long-awaited federal study on the adequacy of nurse staffing has found that hospitals and nursing homes need to adjust the uses to which they put their nursing staffs and develop their personnel better to adapt to the rapidly evolving healthcare system.
However, the report, Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?, published last week by the Institute of Medicine on request of Congress, also found that enough nurses exist to meet national needs.
In 1993, nursing unions had requested federal rules mandating minimum nurse staffing levels. Instead, Congress asked for more data. The Service Employees International Union and the American Nurses Association lobbied to have a special commission investigate whether nurse staffing was sufficient to ensure quality of care.
They didn't get entirely the result they wanted. The institute said in its report that overall, it could not find evidence of inadequate nurse staffing. In particular instances, staffing may be insufficient, but the commission declined to suggest firm nurse-to-patient ratios.
"We honestly looked at that a long time and finally decided we couldn't because the acuity level varies so much between institutions that there's no way you can be fair by mandating a particular level," said Carolyne Davis, a nurse and Ernst & Young consultant who chaired the commission.
The SEIU nevertheless called the report "a giant step in the right direction." Rhonda Goode, an SEIU nurse in Los Angeles, said: "This study officially acknowledges....the strong link between qualified nursing staff and the safety of patients."
David Keepnews of the ANA said: "There's nothing in there we would disagree with. A lot of the recommendations are good, some are a good start. We share their concern with the lack of concrete data, although we do think there is such a mountain of anecdotal evidence that this problem can't be avoided."
During the 21/2 years of its existence, the commission conducted site visits, held hearings in which it took oral testimony, accepted written testimony, commissioned papers and reviewed nursing literature.
Based largely on demographic projections of an aging population and the increasing need for qualified personnel, the study found there are and will be plenty of jobs for nurses. But hospital nurses need to gain advanced clinical and supervisory skills so they can assume a greater role in guiding patient care. Ancillary nursing personnel should get better training from hospitals and nursing homes and should have their competence documented and certified, it found.
Davis said she was shocked to discover that many hospitals are not collecting data to analyze results of redesigned nursing care. "We feel absolutely that hospitals must collect data that relate to the outcomes," she said.
But the diminishing role of hospitals within the healthcare continuum means the real future for nurses may lie elsewhere: in HMOs, ambulatory surgery centers and nursing homes.
The report recommends that nursing homes have registered nurses on duty 24 hours a day, rather than eight, as now required. The aggregate additional cost, which the commission roughly calculated at $338 million, should be recognized in Medicare and Medicaid reimbursement formulas.