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The health care industry is abuzz about the ongoing nursing shortage, and risk managers can expect the problem to land at their doorsteps with an intimidating thud. A shortage of nurses in your facility will inevitably lead to a decline in patient care, some experts say, and that can only lead to an increase in the liability risk.
Risk managers must take notice of the nursing shortage and prepare for its effects, says Geri Amori, PhD, ARM, FASHRM, risk manager with Fletcher Allen Health Care in Burlington, VT. Amori also is president of the American Society for Healthcare Risk Management (ASHRM) in Chicago. Amori notes that the nursing shortage actually consists of several related problems, all of which can create liability if left unchecked.
First, there are not enough people newly trained in nursing and ready to enter the work force. Second, too many nurses currently in the work force are leaving or on the verge of leaving. And third, health care organizations are scrimping on nurse staffing levels, putting as few trained nurses on the job as possible to keep their personnel costs low. Only some of those factors are within the hospital’s control, but Amori says risk managers should be motivated by the possibility of declining patient care.
"The big question is what is the right amount of nurses to take care of patients?" she says. "That’s a loaded question. Too few nurses certainly creates a risk because you have sicker patients in hospitals these days, no doubt about it. Consequently, the level of care needed is more intense. So we really should have more nurses on the job today than ever before."
Nurse staffing levels can be a contentious issue within health care organizations, a tangle of budget constraints, union demands, and differing views on clinical needs. It is understandable that risk managers would not be eager to jump into the fray, but Amori says you must. "Having too few nurses creates risk because your nurses are tired," she says. "People can only deal with a certain amount of stress before they lose it and cannot think clearly, [and they] can’t think with precision. Even if the number of nurses were OK, the intensity of the work today means we are still at increased risk. Couple that with double shifts and mandatory overtime, and you’ve got a real problem."
The risk is more than just theoretical. A hospital in Wichita, KS, recently paid $2.7 million to avoid a trial on allegations that a nurse shortage nearly killed a patient. The patient, a 63-year-old woman, entered Wesley Medical Center in 1998 for lung problems and soon went into a coma. Brad Prochaska, JD, the woman’s attorney, says the lawsuit alleged the hospital did not have enough nurses on staff to check the patient’s condition frequently, allowing her to rapidly deteriorate. At least one hospital administrator publicly admitted that the facility did not meet its own nurse staffing guidelines for significant periods of time, and hospital records filed with the court indicated the short-staffing was a chronic problem and well-known within the facility. The plaintiff originally sought $10 million in damages from the hospital but settled for $2.7 million, and the plaintiff insisted on no confidentiality agreement.
The same hospital now is facing more accusations. The family of a 55-year-old man claims he waited for more than an hour and 38 minutes in the hospital’s emergency department while complaining of chest pains, then died before being examined. In court records, the man’s family claims that even when he collapsed and a nurse screamed for help, no one else arrived until a family member went down a hallway pleading for assistance. The case is pending.
There seems to be little doubt that having too few nurses on the job can harm patients. The American Nurses Association (ANA) recently released the results of a study documenting that hospitalized patients have better outcomes in hospitals with higher staffing levels and higher ratios of RNs in the staffing mix. The study was done by Network Inc., a hospital and health care research organization. ANA president Mary Foley, MS, RN, says the connection is clear.
"Patients fare better when RNs play a significant role in their care," Foley says. "The study confirms what we have known experientially for years and what a decade of various studies has shown: RN care makes the difference in reducing complications and allowing patients to be discharged from the hospital on time and on the path to recovery. However, when RN care is reduced, patients suffer."
The study tracks five adverse outcomes measures that can be mitigated if adequate nursing care is given. Those measures include: length of stay (LOS), pneumonia contracted while in the hospital, postoperative infection, pressure ulcers (bed sores), and urinary tract infections contracted while in the hospital. Using hospital and Medicare data from nine states, the study correlates those five adverse outcomes measures with RN staffing levels and overall hospital staffing levels. All five measures are markedly decreased with higher levels of RN involvement in patient care.
"Shorter lengths of stay and fewer complications translate into lower hospital costs," Foley says. "Not only do patients fare better, but hospitals can actually save money by using highly skilled nurses in adequate numbers. It makes no sense for hospitals to cut RN staff or replace RNs with unlicensed assistive personnel who lack the education and judgment of RNs."
The ANA released the study’s findings at the Nurse Staffing Summit, held recently in Washington, DC.
"Many hospitals are experiencing a shortage of nurses that affects the quality of patient care," Foley says. "Hospitals in part created that shortage by trying to cut costs by reducing their RN staffs through attrition or layoffs in the mid-’90s. What many hospitals are doing now to address the staffing situation is mandating overtime — forcing RNs to work extremely long hours. But forcing RNs to work excessively over time is unsafe for both nurses and patients. In reality, mandatory overtime is often a business strategy to cut costs, since hospitals pay fewer benefits and do not have to keep a reserve of RNs available to address a fluctuating patient census."
The future may be worse than today. The nurse shortage in coming years will be even worse than current estimates, according to a nationwide survey released recently by the Federation of Nurses and Health Professionals, the 55,000-member health care division of the American Federation of Teachers. The survey found that one in five nurses plans to leave the profession within the next five years because of poor working conditions. Sandra Feldman, president of the American Federation of Teachers and the Federation of Nurses and Health Professionals in Washington, DC, says risk managers must look beyond the current state of affairs. "According to this survey, one in five nurses now working is seriously considering leaving within the next five years," Feldman says. "This foreshadows an even more serious and widespread crisis in health care than previously believed."
