Burnout and Moral Distress in Nurses: Can Staffing Numbers Increase Patient Safety?

I know Nurse X only by her failures the night a young woman with asthma died gasping for breath just steps from the emergency entrance of Somerville Hospital. The preventable nature of the woman’s death, and the discovery of that hard truth by her husband, are described thoroughly and compellingly in Sunday’s Boston Globe magazine.

This death was the result of medical error, estimated to be the third leading cause of death behind heart disease and cancer.

But the blurry image of Nurse X, standing in the ER doorway and failing to see the dying woman in the shadows steps away, is for me a snapshot of burnout. I’ll carry it with me to the voting booth on Tuesday when I stare at Question 1, the ballot measure in Massachusetts that could determine and lock into place nurse-to-patient staffing levels.

The prevalence of medical error shocked the American public when it was reported by the Institute of Medicine in “To Err Is Human” (1999). Since then, there has been significant and ongoing change in how health systems work to avoid it. The issue was central to Atul Gawande’s “Checklist Manifesto.”

Medical error is often about unsafe practices or incorrect doses, but it is also sometimes about negligence. Individuals or systems can be to blame, and both seem to bear responsibility in the Somerville woman’s death. In his wrenching story, her husband also expresses remorse over his own absence and responsibility.

But who is responsible for the behavior of Nurse X, other than Nurse X herself? I ask the question as I approach tomorrow’s deadline for deciding how I will vote on Question 1.

Is Nurse X’s negligence attributable in some way to staffing levels at “a hospital whose culture failed to properly emphasize patient safety”?

Burnout and moral distress aren’t unique to any one Boston area hospital, or to nurses. And yet, no one on a patient’s care team spends more time with patients or is more hands-on than a nurse. No surprise, then, that patients and families trust no one like they trust nurses.

When I vote on Tuesday, I will decide based on patient safety.

Notably, and confusingly, both proponents and opponents of Question 1 claim their side is the true champion of patient safety. Who is right? Why is this even on the ballot?

Last week I attended the annual meeting of the Patient-Centered Outcomes Research Institute in Washington, D.C. Among posters describing new work meant to improve patient care and outcomes, none that I saw focused on moral distress and burnout among medical professionals. It wasn’t a glaring omission; I didn’t even notice it when I was there. I didn’t notice it, really, until I was back in Boston and saw the blurry photo of Nurse X staring into the shadows.

A burned-out caregiver has no care to give. I can’t think of a more pressing patient-centered issue.

My sense of moral distress and burnout among nurses and other medical professionals is biased by an increasingly common scenario in Boston hospitals, where critical care wards are at capacity with still more patients awaiting transfer from emergency rooms.

It is well known that the longer patients wait for a bed in critical care, the less likely they are to ever leave the hospital. Imagine yourself as the ER nurse. As the critical care nurse. As the charge nurse in either department. Or as the family of the patients awaiting transfer.

I can’t say whether the gridlock between emergency rooms and critical care had anything to do with the tragic night when Nurse X failed to look long enough or close enough into the shadows and a young woman died a preventable death.

For care to be truly patient-centered, and medical error prevented, policy should begin at the bedside, not the voting booth. Putting an inflexible nurse-staffing policy on the ballot is a desperate act. For nurses in Massachusetts, it seems to have gotten to that point.

Nurses have been there for me in desperate times. I’ll take that knowledge into the booth with me.