Sentinel events now linked to nursing shortage

New information shows that the nursing shortage is responsible for a quarter of sentinel events and poses a major risk to patient safety.

Now the Joint Commission on Accreditation of Healthcare Organizations says the time has come to act. The Joint Commission recently issued a major report, "Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis," and held a news conference to call for immediate action. Broad changes are needed in the health care industry to keep patients safe, says Dennis S. O’Leary, MD, Joint Commission president.

"We now have clear data linking nurse staffing levels to quality of care," he says. "We didn’t have that before."

The report states that the nursing shortage "is putting patient lives in danger and requires immediate attention," leading a special Joint Commission roundtable to develop a set of recommendations. Some of those recommendations involve legislation and other action on a nationwide level, but O’Leary says there also is much to be done in individual facilities. A primary goal of the roundtable’s recommendations is to improve the work life of nurses.

He and the other roundtable members stress that the nursing shortage is no longer just an administrative problem. The data now show a direct, troubling link between the nursing shortage and major medical errors that lead to sentinel events. Marilyn P. Chow, RN, DNSc, FAAN, vice president of patient care services for the California Division of Kaiser Permanente, says, "We have elements of a perfect storm brewing. Aging nurses and faculty, fewer people coming into the profession, and an aging population. We need to intervene now to prevent that perfect storm from occurring."

O’Leary called the nursing shortage "a prescription for disaster."

He and the other experts repeatedly draw attention to the data, to illustrate that the connection between patient safety and the nursing shortage is more than just theoretical. Joint Commission analyses show that nurse-staffing levels have been a factor in 24% of the 1,609 sentinel events that have been reported to the Joint Commission over the past five years. Chow says that nursing shortages could be an underlying cause when other contributing factors, such as patient assessment, caregiver orientation and training, communication, and staff competency led to the sentinel event.

The link can be broken, O’Leary says. Studies have shown a positive impact on patient safety when nurse-staffing levels are optimized. More nurses mean fewer complications, fewer adverse events, shorter lengths of stay, and lower mortality, he says.

The nursing shortage didn’t happen overnight and won’t be solved overnight, O’Leary says. For years, providers have seen a combination of longstanding shortages in the nursing field and rapidly increasing demands for more nursing care. More than 126,000 nursing positions are unfilled now, and O’Leary says that figure will climb as 78 million aging baby boomers begin placing unprecedented demands on the country’s health care system.

"Ninety percent of nursing homes report an insufficient number of nurses to provide even the most basic of care, and some home health agencies are being forced to refuse new admissions," he says.

To make things worse, currently working nurses are aging right out of the workplace. The average age of a working registered nurse today is 43.3, according to the Joint Commission, and that average age is increasing at a rate more than twice that of all other work forces in this country. Researchers project that by 2010, the average age of the working registered nurse will be 50.

Too few nurses and overworked nurses put patients directly at risk, says Sally A. Sample, RN, MN, FAAN, moderator of the Joint Commission’s nurse staffing roundtable and former commissioner of the Joint Commission. In a recent survey cited in the Joint Commission’s report, 31% of nurses reporting that patients in their last shift did not receive necessary skin care, 20% saying patients did not receive oral care, and 28% saying that they were unable to provide adequate education and instruction to patients and their families. Studies also have shown that overworked nurses don’t wash their hands often enough, leading to more nosocomial infections.

When nurses are in such short supply, you also may end up with more new, inexperienced nurses. That can be a significant liability risk when patient safety is threatened, Sample says. Experienced nurses are better able to do several things at once without sacrificing quality of care, she says. Too many of those experienced nurses are quitting the nursing profession or moving on to more appealing work environments such as home care.

"The newer nurses are not as capable of doing these multiple tasks, and that poses an increasing risk to patients," she says. "You may have replaced a nurse with another nurse, but the quality of care isn’t the same."

16 steps you can take to address the problem

The Joint Commission’s roundtable recommended 16 steps that providers can take immediately to help address the nursing shortage. The roundtable members urge risk managers and other hospital leaders to organize local solutions and not depend entirely on the work being done on a national level. These are the Joint Commission’s recommendations:

1. Create a culture of retention for nursing staff.

2. Adopt the characteristics of magnet hospitals to foster a workplace that empowers and is respectful of nursing staff.

3. Provide management training, as well as support, to nurse executives.

4. Delegate authority to nursing executives and other nurse managers, and in turn to staff nurses, for patient care and resource deployment decisions.

5. Positively transform nursing work through the use of information and ergonomic technologies. Adopt information, ergonomic, and other technologies designed to improve workflow and reduce risks of error and injury.

6. Minimize the paperwork and administrative burden that takes nursing time away from patient care.

7. Measure, analyze, and improve staffing effectiveness.

8. Set staffing levels based on nurse competency and skill mix relative to patient mix and acuity.

9. Limit the use of mandatory overtime to emergency situations.

10. Adopt zero-tolerance policies for abusive behaviors by health care practitioners who work with nurses.

11. Diversify the nursing work force to broaden the base of potential caregivers.

12. Increase funding for nursing education, including endowments, scholarships and federal appropriations.

13. Establish a standardized, postgraduate nursing residency program.

14. Emphasize team training in nursing education.

15. Enhance support of nursing orientation in-service and continuing education in hospitals.

16. Adopt fair and competitive compensation and benefit packages for nursing staff. Use nursing career ladders commensurate with educational level and experience.