Today in the chart

A New York Times article this week discussed the increasing vulnerabilities of aviation safety. The near-miss aircraft collisions that happen multiple times a week will not remain just close calls. Deadly crashes are inevitable if the cause of those near misses is not addressed and corrected. Those near misses, by the way, have more than doubled over the last decade. Runway incursions alone are 25% higher than a decade ago. What is the root cause of those close calls? Staffing shortages. Only about 1% of air traffic control sites are adequately staffed. The remaining 99% fill the gap with rotating schedules and overtime. During the same decade that near-miss collisions have doubled, air traffic controller overtime hours have tripled.  

What happens when a person whose job requires focus, attention, critical thinking, rapid reflexes, and alertness is overworked, lacking adequate sleep, chronically exhausted, stressed, and surrounded by other frazzled workers? That person experiences the inability to focus, depression, suicide, anxiety, insomnia, heart attacks, substance use, interpersonal conflict, deteriorating morale, increasing workplace violence, and more human error. Burnout increases resignations and turnover among the less experienced. About 10% of air traffic controllers plan to leave the workforce this year. Global air traffic has been consistently increasing, reaching new highs and further congesting airspace. The net result is fewer experienced air traffic controllers to handle heavier and more complicated air traffic.  

Overwork and understaffing create dangerous situations and, if not addressed, will result in a tragic catastrophe. Because such an event is inescapable, safety experts, pilots, air traffic controllers, and federal investigators have repeatedly made warnings and recommendations. To date, the FAA has not designed or implemented a plan to address the staffing shortage, nor has it announced any intent to do so. Ignoring the experts places the entire flying public at risk.

Like air traffic controllers, nurses are the safety net in our healthcare system. We could perform all surgical procedures in a surgery center instead of a hospital if all those patients could go home after the procedure. But they can’t. After some procedures, there exists a real risk of complications requiring urgent intervention. Patients must be monitored for those complications in a controlled environment before they can go home. They must be medicated, receive post-operative treatments, and be carefully observed.  

Some post-operative patients hemorrhage. Some go into shock. Some acquire infections or abscesses or become septic. Some react dangerously to anesthesia. Some develop deep vein thrombosis or throw pulmonary embolisms. Some develop pneumonia or other pulmonary complications. Some experience bowel obstructions, urinary retention, compartment syndrome, lymphedema, cerebral edema, or many other potentially life-threatening complications.  

These dangers can only be prevented or immediately addressed by an educated, skilled, experienced, and alert nurse capable of critical thinking, decision-making, and task management. Mental status changes must be immediately addressed, and accidentally extubated ventilator-dependent patients must be reintubated before brain damage can occur. Drips must be constantly monitored & titrated to maintain vital signs within necessary parameters. Confused or sedated patients must be prevented from falling out of bed. Cardiac monitors must be observed to detect arrhythmias before they become lethal. Evisceration must be prevented by assessing wounds for dehiscence. Insulin shock and diabetic coma must be prevented by monitoring blood glucose levels and observing patients for those symptoms. Monitoring for clinical deterioration must be constant.  

Every disaster movie begins with a scientist being ignored. -Neil DeGrasse Tyson

Nurses cannot perform their critical surveillance role when tasked with impossible assignments. Vigilant patient monitoring and evaluation cannot be provided with inadequate staffing. Nurses have been sounding the alarm on patient dangers like the air traffic controller warnings. The research is there. The data is clear. Nursing shortages increase patient morbidity and mortality. Overworked nurses cannot safely practice and experience moral distress. They also suffer the physical and mental consequences that cause more human error. And like the air traffic controllers, nursing burnout increases resignations and turnover among the less experienced. Nearly one-third of nurses plan to leave the profession. Patients have more comorbidities, and their care is more complex than ever before. Rising acuity means fewer nurses are now taking care of sicker patients.  

As with air traffic controllers, nurses, patient safety experts, researchers, and scientists have been sounding the alarm. Short staffing endangers patients. Root cause analyses of sentinel events invariably involve an element of short staffing. The Emergency Care Research Institute (ECRI) identifies staffing shortages as the number one patient safety concern, stating that inadequate staffing actively jeopardizes patient safety and that superficial attempts to improve patient safety are insufficient. The response to these alarms has been recruiting nurses from overseas (ignoring the ethics of depleting other countries of their nurses), replacing nurses with less skilled workers, using temporary, per diem, or traveling nurses, rotating shifts and requiring overtime, and relentless focus on recruitment rather than retention. You will never fill the sink by simply putting more water into it. You have to plug the drain. Putting more students through the pipeline to work in the same settings from which others are leaving accomplishes nothing.

The only meaningful response to this danger is to address why nurses leave clinical practice or nursing altogether. To plug the drain, we must fix the workplace. Stop bundling nursing care under room and board, so nursing is an expense. Start costing out nursing services as is done with all other health care professionals. We should be revenue generators instead of cost centers—train managers to be supportive leaders. Adopt just cultures instead of perpetuating punitive systems. Pay nurses what they are worth and stop treating them as fungible. Until you do, patients will continue to experience near misses or actual harm. Medical error should not remain the third leading cause of death in our country because these warnings are ignored.  

The words one air traffic controller used to describe aviation safety apply to nursing, “The staffing shortage is beyond unsustainable. It has not moved into a phase of JUST PLAIN DANGEROUS.”  It seems, however, that the louder we shout, the deafer they become. We must continue to shout until they do hear us. It is truly a matter of life and death.