Patient Safety Alert

Has the nursing shortage decreased health care quality?

Physicans say time constraints, managed care share in the blame

In what some in the industry are calling a "land-mark" study, more than half the U.S. physicians surveyed said their ability to provide quality health care to patients has deteriorated over the past five years, and fewer than one in six said that ability had improved over the same period.

"These findings are alarming," notes Robert Blendon, ScD, survey author and professor of health policy and management at Harvard. "What’s worse is that many doctors fear this decline in quality will continue."

The study, conducted jointly by the Harvard University School of Public Health in Boston and The Commonwealth Fund in New York City, surveyed 528 practicing generalists and specialists (cardiologists, gastroenterologists, and oncologists) in the United States and approximately 2,000 physicians in Australia, Canada, New Zealand, and the United Kingdom.

Survey respondents cited several key factors in the decline of quality:

• Nursing staff levels are inadequate.

• Primary physicians don’t have enough time to spend with patients.

• Hospitals do a poor job finding and address-ing errors.

• Doctors are not encouraged to report medical errors.

• Physicians are concerned about their ability to keep abreast of new medical developments.

American physicians said their greatest concern about hospital resources was inadequate nursing staff levels. Steve Eilen, MD, a physician with Atlanta Cardiology Group, couldn’t agree more. "Hospitals can’t hire enough nurses to fill their staffs," he says. "What happens is they hire agency nurses who don’t know where anything is, how to do anything, or who to call to get anything done. Ironically, on a per-hour basis they’re much more expensive than permanent nurses, so hospitals are forced to spend more money for inferior care."

"There clearly is a shortage," offers Richard A. Lewis, MD, FACC, a partner in Cardiology Associates of Fredericksburg (VA), although he says he does not have a problem with the quality of the nurses with whom he works. "The nurses we have are very qualified and dedicated, but they are being stretched thin. Supply has been decreased because there are so many other career opportunities today, hospital administrations are stretched thin; their reimbursements keep coming down; and the biggest expense is salary."

"In some institutions they have really reduced staff below what I call a safe level," asserts Dave Spencer, CEO of Tampa, FL-based Safety-Centered Solutions Inc., a vendor of medical error reporting systems. "We have seen clearly that as staff reductions are made, the incidence of medical errors goes up."

These staff reductions have a real, and some-times critical, impact on the ability to deliver quality care. "I had an indigent patient with an aortic dissection and tried to get him moved to a tertiary care center for specialized surgery," recalls Eilen. "The hospital wouldn’t take him, citing a lack of beds. I talked to a thoracic surgeon, who told me the administrators no longer wanted to accept indigent patients. They were in such dire straits that they could no longer do surgery after hours. There are only so many nurses to go around, and the hospital did not want them to work after hours because they’d have to pay overtime."

"The busier each nurse is, the more errors they can make," adds Lewis. "They’re under stress; there’s not as much time for review; and there’s not as much time for teaching. Nurses have more bedside time than doctors, and they can help reassure and educate patients if they have the time to do it."

Patients do notice the difference, says Eilen. "I’ve had patients in telemetry beds who vehemently refused to stay at a specific hospital because the nursing care was so bad. With fewer nurses per patient, the patients become frustrated because they don’t get bathed; beds don’t get changed; they don’t get to the procedures they’re supposed to go to; doctors’ written orders are not followed; or their medicines are late."

Compounding the problem is that at the same time the quality of care is dropping, the patients’ level of sickness has increased, Spencer adds. "We’re compressing the length of stay. People are being discharged earlier, so while they are in the hospital, they are sicker on the average. Also, people don’t get admitted for less acute conditions. So we are faced with these two converging forces."

Eilen concurs with the survey respondents who noted that physicians don’t have enough time to spend with patients. He places the blame squarely on managed care. "Here’s what happens: A patient walks into the office, and he has a [copayment] of $10. You make $40 from that patient. That hardly pays for you to walk in the door, not to mention your overhead," he says. "So you need to see more patients or reduce your overhead in order to try to compensate for that. You can use [physician’s assistants], which a lot of people do, but many patients are not happy about it; they want to see the physician. And my personal opinion is that the quality of care is not as good."

Lewis says he also feels frustrated by managed care. "It has definitely driven quality down from many aspects. There are increased demands for record keeping, which detract from the amount of time you can spend with each patient. With decreased reimbursement, you need to see more patients, so you have less time with each indi-vidual patient."

Lewis says the "gatekeeper" structure actually restricts access to specialty care. "The primary physician may not be qualified to determine if there is a need for specialty care. Sometimes, the patients know best, and some-times just the reassurance a specialist can provide is therapeutic."

He adds that nonphysician reviews of charts and cases that "second guess" a physician’s diagnosis and treatment plan can put pressure on physicians. That could cause them to "discharge a patient before [they] think [that patient] is ready and to restrict access to testing [the reviewers] feel is inappropriate but that the practitioner feels is medically necessary. They’re not doctors; they don’t have the experience with patient contact that we do. They go by written guidelines, but every patient is different, and every case is different. Unfortunately, managed care discourages individualism and creativity and doesn’t reward experience."

The good news from the survey is that not all respondents said a continued decline in quality is inevitable. They said that technology, especially electronic record keeping, can serve to curtail a significant number of errors.

"I would think that’s true," says Lewis. "We spend a lot of time documenting, and technology would help. It also may cut down on errors; for example, a lot of programs identify potential drug interactions."

"It’s a very legitimate claim," adds Spencer. "A tremendous number of things can be done to increase the accuracy of reporting and to give caregivers more access to data. Most of the errors can be eliminated if we will use the information and technology intelligently."

Eilen says he has mixed feelings. "I’ve looked into electronic prescription, and in its current state, it’s more labor-intensive, at least in the beginning. For me, it’s not a great timesaver. Electronic record keeping will be good for a lot of reasons, but only if records are centralized."

[For more information, contact:

Steve Eilen, MD, Atlanta Cardiology Group, 33 Upper Riverdale Road, Riverdale, GA 30274. Telephone: (770) 991-9166.

Dave Spencer, CEO, Safety-Centered Solutions Inc., 7650 W. Courtney Campbell Causeway, Suite 400, Tampa, FL 33607. Telephone: (877) 739-6751. Fax: (813) 623-1228. E-mail:

Richard A. Lewis, MD, FACC, Cardiology Associates of Fredericksburg, 2500 Charles St., Fredericksburg, VA 22401. Telephone: (540) 374-3144.

Robert J. Blendon, ScD, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115. Telephone: (617) 432-4502.]