Worked to death
Reports on the financial pressures that threaten nursing
November 13, 2013 -- Recent news reports have highlighted the financial pressures that can affect nurses' practice settings, threatening patients and nurses themselves. On September 6, 2013, NBC television affiliates reported that Nashville's Vanderbilt University Medical Center had decided to give registered nurses responsibility for cleaning patients' rooms. Kimberly Curth's article indicated that hospital management had defended the shift as consistent with the history of nursing practice, which has focused on a hygienic care environment and a holistic approach to infection control. However, it was pretty clear that this change was driven by budget constraints, not a concern for patients or nursing tradition. There was no indication that nurses' patient loads would be reduced to accommodate this extra work, nor that nursing education was required to mop floors or clean bathrooms. The report noted that at least one nurse was concerned about cross contamination. One bright spot, maybe, was that at least some of the media evidently thought nurses cleaning patient rooms was news, as if nurses don't already do that and might be busy doing something else for patients. Today, CNN's Dominique Debucquoy-Dodley reported that a man had filed a wrongful death lawsuit against Cincinnati's Jewish Hospital after his wife, a nurse there, had died in a car crash on her way home from work. According to the piece, the suit alleges that overwork contributed to the nurse's death. In fact, it alleges that the nurse's own supervisor had previously warned that she was being "worked to death." The suit says the nurse had often worked extra hours in a "regularly understaffed" unit. And the report includes comment from a representative of National Nurses United, who argues that understaffing is a major issue for U.S. direct care nurses and that it impairs patient health. The article might have noted that research confirms the deadly effects of understaffing. In any case, both pieces suggest that nurse understaffing remains a critical problem in U.S. hospitals.
Our new reality
The Vanderbilt piece is pretty clearly intended as an exposé. It's the work of the Nashville NBC affiliate WSMV's "I-Team" (presumably meaning "investigative team") and the print headline is "Vanderbilt Medical Center to have nurses cleaning up." The report makes clear right up front that the hospital's decision to put some nurses "in charge of cleaning patients' rooms, even bathrooms," is the result of its "latest budget moves."
The piece seems to have based its account of the change mainly on a hospital email and video it obtained from one or more anonymous staff. Both items are revealing. In the email, an unnamed hospital manager notes that "we have undergone some major budgetary changes ... this means we will need to pull together like never before." Specifically, that seems to mean that nurses will now have to (in the piece's words) "pull their own trash and linens, sweep up and spot mop." The email advises: "Be sure to wear the appropriate [personal protective equipment] when doing any disinfecting - that includes, a cover up gown, gloves, mask and even an eye shield when necessary." That sounds serious, but the email also says: "The priority will be what the patient sees." Another element of the email that seems to focus on appearance advises nurses to "refrain from speaking negatively about this in an open forum where our customer can hear. If you need to vent come see me." Evidently the email did note that the hospital's environmental services department, which previously did all of the cleaning, would still do some of it.
The TV station also got a video from an anonymous "hospital employee" who may or may not be the same person as the nurse the piece consults.
It is clear that everyone who gave the station information needed anonymity. The video has more candid commentary from a hospital administrator:
Cleaning the room after the case, including pulling your trash and mopping the floor, are all infection-prevention strategies. And it's all nursing, and it's all surgical tech. You may not believe that, but even Florence Nightingale knew that was true. ... This is our new reality. The work still must be done. We must still care for patients, and we must do so in an efficient manner.
In a similar vein, the report quotes a statement by ... Vanderbilt Assistant Vice Chancellor of Communications John Howser, presumably in response to a request for comment from the TV station:
The safety of our patients is always of foremost concern. All decisions about operational process redesign at the Medical Center are being made in a patient-centric manner and will not affect the safety of patient care.
Of course, as the report correctly notes, "sanitized environments in hospitals are critical to a patient's health." However, the piece says, an anonymous nurse "is concerned that doing both cleaning and patient care could lead to cross contamination." She notes that the environmental services staff that used to do all of this cleaning had no contact with patients. The piece closes with a little more context. It notes that the Tennessee Department of Health does not have specific requirements for cleaning methods, as long as staff are trained and follow guidelines of the Centers for Disease Control. And although the piece does not include any reaction from Vanderbilt nursing school faculty, it does say that an executive associate dean of nursing at Nashville's Lipscomb University, "who has been a nurse for 25 years, says she hasn't heard of a hospital doing this before."
Infection control is critical to patient care, and nurses have traditionally taken a broad, holistic approach to improving and preserving health. They should be concerned about and involved in practices to prevent infection. However, as the piece makes clear, this hospital decision was not driven by health concerns, but budget issues. And the anonymous nurse's concerns about cross-contamination seem reasonable not just because nurses are likely to encounter dangerous agents from multiple patients, but also to the extent that short-staffing means they are working under time pressure, which could encourage them to skip the very precautions that would otherwise guard against the spread of infection. Of course, time will be even shorter if nurses are given additional cleaning responsibilities on top of their current duties.
