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Oh, Inverted World

"The New York Times" on compassion fatigue

world upside down 
July 5, 2012 -- Today The New York Times ran a very good "Doctor and Patient" piece by physician and regular columnist Pauline W. Chen about threats to hospital nurses' physical and mental health that can affect patient care and, of course, the nurses themselves. Chen uses the story of a back injury suffered by "one of the most respected nurses" in her hospital as a lead-in to discuss the causes and effects of nurses' health problems. Chen cites recent research in nursing journals and repeatedly quotes University of North Carolina professor Susan Letvak--a scholar Chen identifies as a nurse and then commendably refers to as "Dr. Letvak." At a few points the piece is too cautious, notably in suggesting that nurse staffing ratios "are not always standardized" and so "nurses can find themselves in the potentially devastating situation of caring for more patients than is comfortable." "Non-standardized" staffing can make nurses less than "comfortable"? Does Chen mean research shows under-staffing kills patients because nursing is a high-skilled scientific profession that is vital to patient survival? Chen might also have mentioned the add-on effects of compassion fatigue, which has received attention recently, for instance in January 2012 pieces in The Wall Street Journal. Chen does make clear that illness-related nursing errors cost the U.S. health system billions of dollars annually, and as usual, she goes out of her way to avoid stereotypes and convey respect for nursing. We thank Chen for another very helpful report about the challenges that nurses and their patients face.

The piece, "When It's the Nurse Who Needs Looking After," begins with a short portrait of the senior nurse who hurt her back:

Tall, in her 50s and sporting a perfectly coiffed salt-and-pepper pixie cut, the woman was one of the most respected nurses in the hospital. She had nearly three decades of clinical experience, so older nurses and doctors valued her insight, younger ones sought her approval, and those of us in between tried to stand a little straighter in her presence.

This is great because it conveys that the nurse gets respect because of her knowledge and insight, and she gets it from nurses and physicians alike. Unfortunately, the nurse arrives one morning to find, not for the first time, that her unit is "understaffed," and after her 12-hour shift, she notices a "slight twinge in her lower back" from helping to lift a patient--a twinge that would soon become  "debilitating back pain." put on oxygen mask firstThe nurse continues to work with the pain, noting that patients would suffer "without the additional nurse," presumably meaning she would not be replaced if she took time off. Speaking to Chen, the nurse "whispered":  "How terrible is it that we do everything to care for the health of others, but we cannot care for ourselves." Yes, that is ironic, and self-defeating, since a nurse can't care effectively for others if she is falling apart herself, much as we are advised in emergencies to put on our own oxygen masks before helping others.

Chen steps back to explain that nurses are "the largest group of health care providers in the United States," working in a wide variety of settings, "trusted more than almost any other professional," and exerting "a wide-ranging influence on how health care is delivered and defined." But, Chen notes, nursing is not easy, especially in hospitals where nurses confront "intense intellectual and significant physical demands over three or more grueling 12-hour shifts each week." So it's no surprise that nursing is among the worst professions for work-related injuries, and "studies have shown that in a given year, nearly half of all nurses will have struggled with lower back pain." Chen does not pursue the research on this, but it's a pretty amazing statistic. How many other professions requiring a college degree would also feature that level of physical trauma as a normal component? Chen deserves credit for working in the "intense intellectual demands" of nursing, though it would have been even better to mention briefly what they are. And she probably deserves credit for resisting the temptation--especially in a piece partly about back pain--to say nurses are the "backbone" of health care, a common statement that's presumably meant to be a compliment but suggests nursing is just unskilled physical labor.

Chen goes on to discuss how the stress on nurses affects patients, citing recent research published in the American Journal of Nursing and Clinical Nurse Specialist. Susan LetvakBased on more than 1,000 responses from hospital nurses, the researchers found that almost 20 percent had symptoms of depression--a rate twice as high as the general population--and that "roughly three-quarters of the nurses experienced some level of physical pain from a muscle sprain or strain while at work." Further questions about the care the nurses gave led researchers to conclude that "the risks of a patient fall or medication mistake increased significantly -- by about 20 percent -- the more a nurse was in pain or depressed." Based on that, the researchers estimated that the medication errors and patient falls caused by nurses' health issues cost as much as $2 billion annually in the U.S.

