Joint Commission issues marching orders to combat nursing shortage

There’s plenty you can do to retain nurses and improve quality

Hospitals and other health care organizations must take action on a local level to combat the nursing shortage that threatens the quality of the nation’s entire health care system, says Dennis S. O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations. Quality and peer review professionals must take the initiative to improve the lot of nurses currently in the workplace and to attract more people to the profession, he says.

O’Leary cautions that health care providers must not rely on the work being done at the national level to solve the problem. Grass-roots efforts must address some of the most fundamental problems that caused the nursing shortage, he says. The Joint Commission’s recent call to action on the nursing shortage, in which O’Leary announced that a significant number of sentinel events and other adverse outcomes are a direct result of the nursing shortage, includes a plan for the organization to push for major changes on a federal level, but that is only part of the response. He also stresses that this problem is one for all health care leaders, including quality professionals, to address. It is not simply an issue for nursing directors.

"This is a call to action," O’Leary says. "We in health care are at a crossroads, and the time to act is now."

While the Joint Commission lobbies Congress and takes other large-scale actions, O’Leary encourages health care quality professionals to follow the steps outlined in the Joint Commission’s report, Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis.

In that report, the Joint Commission warns the nursing shortage "is putting patient lives in danger and requires immediate attention." To counter that problem, local providers should pursue 16 steps that change the nursing workplace into one that nurses will want to stay in for years, while also creating a clinical foundation for nursing educational preparation and advancement.

The Joint Commission’s roundtable of experts came up with 16 recommendations for transforming the workplace and aligning nursing education and clinical experience.

These are the specific steps that the Joint Commission says hospitals should start working on immediately:

1. Create a culture of retention for nursing staff.

2. Adopt the characteristics of "magnet" hospitals to foster a workplace that empowers and respects 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 work flow and reduce risks of error and injury.

6. Minimize the paperwork and administrative burdens 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, post-graduate nursing residency program.

14. Emphasize team-training in nursing education.

15. Enhance support of nursing orientation inservice 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.

Make nurses’ jobs better to retain them

Many of those steps are aimed at improving the everyday work life of nurses, explains Marilyn P. Chow, RN, DNSc, FAAN, vice president of patient care services for the California Division of Kaiser Permanente, and a member of the Joint Commission’s roundtable.

"Part of the problem, a big part, is that nurses don’t like coming to work every day because of what they face, and that means you can lose that nurse and you can lose every potential future nurse that person talks to," she says. "To have young people and people in other careers be attracted to nursing, we need to have an environment that people will want to be involved in."

O’Leary seconds that point, saying "Young people have lots of opportunities for other careers, and when nurses go home and say bad things about nursing to their friends and family members, they’re turning people off from joining that profession."

Many of the 16 tactics address what nurses report is their main complaint on the job: spending their time on everything but actual patient care. Excessive administrative tasks and paperwork must be eliminated, Chow says, and nurses must be excused from performing "non-nursing" duties such as ordering, coordinating, or performing ancillary tasks. The Joint Commission’s report notes the problem of what it calls "scope creep" for the nurses’ role, adding supply chain management, housekeeping, food service, and many other tasks that pull nurses away from patient care.

Chow says the way you utilize nursing resources within the organization can have a tremendous effect on how nurses feel about their jobs.

"Often they will report that they are well paid but still don’t feel valued because they are required to act as transporters, or they have to run to the pharmacy at midnight," she explains.

One particular problem cited by the Joint Commission is abusive behavior by physicians. The Joint Commission urges hospitals to adopt a zero-tolerance policy on physicians using their authority to berate, belittle, or otherwise abuse nurses.

"I don’t think most physicians treat nurses poorly or regard nurses as their handmaidens, though I suppose there is an old guard out there," O’Leary says.

"But it doesn’t take a lot of bad-acting physicians to treat nurses poorly. Maybe you’re tired; maybe you’re busy; but that’s not a license to be a jerk. You’re not going to get a lot of improvement on this issue until you establish a zero-tolerance policy and call them on it," he says.

Kaiser Permanente is developing a zero-tolerance policy on abuse, and other efforts already have improved job satisfaction for nurses, Chow says. The Joint Commission points to Kaiser Permanente as a leader in implementing many of the recommended steps. 

"It’s definitely an issue of leadership," Chow says. "The nursing leadership and hospital leadership must work together to establish a system in which this kind of abuse is just not accepted."

Improvements could have ripple effect

Some of the changes suggested by the Joint Commission will be challenging, but you may be surprised at how much they can improve quality in your organization, says Keith F. Safian, FACHE, president and chief executive officer of Phelps Memorial Hospital Center in Sleepy Hollow, NY.

The nursing shortage affects other caregivers in the hospital who may be experiencing shortages of their own, he says. When there aren’t enough nurses, some of their tasks may be shifted on to overworked pharmacists, for instance.

"Nursing care is the backbone of the hospital, and when you have a shortage there, it increases the strain on other staff who will have to pick up some of the work load," Safian says.

"And vice versa — when you improve the nursing situation, you can improve the experiences of many other departments and employees within the hospital. The benefits may reach further than you expect," he points out.

Any steps you take to address the nursing shortage should involve substantial input from your nursing staff, Chow says. The Joint Commission’s recommendations may provide you a basic plan, but how you implement them should depend on what your own nursing staff tell you needs to be done.

"Listen to the work force, then start systematically putting in programs that address what they say they need. Let the staff tell you what the priorities are. Don’t guess what they want and need," she adds.

[For more information, contact:

  • Dennis O’Leary, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Web:
  • Marilyn P. Chow, RN, DNSc, FAAN, Vice President of Patient Care Services, California Division, Kaiser Permanente, Telephone: (510) 987-3900.
  • Keith F. Safian, FACHE, President and Chief Executive Officer, Phelps Memorial Hospital Center, 701 N. Broadway, Sleepy Hollow, NY 10591. Telephone: (914) 366-1000.]