Changing how the world thinks about nursing

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Are your knuckles white?

Linda Aiken quoteMay 25, 2012 -- Today National Public Radio's Morning Edition ran a generally helpful 5-minute report by Patti Neighmond about widespread nurse understaffing in U.S. hospitals, as part of the radio network's "Sick in America" series. Following a poll showing that one third of U.S. hospital patients reported that nurses were "unavailable" when needed, NPR placed a "call out" on Facebook for nurses themselves to explain what was going on. Nurses responded with stories of being compelled to care for patients non-stop for their 12-hour shifts, with few or no breaks, and worrying that understaffing made it impossible to provide safe care. The Morning Edition piece consults University of Pennsylvania nursing scholar Linda Aiken, who argues that the U.S. now faces not so much a shortage of nurses as a shortage of nursing care at the bedside, which matters because nurses are the "surveillance system" in health care. And commendably, the piece explains, partly through an audio clip from a direct care nurse, how under-staffing can endanger patients, for example if a nurse is too busy to note subtle condition changes or respond to an alarm. An American Hospital Association representative stresses that hospitals today face financial constraints as well as sicker patients and a proliferation of care technologies. white knucklesBut NPR presents no advocate on the other side, like a union leader, to respond with the argument that it is conscious policy choices, not something totally beyond the control of hospitals or government, that result in nursing being severely underfunded. No direct care nurse featured on the segment is identified, because almost all who responded were "worried about retaliation" from employers. And sadly, it seems that whoever wrote the piece could not resist having Morning Edition host Renee Montaigne lead off with the inane cliché that nurses are the "backbone" of the health care system, which suggests that nurses are tough but unthinking pieces of hardware, like beds. Still, we appreciate the report's basic points that the current understaffing means nurses are working on the edge and that this can threaten patient health. We thank NPR and Patti Neighmond. 

Linda AikenMontaigne begins by asserting that "nurses are the backbone of hospitals; pretty much any patient or doctor will tell you that." Maybe they will, especially if influential media figures continue to repeat it as if it were some great compliment. We understand that the backbone is important, and the one good aspect of the metaphor is that it suggests nurses are strong and important; the hospital could not work without them. But the image also implies that, like the backbone, nurses have no brains or education. They just work hard, hang tough, go the extra mile, pick your own companion clichés. But what people need to know about nurses is that, like physicians but unlike bones, they are university-educated professionals who save lives. 

Montaigne says that a new poll by NPR, the Robert Wood Johnson Foundation, and the Harvard School of Public Health has found that "one-third of hospitalized patients say nurses weren't available when needed, or didn't respond quickly to requests for help." pull out quote 1Montaigne introduces NPR health reporter Patti Neighmond, who notes that nurses provide "most of the hands-on patient care," so NPR was "surprised" that its polls showed they were often unavailable. NPR put a call out on Facebook, and in response "hundreds" of nurses reported that "they get no breaks, no lunches, barely time for the bathroom." And even when these nurses do get a break, they're not relaxing, as the first audio quote from an "unidentified nurse" makes clear:

We're always afraid that something will happen to our patients during the time that we're off the floor. And I, personally, don't feel comfortable leaving my patients unless I know that a co-worker is actually looking after them during the time that I'm off the floor.

Neighmond says that nurse works in a busy urban emergency department, and "like nearly all we talked to, . . . didn't want her name used because she's worried about retaliation from her employer." The nurse told NPR that she "rarely stops - not for 12 hours," and that although one nurse for three patients would be ideal in her ER, she "typically" has five or more patients, "often eight, if she's covering for a colleague taking a lunch break." The nurse also gives a good example of the perils of understaffing:

There are times that I've been with a patient where I, literally, could not leave their bedside because maybe I was injecting a medication that you have to push slowly over five to 10 minutes so that it doesn't harm them. And I can see a call bell going off down the hallway, and there's no way I can go and respond to that.

Neighmond notes that the only option there is to yell for another nurse to help. Of course, this scenario would be a problem even if the nurse had only two patients, but a colleague is far more likely to be available to help if she has three patients, rather than five, or eight.

white knucklesThe report goes on to quote the "unidentified nurse" about how these shifts affect her:

There have been shifts where I've driven home at the end of 12 hours, and I'm gripping the steering wheel, and all I can think of is, what happened during my shift? Did I miss anything? I've run ragged; I didn't get a break; my knuckles are white. … I've thought, before, that the day that I come home and look back, and realize that I made a mistake because the demands exceeded any reasonable capacity on the part of a nurse, that's the day that I never want to be a nurse again.

