A new study connecting overworked nurses and medical errors may arm nursing organizations with a new weapon as they lobby for state and federal legislation aimed at increasing the number of nurses at the bedside. Meanwhile, new federal immigration regulations may make such legislative relief more urgent by potentially limiting the number of foreign-born nurses who can work in the U.S.
The regulations, issued by the Department of Homeland Security, are scheduled to take effect on July 26. They will require a broad group of foreign-born healthcare workers, including nurses, seeking to work in this country to obtain special visa certifications.
The use of foreign-born nurses has been around for many years, said Judy Pendergast, director of planning, marketing and communications for the Commission on Graduates of Foreign Nursing Schools in Philadelphia, which opposed the regulations. Foreign-born nurses have never been the total solution to the nursing shortage, but they are part of the answer, Pendergast said.
The American Hospital Association said the regulations could have severe implications for facilities, especially those in large metropolitan areas and along the Canadian border that rely on nurses from north of the border.
"In this day of nursing shortages, every nurse is essential," said Carla Ruggiero, senior associate director of federal relations at the AHA, which also opposes the regulations.
When essential nurses are stretched beyond capacity, bad things can happen to patients, according to a study released last week that was conducted by the University of Pennsylvania School of Nursing. The study, which appeared in the July/August issue of Health Affairs, found that nurses who work 12.5 or more consecutive hours are three times more likely to make a patient-care mistake than nurses who worked up to 8.49 consecutive hours.
The study examined 393 full-time registered nurses who worked a total of 5,317 shifts at an unspecified number of hospitals around the country. The units included general medical-surgical floors as well as specialty-care units. The nurses were asked to keep a logbook for a two-week period to record mistakes. The study found that in 5% of shifts worked by nurses working at least 12.5 consecutive hours at least one medical error occurred. By comparison, 1.6% of shifts in which nurses worked up to 8.49 hours experienced a medical error.
The nurses reported a total of 199 errors and 213 near-errors. Some 58% of the errors involved medications; 18% were procedural; 12% were charting errors; and 7% were transcription errors.
The authors also concluded that despite efforts by individual facilities and state and federal governments to limit mandatory overtime, the practice may be on the rise. One in four nurses tracked by the study reported having to work mandatory overtime at least once during a one-month period.
"(The report) underscores things we have said for a number of years," said Carol Cooke, a spokeswoman for the American Nurses Association. The Institute of Medicine also released a report last year recommending a 12-hour limit per 24-hour work shift.
Rep. Pete Stark (D-Calif.) and Sen. Edward Kennedy (D-Mass.) last year introduced legislation to limit the number of mandatory overtime hours a nurse can work, but both bills are stuck in committee.
About 19 states have considered banning mandatory overtime, but to date such laws have been passed in only four states: California, Maine, New Jersey and Oregon, according to the Health Affairs study.
"A study like this is fuel for passage of legislation like (Stark and Kennedy's)," Cooke said.
The hospital industry has opposed laws banning mandatory overtime because it says such legislation makes it difficult to staff adequately and thereby threatens patient safety.
Meanwhile, the new immigration regulations will require nurses and other healthcare workers to receive a certificate authenticating their English proficiency, educational transcripts and work license. The regulations extend to both new employees as well as staff who have worked in this country for years and have graduated from U.S. training programs and passed exams indicating they have met minimum standards for safe practice (June 14, p. 28). The regulations apply to audiologists, licensed practical nurses, medical laboratory technologists, medical technicians, occupational therapists, physical therapists, physician assistants, registered nurses and speech-language pathologists.
According to the Immigration Policy Center in Washington, 17% of all nurses are foreign-born while 16% of clinical laboratory technicians and more than 11% of registered nurses are foreign-born.