Articles: Medical Topics
Nursing Staffing: Critical Condition
 This
material is excerpted from Patricia Iyer's article, Roots
of Patient Injury, from her book:
Iyer, P. (Editor), Nursing Malpractice,
Lawyers and Judges Publishing Company, Second Edition, 2001.
See
also her video, Nursing
Home Liability, as well as other medical
malpractice products at our webstore.
One of the most frequent reasons
raised by nurses for why incidents occur is inadequate staffing.
The attorney can determine the staffing at the time of an
incident by asking for the agency’s staffing sheet
for the date in question. Inadequate staffing may result
from an insufficient supply of nurses coming into the work
pool, or because healthcare agencies have cut back registered
nursing positions. There is growing recognition that there
is an inadequate number of nurses to meet the needs of patients
in hospitals and nursing homes.
The demand for healthcare and nurses shows no sign of diminishing.
As older people live longer, they acquire more chronic illnesses
that require medical and nursing attention. There are fewer
nurses in both hospitals and nursing homes to meet these
needs. The shortage of nurses can be compared to a pipeline.
There are fewer people entering nursing school (the opening
of the pipe). As nurses age, they are reducing their working
hours and retiring. The pipe has developed leaks, as nurses
leave hospitals and nursing homes to work in other healthcare
settings. The resultant stream of nurses through the pipe
is not sufficient to meet the ever-increasing demands for
skilled healthcare providers.
The Bureau of Health Manpower
statistics show hospitals are now short 300,000 nurses who
are willing to work. By 2010, that figure will grow to 750,000
(Levenson, 2000). Recent data made headlines when it was
shown that many nursing homes are also short staffed. In
1998, nursing staffing time averaged just 3.5 hours per
resident per day (a little more than one hour per shift.)
Approximately 36% of US nursing homes offered less than
three hours of nursing care per resident per day and 11%
of facilities had staffing levels well below the average
of 3.5 hours per resident per day. Smaller, nonprofit, governmental,
and nonchain facilities had significantly more staff than
comparison groups. HCFA is beginning to determine the costs
and feasibility of implementing minimum staffing requirements
(Kovner and Harrington, 2000).
Drop in enrollment in nursing
schools
The shortage
of nurses has been a gradually evolving issue. Nursing is
still a predominantly female occupation. Young women have
more choices for careers thanexisted in the past. Many within
nursing believe that the profession has not done enough
to attract candidates. Beginning in 1994, due to changes
in the healthcare industry, new graduates had a hard time
finding jobs in hospitals, the traditional employers of
new graduates. Wages for nurses have declined since 1994,
partly due to a decline in hospital salaries and partly
due to a move by nurses from higher paying hospital positions
to lower paying nonacute care settings. Not every prospective
nursing student evaluates a career based on earning potential,
but a lower salary may be a deterrent for a person who is
choosing between two career paths (Buerhaus, 1999).
A drop in the enrollment in
nursing programs has been evident since 1995, according
to annual surveys by the American Association of Colleges
of Nursing. For the last four years, the average annual
drop in baccalaureate admissions has been 5 percent. Similar
declines are evident in associate and diploma degree programs
(Buerhaus, 1999).
The nursing profession is recognizing
the need to be more proactive in marketing the benefits
of nursing, and the diversity of career options that are
available. The shifting job market has had a ripple effect
on nursing educational programs. Faculty in many nursing
programs are expanding the student’s exposure to community
health and to geriatric care programs including adult care
and day care programs and boarding homes. Health care reform
has created an even greater demand for nurses with advanced
degrees in nursing who have been educated to provide primary
care to patients in nurse-run clinics and physician’s
offices.
Aging workforce
The nursing
shortage is also affected by the aging of nurses. The average
age of today’s nurse is 47. There are a fairly substantial
number of nurses in their 50s and 60s. A large segment of
the current workforce will be retiring in the upcoming years.
These individuals cannot be replaced, either in experience
or in sheer numbers. If the number of registered nurses
under 30 entering the labor market is compared with the
number of nurses who need to be replaced, the shortfall
will be tremendous. A huge amount of knowledge and experience
will be lost at the same time that the demand for these
skills will be increasing (Buerhaus, 1999).
Attractive alternatives
to working in the hospital or nursing home
In the mid
to late 1990’s, many hospitals changed the composition
of the nursing staff by reducing the number of registered
nurses and increasing the numbers of unlicensed assistive
personnel. As a result of this change, the demands on registered
nurses to be more proficient and skilled have intensified.
New employees are expected to get "up to speed"
as quickly as possible. Nursing homes are heavily staffed
with certified nursing aides with few professional staff.
Most facilities do not have a registered nurse in the building
at all times.
Some nurses, burned out with
the stress of the hospital or nursing home environment,
have discovered work opportunities beyond the institution
walls. Rotating shifts, weekend work and working on major
holidays have added to the stress of employment in a hospital
or nursing home. Jobs are increasingly available which permit
a work life that fits in better with family responsibilities.
Specialty nurses
Not only are
sheer numbers of nurses reduced according to the need, but
the experienced competent nurse is in short supply. The
shortage primarily involves specialty areas of critical
care, emergency department, operating room and pediatric
intensive care units. Although the census of patients in
American hospitals has been reduced by the swing to outpatient
care, the patients who are in the hospital are more acutely
ill. Their care requires highly skilled nurses, who are
no longer available in the numbers needed (Hawke, 1999).
Many experienced critical care
nurses are choosing options such as case management, nursing
education, clinical information management systems (computers),
and outpatient surgicenters (Hawke, 1999). Critical care
nurses are caring for patients at home on ventilators and
continuous intravenous infusions, and are often enjoying
the change from infusions, and are often enjoying the change
from hospital nursing. Outpatient surgical centers have
drawn operating room nurses out of the hospital (Gray-Siracusa,
1999).
Do nurses make a difference?
Several
studies have suggested that higher nurse-to-patient ratios
are associated with improved patient outcomes, affecting
both morbidity (illness) and mortality (death). An American
Nurses’ Association study (American Nurses Association,
1997) found that higher nurse-to-patient ratios were associated
with shorter lengths of stay in hospitals and a reduction
in complications such as pressure sores, pneumonia, urinary
tract and postoperative infections (Knox, Kelley, Simpson
et al, 1999). These results were consistent with a study
published in 1993 (Prescott) that suggested that a higher
ratio of RNs to other nursing personnel (licensed practical
nurses, nursing assistants) was associated with lower patient
mortality. In a large-scale study of 589 randomly selected
community hospitals, Kovner and Gergen (1998) demonstrated
that there was an inverse relationship between the number
of registered nurses and adverse events following surgery.
In other words, the fewer the registered nurses, the more
frequent the complications (Knox, Kelley and Simpson et
al, 1999).
A recent literature review
shows a positive relationship between nurse staffing levels
and quality of care nursing home residents receive. Increased
RN hours were associated with fewer pressure ulcers, lower
rates of catheterization and urinary tract infection, and
a probability of longer life (Harrington, 2000.) America
needs nurses to save lives and to make a difference in the
quality of care.
A reference list is available upon request. This material
is extracted from Iyer, P. Roots of Patient Injury, in Iyer,
P. (Editor), Nursing Malpractice,
Lawyers and Judges Publishing Company, Second Edition, 2001.
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