For expert comment, Chen consults "Susan Letvak (right), the study's lead author and a registered nurse who is an associate professor of nursing at the University of North Carolina at Greensboro." Chen goes on to refer to her as "Dr. Letvak," which most readers will likely understand means Letvak is a nurse with a doctorate; it might have been even better to include a reference to that doctorate (e.g., "PhD"), much as Chen's name is always followed by "M.D." money going down the drainIn any case, Letvak bluntly notes: "We have money bleeding out the back door because we don't have a healthy work force." Chen observes that the hospital nursing environment is "increasingly stressful."  

Patients are sicker than before, and nurse-to-patient staffing ratios are not always standardized. Over the course of a 12-hour shift, nurses can find themselves in the potentially devastating situation of caring for more patients than is comfortable.

These are good basic points, although the way Chen has muffled them is hard to explain. Nursing ratios are not "standardized" in many places because cost-cutting hospitals may resist staffing their units with as many nurses as those nurses believe good care requires, rather than because there is some accidental variation in ratios. And we're not sure what to make of a statement that caring for more patients than is "comfortable" can be "devastating"--which is it? In fact, understaffing leads to poor care, including suffering and death, as well as nurse burnout and turnover. Chen does rightly note that many nurses "feel pressure to show up for work," presumably meaning on a day-to-day basis, "because their absence means even more work for their colleagues and even spottier care for their patients." Of course, that is only the case if the hospital does not arrange for a replacement nurse. And Chen includes the excellent point that many nurses feel they must come to work because of an "ethos" in the profession, quoting "Dr. Letvak":  "Nothing is supposed to stop a nurse. We are supposed to care for everyone else and soldier on."

Another factor Chen might have mentioned is compassion fatigue, which many nurses suffer not only as a result of the normal stresses of their profession but also because of understaffing and moral conflicts related to end-of-life care. This is just the kind of nursing mental health issue that can cause burnout and high turnover and also threaten patient care directly, as it can lead to a failure to engage with and assess patients. In January 2012, The Wall Street Journal's "Informed Patient" columnist Laura Landro ran good pieces on compassion fatigue.

Chen concludes with a short discussion of what can be done. She says that there are "few work-based resources" available to nurses, and that few hospitals mandate safe lifting practices or offer programs to support temporarily disabled nurses. Chen notes that few nurses, including managers, are trained in identifying and handling colleagues who may be "impaired by illness." And Chen says that some nurses may fear losing their jobs, quoting Letvak:  "We have a system of penalizing nurses instead of early recognition and treatment." This, of course, implicates the iron-nurse "ethos" mentioned earlier, and perhaps also the high levels of horizontal aggression in the traditionally disempowered nursing profession, which Chen might have explored. Chen does mention that the "predicted nursing shortage will likely exacerbate many of these issues." And she describes "several initiatives that could strengthen the current work force."

These include measures like standardizing the nurse staffing ratios, providing the option of working shifts shorter than 12 hours and creating more health screening programs. [Dr. Letvak] and her colleagues already have plans to study how helping nurses who are in pain and making shift lengths more flexible might improve patient outcomes and help experienced nurses practice for as long as they can. "The only way to ensure the best quality for our patients is to have an expert staff of qualified nurses who are healthy enough to offer that kind of care," Dr. Letvak said. "We can't ignore nurses' health anymore."

This is a great way to close the column. Letvak mentions "standardizing" (our favorite word) the staffing ratios, which in this context seems like a nice neutral-sounding way to say, "barring hospitals from staffing below set levels," as California has done--of course, as the battle in California showed, that will not be easy. The information about shorter shift lengths is also helpful, including the reference to Letvak's future research into the effects of such staffing measures on patient outcomes and the effective use of experienced nurses. And we like Letvak's closing comment, which not only includes a plea to recognize the importance of nurses' health, but also slips in the phrase "expert staff of qualified nurses." That almost sounds like a subtle recommendation that we "standardize" nurses' minimum educational requirements, and if nothing else, is a message to readers that nurses can be "expert."

We thank Chen and the Times for this generally very helpful piece.


See the article "Doctor and Patient: When It's the Nurse Who Needs Looking After" by Pauline Chen, posted July 5, 2012 on the New York Times site.