The report offers no comment about whether we should be concerned about the nurses who are going through this, or whether anyone else is concerned, but maybe the audio clips are enough.

pull out quote 2And the report does go on to offer some helpful information about why understaffing happens and how it might affect patients. Neighmond observes that these stories make it sound like there is a shortage of nurses, but according to Linda Aiken, "a researcher and professor of nursing at the University of Pennsylvania," that is not the case now. Aiken notes that we "have a shortage of nursing care, but not a shortage of nurses." According to the report, Aiken says there was a shortage "about a decade ago," but "that's changed," and many new nursing graduates now can't find jobs. While the last part is correct, the U.S. shortage continued long after 2002. And the improved supply of U.S. nurses today has been driven to a large extent by the return of veteran nurses to the bedside in the recent recession. If entry into nursing remains at current levels, the U.S. is still predicted to be short 15% of needed nurses by the year 2030. And the global shortage of nurses remains a public health crisis that kills millions of people every year.

In any case, rather than asking a nursing advocate to explain why understaffing occurs, NPR consults only Nancy Foster, a vice president with the American Hospital Association. Foster reportedly says hospitals "are facing big financial challenges."

Foster:  In part, it's because our patients are sicker. They are coming to us with many more intense diseases and disorders than they would have 25 years ago. In part, that's because there are so many more medications and devices and other interventions at our fingertips, we can help many more people than we could have 25 years ago - and restore them to health.

Neighmond goes on report that Foster says nurses "aren't alone in feeling the crunch," but does not explain who else is feeling it. Are AHA executives also gripping the steering wheel white-knuckled on their way home every night, wondering if they killed anyone today?

NPRThe report does at least go back to Aiken for more on how nurse short-staffing affects patient outcomes. Aiken says (in the report's words) that "any reductions in nurse staffing, at a time of increasing patient demand, jeopardizes care," and in a direct quote, she states:  "Nurses are the surveillance system in hospitals for the early detection and intervention, to save a patient." Neighmond focuses on the not-enough-time-for-early-detection point, using another audio quote:

Unidentified nurse: You know, you might walk into a room, and they're breathing and they look OK and they answer your questions. But if you look at their neck and their jugular vein is just slightly distended, or you check their nail beds and they're a little bit dusky - you know, taking the time to pick up on the small details like that, those are the early warning signs that somebody is getting sicker fast.

Fantastic. That is exactly the kind of information the public needs about the importance of nursing skill to patient outcomes--and the nature of nursing as, in part, a critical exercise in preventing bad things from happening, perhaps not something most of us are conditioned to appreciate. Just as offensive players in team sports tend to get more attention than defensive ones, care givers associated with dramatic interventions tend to get more attention--and funding--than those associated with prevention. This might have been a good place to mention the growing body of research by Aiken and others in the last decade showing that lower nurse staffing means worse patient outcomes and a significantly increased risk of death.

pull out quote 3Instead, Neighmond returns to the poll, which showed that half of "Americans" hospitalized overnight in the past year were "very satisfied" with their care, a third were "somewhat satisfied," and 16 percent were "dissatisfied,"  "so it's not all bad news." But "with a rapidly aging population, the fear is that the nursing staff will be stretched even more thinly."  

So--we're not that concerned with the current situation, it just bears watching? Anyway, Neighmond says that the Facebook call-out was not scientific, so many nurses may disagree with "this overworked nurse," but the poll is "scientific," and "it does point to significant problems when it comes to the availability of nurses at the bedside."

There is very helpful information here, particularly about the effects of nurse understaffing on patients, and the distressing prevalence of the problem. The audio clips from the "unidentified nurses" are compelling. And the fact that the nurses must hide from their hospital employers' potential retaliation only makes their accounts more persuasive.

However, neither the ground-level reports of the direct care nurses nor Aiken's quotes about the effects of understaffing are adequate to counter the AHA's unchallenged account of what is causing it, with its implication that there really isn't much to be done. NPR should have consulted a strong advocate for better nurse staffing, and should have been more explicit that understaffing doesn't just happen because of changes in financial structures, demographics, and care technologies, but it is also the result of policy decisions, made by humans, who do not think that nursing is important enough to merit adequate reimbursement. When more patients and care technologies appear, more nurses are required, and decision-makers know how to find them, if they are willing and able to pay. Those policy decisions should be identified and questioned, at least through input from advocates, not merely alluded to with timid mainstream media phrases like "significant problems when it comes to the availability of nurses at the bedside."

Still, the report has some very good elements, and we thank Patti Neighmond and NPR.

Listen to and / or read the piece "Need A Nurse? You May Have To Wait" by Patti Neighmond. You can contact Patti Neighmond at Morning Edition through NPR's contact us form. If you do send her a letter, please send us a copy too, at Thank you!


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