Another way to empower nurses: Listen to them

Five days before my mother died of septic shock, a nurse tried to alert me that something might be wrong. I wish I had listened.

After surgery for colon cancer, my mother spent two weeks in the hospital. The medical team began discharge planning. One afternoon, what we thought of as her “going home” presents — a walker and a toilet adapter — arrived at her bedside. But the next morning, my mother was tired and out of sorts. She sat in a chair and listlessly pushed a bit of egg around the plate, then leaned back and closed her eyes.

Lisa, her nurse, had been watching us for several minutes. In the hallway, she asked what I thought about my mother’s appetite, energy level, and alertness. The more questions Lisa asked, the more annoyed I became. I thought my mother was just having a bad day. Besides, the doctors didn’t seem concerned, even as my father and I grew worried over the next few days. After a diagnostic procedure performed mainly to placate us, the attending physician smiled when he told us that the surgery was healing well.

My mother died the next day.

Each year, more than 100,000 hospital patients in the United States die from sepsis and other surgical complications, a phenomenon known as “failure to rescue.” Although many factors affect the ability to rescue patients, a landmark study found that two are key: timely recognition and effective intervention. Nurses play a vital role in both. But, as my mother’s experience shows, they need enough time with patients to spot complications, and they must feel empowered to voice their concerns.

A recent survey by McKinsey & Company found that 1 in 3 registered nurses who provide direct patient care say they may quit their jobs in the next year. It’s not just that hospital nurses are fed up with understaffing that makes it impossible to safely care for patients. The McKinsey survey revealed another important factor: Nurses are tired of not feeling listened to or supported at work. For decades, nurses have been asking for adequate nurse staffing and better practice environments. Hospital leaders and policymakers need to start listening to what nurses say they need to keep patients safe. Otherwise, people like my mother are going to continue to die.

When I obtained my mother’s medical records and reviewed them with a doctor, I learned that her white blood cell count was climbing around the time that Lisa became alarmed. The doctors searched for the source of the infection, but they remained so focused on her colon that they failed to look elsewhere. The infection grew worse and sparked sepsis. If detected early enough, sepsis can be treated with antibiotics. But once it progresses to septic shock, as it did with my mother, it causes organ failure and death.

Like other complications, the earliest symptoms of sepsis can be nonspecific, such as confusion, fever, and shortness of breath. As they conduct daily assessments of patients, nurses are often the first to spot subtle but significant changes. In fact, a review of 18 studies found that nurses are sometimes able to identify the development of lethal complications before any change in the patient’s vital signs. But here’s the rub: Such vigilance requires adequate staffing so that nurses like Lisa have enough time to observe the patient.

Of course, recognizing that a patient has developed a complication is not enough to save their life. The next step is translating recognition into action. University of Michigan researchers have found this requires interdisciplinary teamwork, a practice environment in which nurses feel empowered to escalate concerns, and effective communication among doctors, nurses, and other clinicians.

Unfortunately, I never observed much teamwork or communication between doctors and nurses at my mother’s hospital. Two days before she died, several doctors entered my mother’s room to discuss the diagnostic procedure we requested. The nurse on duty stepped back and remained silent. She spent more time with my mother and knew her better than any of the doctors, yet she was not invited to join our huddle or offer her opinion.

A more empowering practice environment for nurses is found in hospitals that receive “Magnet” designation by the American Nurses Credentialing Center. Research shows that patients admitted to Magnet hospitals have better outcomes and are less likely to die after surgery than patients in non-Magnet hospitals. Only about 9% of American hospitals currently have Magnet designation.

Hospital executives have fought hard when nurses suggest changes. A major flashpoint is implementing nurse-to-patient ratios. That approach, opponents say, is too rigid, too expensive, and will ultimately harm patient care. In 2018, hospitals in Massachusetts spent $25 million to defeat mandated ratios — the most money ever spent on a ballot question in state history.

While mandates are controversial, hospitals can take other steps to improve work environments for nurses — many of them detailed nearly 20 years ago by the Institute of Medicine. Key recommendations, reiterated recently, include empowering nurses by flattening hierarchies, fostering interdisciplinary patient care, and seeking input from nurses providing direct patient care before making decisions.

It’s time to start making these changes. A recent editorial in the New England Journal of Medicine warned that patient safety has deteriorated significantly during the pandemic. Infections caused by central lines and urinary catheters, for instance, have risen markedly. The authors urged hospital executives and policy makers to make changes, such as addressing workforce shortages.

Nurses make up the largest share of a hospital’s workforce. If hospitals want to retain nurses, they must create practice environments where nurses feel empowered to speak — and are listened to — rather than silenced.

I wish I had listened more closely to a nurse when my mother was in the hospital. At the time, I dismissed Lisa’s concerns as trivial; I didn’t realize that the subtle changes she noticed might be early signs that my mother could rapidly deteriorate. Now I wish I had paid closer attention to Lisa and asked what she recommended we do to help my mother. Maybe she would have survived.

As hospital leaders and policymakers consider ways to improve health care, they need to ensure that nurses have a voice in the decision-making process. This is not just about respecting what nurses have to say; it’s about saving patients’ lives.

Ann MacDonald has been a medical writer for 25 years. She has worked as an editor at Harvard Health Publications and held senior communications positions at several Harvard teaching hospitals.