In recent posts, we’ve articulated why Partners feels Question 1, mandating nurse staffing ratios, would threaten patient care quality. As election day nears, Newton-Wellesley Hospital Chief of Hospitalist Service Steven Pestka, MD, has penned an opinion piece highlighting his own concerns with the proposed mandate—concerns informed by his vantage as a practicing physician for more than 13 years. He explains why the term “safe patient limits,” espoused by the Question’s supporters, oversimplifies the complex realities of patient care. Below is his article in its entirety, exploring the harmful impacts of nursing mandates.
I have been a practicing physician for over 13 years. I have listened to the debate over mandated nursing staffing ratios and am struck by the focus on “safe patient limits,” a loaded phrase which itself impedes the ability to have a balanced public discussion.
The issue is complicated. Yet, I continually hear from people who want to support “safe patient limits,” then look no further than that one catchphrase to decide their vote. This is reminiscent of the phrase “support our troops” - we all support the brave men and women who defend our freedom, but that does not necessarily mean we would vote to increase the Pentagon budget or declare war. It is for this reason that I am sharing my perspective.
Patient safety is a complicated issue involving many factors. Nurse-to-patient ratios is only one of them. Other factors include: a safe work environment, effective communication between nurses and doctors, the education level of nurses, nursing experience, nursing work schedules, hand-hygiene, and many others.
"If improving patient outcomes is the goal, then I am perplexed as to why there is a proposed mandate focusing on only one factor."
Consider a patient who is admitted to a hospital for pneumonia and a few hours later, develops more shortness of breath, which is noted by a nurse. The nurse communicates this finding to the physician, who requests that the nurse check the patient’s breathing again in two hours. If, for whatever reason, the nurse doesn’t recheck the patient’s breathing in two hours, and the patient ends up on a ventilator due to this delay, one could conclude that this was the result of unsafe staffing levels and could have been avoided with more nurses. Such a conclusion would be short-sighted and potentially dangerous.
The reality is that many factors may have contributed to this hypothetical outcome: communication between the nurse and physician may have been ineffective, the nurse may not have used an effective system to remember this important task, or the physician may have had a knowledge deficit related to this clinical situation. Through hospital safety reporting mechanisms and a detailed review of the case, the factor or factors that contributed to this undesirable outcome would be identified and changes would be implemented to reduce the likelihood of a similar outcome in the future.
If, for example, it was determined that this nurse did not use a systematic method to remind him/her of important tasks, the hospital could support all nurses in their work by standardizing the system used to track their highest priority clinical follow-up items. By suggesting that mandated nurse-to-patient staffing ratios are the sole answer to such situations represents a narrow approach which neglects to acknowledge other improvements which can have an even more profound impact on patient safety.
The debate over Question 1 includes commentary about cost. While different opinions about cost have been voiced, it is clear from the Massachusetts Health Policy Commission, an independent state agency, that the cost would be considerable. A basic understanding of health care reimbursement makes it immediately clear that some hospitals would face difficult decisions about how to fund the extra nurses that would be required. Sadly, the reality is that behavioral health and substance use disorder clinics - vital community services, would be vulnerable.
"The tragedy that would result from diminishing those critical services would be a blow to patient safety – one of several unintended, but foreseeable, consequences of Question 1."
Aside from an uncertain improvement to patient safety, inflexible nurse staffing ratios just don’t make sense to me. One example of why, is how things change from the day as compared to the night in hospitals. During the day, a hospital is a busy place. Doctors examine and discuss care plans with patients; nurses administer medications and educate patients; case managers and social workers meet with patients and family members; new patients are admitted to the hospital; diagnostic tests, procedures and surgeries are performed. Additionally, patients are discharged during the day, a process which takes a lot of time for physicians, nurses, physician assistants, case managers, and many others.
Not surprisingly, it quiets down at night. Visiting hours end, people are not discharged, and patients try to get some sleep. Certainly a patient can become sick at night, but in general the overnight period is a much less intense time and requires fewer resources. I would rather not see precious health care dollars directed to increase resources for sleeping patients.
Similarly, when a patient becomes ill (or more “acute”), there may be a need to reduce the number of patients that a nurse is caring for. I believe that these decisions should be left to the nurses in charge, giving them flexibility in the moment to make decisions in the best interest of their patients. A rigid, one-size-fits-all mandate is not consistent with what our patients need and deserve. This all comes down to the patient – we need to remember that each patient deserves individualized, compassionate, and thoughtful care at every level – giving those nurses in charge, at the local level, the ability to use their experience and judgement to make sure a patient has the attention they need just makes sense.
We need to be careful with sound bites like “safe patient limits.” Clearly the story is more complex. I support safe patient limits, but I am voting no on Question 1 as we are not doing our best to promote safety when a blunt legal mandate is applied. I am privileged to work with dedicated, professional, highly-skilled nurses, whose contributions to the lives of our patients cannot be overstated. Regardless of what Massachusetts decides on Question 1, I will continue to work with pride alongside my nursing colleagues.
Steven Pestka, MD
Chief, Hospitalist Service
This editorial originally appeared in the Sudbury Patch.