Nurse Staffing: Critical Condition

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 shows 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 than existed 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 another 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 Nursing Malpractice, Lawyers, and Judges Publishing Company, Second Edition, 2001.

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