There may actually be good reasons for nurses to do some things that outsiders might see as tasks not requiring advanced training. For example, changing bedpans allows nurses to perform critical assessments that less-trained personnel could not do.
But we see nothing in the hospital's statements to suggest that nurses will be doing these cleaning tasks because their special knowledge and skills are needed. The statement of the Vanderbilt assistant vice chancellor seems especially disengaged from the reality of this "environmental process redesign." The hospital's statement that the cleaning work "is nursing" is at least making an argument, but that general statement means little if the practical result is that nurses will be forced to choose between endangering their "customers" by sacrificing infection control or some other vital aspect of patient care. Maybe it's too obvious even to point out, but cleaning up a hospital room can be time-consuming, especially to the extent there is a need for infection control precautions. And even if the nurses could do it all, the potential for burnout would seem to increase if they were expected to do a lot more work in the same time. That may be the "new reality" because of cost-cutting, but it does not mean it's good for nurses or "patient safety." And the news story does a surprisingly good job of bringing that out.
Of course, the piece would have benefited from more detail. For instance, it might have explored the current staffing situation at the hospital and discussed the well-documented risks to patients of piling more tasks on direct care nurses--even apart from infections resulting from doing basic cleaning tasks. On the whole, though, it's a helpful investigative report.
According to the CNN piece, a recently filed wrongful death lawsuit alleges that an Ohio nurse who died in a car accident while driving home after a 12-hour shift was "worked to death." The suit filed by Jim Jasper reportedly says that his wife, Beth Jasper, was a nurse at a unit of Cincinnati's Jewish Hospital that had been "regularly understaffed" since 2011. That allegedly meant working through breaks, additional shifts, and in Jasper's case, being "routinely called into work while off duty because she was one of the few nurses qualified to work the unit's dialysis machines." The suit says that during Jasper's last shift, she told other nurses that she was "really stressed" and "hadn't eaten." The CNN report quotes Jim Jasper's attorney, Eric Deters, as saying that Beth Jasper may have fallen asleep before her car veered off the road and struck a tree in March 2013. She and her husband had two children.
The lawsuit reportedly alleges that the hospital's management and parent company, Mercy Health Group, had been made aware of the staffing problems. In fact, it asserts that Jasper's supervisor told her own superiors that she feared Jasper was being "worked to death." Jasper's husband told CNN affiliate WCPO that "they can't continue to work these nurses and expect them to pick up the slack because they don't want to staff the hospitals." The attorney Deters said that the hospital "clearly did not take care of its own people, and it did so deliberately." A hospital spokeswoman "expressed sympathy for the family, but declined to comment on pending litigation."
The piece provides context through commentary from National Nurses United (NNU), "the nation's largest union representing registered nurses, with nearly 185,000 members throughout the country." The report notes that NNU has supported legislation to improve staffing nationwide. The union's government relations director Bonnie Castillo is quoted:
Chronic understaffing is rampant throughout hospitals around the country. It is probably the single biggest issue facing nurses nowadays, and it's not only affecting nurses, but patient health as well.
Castillo notes that "safe staffing ratios" of nurses to patients are still "largely unregulated in the United States," with California the only state so far to mandate minimum staffing ratios. (More recently Massachusetts has established minimum ratios for ICUs.) The piece notes that the California law, in effect since 2004, requires that nurses on general medical and surgical floors have no more than five patients and ICU nurses no more than two.
The piece does a good job of laying out the basic problems. In fact, it's a little unbalanced in favor of mandatory minimum staffing ratios, with no real indication of what opponents argue or explanation of why hospitals may not have adequate nurse staffing. Cost pressures generally drive those decisions. Those who oppose mandatory minimum ratios typically argue that they are inflexible and threaten to undermine hospitals' ability to provide care, concerns that do not seem to have been borne out in California. In addition, research shows that if California minimum ratios were in in effect in New Jersey, that state could reduce deaths by 14%. Still, the reporter might have consulted someone who represents hospitals for comment. On the other hand, the piece might also have mentioned the research showing that worse nurse staffing means worse patient outcomes, including higher mortality rates, and that better nurse staffing does not necessarily cost much more (or any more) because it means better outcomes, including lower rates of preventable complications--like infections.
Together, these two press reports illustrate different facets of the problem facing many nurses today: there is too much work and not enough time. Of course, that reflects the money that the hospitals, health care financing sources, and in a broader sense all members of society are willing to allocate to nursing care. How much is nursing worth?
See Kimberly Curth's "Vanderbilt Medical Center to have nurses cleaning up," posted on the WSMV website on September 6, 2013.
See the article "Lawsuit: Ohio nurse was 'worked to death,'" by Dominique Debucquoy-Dodley, posted on the CNN website on November 13, 2013.