Findings underscore need for ‘Bill of Rights’ for nurses, patients

A survey by National Nurses United (NNU), the nation’s largest union of registered nurses, found that artificial intelligence technology (A.I.) often contradicts and undermines nurses’ own clinical judgment and threatens patient safety. The findings, coupled with anecdotal reports from nurses at hospitals nationwide, underscore the urgent need for stricter regulation and greater input from nurses and health care staff on whether and how A.I. is deployed.

“The survey and reports from nurses across the country demonstrate that we need an immediate pause on implementing A.I. in health care settings,” said Deborah Burger, RN and president of NNU. “As patient advocates, it is our duty to assess the evidence in front of us and question the unfounded marketing claims that A.I. will complement our bedside skills or improve the quality of care for our patients.”

In addition to surveying its members, NNU recently announced a “Nurses’ and Patients’ Bill of Rights,” a set of guiding principles designed to ensure just and safe application of A.I. in health care settings. Meanwhile, NNU’s affiliates have been bargaining over A.I. implementation in contract negotiations and protesting the hospital industry’s attempts to push A.I. instead of investing in safe staffing. An April 22 action in San Francisco, California drew hundreds of California Nurses Association RN members to protest Kaiser Permanente’s International Integrated Care Experience conference that featured the system’s use of advanced analytics and A.I. (B-Roll).

Burger continued, “Nurses regularly embrace technology that complements our bedside skills and improves the quality of care for our patients. But this rush to implement untested and unregulated A.I. into care settings threatens our patients’ rights to person-to-person care, and their rights to privacy, transparency, and safety.”

The survey received responses from over 2,300 registered nurses and members of NNU. In the survey conducted from January 18 to March 4, 60 percent of respondents disagreed with the statement, “I trust my employer will implement A.I. with patient safety as the first priority.”

“The pandemic destroyed nurses’ trust in our employers,” said Michelle Mahon, RN and assistant director of nursing practice at NNU. “Hospitals were completely underprepared for the public health crisis, after years of purposely understaffing and understocking supplies, despite nurses’ safety concerns. We then watched how hospital executives, many with no experience treating patients, used the emergency to introduce untested and unproven technologies to ‘solve’ the staffing crisis that they manufactured.”

Forty percent of respondents said their employer has introduced new devices, gadgets, and changes to the electronic health records (EHR) in the past year. While they’ve been marketed as tools to free clinicians from documentation burdens and support clinicians in decision making, NNU’s survey finds otherwise.

Half of survey respondents said their employer utilizes algorithmic systems to analyze EHR data to determine patient acuity, which is a measurement of how ill or fragile the patient is, and predict the number of hours of nursing care a patient will need. Of those nurses, 69 percent said their assessments don’t match the computer-generated acuity measurement, which doesn’t take into account many of the educational, psycho-social, or emotional needs of a patient or their families. Additionally, these systems depend on a nurses’ ability to chart in real time, which is rarely possible when hospitals are understaffed and health care workers are overloaded with patient assignments.

“The result of relying on the algorithmically-driven acuity measurements is that, on a daily basis, in unit after unit, we have multiple patients whose acuity is underrepresented, which means there are not enough nurses to provide optimal care in a timely manner,” said Cathy Kennedy, RN, a vice president of NNU and a president of California Nurses Association, who works at Kaiser Permanente in Roseville, California “That makes it impossible for nurses to chart in real time, and a vicious cycle is set in motion.”

A growing number of nurses — around 12 percent of nurses — said their hand-offs are generated by a computer with the help of A.I. Handoffs, which are traditionally done through direct communication between nurses, are critical for continuity of care when patient care is transferred from one nurse to the other. Disturbingly, of the nurses whose employers use automated handoffs, 48 percent said that these automated reports don't match their assessment.

“There is critical patient care information that I’ve seen missing from these reports — for example, a patient having Covid-19 or a patient having an extremely weakened immune system — and would not be missed by a nurse talking to another nurse,” said Jeff Breslin, RN a vice president of NNU and a board member of Michigan Nurses Association, who works at University of Michigan Health-Sparrow in Lansing, Michigan “Nurses see that the tech is used to justify understaffing while removing an essential safeguard. Management is pushing for speed and efficiency, but we must demand a process that ensures our patients' safety. Anything less than direct nurse-to-nurse communication puts our patients at risk.”

In addition to a significant number of nurses reporting inaccuracies with A.I. in the patient care setting, many said they were not always able to modify algorithmically-driven recommendations based on their own clinical judgment of patients’ needs.

Some 29 percent of nurses said they are unable to change assessments or categorizations that are software-generated by A.I., in facilities that use devices to capture images and sound information about patients, such as pain scores and wound assessments. In facilities that use a scoring system to predict a patient’s outcome, risk for a complication, or determine if patients are on schedule for discharge, 40 percent of nurses said they are unable to modify scores to reflect their clinical judgment and the individualized needs of the patient.

“While our employers argue A.I. will help us, they’re using these technologies to erode our ability to practice our clinical judgment,” said Aretha Morgan, RN in emergency pediatrics at New York Presbyterian in Manhattan and a board member of the New York State Nurses Association, who also teaches nursing. “At the core of nursing is assessment of the patient: touching, hearing, seeing, smelling, and showing comfort and compassion to build the bonds of trust. Healing our patients requires time that we are not given by our employers and so A.I. is used to justify the crisis conditions they’ve made us work under.”

Burger agreed, “By no means is A.I. a panacea for the systemic issues in our health care system. We desperately need better working conditions to bring back the 1.3 million licensed registered nurses who are choosing not to work, and from what we’ve seen, A.I. may make working conditions even harder as we respond to false alarms, review A.I. recommendations for errors, and feed data into applications ‘learning’ from nurses.”

Morgan concluded, “What nurses and our patients need is more nurses and better staffing. Research has shown that safe staffing levels save lives. The tech and hospital industries cannot say the same about the products they’re pushing on us and our patients.”

Background and Additional Resources on NNU and A.I.:

In contract bargaining, public protests, and meetings with regulators and elected representatives, NNU nurses have been raising concerns about the deployment of these technologies in patient care settings without adequate testing, regulation, or input from health care workers.

• Recording of a NNU expert panel on A.I. and its potential impact on the nursing profession can be found here.
• NNU’s A.I. principles — a ‘Bill of Rights’ for nurses and patients — can be found here.
• B-roll from a protest held by NNU affiliate California Nurses Association in San Francisco, California on April 22, 2024 against A.I. can be found here.
• Remarks from NNU Executive Director Bonnie Castillo, RN at Senator Schumer’s A.I. Insight forum and the importance of implementing the ‘precautionary principle’ can be found here.
• An explainer on A.I. for health care workers and the public can be found here.
• More resources on A.I. from NNU can be found here.