Op-Ed: Ration Nursing Care – And Patients Pay
May 1, 2000
Another nursing shortage is looming -- in some regions it has arrived -- causing concern to those of us in the profession who recognize the impact less RN care has on patients. While cyclical shortages are not new, this one is different in that those who have the greatest interest in fixing the shortage – employers of nurses – have contributed to the shortage and in some cases are making it worse.
There are exceptions, but many providers of health care services, such as hospitals, in part created the shortage themselves by reducing their RN staffs in the 1990s in response to pressures to cut costs. Nurse staffing levels were reduced through layoff and attrition. But in a fairly short amount of time, even management consultants had to recognize what nurses have known all along – that patients suffer when RN care is rationed. Not only do patients suffer, but in the long run, care is more expensive.
A new study further substantiates the link between RN staffing and quality patient care. Released early in May 2000, a study from the American Nurses Association, done by hospital and health care research organization Network, Inc., finds that hospitalized patients have better health care outcomes -- better results -- in hospitals with higher staffing levels and higher ratios of RNs in the staffing mix. Network, Inc. tracked several adverse outcomes measures that can be mitigated if adequate nursing care is given. Those measures include: length of stay in the hospital, pneumonia contracted while in the hospital, postoperative infections, bed sores, and urinary tract infections contracted while in the hospital.
Using hospital and Medicare data from nine states, the study correlates these measures with RN staffing levels and overall hospital staffing levels. All measures are markedly better with higher levels of RN involvement in patient care. In other words, patients had fewer complications and recuperated more quickly. Patients who recuperate more quickly leave the hospital sooner, with a lesser chance of being readmitted, which satisfies those watching the bottom line.
This study was released at a Nurse Staffing Summit held in Washington, DC, May 1-2. Nurse leaders and representatives of various public and private organizations involved in health care quality gathered to evaluate the staffing situation and define solutions.
The summit heard from nurses who report that some hospitals are using the rationale of shortages to justify excessive mandatory overtime – forcing RNs to work 16 or more hours non-stop. The most egregious hospitals claim they must have the ability to require nurses to stay up to an additional eight hours, even when those nurses are just coming off an eight-hour shift. Requiring up to four hours of mandatory overtime is commonplace.
No other industry mandates such excessive overtime. In fact, many industries regulate hours of work and rest to protect public safety. Truckers are required to rest for eight to ten hours before an eight to ten hour driving shift. Public transport workers also have standards. Yet those who care for the sickest among us have no such protections, and many feel obliged to accept additional hours when managers threaten their jobs if they refuse overtime assignments.
While staffing issues are very real, forcing nurses to work exhausted is not the solution. In reality, all to often this is another cost-cutting tactic. By using overtime, hospital management does not have to pay benefits to additional nurses and does not have to maintain a pool of reserve nurses to address fluctuating patient levels. What is the result of forcing nurses to work excessive mandatory overtime? A greater chance of injury to patient and nurse, more turnover and a compounded staffing problem.
Beyond abusing overtime, some hospitals are slow to address other health and safety issues, such as investing in lifting equipment necessary to move patients safely – for both the patient and the attending nurse. Many are slow to invest in systems that make handling needles and other sharp instruments less risky. More than 1,000 health care workers each year contract hepatitis B or HIV by accidentally injuring themselves in the rush that now defines the pace of work in American hospitals. Staffing levels play into these situations as well. Shortages mean everyone is stretched thin and errors are made, errors that may hurt nurses and patients.
The Institute of Medicine (IOM) surprised many with its report which unveiled the number of deaths that occur annually due to medical errors – close to 100,000. The IOM recommends that part of the solution rests in developing safe health care systems that address work hours, work loads, sufficient staffing and personnel support, shift assignments as well as the impact on patient care when nurses work beyond their ability to provide safe and quality services.
The real solution to the nursing shortage lies in making the nursing work environment rewarding, safe and professional, so that nurses can offer quality care to patients. Until administrators recognize the value of a safe and healthy work environment, hospitals will reap the fall out: not enough professional staff to provide the best care possible.
Just as consumers objected to "drive-through" deliveries and mastectomies, they must make their voices heard in protest against the rationing of nursing care. Nurses' advocacy on behalf of their patients is a professional responsibility. Consumers have much to fear if their advocate is absent from their bedside.
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ANA is the only full-service professional organization representing the nation's 2.6 million registered nurses through its 53 constituent associations. ANA advances the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying Congress and regulatory agencies on health care issues affecting nurses and the public.