JCAHO: Nursing shortage puts patients at risk, demands immediate attention

Joint Commission announces push for wide-ranging changes

The worsening shortage of nurses in the United States poses a direct threat to the quality of health care and the safety of patients, according to an urgent call to action by the Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.

A significant number of sentinel events and other adverse outcomes are a direct result of the nursing shortage, says Dennis S. O’Leary, MD, president of the Joint Commission.

The accrediting body recently released a major report, Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis, and held a news conference to announce a push for wide-ranging changes in the health care industry.

A shortage of nurses may seem like old news to most hospital administrators and quality leaders, but the Joint Commission now is going on the offensive to fight the problem. In a recent report, the Joint Commission warns the nursing shortage "is putting patient lives in danger and requires immediate attention."

A special Joint Commission roundtable has developed a set of recommendations for combating the problem, and many of those steps would require substantial action by the federal government and national organizations.

There is much to be done on a local level, however, and the task force has a list for individual facilities and quality professionals to start working on. 

The task force’s major recommendations involve transforming the nursing workplace into one that nurses will want to stay in for years, creating a clinical foundation for nursing educational preparation and advancement, and providing financial incentives for health care organizations to invest in high-quality nursing care.

O’Leary stresses that the goal is bigger than just trying to make nurses more content with their work, and it’s bigger than simply filling nursing positions that are currently open.

Failure to address this problem aggressively, he says, is likely to result in increased deaths, complications, length of stay, and other undesirable patient outcomes.

"Nurses are the front line of health care, but today there are simply not enough nurses to meet the needs of patients," O’Leary says. "Dramatic changes must be made now and in the next few years to avoid a crisis in patient care."

The problem is acute, 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 that number is expected to skyrocket just as 78 million aging baby boomers begin placing unprecedented demands on the country’s health care system, he says.

"The nurse staffing problem is today a major factor in emergency department overcrowding, cancellation of elective surgeries, discontinuation of clinical services, and the limited ability of the health system to respond to any mass-casualty incident," O’Leary says. "In addition, 90% 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." The future looks even worse, and that is one reason the Joint Commission is urging immediate action, he adds. The Joint Commission estimates that by 2020, there will be at least 400,000 fewer nurses available to provide care than will be needed.

Compounding the shortage is the fact that the nurses who are available to care for patients will be aging right along with their baby-boomer peers. 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. Only 12% of registered nurses in the work force are under the age of 30, a decline of 41% compared to a 1% decline for all other occupations.

Researchers project that by 2010, the average age of the working registered nurse will be 50.

The shortage of nurses affects quality of care in a number of ways, O’Leary says. Some effects are hard to quantify but still very serious, such as an overworked nurse’s inability to pay attention to his or her patients. Other problems can be demonstrated more directly, such as the fact that overworked nurses tend not to wash their hands as often as they should, leading to an increase in nosocomial infections.

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

In one recent survey cited in the Joint Commission’s report, 31% of nurses reported that patients in their last shift did not receive necessary skin care; 20% said patients did not receive oral care; and 28% said that they were unable to provide adequate education and instruction to patients and their families.

Another problem is that new nurses are being thrust into complex care situations without the necessary experience, says Sally A. Sample, RN, MN, FAAN, moderator of the Joint Commission’s nurse staffing roundtable and former commissioner of the Joint Commission. Experienced nurses gain the ability to multitask — to take care of several patient concerns at once without diminishing quality, she says. But those experienced nurses are either quitting the nursing profession altogether 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."

Participants in the Joint Commission round-table brought out the big metaphors in an effort to emphasize the seriousness of the nursing shortage and its direct effect on quality of care. Marilyn P. Chow, RN, DNSc, FAAN, vice president of patient care services for Oakland, CA-based 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."

According to O’Leary, the nursing shortage is "a prescription for disaster." Recently acquired data bring the threat into sharper focus, he says.

Joint Commission data show that staffing levels have been a factor in 24% of the 1,609 sentinel events that have been reported to the Joint Com-mission over the past five years.

Other identified contributing factors, such as patient assessment, caregiver orientation and training, communication, and staff competency, implicate nursing problems as well. Conversely, O’Leary says, several studies have shown the positive impact on quality, costs, and health outcomes when nurse staffing levels are optimized — fewer complications, fewer adverse events, shorter lengths of stay, and lower mortality.

Quality is not the only casualty of the nursing shortage; hospitals also are able to treat fewer patients than if they were fully staffed with nurses. In a recent study conducted on behalf of the American Hospital Association, respondents reported that the nursing shortage has caused emergency department overcrowding in their hospitals (38%); diversion of emergency patients (25%); reduced number of staffed beds (23%); discontinuation of programs and services (17%); and cancellation of elective surgeries (10%). In this same study, nearly 60% of respondents reported that nurses feel it is more difficult to provide quality care today because of work force shortages.

Some health care professionals may dismiss the Joint Commission’s call to action as just another superficial response to a longstanding problem, but Sample discourages that reaction. The current crisis is far worse than any in the past and demands a more serious response, she says.

"I’ve seen many shortages in my career, but this situation we face now is untenable," she says. "Nurses are being described as the canaries in the coal mine, and if the coal mine is our nation’s hospitals, they need immediate improvement."

[For more information: Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Web: www.jcaho.org.]

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