Hospital restructuring and changes in the nursing workload are harming patients, U.S. nurses report in a survey to be released this week.
By a wide margin, nurses think they have less time to teach and comfort patients and to provide basic nursing care. They also report increases in the numbers of patients assigned per nurse and in adverse patient-care events.
"The survey results are painting a bleak picture of what's going on in hospitals today," said Martin DiCarlantonio, editor of the American Journal of Nursing, where a news story about the survey will be published in July. Results are being released this week in Washington in conjunction with the American Nurses Association's centennial convention.
The patient-care survey was designed by Judith Shindul-Rothschild, an assistant professor at Boston College School of Nursing, to find out how changes in nursing-specifically, moves to reduce nursing labor costs-are affecting patient care. Her goal was to analyze how the number and mix of nursing personnel, combined with organizational changes in healthcare delivery, is altering nurses' perception of the quality of care where they work.
The survey form was inserted in the March issue of AJN. So far, 5,000 surveys have been tabulated and analyzed. Shindul-Rothschild expects the eventual sample size to number about 10,000, making this the most comprehensive survey of nurses' views on patient care.
"It is a huge sample," she said. "It is tough to ignore the responses of five figures of what any group of providers say is happening in healthcare."
Seventy-six percent of respondents are hospital nurses, slightly higher than the actual percentage of nurses in that care setting.
The results are sobering. Fully 57% feel the quality of nursing care they provide fails to meet their professional standards; 37% would not recommend a family member receive care where they work. An overwhelming majority-87%-believes the use of unlicensed assistant personnel does not improve the quality of nursing care.
A rise in hospital infections was reported by 32% of respondents, while 58% said they stayed the same and 10% said they declined. Some 27% said patient skin problems were more frequent, while 57% said they were the same. Twenty-two percent said patients are injured more, vs. 14% who said they were injured less and 64% who said injuries remained constant.
Medication errors have increased, said 37% of respondents, and even more-42%-indicated that secondary complications are up. Complaints by patients and families are rising, 55% said. And 53% said their hospitals are seeing more unexpected readmissions.
"What surprised me most were the numbers of nurses reporting reductions in nurse managers and loss of RN executive without replacement," Shindul-Rothschild said. "Those figures shocked me."
Thirty-nine percent reported they had lost the top registered nurse executive at their facility and the executive had not been replaced. Forty-five percent reported a reduction in nurse managers.
"Nurses are getting hit at all levels of the hierarchy in our profession," Shindul-Rothschild said. "You have this dramatic structural change in the use and numbers of RNs at all levels. Then you see that overwhelmingly, 74% say they have less time to teach patients, comfort and talk to patients; 69% say they have less time to provide basic nursing care; 58% say they have less time to consult with the patient-care team."
Although the survey consists of multiple-choice questions and is designed to be read by machine, many respondents submitted written comments. A nurse from Alaska described the "fiasco" of unlicensed personnel being hired to replace registered nurses: "People off the street with no medical knowledge or experience after one day's training are drawing labs. People are being stuck three to 10 times for lab work."
The nurse said she is so exhausted from overwork that she sometimes calls the nurse on the next shift to double check that she gave the right medications to patients. At age 30 she is wondering how long she will have the physical and mental stamina to continue in nursing.
Shindul-Rothschild said physical exhaustion is a common thread in the written responses.
"Nurses are working extraordinarily hard so that quality of care is not jeopardized in any way, to the point that they may be incurring injuries themselves," she said. That conclusion would be supported by the data, which show 43% of respondents said nurses are suffering more work-related injuries. About 9% reported fewer injuries, and 48% indicated the same amount.
"What this study suggests to me is, before we start seeing bad things happen to patients, you're going to see nurses themselves suffering, taking the toll physically for the inordinate demands that have been put on them to care for seriously, seriously ill patients," Shindul-Rothschild said.
Another surprising finding is that nurses reported declining continuity of care. The managed-care revolution is supposed to increase continuity. Yet only 12% of nurses support that view. The majority, 54%, said there is less continuity, and 34% said it has stayed the same.
"As a psychiatric nurse, I can say it makes sense with my personal experience," Shindul-Rothschild said. "As managed-care providers seek to negotiate lower and lower discounts from year to year, they change contracts." Patients' relationships with providers and therapists constantly are being disrupted. Based on the nurses' responses, Shindul-Rothschild thinks continuity of patient care under managed care should receive further research.
Shindul-Rothschild said the survey results should be taken seriously because nurses work in every facet of healthcare, and they work in closest proximity to patients.
"Nurses are trying to get patients the care they need," she said. "Their views can be trusted. I think the public knows that."