But Feldman says the survey also suggests a solution. The nurses threatening to leave say they would consider staying if improvements are made, including better staffing levels, more flexible schedules, and higher salaries. "Hospitals have to do what it takes to retain the nurses they have, try to bring back those who left in frustration, and recruit new people into the profession," she says.
According to the U.S. Department of Labor, an additional 450,000 registered nurses will be needed through the year 2008. Feldman says the newly discovered group of highly discontented nurses would exacerbate the already acute demand for more nurses.
The survey, conducted by Peter Hart Research, interviewed 700 current direct-care nurses and 207 former direct-care nurses. These are some more highlights of the survey:
• Half of nurses think about leaving. Fifty percent of current nurses say they have thought about leaving nursing. This number excludes those expected to retire. Current nurses under age 40 are nearly as likely to have thought about leaving nursing as their over-50 colleagues.
• One-fifth expect to quit soon. One in five current nurses, or 21%, say they expect to leave nursing within the next five years. These nurses, ages 18-59, plan to leave, not because they want to retire, but because they are fed up with working conditions.
• But they could be persuaded to stay. Three-fourths of the 21% who expect to quit say they would consider staying if improvements were made. Increasing staffing, better hours, and higher salaries were the top reasons for staying.
• They blame stress, irregular hours, and low morale. More than half, or 53%, of current nurses say the job has become too stressful and physically demanding. Twenty percent of current nurses say they would rather have a job with more regular hours. Among former nurses, the results vividly show declining working conditions. Of the nurses who left nursing at least five years ago, 11% say it was because of stress and the physically demanding nature of the job. Of the nurses who left less than four years ago, the percentage for that reason jumped to 35%.
Among current nurses, 68% say morale is fair or poor. The situation is most severe among hospital nurses, with 74% reporting fair or poor morale. Among those nurses who say they might leave the profession, 81% report fair or poor morale.
• If I knew then what I know now . . . Nearly half, or 49%, say they would have pursued a different career if they were just starting out. The situation is worse among those already considering a change, with 75% saying they would have chosen a different career.
• Not enough nurses. Of all the problems facing nurses, the No. 1 issue is staffing. Sixty-six percent say large patient loads are a fairly or very serious problem, and 65% say understaffing is especially problematic since patients are sicker. Sixty-four percent say they don’t have enough time to spend with patients, and 60% note the paperwork burden.
In the survey, those on the verge of leaving nursing were called "potential leavers." These are the changes that they said would convince them to stay: Better staffing ratios (87%); more patient time (81%); more input in decisions (79%); raise salaries (76%); provide performance bonuses (71%); more flexible schedules (69%); more part-time options (63%); continuing education funds (61%) and better health coverage (60%).
Feldman says risk managers concerned about the effects of a nursing shortage should work for a legislative ban on mandatory overtime as well as federal standards for health care staffing levels in hospitals and other health care facilities. She says such improvements will improve the quality of life for nurses and therefore tend to keep them on the job, but health care facilities don’t have to improve conditions purely for altruistic reasons. Improving conditions for nurses will improve patient care, she says.
Her point is supported by research from the Harvard School of Public Health in Boston. New study results show a strong relationship between nurse staffing levels and better patient outcomes. Jack Needleman, MD, and colleagues analyzed 1997 data from more than 5 million patient discharges from about 800 hospitals in 11 states. The research revealed that a higher number of registered nurses was associated with a 3%-12% reduction in the rates of five different adverse outcomes: urinary tract infection, pneumonia, shock, stomach bleeding, and longer LOS.
Higher staffing levels for all types of nurses to a decrease in adverse outcomes of up to 25%, according to the Department of Health and Human Services, which funded the study. The authors say the findings have broad implications for policy-making, data collection, and research. John Eisenberg, MD, director of the Agency for Healthcare Research and Quality, one of the study’s sponsors, says the number of nurses on the job is only part of the equation.
"We need to know more not only about how nurse staffing affects quality, but also about the working conditions in which nurses provide care," Eisenberg says. "Excellent nurses may have difficulty providing excellent care if they are working in conditions that are not conducive to quality care."
Amori says it can be difficult to make a direct correlation between a single medical error and nursing shortages, but the bigger picture is clear. "You can’t say that the fact that we had a medical error is directly attributable to the nursing shortage, but we can assume there is a correlation with hours worked, number of nurses on the floor at one time, and so on," Amori says. "Patients are far more likely to be harmed if we don’t have enough nurses caring for them. The environment is not conducive to good care, and you also see an increase in the risk to nurses, more injuries there."
Amori suggests that risk managers assert their role within the health care organization to help solve the problem, stressing to administrators that there is a financial incentive for improvement. Consider how the organization structures rotation patterns, how much assistance you provide nurses with nonskilled tasks, and how much of a paperwork burden you place on the nursing staff.
"And of course, we have to ask if we are reimbursing our nurses properly. Do we give people incentives to go into nursing and remain in nursing, or do we teach them that nursing is a second-class activity?" Amori says. "We need to advocate for these things, not only because it is the right thing to do to treat them like human beings, but because there will be financial costs if we don’t."