TITLE: How Nurse Staffing Variations were Associated with Hospital Patient Deaths During the COVID Pandemic
https://ldi.upenn.edu/our-work/research-updates/how-nurse-staffing-variations-were-associated-with-hospital-patient-deaths-during-the-covid-pandemic/
EXCERPTS: The only study to evaluate the association of hospital nurse staffing level variations and patients’ odds of dying during the COVID-19 emergency concluded that many deaths among patients hospitalized for COVID-19 could have been prevented if hospitals entered the pandemic with adequate numbers of registered nurses (RNs), a workforce rich in Bachelor of Science degree qualified RNs, and high-quality nurse work environments.
Titled “Hospital Nursing Staffing Variation and COVID-19 Deaths: A Cross-Sectional Study,” the paper was co-authored by LDI Senior Fellows and University of Pennsylvania School of Nursing faculty members Karen B. Lasater, PhD, RN; Matthew D. McHugh, PhD, RN; and Linda H. Aiken, PhD, RN.
Published in the International Journal of Nursing Studies, the work adds to a large body of evidence generally associating nurse staffing variations to trends in patient outcomes and deaths at the same time it underscores elements of the national debate about the overall adequacy of hospital emergency preparedness during the pandemic as well as for the next major national health emergency.
The study pointed out that during the pandemic, COVID-19 mortality varied depending on the hospital where patients were admitted, but it was unknown what aspects of the hospitals’ operations were important for mitigating preventable deaths.
The investigation evaluated data from 237 hospitals and more than 87,000 older adult patients admitted with COVID-19 during the height of the pandemic and found that “variation in hospital nursing resources prior to the COVID-19 pandemic is associated with many thousands of preventable COVID-19 deaths during the pandemic.”
One study finding that directly relates to the outlook for current and future hospital emergency preparedness was that “Hospital nursing resources are often overlooked in conversations about lessons from the U.S. COVID-19 response and hospitals have not yet been able to recover from the effects of COVID-19 as they continue to experience difficulties recruiting and retaining nurses after the official end of the pandemic.”
And as further context for the issue, the study points back to multiple previous works that looked at nursing during the pandemic and found “serious misalignments” between the resources nurses were provided with and what they actually needed to optimize patient care. One of those earlier studies found that the most important resources nurses said they needed in order to provide safe and quality care during and after the COVID-19 emergency were flexible work scheduling and adequate staffing. But more than two-thirds of nurses surveyed reported these resources were not provided to them by their hospitals.
A currently related controversy suggests that insufficient RN staffing is associated with the lack of sufficient registered nurses available in the U.S. But Lasater pointed to a just-released national analysis by Marsh McLennan’s Mercer, a human resources and financial services consulting firm. It reports that, “At a national level, the supply of RNs is projected to outpace demand, resulting in an estimated surplus of nearly 30,000 RNs by 2028.”
In previous papers, Lasater has explained that the current insufficient numbers of nurses in hospitals is not a function of overall supply but rather poor working conditions in hospitals that drive high clinician burnout, job dissatisfaction, turnover, and poor patient outcomes. Other recent evidence documents the continued growth in the number of newly licensed nurses but notes a shift in employment away from hospital settings toward ambulatory and community settings.
The American Nurses Association (ANA) endorses safe staffing ratios that would require hospitals to meet a minimum standard level of nursing care. Meanwhile, California and Oregon have already established enforceable staffing ratio requirements. As a result, patients hospitalized in California receive an average of three more hours of RN care per day compared to patients in other states. Oregon implemented their ratio policy in the summer of 2024.
Other U.S. jurisdictions including Pennsylvania, Maine, Georgia, Illinois, and New Jersey have all introduced safe staffing bills. Elsewhere in the world, a prospective evaluation of staffing ratios in Queensland Australia showed the introduction of staffing legislation in hospitals resulted in better staffing ratios, lower mortality, fewer readmissions, and shorter stay durations for patients.
TITLE: Nursing Aides Plagued by PTSD After ‘Nightmare’ Covid Conditions, With Little Help
https://kffhealthnews.org/news/article/essential-worker-ptsd-pandemic-massachusetts/
EXCERPTS: Covid killed more than 3,600 U.S. health care workers in the first year of the pandemic. It left many more with physical and mental illnesses — and a gutting sense of abandonment.
