This morning, I was reading through some of my favorite websites when I found this article that really annoyed me and it made me feel that I really needed to mention some things on this topic. The article, "Why Some Hospitals are Allowing Unnecessary Suffering" by Maggie Mahar of Health Beat. In the article, she discusses the poor management of pain and issues such as poor end of life quality resulting from restraint use by facilities. In the post, she interviews Dr. Diane Meier, a palliative care specialist, who in my professional opinion, is prone to gross over-simplifications and scapegoating.

First, let's look at her statements, then I will tell you what she apparently is overlooking.

"The relief of suffering is a fundamental part of medicine," Meier concluded. "In this country there is a tremendous amount of stigma associated with opiates. When you are caring for patients, and you leave an order for the nurse to administer the pain-killers, remember, there's a real chance that she'll think, 'This is dangerous. I don't want something bad to happen on my shift. Okay, I'll give it to you -- but I won't give you enough.'

"This is why pain is so poorly managed in this country."

Wow, how is that for some blame shifting? Unfortunately Dr. Diane Meier I am afraid you are not even looking at half of the issues that complicate pain management, plan of care implementation and restraint usage. The whole situation is complicated beyond what the good doctor discussed in that article, and staffing of medical professionals by health care facilities is a major component of the problem.

First off, let me say it is not a secret that people go to hospitals for medical interventions performed mostly by other health care professionals such as diagnostic studies and medical treatments that require either the equipment, assessment or medications that only those facilities offer or that would be impractical to attempt at most people's homes. Sure, major invasive procedures are the realm of the physician, but the majority of the care you receive, and the assessments done of the patients are performed by other health care professionals such as nurses, respiratory therapists, social workers, counselors and other members of the hospital staff.

A report published by the New York times in March of 2006 points out that physician's actual time with patients has been drastically reduced by managed care, and averages as little as seven minutes of contact. The rest of your monitoring and care plan is performed and coordinated through the nursing staff.

And Nursing staff or other direct patient care staff (nursing assistants, secretaries, etc) are the first ones expendable when this broken business of medicine requires facilities to try to save money, which leads to the problem of facilities and "mandatory overtime". That, of course, complicates and reduces the ability of the remaining nursing staff in performing general and pain assessments, utilizing alternative methods of patient safety rather than resorting to restraints (which MUST be ordered by a physician, I might add), and preventing medication errors. In regards to medication errors, let me point out some findings from a recent survey of nurses, which shines some light on that aspect of the situation...

* Among nurses who usually worked overtime, 22 per cent reported medication error, compared with 14 per cent of those who did not work overtime.
* Among registered nurses whose working relations with physicians were least favourable, 27 per cent reported medication error, compared with 12 per cent among those whose working relations with physicians were most favourable.
* Nurses with low support from co-workers were significantly more likely to report medication error than were those with more support. The study pointed out that low co-worker support might result from inadequate staffing as busy nurses may be less able or willing to help co-workers.
* Just under a third (32 per cent) of nurses with low job security reported medication error, compared with 19 per cent with better job security.
* About 28 per cent of those who said they were dissatisfied with their job reported medication error, compared with 18 per cent of those who were satisfied.

Of course, mandatory overtime, short-staffing, unsafe work environments and "difficult" physicians don't help the nursing shortage. And of course, the mantra of "less regulation for businesses" that many on the right like to spout as if hospitals were distributing nachos and not working to save or improve peoples lives keeps these issues from being seriously addressed. Only a few states have laws mandating staffing levels, others leave it often to the discretion of the patient care administrative staff, most of whom do not work at the bedside. What studies have shown in regards to safe staffing practices includes the following...

In a given unit the optimal workload for a nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission. A workload of 8 patients versus 4 was associated with a 31% increase in mortality. 4
Higher nurse staffing levels resulted in reduced numbers of urinary track infections, pneumonia, upper gastrointestinal bleeding and shock in medical patients and lower rates of "failure to rescue" and urinary track infections in major surgery patients. 5
Low registered nurse (RN) staffing levels and poor organizational climates have been found to put nurses at greater risk of needle stick injuries. 6
These and other recent studies show a significant association between higher nurse: patient ratios and better patient outcomes.

So then the cycle gets worse, because now with the increased errors and the decreased quality of delivered care, the hospitals have to assess the problems and find solutions. These of course rarely point to staffing as a problem, and the solutions become more time consuming on the staff, again decreasing the quality of patient care by reducing Nurse/Patient contact or again pulling more money from the hospital coffers to hire middle management staff to monitor and try to fix these problems, and to implement more paperwork on the staff

Everyone from patients and their families to staff and physicians (Even you, Dr. Diane Meier), need to look at the whole picture regarding our broken health care system. We shouldn't be laying blame without knowing all the driving factors. Of course everyone should have their pain treated, of course restraints should always be a last resort. I don't doubt that the stigma on narcotic medications is part of the problem, but not just for the nursing staff. Physicians and dentists have become increasingly reluctant to prescribe them, especially if someone has a history of abuse. Keep in mind though, even former and current users may have legitimate pain too, and any pain should be assessed. Furthermore those who are abusers, when in situations which cause them pain, may have a tolerance and may require more to actually control their pain issues. But we need to dig a little deeper than I believe Health Beat and Dr. Meier apparently did, just from my observations working as a RN in multiple CCU/ICUs, Medical/Surgical & pediatric units.