The Nurse in Me

As a pediatric nurse in California, my work focused on an important principle: patient safety.

Accomplishing this wasn’t just my priority, but the priority of the California Nurses Association (CNA). In 1999, the CNA embarked on landmark legislative reform with the introduction of Assembly Bill 394. This was the nation’s first mandated nurse-patient ratio legislation. When AB 394 passed, California became the first state to establish defined nurse-patient ratios for all hospitals.

In 2004, the “ratio law” was finally implemented, and required hospitals to maintain a minimum number of nurses in all units at all times, as well as additional nurses to be assigned based on patient acuity.

Governor Arnold Schwarzenegger tried to delay the implementation until 2008, citing “financial reasons”; however, the nurses fought back and won.

The premise behind this battle: specific guaranteed nurse staffing ratios would produce better patient outcomes, decrease mortality, alleviate nurse workload, and increase job satisfaction.

California remains the only state that stipulates a required minimum nurse-to-patient ratio. For 5 years, I was protected by nurses so fierce that they could beat the Terminator.

I became a doctor. Things changed.

As a senior resident, I was responsible for overseeing the general pediatric service in an inner-city hospital in Boston. A 24-hour period consisted of a census of 28 patients, plus 12 admits and 9 discharges. The sheer volume of patients and paperwork left my fellow residents and me stretched thin.

The nurse in me was unsettled. How could I possibly keep all those patients safe? Ensure every order was correct? Guarantee medications were dosed right and vital signs were reassuring? How could I dedicate time to actually caring for my patients, spending time at their bedside, teaching them, talking to them, listening to them? Doing everything I had valued as a nurse?

Throughout residency, the nurse in me screamed, “this is not safe; you are taking care of too many patients.” But the doctor in me carried on, hiding fears and following in the footsteps of everyone before me.

This experience led me to ask the question: How many patients are too many for one resident?

There is a rapidly growing body of literature that exists for nurses addressing this issue.

In March 2004, the Agency for Healthcare Research and Quality (AHRQ) released a report summarizing research on nurse staffing related to adverse patient outcomes.

The research showed significant associations between lower levels of nurse staffing and higher rates of pneumonia, gastrointestinal bleeding, shock/cardiac arrest, and urinary tract infections.

In 2011, a study released in the New England Journal of Medicine found staffing of nurses below “target levels” was associated with increased patient mortality.

In May 2013, the British Journal of Medicine published a study looking at re-hospitalization rates among children. The study found that “children with common conditions treated in hospitals in which nurses care for fewer patients each, are significantly less likely to experience readmission between 15 and 30 days after discharge.”

For the past 10 years, data have repeatedly shown that nurse-patient staffing ratios have a direct impact on morbidity, mortality, and re-admission.

What does the literature say for doctors?

There isn’t much.

One study in JAMA that was released in 2002 looked at outcomes related to physician staffing in the ICU. They found that high-intensity staffing led to better outcomes for patients.

Another study from Quality and Safety in Health Care reported that patients in ICUs with better staffing models were more likely to receive evidence-based care, including prophylaxis for deep vein thrombosis, spontaneous breathing trials, stress ulcer prevention, and insulin treatment.

The majority of studies looking at physician staffing models have been in intensive care units. There are none that look at resident workload related to patient outcomes.

Fatigue and sleep deprivation have historically been blamed for resident errors and patient safety issues. To address this, duty hours were created and implemented. In 2003, the Accreditation Council for Graduate Medical Education declared an 80-hour work week to be enforced, as well as a 24-hour limit on continuous duty.

Around the same time, a study came out in Quality and Safety in Health Care that looked at residents’ perceptions of errors. Residents reported job overload (too much work to do within time allotted) as a major reason for making errors. In fact, they found that “excessive workload, inadequate time and distractions” contributed more often to errors than inadequate knowledge or supervision.

A study published in 2008 in the Archives of Internal Medicine looked at residents’ perceptions before and after the implementation of duty hour limits. Despite duty hour restrictions, residents continued to identify carrying/admitting too many patients or cross-covering too many patients as major contributors to errors.

Don’t get me wrong. I am not saying that residents provide bad care. In fact, I believe residents provide great care. But I also believe residents are forced to work in a system that has a delicate breaking point and there are no data to suggest what that point is.

As a resident, can I safely take care of 10 patients? Twenty patients? Should I take what comes my way, not complain, and say a prayer that I don’t make any errors?

In September 2013, the Journal of Patient Safety released a new report stating that between 210,000 and 440,000 patients every year suffer some kind of preventable harm that contributes to their death.

If these numbers are to be believed, I don’t think the answer to patient safety issues is prayers.

To know the answer, we have to ask the question: Would changing the way we staff our hospitals improve patient outcomes?

The nurse in me says yes, but the physician in me says that until there is a randomized controlled trial, there will be no change in the attitude toward doctor-to-patient ratio regulation.