What workers experienced has been detailed in state investigations, surveys of nurses, and published studies. These found that many health care workers weren’t given masks in 2020. Many got covid and worked while sick. More than a dozen lawsuits filed on behalf of residents or workers at nursing facilities detail such experiences. And others allege that accommodations weren’t made for workers facing depression and PTSD triggered by their pandemic duties. Some of the lawsuits have been dismissed, and others are pending.
Health care workers and unions reported risky conditions to state and federal agencies. But the federal Occupational Safety and Health Administration had fewer inspectors in 2020 to investigate complaints than at any point in a half-century. It investigated only about 1 in 5 covid-related complaints that were filed officially, and just 4% of more than 16,000 informal reports made by phone or email.
Nursing assistants, health aides, and other lower-wage health care workers were particularly vulnerable during outbreaks, and many remain burdened now. About 80% of lower-wage workers who provide long-term care are women, and these workers are more likely to be immigrants, to be people of color, and to live in poverty than doctors or nurses.
Some of these factors increased a person’s covid risk. They also help explain why these workers had limited power to avoid or protest hazardous conditions, said Eric Frumin, formerly the safety and health director for the Strategic Organizing Center, a coalition of labor unions.
He also cited decreasing membership in unions, which negotiate for higher wages and safer workplaces. One-third of the U.S. labor force was unionized in the 1950s, but the level has fallen to 10% in recent years.
Like essential workers in meatpacking plants and warehouses, nursing assistants were at risk because of their status, Frumin said: “The powerlessness of workers in this country condemns them to be treated as disposable.”
The plight of health care workers is a problem for the United States as the population ages and the threat of future pandemics looms. Surgeon General Vivek Murthy called their burnout “an urgent public health issue” leading to diminished care for patients. That’s on top of a predicted shortage of more than 3.2 million lower-wage health care workers by 2026, according to the Mercer consulting firm.
A third of health care workers reported symptoms of PTSD related to the pandemic, according to surveys between January 2020 and May 2022 covering 24,000 workers worldwide. The disorder predisposes people to dementia and Alzheimer’s. It can lead to substance use and self-harm.
Since covid began, Laura van Dernoot Lipsky, director of the Trauma Stewardship Institute, has been inundated by emails from health care workers considering suicide. “More than I have ever received in my career,” she said. Their cries for help have not diminished, she said, because trauma often creeps up long after the acute emergency has quieted.
Another factor contributing to these workers’ trauma is “moral injury,” a term first applied to soldiers who experienced intense guilt after carrying out orders that betrayed their values. It became common among health care workers in the pandemic who weren’t given ample resources to provide care.
“Folks who don’t make as much money in health care deal with high job demands and low autonomy at work, both of which make their positions even more stressful,” said Rachel Hoopsick, a public health researcher at the University of Illinois at Urbana-Champaign. “They also have fewer resources to cope with that stress,” she added.
People in lower income brackets have less access to mental health treatment. And health care workers with less education and financial security are less able to take extended time off, to relocate for jobs elsewhere, or to shift careers to avoid retriggering their traumas.
TITLE: Nursing Homes Overuse ‘Chemical Restraints’ on Dementia Patients
https://undark.org/2024/09/25/nursing-homes-overuse-antipsychotics-dementia/
EXCERPT: Antipsychotics have sedating effects and are justified only as treatments of last resort when behaviors such as agitation, aggression, or wandering become self-threatening to people with dementia or others around them, said Bruce Miller, a neurologist who directs the Memory and Aging Center at the University of California, San Francisco. But the Long Term Care Community Coalition (LTCCC) also found that hundreds of nursing homes around the country have drugging rates between 50 and 100 percent, raising what Richard Mollot, the organization’s executive director, described as “significant concerns about resident abuse and neglect.”
According to the LTCCC’s analysis, nursing homes treat with antipsychotics at nearly 10 times the rate at which certain disorders that these drugs are considered “appropriate” for — including schizophrenia — are diagnosed in the U.S. population. Treated residents in these facilities — owing in part to their physical frailty and how the drugs interact with other medications — can suffer the consequences. Many treated patients develop Parkinson’s-like symptoms such as tremor and gait instabilities. In 2005, the Food and Drug Administration issued a black box warning (now called a boxed warning) cautioning that certain antipsychotics — including commonly used drugs such as Abilify, Zyprexa, and Seroquel — put elderly patients with dementia at an increased risk of death from heart failure and infections. The FDA extended that same warning to all antipsychotic medications in 2008.
