Despite a nurse shortage that worsens each year, hospitals must find ways to scale back the workload of their staff nurses, send them off to training sessions more often and avoid using agencies for fill-in nurses, according to yet another Institute of Medicine report critical of safety conditions in healthcare.
The 328-page report issued last week described a daily norm in which hospital nurses often struggle to care for more patients than they should while fighting off fatigue from too many hours on the job. In hospitals regularly filled nearly to capacity with patients suffering from ever more complex problems, nurses face deficits of time and experience in meeting their responsibilities without making mistakes that cause harm to patients, the report asserted.
Among the recommendations for improvement, the IOM called on state regulators to prohibit nurses from working more than 12 hours per day and more than 60 hours per week. It also said facilities should incorporate some excess nurse capacity into each shift to accommodate unanticipated increases in workload.
The report criticized cutbacks in continuing education of nurses when higher acuity levels of patients are combining with new techniques and technology to make training critical to an adequate understanding of their jobs. The IOM said increased use of nurses from temporary agencies who are unfamiliar with the work environment further detracts from the knowledge and skill level of nursing staff.
In addition, the report called for following other methods of preserving safe staffing levels, such as giving nurses authority to halt admissions to their units when they determine that staffing is inadequate to take any new patients.
"Creating work environments that reduce errors and increase patient safety will require fundamental changes in how nurses work, how they are deployed and how the very culture of the organization understands and acts on safety," said Donald Steinwachs, chairman of the 18-member panel that wrote the IOM report.
Until hospitals make those fundamental changes, hospitals will continue to be breeding grounds for medical errors, the report warned. Falling back on the nurse shortage as a reason for inaction won't cut it, said Steinwachs, who chairs the health policy and management department of Johns Hopkins University's Bloomberg School of Public Health.
"We believe strongly that it is not an excuse to allow current problems in patient safety to continue just because you are saying, 'Well, it is difficult to recruit nurses,' " he said.
The expansive report "identified areas where there are potential efficiencies that would free up nursing time, and therefore effectively the same staff could do more patient care than they had been (doing) before," Steinwachs said.
Much of the emphasis was on reducing nurse turnover, which aggravates shortages while increasing the risks and costs of care during extended periods of recruiting and training. But retention strategies won't be enough to offset the shortage and achieve the IOM's "wonderful ideal" for improved safety, said Susan Van Gelder, senior vice president of strategic policy at the Federation of American Hospitals.
Escalating general demand for nurses, complicated by additional spikes in demand for such needs as required staffing ratios in California, have healthcare managers scrapping for available professionals, she said. Meanwhile, nursing schools are not turning out graduates at the rate needed to keep up with the demand. The 70,500 candidates taking the registered nurse licensing exam in 2002 was nearly unchanged from the 71,000 registrants in 2000 and represented a 27% decline from 96,500 in 1995, according to the American Association of Colleges of Nursing.
"It's just so frustrating to hospitals," Van Gelder said. "They want to do the right thing, but these nurses don't exist." To fix that, it's up to hospitals to make nursing more appealing and bring more satisfaction to the job through changes in culture that bestow more value and power, Steinwachs said.
"Nurse turnover creates part of the staffing problems that we face today at hospitals and nursing homes," he said. "And to the extent that nurse turnover is tied-as we suspect-to levels of dissatisfaction as well as other factors, it contributes to many of the problems that we may face in trying to attract people into nursing careers in the future."
Among other things, hospitals would have to reverse a widespread loss of trust in hospital administration that "stems in part from a perception that initiatives in patient care and nursing work design have emphasized efficiency over patient safety," according to the report.
The report blamed part of the management problem on a reduction in clinical nursing leadership during a decade of budget-driven reorganization. By eliminating separate nursing departments, reducing ranks of nursing managers and increasing work responsibilities of remaining managers, hospitals cumulatively have reduced direct support of patient-care staff. "This situation hampers nurses' ability to fix problems in their work environments that threaten patient safety," the report concluded.
Commissioned by the HHS' Agency for Healthcare Research and Quality, the new report built on previous IOM reports in 1999 on the prevalence of medical errors and in 2001 on reorganizing the healthcare delivery system, IOM President Harvey Fineberg said. Like the first two, the latest report, Keeping Patients Safe: Transforming the Work Environment of Nurses, maintained that better execution will not help and fundamental processes of care must change.
"We are talking about building a culture that pushes decisionmaking down in the organization," said William Rupp, an IOM committee member and president and chief executive officer of Immanuel St. Joseph's-Mayo Health System, Mankato, Minn. "Most organizations in healthcare are quite hierarchical. ... We're putting it on paper saying we have to do it differently."
At Luther Midelfort-Mayo Health System in Eau Claire, Wis., where Rupp was the top executive until a year ago, a host of changes along the lines of the IOM recommendations helped reduce the nurse vacancy rate from about 9% to less than 1% within two years.
Citing mentions of turnover rates as high as 25% at some hospitals, Rupp emphasized, "If we can build a culture in our organizations where the nurses have an active role in making decisions ... that turnover drops dramatically." He added, "The number of people you have to hire then goes down dramatically when you're not replacing 25% of the workforce every year."
"So often people are not calculating that into the cost of turnover," said Rita Turley, president of the American Organization of Nurse Executives and an interim nurse executive at St. Mary's Mercy Medical Center, Grand Rapids, Mich. Turley said it costs $30,000 to $60,000 to replace a nurse depending on specialization.
Luther Midelfort managers "spent a lot of time talking about safety, asking nurses what we should do to make the place safer," Rupp said. The organization set up a staffing policy that allows nurses on a unit to halt admissions.
The administration gave floor nurses authority on an hourly basis to determine whether they had the numbers of nurses and right mix of experience to handle more patients, he said.