A nurse ponders the “July Effect.”

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There is an open secret in healthcare that being admitted to teaching hospitals in July is bad, even fatal, for the patient. This injunction is based on the accepted, but not well understood, notion that the wholesale replacement of senior medical residents in the month of July by newly minted physicians leads to medical misadventures. In American medicalese, this phenomenon is called the “July Effect.” In the United Kingdom, the same pattern carries an ominous and bone-chilling label of “killing season.”

For decades, researchers have reported mixed data. Among coronary artery bypass graft patients, the cohort changeover in July did not show significant differences in morbidity and mortality. A 2011 systematic review reported an increased mortality risk and a decrease in care efficiency in hospitals during the July changeover. The researchers noted that the degree of risk attributable to the July Effect is difficult to fully ascertain due to the heterogeneity of the studies reviewed. In April 2022, a retrospective analysis showed that the odds of an adverse event affecting patients admitted in the months of July and August in major teaching hospitals was not higher compared with the rest of the year. This study analyzed records of 168,552 adult patients discharged from a hospital for acute myocardial infarction, heart failure, pneumonia, or major surgical conditions between 2010 to 2017.

Why the July Effect?

The disparate results of the various studies looking into the July Effect highlights the complexity of this phenomenon. Some experts propose that perhaps, like the alligator in the New York City sewer, the July Effect is not real. The accepted explanation for the assumed decline in quality and safety during the month of July is the sudden influx of inexperienced medical interns charged with the care of complex hospitalized patients. Another possible explanation is that en masse departure of experienced medical and surgical residents leads to lapses in supervision of novice physicians.

The Joint Commission reports that inadequate staff orientation, supervision, and staffing levels or skill mix are major contributing factors in patient safety sentinel events. July Effect is the proxy for adverse events due to lack of proper oversight. Perhaps another less well understood contributor to the July Effect for the past 2 years is the limited clinical experience of medical students joining the workforce due to restricted clinical rotations during the peak of the pandemic.

The July Effect in Nursing

Mass departure of nurses, inadequate staffing, poor supervision, shortened orientation, and working night shift (think sleep deprivation) for new grads mirror the same factors attributed to the July Effect. In medicine, this cohort change happens once a year. In nursing, it is an ongoing battle, as nurse turnover does not follow a fixed changeover cycle. Where there is high staff nurse attrition or turnover, expect to see similar quantifiable consequences of the July Effect—it can happen in any month.

The exodus of experienced frontline staffers in the aftermath of the pandemic left a gaping expertise void; its full effect is yet to be quantified and analyzed. There are patient units where the most senior staff nurse has only been on the job for 3 years. It is hard to say if patient outcomes are less than ideal in units with overwhelmingly novice staff, as there is not much research on this topic. What is certain is that high turnover can lead to precepting fatigue, burnout, loss of knowledge transfer when expert nurses leave at the prime of their careers, and low unit morale. These days, replacing and retaining nurses is a Sisyphean task for nurse managers.

The pandemic has tremendously exacerbated the limited clinical skill acquisition of pre-licensure nursing students. The nursing classes of 2020 and 2021 have transitioned into the registered nurse role with very little contact with real patients with larger-than-simulated medical issues. It is likely that for these cohorts, their baseline nursing skillset is even lower than pre-pandemic new grads and are no match for the complex patients they are meant to care for. Many new grads have never given an injection, set-up a nebulizer, cleaned an incontinent patient, or served a bedpan to a patient. Can you imagine?

More falls in July?

The large retrospective study cited earlier reported that adverse events were more common in major teaching hospitals than in non-teaching facilities. However, in major teaching hospitals, the authors found that the rate of adverse events among non-surgical patients were lower in the month of July, repudiating the July Effect. Of interest to nursing is that the study found a higher risk of pressure injuries and falls among surgical patients in major teaching hospitals in the month of July. The researchers were unsure of how to interpret this finding, given that pressure injuries and falls are nursing-sensitive events and are not under the domain of practice by medical interns. Perhaps we will never know why. But I’ll hazard a couple of guesses as to why this might be. Typically, July is vacation time. The unit’s equipoise might be disrupted by the short staffing and the entry of newbie physicians. It is possible that the nurse staffing ratio might be higher, and the workload heavier in July while some nurses are away. Staff nurses are the underrecognized trainers of rookie house staff. The added burden of helping interns navigate their workflow in the first couple of months could possibly distract nurses from attending to their own patients, hence the higher rate of pressure injury and falls. But this is just a maybe.

Someone to watch over me

Whether the July Effect is real or simply an imagined threat, experts observed that in whatever setting, unfamiliarity with the work environment independent of clinical experience may contribute to decreased quality of care. For example, a staffer who does not know the location of the crash cart could lead to delays in initiating lifesaving interventions in an emergency. New hires spend a lot of time locating supplies and equipment (if you don’t believe me, try looking for a bedside commode as a new nurse). The July Effect highlights the importance of effective supervision and clinical coaching. A physician who wrote to the New York Times in response to a 2012 July Effect article said August, not July, is the worst month to be in a hospital, because by then the residents think that they know everything. I couldn’t help humbly humming: I like New York in June. How about you?

A well-run unit and a seamless workflow rely, to a large degree, on the collective “systems knowledge” of people who work closely together as a team. This relationship develops over time, aided with a collaborative mindset. When a large cohort of staff leaves, in July or any other month, not only is the systems literacy thrown off-balance by the departure of experienced clinicians, but the animating spirit of the community wisdom that makes patient care safe also is lost—in some places, irrevocably. It is time hospitals invest in meaningful and sustainable staff retention programs. Next time you see a new nurse or physician seeming lost, smile and ask: How can I help you?

References

Metersky M, Eldridge N, Wang Y, et al. Rates of adverse events in hospitalized patients after summer-time resident changeover in the United States: Is there a July effect? J Patient Saf. 2022;18(3):253-9. doi:10.1097/PTS.0000000000000887

Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. “July effect”: Impact of the academic year-end changeover on patient outcomes: A systematic review. Ann Intern Med. 2011;155(5):309-15. doi:10.7326/0003-4819-155-5-201109060-00354

Gopaldas RR, Overbey DM, Dao TK, Markley JG. The impact of academic calendar cycle on coronary artery bypass outcomes: A comparison of teaching and non-teaching hospitals. J Cardiothorac Surg. 2013;8:191. doi:10.1186/1749-8090-8-191

The Joint Commission. The most commonly reviewed sentinel event types. 2020. jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/most-frequently-reviewed-event-types-2020.pdf

Fidelindo Lim is a clinical associate professor at New York University – Rory Meyers College of Nursing.