The task facing the new federal nursing commission will be as easy to accomplish as finding a nurse who doesn't claim to be overworked and underpaid.
In other words, next to impossible.
But that didn't stop Congress from authorizing the federal Institute of Medicine to convene a panel of experts to explore the relationship between nurse staffing levels, patient care and workplace injuries suffered by nurses.
At a cost of $900,000, the new commission is charged with solving problems created by healthcare employers who followed the recommendations of the first national nursing commission, which disbanded in 1989.
The first commission concluded that one of the causes of the nursing shortage in the mid-1980s was that hospitals and other healthcare employers hired too many nurses. It recommended reassigning the non-nurse duties often delegated to nurses.
Gone too far? Now, many of the same special-interest groups that wanted healthcare employers to relieve nurses of responsibilities deemed unworthy of them say employers have tinkered with the skill mix of bedside workers to the point of hurting patients and nurses.
MODERN HEALTHCARE's 1993 human resources survey found that more than a quarter of the hospital respondents are trimming their work forces-many by as much as 24% (Dec. 20-27, 1993, p. 49). Some 20% of those making staff cuts are targeting nurses.
Healthcare employers say they have to take such actions to reduce their cost structure and cope with reform. They say nursing groups simply are trying to protect nursing jobs while wrapping their true intentions in the "We're-doing-it-for-patients" banner.
Nursing groups took their complaints to Congress in early 1993, and the Service Employees International Union led the charge.
The Washington-based SEIU represents 400,000 healthcare workers. About 90,000 of those workers are either registered nurses or licensed practical nurses.
In January 1993, the SEIU released the results of a survey of 10,000 of its nurses (Jan. 11, 1993, p. 6). Sixty-nine percent of the nurses said their facilities operated with inadequate nurse staffing levels. Another 45% attributed adverse patient incidents, such as medication errors, to staffing and workload problems. Many also blamed inadequate staffing for workplace injuries.
The SEIU presented its survey results to the House Energy and Commerce health subcommittee at a Feb. 3, 1993, hearing. The SEIU called for federal legislation that would set minimum nurse staffing levels at healthcare facilities, said Mary Kay Henry, director of SEIU's healthcare division.
She said the union approached Sen. Edward Kennedy (D-Mass.), who chairs the Senate Labor and Human Resources Committee, as well as Rep. Henry Waxman (D-Calif.), the House subcommittee chair, with its request.
"But they said they were not ready for legislation because there was no data, and they didn't want to fix something in the wrong way," she said.
Another forum. Instead, the SEIU-at this point joined by the American Nurses Association-successfully lobbied to have its concerns addressed by a new federal commission created under the National Institutes of Health Revitalization Act, which Congress passed in June 1993.
The Washington-based ANA represents 205,000 registered nurses through its affiliated state nursing associations. In a Feb. 10, 1993, letter to Mr. Waxman, the ANA said, "ANA stands behind a strong tradition of advocating for patients' rights and fully believes that adequate staffing levels in healthcare settings directly result in patient satisfaction and quality patient care."
A provision of the 1993 law authorized the Institute of Medicine, an arm of the National Academy of Sciences, to conduct a study to determine "to what extent there is a need for an increase in the number of nurses in hospitals and nursing homes in order to promote the quality of patient care and reduce the incidence among nurses of work-related injuries and stress."
That's the job facing the Institute of Medicine and a committee of 15 healthcare experts appointed by the agency in April. They've since embarked on a 22-month journey to study the overall question of the adequacy of the supply and skill mix of nurses in hospitals and nursing homes.
Carolyne Davis, a top healthcare adviser in the Washington office of Ernst & Young, chairs the Institute of Medicine's nurse staffing committee. She's a nurse and former HCFA administrator, and she was chair of the first federal nursing commission.
In fact, four members of the original commission now sit on the new committee (See box).
The first commission was appointed in 1988 by former HHS Secretary Otis Bowen. Its 20 members studied the then-serious nursing shortage, detailing its causes and offering solutions in a final report to HHS (Dec. 16, 1988, p. 5). The commission disbanded in September 1989 after Congress failed to authorize money to save the group.
The new committee will carry out its mission in much the same way as the original did. It will:
Collect and analyze existing data on staffing levels and patient outcomes.
Conduct site visits to hospitals and nursing homes.
Solicit and review written testimony from nurses and healthcare employers.
Hold two public meetings to hear oral testimony from nurses and healthcare employers. The first meeting will be in Washington in October. The second, in Irvine, Calif., in January.
It will then issue a final report to Congress on its findings, and those involved expect that another hearing will occur.
High stakes, emotions. The road to the final report likely will be bumpy given the emotion surrounding the issue and the stake that nursing organizations have in the outcome. They need the report to validate their complaints, and they're already putting heat on the new committee.
For example, the appointees' backgrounds have been an issue, according to several of the committee's key players, who've expressed trepidation about the task before them.
"There's some nervousness that I'm chairing the committee," Ms. Davis said. "The unions preferred a union person."
The committee's mix of nurses, academics, employers and economists was an attempt by the Institute of Medicine to keep the panel neutral, Ms. Davis said.
Gooloo Wunderlich, the institute's study director assigned to the nursing project, said the agency rejected calls for an all-nurse committee.
"We have six nurses on the committee. We couldn't have all nurses because the public wouldn't accept our findings," Ms. Wunderlich said.
To throw some water on overheating nursing organizations, the institute created a special liaison committee to the commission. It will be composed of representatives from about 20 special-interest groups, including nursing organizations, Ms. Wunderlich said.
Represented on the liaison committee will be groups such as the ANA, the SEIU, the American Hospital Association and the American Organization of Nurse Executives. But Ms. Wunderlich declined to provide the names of all the organizations, fearing a release of the list would elicit complaints from those not invited.
If the commission doesn't conclude that healthcare employers are cutting nursing positions to the detriment of nurses and patients, the commission probably didn't do its job right, said Karen O'Connor, the ANA's deputy executive director.
"I don't believe it will happen. There's too much data in the field that say otherwise," Ms. O'Connor said.
Just in case, the Washington-based trade group has hired Lewin-VHI, the Fairfax, Va.-based consulting firm that's received some notoriety in the healthcare reform debate for often reaching conclusions that support whoever's paying for the study.
Ms. O'Connor said the Lewin study is based on a series of focus groups involving nurses who attended the ANA's annual meeting last month in San Antonio, Texas.
She said the study, expected to be released this fall, will show that the ANA's concerns are based on more than just anecdotal reports from nurses. She said the study will reveal that some healthcare employers have violated state nursing practice acts by assigning lower-skilled workers to jobs formerly held by registered nurses.
"It's easy to conceive of our position as self-serving. But we're not talking about jobs. We're talking about patient care. Patient advocacy is at the core of the nursing profession," she said.
The ANA is concerned about the staff reductions taking place at many hospitals, but patient days are declining and staffing levels have to be adjusted, said Diana Weaver, president of the AONE, an AHA subsidiary. She's senior vice president for patient care at Yale-New Haven (Conn.) Hospital.
Ms. Weaver said the AONE will be encouraging hospitals that have developed innovative nursing-care delivery models to come forward with their stories and any data they have about the models' effects on patient care.
Still, the relationship between nurse staffing levels and the quality of patient care should be studied by the new federal committee to ensure patient safety isn't jeopardized, Ms. Weaver said.
"I don't believe anyone is willingly moving in that direction," she said. "But there's no baseline. We can't say how far hospitals have gone."
But, Ms. Weaver emphasized that the committee's final report shouldn't be a foregone conclusion.