Nurse short-staffing on the roads of Long Island
January 29, 2006 -- Recently the New York press has run good articles about the critical shortage of Suffolk County public health nurses. Today Newsday ran a piece by Ridgely Ochs, "Debate on public health services," that explained some of the effects of this situation on needy patients and the overwhelmed nurses. It also included comments from local politicians and health care figures as to how the problem should be addressed. This followed a very good and more comprehensive January 22 story in The New York Times, Julia C. Mead's "On the East End, A Nursing Shortage Is Felt Most Deeply." The Times piece powerfully conveyed both the key role the public health nurses play in patient outcomes and the desperate state of the program, following what some describe as years of neglect by the County government. Both pieces suggest that the nurses get lots of verbal support, but that they have not received the resources and real respect they need to do their jobs, even though their work is cost-effective in the long run. We commend those responsible for these two helpful pieces.
Both pieces start with brief descriptions of patients the public health nurses have helped. In the Newsday piece, a teenage Central Islip mother tells how a public health nurse helped her learn to care for her baby and access helpful public programs. And the Times piece starts with quick portraits of three "grateful clients" of Suffolk public health nurses: a mother with six disabled kids, a double amputee with multiple chronic health problems, and a former cocaine addict who managed to get off the drug through outpatient treatment when her daughter was a newborn. However, the piece notes, advocates for the nurses could not point the reporter to such patients for the East End of the county, because the "severe and longstanding staff shortage" there has meant reduced services and even the routine refusal of patient referrals. The pieces explain that the county's public health nurses serve mainly lower-income, home-bound patients who need regular monitoring and help. They deal with critical maternal-child health issues (including abuse and neglect) and diseases like AIDS, TB, and diabetes, and they care for the disabled and the elderly. Both pieces quote Laurel Breen, a public health nursing professor at St. Joseph's College. She decries the short-staffing and (in the Times) says the nurses have been "watching a very slow dismantling of the program, and their morale has never been lower." In that piece Breen also notes that since 1998, she has seen only one of her students take a county job.
Both pieces also include helpful quotes from nurses and health officials that underline the nurses' value to patients. Former deputy health commissioner Elizabeth Harrington appears in both stories. In the Times she describes the "vital service" of the nurses. She notes that the private agencies some counties use don't deal with bad neighborhoods, child abuse, AIDS or high-risk pregancies, and that the Suffolk nurses helped to cut the county's black infant mortality rate and to get 85% of its drug-addicted pregnant women into treatment, compared to 10% nationally. In Newsday, Margaret Comerford Freda, editor of the American Journal of Maternal Child Nursing, points to similar data about the county nurses, and the piece stresses the "irony" that the Suffolk nurses are very highly regarded outside the county. Data aside, the Newsday piece actually ends with comments by Harrington, a lawyer, about the time she accompanied one of the nurses to the roach-infested home of an elderly woman and was astonished at the "dignity" with which the nurse treated the patient. Each piece also relies on a pediatric nurse practitioner. The Times piece quotes NP Harriet Hellman, who often refers patients to the nurses, on the nurses' value to disadvantaged patients, like an infant patient of hers who just tested positive for cocaine. But Hellman says that the nurses can't really help such patients if there's "inadequate staffing." In the Newsday piece, NP Lisa Clark notes that many do not understand that the public health nurses have prevented many hospitalizations. The piece also has retired Family Court judge Nicolette Pach echoing the cost-effective point, pointing out that the nurses' focus on prevention saves a lot of money in the long run. The piece might have explored that in more detail, perhaps with an anecdote or two about what can happen to a homebound patient who has no access to the nurses.
The Times quotes a Suffolk county nurse (unnamed because she feared repercussions) as saying that staffing had never been lower, that her office had to turn down new referrals every month, and that one of the four nurses there had a caseload of 77 patients. She said that long drives between patients took a lot of time, and so the nurses had to spend evenings and weekends on paperwork, noting: "They're just overwhelmed, and feel they've never really finished their work." The result: "If they get the opporunity to leave, they leave....And as quick as the county can hire new nurses, others are leaving." Confirming this, the piece quotes retired nurse Anne Kellett as saying that few people apply for open positions (Suffolk reportedly now has 10 unfilled openings for public health nurses), and that there is high turnover. Kellett also links the turnover to the "comparatively low pay," which for 2006 is about $50,000, about $20,000 less than the typical starting pay for nurses on the Island, which has a fairly high cost of living. Newsday quotes Kellett as saying that the nurses are "so stretched I don't know why they're not sick." In fact, as Suzanne Gordon's Nursing Against the Odds explained, severely short-staffed nurses do tend to suffer significant physical and mental health problems. Neither piece explores this issue in depth.
The pieces also give a sense of the political drama of the current situation, including quotes from many of the same players. Obviously, Suffolk health commissioner Dr. Brian Harper is taking some heat for the plight of the public health nurses and their patients. The Times reports that Harper was "peppered" with questions about the nurse vacancies at a recent county health committee meeting. Newsday quotes Harrington, who reportedly resigned as his deputy commissioner in October, saying that the nurses are "not a priority for this commissioner." Ouch. The pieces have Republican county legislator Edward Romaine "fuming" (Newsday) and "expressing frustration" (the Times) about the state of the program, especially the unfilled positions. Both pieces have Democrat Vivian Viloria-Fisher voicing similar dissatisfaction. The Times quotes her as wondering why the nursing positions are left open when police positions are not.
The pieces include some responses from Harper. In Newsday, he points to an ongoing study that will assess how the nurses are deployed, and gives assurances that his department will come up with a "plan," but that it is "not looking to do away with public nursing." The Times piece suggests that Harper does not disagree that the public health nursing unit is "in dire straits," though it also has him suggesting that there is "a need to evaluate the management" of the unit, which presumably means someone other than him; the piece might have pursued who that is. Harper points to an October proposal by his office that the nurses' salaries be increased, and says that his staff is also looking for ways to free the nurses to spend more time in the field, perhaps by "adding clerks to help with paperwork."
Both pieces suggest that those with decision-making responsibility say nice things about the public health nurses, but do not seem to value them enough to allocate scarce resources to the program. Newsday quotes Suffolk's principal financial analyst Connie Corso as noting that some counties (like nearby Nassau) have been eliminating their public health nurses, relying instead on "home health agencies, which can cost less money." Corso also notes that the Suffolk nurses' program operates at a $1-2 million annual deficit, even accounting for revenues and aid reimbursement. It seems unlikely that these figures include all the money the nurses save through preventing costly hospital admissions and other adverse events. Indeed, studies of programs like the Nurse-Family Partnership have shown that public health nurses can pay for themselves several times over when their full effects are examined over the long term. In the hospital setting, recent research by Peter Buerhaus and others has demonstrated that higher nurse staffing can pay for itself because of the improvement in patient outcomes. The pieces might have benefited from more analysis of these issues, though as noted above, both do include helpful general quotes as to the nurses' cost-effectiveness.
On the whole, both the Times and Newsday pieces give readers a good sense of the value of public health nurses and the desperate straits in which many of the nurses--and their patients--now find themselves. We thank those responsible.