Holding On / D’Arcy Norman, via Flickr
Amanda Anderson, BSN, RN, CCRN, works in critical care in New York City and is enrolled in the Hunter-Bellevue School of Nursing/Baruch College of Public Affairs dual master’s degree program in nursing administration and public administration.
There are two news stories I’ve been chewing on lately. One made it to the front page of my New York Times almost every day for a while, and the other I saw just once in the paper’s international news section several weeks ago.
The blockbuster story involves a single company that covered up a problem with an important part in one of its products. Ten years passed and a number of people died before they finally informed the public about the problem. The products with the flawed part have now been recalled, and the company is embroiled in an investigation and likely to face lawsuits and massive fines.
The far less publicized story is about a growing body of research exposing a problem that results in similar levels of harm. Unlike in the first story, the crucial ‘part’ that affects the product’s safety is human labor—and the detrimental effect of mismanagement of this labor is likewise injury or death. The link between the product flaw and its effects is well established, but there has been no public outcry, product recall, or lawsuit. The story barely made it past the gates of major media, and although the evidence linking this problem to dire results is strong, few industry players are acting on it.
You’ve probably guessed that the first story is the tale of General Motors and their fishy dealings related to the flawed starters in the Chevy Cobalt and a number of other Pontiac and Saturn models. Some are linking the ignition problem found in these models to a death toll in the hundreds. This glitch went unfixed for over 10 years. GM has recalled all the affected car models, and despite some efforts to do damage control, they’ve taken a big hit in the media and market.
To be sure, the GM story is a tragedy deserving of front page news. But the second story—as seen in a New York Times article written about findings from a study by Linda Aiken that was published in the Lancet this February, should be right beside it. Aiken’s study showed an association between increased hospital complications and mortality and lower nurse education and staffing levels in nine European countries. Drawing on discharge data from hospital med–surg units as well as from a survey of nurses, the study found that patients in hospitals where 60% of nurses had bachelor’s degrees and each cared for an average of six patients were likely to have an almost a 30% lower chance of dying than were patients in hospitals where 30% of nurses had bachelor’s degrees and each nurse cared for an average of eight patients. Or, since it may be clearer if we look at the effects of nurse staffing levels and nurse education levels independently of each other, the study abstract puts it this way:
An increase in a nurses’ workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031—1·106), and every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886—0·973).
At the risk of oversimplifying the findings, the data appear to be saying that when you’re short-staffed, your patients suffer, and when you have more nursing education, they benefit. While we can’t recall the product—in this case, health care—once it’s been delivered, there’s definitely been insufficient attention to this most crucial aspect of its delivery—nurse staffing.
I’d be hard-pressed to find a nurse who didn’t agree with this study’s findings or couldn’t back it up with their own clinical experience. And this isn’t the first important study by Aiken to reveal an association between nurse staffing levels and hospital outcomes.
A number of nursing organizations have advocated for better nurse staffing levels; many position papers have addressed the issue. But the general public remains mostly unaware of this information. The middle-of-the-paper coverage of Aiken’s Lancet study, along with a greater emphasis on nurse education levels than on nurse staffing levels in the coverage of the study’s findings, could lead the reader new to the issue to form an incomplete idea of this important and pervasive problem.
GM was tried in the halls of the Internet—why not the hospitals now expecting higher education levels but offering no solution to inadequate nurse staffing? The failure starts with media coverage, but what about the lack of data reporting? Have you ever tried Googling “How many patients will my mother’s nurse be assigned to care for at Such-and-Such Hospital” when you were searching for a place to send her for knee surgery? Zero results—despite the fact that the nurses will see her far more often than the physicians.
Hospital Compare—the Medicare.gov site that reports on questions like “How often did nurses listen to you?”—makes no mention of how many patients those nurses might have had. Although transparency laws to tear down the murky data shroud that hospitals hide behind are on the table, public awareness campaigns remain muted. The public doesn’t realize they’re speeding down the health highway in a car with faulty ignition.
It’s true, I often hear about rallies and ads for safe staffing, but many of these seem to focus on the nurse’s experience. Yes, totally, working short-staffed is dangerous and diminishing—and can be harmful to the nurse. AJN published a February news piece about a lawsuit claiming that understaffing and long shifts experienced by a nurse caused her to have a fatal car crash while driving home from work. Short-staffing throws the shift off-kilter from the very start, and the care you want to give is replaced by the care that is humanly possible.
But Aiken’s study again raises the issue that should matter to everyone: Unsafe staffing kills. Maybe, given the complexity of the care process, each death can’t be directly linked back to staffing ratios (as they perhaps can be to GM’s faulty ignition switches). But the connection is strong, and these deaths are the fault of the system, not the nurse. Our patients deserve better.
More education, improved clinical reasoning and critical thinking patterns. the research is there, we have to respect and believe it. this is important stuff!
I find that ADN nurses are older, more mature, and often more motivated than young BSN’s. The ADN does the same number of clinical hours, and passes the same boards as a BSN or CNL student. the research above is simply flawed.
Better staffing is better for everyone no matter what your degree. Taking care of patients is serious business and doing it right can eliminate sentinel events which cost hospitals money. Happy nurses who continue their education also get better outcomes.
It all comes back to one thing: nursing. Better nursing staffing is good for all.
I personally think 6 patients are too many.
I would like to respond about the survey done with BSN and 6 patients and ADN with 8 patients and the difference posted of how there was less chance of dying if you were taken care of by a nurse with BSN. First of all, the ratio should be taken into account. 6 patients might be easier to take care of rather than 8. It depends on the acuity. I know there is a push to get ADN’s to get their BSN. I don’t agree that one gets better care from a BSN.