How many patients can a nurse reasonably care for at one time? This is perhaps the biggest issue facing the nursing profession right now. In fact, there are two bills in Congress right now that seek to decide just this, not only to protect patients but also the nurses who care for them.
California is the only state in the United States that regulates the number of patients a nurse can have under his or her care. The safe staffing law was passed there in 1999 (more than 15 years ago!) and it went into effect in 2004. The law breaks down the maximum number of patients for a nurse by acuity and type of care.
But in 49 other states and in the District of Columbia, there is no mandated limit to the number of patients a nurse can safely or reasonably be expected to care for.
What does this mean? This means on busy days in an emergency department, nurses may be caring for 4-6 acutely ill patients, some of whom need to be transferred to the intensive care unit, to a telemetry unit, or to the OR. This means a psychiatric nurse could be expected to care for more than 10 patients at a time, or that on a low-staffed unit at night, a med-surg nurse may be caring for up to eight or more patients.
A nurse’s name on a patient’s chart confers ultimate responsibility for that patient’s safety and well-being. The expectation is that the nurse will prevent a patient from harm and will keep a patient safe. It is the nurse who will discover a medication error before it gets to the patient (whether it be an error on the part of a resident or the doctor or the pharmacist); she or he will keep a patient from falling should they try to get up out of bed unassisted, and he or she will medicate, assess, chart, document, comfort, and care. But what happens when that nurse is stretched so thin there is no possible way for her to ensure a patient’s safety? The patient is at risk, and so is the nurse’s license. How can she be everywhere at once when she is caring for five or even six patients at a time?
Unfortunately, this is an issue that is unlikely to be resolved in the near future, despite the two bills currently before Congress. Over the next decade, the number of aging baby-boomers continues to increase while the number of new nurses entering the workforce decreases (not to mention those nurses leaving the profession altogether as a result of burnout and fatigue). Administrators still incorrectly fear the cost ramifications of nursing mandates. Specifically, the bill would require hospitals to write a staffing plan, and “allows a nurse to object to, or refuse to participate in, any assignment if it would violate minimum ratios or if the nurse is not prepared by education or experience to fulfill the assignment without compromising the safety of a patient or jeopardizing the nurse’s license.” Importantly, the bill also carries an anti-retaliation clause. The bills are a start, but are not a panacea by any means. And, they have yet to pass.
Earlier this week, a report released by Johns Hopkins purports that medical errors are the third leading cause of death in the United States each year. The high number of deaths relating to errors point not to bad doctors or to mistakes, but more to systemic problems, a lack of standardization, a lack of reporting and data collection about mistakes, and issues with medical staff turnover, burnout, and fatigue. Many people are quick to point out the myriad studies correlating positive patient outcomes and higher levels of nurse staffing, as well as the decrease patient lengths-of-stay.
It’s not that data don’t exist, as hundreds of studies demonstrate the positive relationship between patient safety and nurse staffing. Moreover, studies also show that increasing nursing staff does not contribute to higher hospital costs. A longitudinal study by the Agency for Healthcare Research and Quality concluded that it actually decreased costs over time, including a decreased patient length-of-stay. Additionally, increased nurse staffing has been shown to decrease patient mortality, increase patient satisfaction, and decrease nursing turnover and job dissatisfaction.
Safe staffing is an issue that is not likely to fade, and many nurses are eagerly tracking the legislation before Congress. A rally to demonstrate support of safe staffing is planned in Washington, DC, for May 12th. More information can be found here.
In April, the MedStar Health system of 10 hospitals and hundreds of physician-affiliated offices around the Maryland and Washington, D.C., area became the latest hospital system targeted by ransomware. Ransomware is a type of virus or malware that blocks access to a computer system until a payment is rendered. The hospital system was reportedly without access to its electronic medical record (EMR) system for days, including restricted access to e-mails, imaging software, and scheduling systems. Many physicians had no access to patient medical records or labs and test results, and most locations resorted to a system of paper charting.
Clearly, losing access to the EMR is debilitating. “Think about it—we couldn’t even print patient armbands,” said a MedStar employee who agreed to discuss the situation with me on the basis of anonymity. “It was a systematic breakdown both for patients and staff, with safety at the forefront,” he said.