Ironically, antipsychotics aren’t all that consistent in alleviating dementia’s neuropsychiatric symptoms. A 2021 review of 24 clinical trials testing the drugs in dementia showed only slight improvements in agitation and a negligible effect on psychosis. An earlier review of 17 studies, which was published in 2019, concluded that a single most effective and safe antipsychotic treatment for managing dementia’s behavioral and psychological symptoms does not exist. “I’m always wondering when I start these medicines whether they’re really going to be helpful,” Miller said. “It’s a little bit of an experiment.”
“They may not work at all,” he added.
What Miller and other experts find concerning is that antipsychotic sedation might simply muzzle the efforts of those who can’t speak to convey unmet needs, frustrations, discomfort, and even pain. Polypharmacy — the regular use of five or more medications at the same time — can lead to constipation, which is a frequent problem in people with dementia. Often the best solution “is not adding a drug, but subtracting a drug,” said Michael Wasserman, a retired geriatrician who formerly oversaw operations at a large nursing home chain in California. If antipsychotics blunt agitation without addressing its underlying cause, Wasserman said, then using them is tantamount to “putting a sock in their mouth and tying them down.”
A series of papers published by the Senate Special Committee on Aging in the mid-1970s, cited “ample evidence that nursing home patients are tranquilized to keep them quiet and to make them easier to take care of.” Congress later passed the Nursing Home Reform Act of 1987, which stipulated that residents have a right to be free of unnecessary and inappropriate physical and chemical restraints.
Still, antipsychotic drugging rates remained stubbornly high. Claiming that unnecessary antipsychotic use poses significant challenges to ensuring appropriate dementia care, the Centers for Medicare & Medicaid Services in 2012 launched a program to lower the use of the drugs when not clinically indicated. Called the National Partnership to Improve Dementia Care in Nursing Homes, the program offered training in “person-centered” care and non-drug interventions, which aim for a better understanding and response to how people with dementia view the world. The Partnership limited appropriate antipsychotic treatment to just three major mental illnesses: schizophrenia, Tourette’s syndrome, and Huntington’s disease. In 2015, CMS started flagging facilities with a track record of using the drugs for other purposes by including antipsychotic medication use in the quality care ratings on the agency’s Nursing Home Care Compare website, a public resource for consumers.
Yet according to the LTCCC’s most recent analysis, the drugs are still being given to 21.3 percent of nursing home residents, irrespective of whether they’ve been diagnosed with a major psychotic disorder.
Staffing shortages at nursing homes — which have grown more acute since the beginning of the Covid-19 pandemic — exacerbate the problem.
A 2022 study of more than 10,000 U.S. nursing homes found that unit increases in certain licensed staffing hours was associated with a unit decrease in inappropriate antipsychotic drugging. “Optimal care for those conditions is more hands on, spending more time with patients,” said Jason Falvey, a geriatric physical therapist at the University of Maryland School of Medicine. “When nursing homes are understaffed, the shortcut is you essentially use antipsychotics as a way to control those behaviors.” Falvey coauthored a study published this year which showed that associations between low staffing and inappropriate use of antipsychotics are especially egregious in low-income neighborhoods. He and his co-authors asserted that high staff turnover and a lack of resources in such areas make non-pharmacological interventions more challenging.
Staffing has always been a problem for nursing homes — a typical facility turns over nearly half its nursing staff every year. But after the Covid pandemic “a lot of people left the field,” said Ruta Kadonoff, vice president for programs at the nonprofit Maine Health Access Foundation. Nursing homes rely on women, immigrants, and people of color for staffing, most of whom “are paid insufficiently to support their families,” Kadonoff said. During Covid, “they were asked to work in conditions that were potentially fatal to them and or their families. And they said ‘You know what? I’m not doing this anymore.’”
Research supports Kadonoff’s assertion. A 2023 analysis by Altarum, a nonprofit health care research organization based in Michigan, found that 266 U.S. nursing homes shut down between late 2019 and the end of 2022 — a decline that the authors attributed to the pandemic. The staff who remain, Kadonoff added, are deeply devoted to the work. “The fact that they care so much about the people they’re caring for lends them to being exploited, honestly, by employers,” she said. “I’ve talked to many of them over the years who say, ‘If not me, who’s going to be here for these people?’”