A story in today’s Modern Healthcare (a magazine I just discovered through the good offices of Emily Friedman, who was one of my favorite teachers at BUSPH) (Also, registration required) reports that a significant minority of nurses have little confidence in the institutions where they work, and a remarkable 72% majority feel that the institution where they work understaffs for the work done.

As someone who is not a nurse, but works with a lot of them very regularly, I agree with this assessment on both counts. While it is not unusual for employees to feel they are overworked, nurses are asked to provide direct care to increasing numbers of increasingly ill patients, which requires not only making people comfortable and handing out their meds, but making accurate snap judgements on how they’re doing, whether they’re getting better or worse, how to intervene if things aren’t going well, and generally expected to be the patient’s first line of defense against the system (which we all know patient’s need defending against, ref. IOM report on medical error). Institutions don’t want there to be many nurses (because a good nurse is expensive), and so try to remove a lot of the “direct care” from nursing hands, leaving them with the more technical aspects of care. This ignores a huge part of what a nurse does, though; nurses spend a lot of time with patients in the course of changing the sheets, bathing and toileting, assisting with ambulation, and all of the “direct care” which can be done by others but ought to be done by nurses. Because it’s that time with the patient where the nurse learns the patient’s baseline, and can then judge departures from that baseline, and either intervene themselves, or call other providers to intervene if the problem is outside their scope of practice.

It’s like this: when I was learning physical diagnosis (how to examine people), one of my instructors pointed out the value of seeing as many “normal” things as possible. That way, when I saw something subtly abnormal, I would recognize it as abnormal and investigate, even if I didn’t know what exactly the abnormality was. Realizing that something “doesn’t look right” is a highly valued skill in medicine. Nurses are in a position to look at a patient and recognize, because they’ve spent a lot of time with the patient, that they “don’t look right”. They may not know exactly what is wrong (although usually they do, especially at the higher experience levels), but they know it’s something. The earlier that recognition takes place, the earlier something can be done, and a problem, error or complication avoided.

This is the problem which led the California Nurses Association to demand, and get, mandatory staffing levels in California hospitals. Hospitals moaned loudly, because nurse staffing has traditionally been a management prerogative, but since nursing management (like physician management) has been co-opted by general management (whose priority is profit, even in non-profit institutions), that prerogative has been abused in the service of improving the bottom line. Rather than pay for proper nursing, management would rather buy a new magnet (MRI machine), or outfit a catheterization lab for which they don’t have enough volume, in the hopes of increasing that volume, or do some other thing which increases their “business competitiveness” while decreasing their ability to perform the core function of a hospital, which is to care for the patient. CNA had little confidence that management would protect the core mission when confronted with the desire of physicians and managers (and, let us be honest, patients) for the latest and greatest technology. And my confidence is just as low.