Another MedStar nurse told me about the drastically increased wait times in the ER and numerous patient safety issues. “I had a patient who was possibly having a heart attack, but it took hours to get labs results, and I had no way to compare the EKG [electrocardiogram] to any previous EKGs to look for changes,” she said. “The other problem was that [MedStar] kept telling people we were under ‘normal operations,’ so people walked through the door expecting a functioning department.”
Many nurses are inexperienced with paper charting because EMRs have been in use longer than their tenure. “We were boarding patients, no one knew how to paper chart, and the lab was backed up more than six hours for a stat result,” said one nurse.
MedStar is not the first hospital system to be affected by malware: In February, a hospital in California paid $17,000 in bitcoin ransom. Is this the start of a frightening new trend? Hospitals seem like a perfect target because regaining EMR access is time-critical. Systems are very likely to pay up, and quickly, in order to access the hostage information. Patient safety is on the line.
Every hospital employee is familiar with the importance of patient privacy and protected health information because of the HIPAA privacy rule. However, at many hospitals, nurses do not even log into shared workstations—they are all unlocked—and passwords often have lax requirements. In hospital orientation, the focus is on patient privacy, not network security.
What can you do as a nurse to make sure you aren’t contributing to a possible security threat?
1. Be a “discriminating clicker.”
If something seems fishy on your computer, do not click it. Be wary of e-mail attachments specifically, and utilize the “hover-over” feature many programs and browsers use to help verify the legitimacy of the sender or link. Never click a suspicious link, even if it appears to be sent from a friend.
2. Call the help desk if anything strange pops up on your screen.
If a pop-up asks for you to provide log in credentials to a workstation you are already using, be suspicious. Third, immediately report any e-mails you receive from unknown senders. Forward a questionable e-mail to the help desk only if requested, because doing so can help the virus “spread.” Some web sites are able to create a pop-up that asks you to call a certain phone number; do not call these numbers and report this to a help desk.
3. Do not attempt to fix a suspicious problem yourself.
In some cases, turning off a machine altogether can exacerbate a problem or even eliminate potential forensic evidence that could be helpful to law enforcement. When in doubt, check it out with the help desk.
The recent ransomware attack on the D.C. hospital system is unlikely to be the last. Familiarize yourself with the systems information policy at your organization. Even these guidelines will not prevent ransomware, because based on FBI reporting, certain pieces of ransomware can attack application servers directly. However, these tips can help vigilant nurses remain well informed, and can help ensure malware infection attempts through e-mail or browsing are unsuccessful.
The American Association of Nurse Practitioners (AANP), the nation’s largest professional organization representing nurse practitioners (NPs), is asking Congress to strengthen patient access to vital health care services. Over 300 members will be in attendance, serving as the voice of 205,000 nurse practitioners around the nation.
In today’s meetings with Congress, AANP’s present members will be providing personal insight on health care challenges being faced all over the US. They will bring awareness to the members of Congress to support health care priorities in combatting chronic disease, substance abuse, and patient access to primary, acute, and specialty health care services in rural and urban communities.
Currently only 21 states and the District of Columbia grant full practice authority to NPs. Nurse practitioners are growing in popularity, but it hasn’t been enough to grant them full practice authority nationwide. In states where licensed and fully trained NPs are not being allowed to practice at their full education and training levels, many citizens are missing out on access to care. At a time when primary care shortages are so prevalent, every capable provider is needed to reach patient needs.
By 2025, the number of licensed nurse practitioners in the US is expected to rise from 205,000 to 244,000, a statistic released by AANP. This growth prediction is based on the increase in baby boomers and the millions of new patients who have entered the American healthcare system under the Affordable Care Act. With 80% of NPs being educated in primary care programs, and 49% of those entering into family practices, nationwide full practice authority will increase access to care everywhere, especially for underserved communities.
Across the country nurse practitioners serve as primary, acute, and specialty care providers. They have a wide range of abilities including assessing, ordering, and interpreting diagnostic and laboratory tests; making diagnoses; initiating and managing treatment plans; prescribing medications and nonpharmacological treatment; and counseling patients and their families.
AANP is also involved in providing legislative leadership at local, state, and national levels. Their legislative involvement allows for advancing health policies, promoting education and research, and establishing best practice standards for nurse practitioners and their patients. The role of AANP is to provide a networking platform for nurse practitioners and advocate for their role as providers of high quality, cost effective, comprehensive, patient-centered, and personalized health care all over the country.