Recently, my husband and I visited a friend in the ICU at one of New York City's premier teaching facilities. It was Nurses' Week, and the lobby displayed large posters of some of the hospital's smiling nurses. Upstairs, our friend introduced us to his unsmiling nurse, Dean. I asked Dean how many patients he was caring for during that shift. "I'm not allowed to tell you," he replied. "It's hospital policy." He later told me that he almost lost his job for violating the policy. "The hospital doesn't want patients and families to not be confident in the care they're receiving." "That's appalling," I said. "No, that's nursing," he replied.
A few days later, a nurse on a listserv wrote about having given her chief nurse officer (CNO) a copy of Aiken and colleagues' study published in the Journal of the American Medical Association (288[16]:1987-93) showing that with every surgical patient added to the average nurse's case-load above four patients, there's an increased risk of death among patients (and greater job dissatisfaction and burnout among nurses). The CNO dismissed the study by saying, "You can prove anything with statistics."
Perhaps Dean didn't know that Maurice Hinchey (D-NY) reintroduced to the House of Representatives the Patient Safety Act of 2004 (HR 4374), a bill that would require hospitals receiving Medicare funds to make public their nurse staffing ratios and patient outcomes. And perhaps the CNO at the listserv nurse's institution is facing serious financial challenges, and the chief executive officer dismisses the mere idea of adding staff. Perhaps they don't know about the research by McCue and colleagues published in the Journal of Health Care Finance (29[4]: 54-76). The analysis of data culled from 422 hospitals in 11 states between 1990 and1995 showed that for every RN added to a hospital's staff, operating costs increased by 0.25%-but there was no decrease in profits. Furthermore, for every non-RN added, operating costs increased by 0.18%, but profits decreased by 0.21%.
I responded to the nurse on the listserv, recommending that she send copies, anonymously, of Aiken and colleagues' and McCue and colleagues' studies to her hospital's board of trustees. My suggestion shocked a colleague of mine, but I argued that trustees have a responsibility to align their institutions' best interests with those of patients. Yet I know from personal experience that many hospital trustees have little or no knowledge of the data linking nurse staffing with improved patient outcomes and finances. Perhaps it's a drastic strategy, but as Connie Barden, former president of the American Association of Critical-Care Nurses, said, "It's immoral not to act."
I'm tired of nurses who aren't at the bedside and yet who oppose whistleblower-protection laws, bans on mandatory overtime, minimum nurse-patient staffing ratios, or public disclosure of these ratios. If you're a staff nurse and oppose these things, you're probably working in a fine institution. But too many nurses aren't. Schools of nursing are reporting dramatic increases in applicants, but how can we keep attracting good people if we don't fix the work environment?
The excellent work environments I know of have good nurse staffing and executive administrators who understand that nursing is every bit as important as medicine to the aims and missions of the institutions. But such institutions are outnumbered by facilities that see nurses as expendable rather than essential.
I recently met with a new nurse five months after she assumed her first hospital position. She said that after six weeks of orientation she was told to carry a full patient load. She was put on night shift with 10 or more acutely ill patients in her care. When she went home with the keys to the medication cart, she received an angry phone call from the nurse manager, telling her to return them immediately if she wanted to keep her job. What nurse hasn't walked off with the keys? Why a scolding threat? The nurse says that she and her fellow new nurses feel physically ill before their shifts. "I can't do this," she said to me.
What should I tell her? "That's nursing"?