues hospitals face in trying to control costs while staffing units with enough nurses to provide good care.
The column begins by noting that "all the big-picture policy talk about controlling the cost of health care runs smack into the real world at the hospital nursing station." The piece cites current contract talks between nurses and hospitals, particularly one at Boston's Tufts Medical Center, in which staffing levels are a central issue. The piece summarizes the basic conflict:
Hospital administrators say they are trying to manage in challenging times, reorganizing work to become more efficient while maintaining the quality of care. Many nurses and their union say the practical result of efficiency plans is a thin staff that put patients at greater risk.
The column quotes Barbara Tiller (right), a veteran Tufts nurse and "chairman of the union bargaining committee there," as saying that the "hospital has set us up to fail" because "it's not possible to take care of people like parts on a factory line." The piece does include a limited indication of what nurses actually do in hospitals, quoting and citing recent research by UCLA School of Public Health professor Jack Needleman. It describes a study by Needleman and others published the prior week in the New England Journal of Medicine that "reviewed nearly 200,000 admissions at an unnamed academic medical center and found an increased risk of patient death when nursing shifts were staffed below optimal levels." That is helpful to mention, but the piece gives no detail about this study--it is actually the Mayo Clinic study described above--and thus no indication that nurses were involved. The suggestion that the Mayo Clinic's targets are "optimal" is unsupported, to say the least. And even this discussion is buried near the end of the piece.
The majority of the column hammers home the message that nursing costs hospitals a ton of money, without giving readers much sense of why that is. The piece notes that slowing the increase in health care costs is now the priority at all levels in the public and private sectors, and it repeatedly stresses that nurses are the most obvious target:
Hospital administrators look at their budgets and see labor as the thickest slice of the pie by far. Inside the payroll numbers, nurses are the biggest expense and a natural target for cost control. . . . "We think of hospitals as very technological, but labor is still over half the cost,'' says [Needleman.] "In an environment where you're trying to control costs, hospitals quite understandably apply the Willie Sutton theory." That means going where the money is, and Needleman says nursing payrolls can make up as much as 25 cents of a hospital-budget dollar, though the Massachusetts Nurses Association puts the statewide figure at about 17 cents. Nurses are a major expense because hospitals employ lots of them at good full-time salaries -- nearly $96,000 a year on average at Tufts (the union places the statewide average for members who are hospital nurses at $82,000). Hospital executives often promote sophisticated strategies to curb medical costs, from aggressively managing small groups of the most expensive patients to targeting a handful of health problems that account for much of the big-ticket volume. Truth is, any hospital chief who needs to save money soon will go first to the budget and look for big targets. . . . "The concerns the nurses are raising are real," says Needleman. "But the cost pressure is real too. How one solves that is an issue."
The piece adds some detail about the financial pressure on Tufts, which says it is getting "$18 million a year less in Medicaid payments from the state than two years ago." The university president Ellen Zane (right) is quoted as saying that the governor’s health plan “says everyone needs to be more creative, get their heads out of the sand and understand we can’t turn back the clock,” and that “responsibility is put on all of us, including the union.”
Tufts has been trying to cut costs for some time, and now its "executives want the nurses union to agree to a one-year contract to complete that work"; not surprisingly, they "balk at the idea of mandated nurse-to-patient ratios." The piece notes that one idea to improve "nursing efficiency" is to "push more unskilled work to other employees." To its credit, the piece conveys some sense that that is not so simple, explaining that it is "hard to say how those efforts actually work on a hospital floor." The Tufts executives argue that they get high quality ratings, but the nurses cite hundreds of complaints they have made about specific staffing problems. In fact, hospitals have been assigning nursing tasks to unlicensed assistive personnel for many years, as part of a cost-driven denursification that studies like those mentioned in these pieces show threatens lives.
It's not that so much of the Globe column is really wrong, but the intense focus on nurses as a huge expense--without much of any explanation of why that is, why hospitals employ so many, or why nurses receive the salaries they do--certainly makes it easy for readers to conclude that the nurses are just a demanding bunch who are sucking up much of the money in health care because they have a strong union and have gotten used to a pampered position that society can no longer afford. But of course, nursing compensation consumes some part of the hospital budget because nursing is the thing hospitals exist to provide; if patients did not need skilled nursing, they could get care at an outpatient center.
Looking at the chart to the right, what strikes us is that if an institution exists to provide nursing care, why is such an amazingly tiny amount of money spent on nursing? And because of the obsession with costs, hospital patients today are sicker than ever--many are sent home before they are really ready--so they require more care than ever. The piece does at least mention the study showing that subpar staffing increases the "risk of death," but that's not enough in the face of the relentless overall emphasis on cost. And the piece does not explain why nurses can make pretty good salaries: They are college-educated science professionals who do a demanding, stressful job in which they save lives and improve patient outcomes, if they have the time and resources.
If you think nurses are expensive, try health care without them. Oh, right--that's what we're doing!
See the article "Too few nurses, greater death risk, Mayo finds: Study certain to stir debate over hospital staffing in wake of Twin Cities nurses strike" by Christopher Snowbeck posted March 16, 2011 on the St. Paul Pioneer Press website. Mr. Snowbeck can be reached at firstname.lastname@example.org