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One in five nurses currently employed is seriously considering leaving the profession within the next five years because of working conditions, according to a nationwide survey released April 19 by the Washington, DC-based Federation of Nurses and Health Professionals, the 55,000-member health care division of the American Federation of Teachers (AFT). Those findings were released just days before the Department of Health and Human Services (HHS) issued a study that shows the number and mix of nurses in a hospital makes a major difference in the quality of care patients receive.
Sandra Feldman, president of AFT and the Federation of Nurses and Health Professionals, says the survey points to an even more serious and widespread crisis than previously believed. But she says the silver lining is that the nurses threatening to leave indicate they would consider staying if improvements are made, such as better staffing levels, more flexible schedules, and higher salaries.
The study, Nurse Staffing and Patient Outcomes in Hospitals, is based on 1997 data from more than 5 million patient discharges from 799 hospitals in 11 states. It found a strong and consistent relationship between nurse staffing and five outcomes in medical patients: urinary tract infection, pneumonia, shock, upper gastrointestinal bleeding, and length of stay. (See "AFT survey offers clues to nursing shortage," in this issue.) A higher number of registered nurses was associated with a 3% to 12% reduction in the rates of adverse outcomes, while higher staffing levels for all types of nurses were associated with a decrease in adverse outcomes from 2% to 25%.
According to the study, the costs associated with patient complications can be substantial. Reductions in the rates of adverse outcomes reduce hospital costs as well as significant financial and psychological costs to patients and their families. "Hospitals can use these findings to improve quality and performance measures across the board to ensure better nursing care for all patients," says Sam Shekar, MD, MPH, HRSA’s associate administrator for health professions.
According to the U.S. Department of Labor, an additional 450,000 registered nurses will be needed through the year 2008. Feldman points out that the newly discovered group of highly discontented nurses would exacerbate the already acute demand for more nurses. Hospitals can take steps to retain the nurses they have, bring back those who left in frustration, and recruit new people into the profession, she adds.
That contention echoes the sentiments of Dennis O’Leary, president of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). "There is a numbers problem out there," asserts O’Leary, who points out that JCAHO is studying this problem under the context of staffing effectiveness. "There is really no debate that the staffing issues are related to all of the patient safety issues."
"This actually may be where performance measurement ends up." According to O’Leary, that means the application of evidence-based measures to solve problems. "That will make sense to a lot of people as opposed to gathering performance data to look at and say, Isn’t this nice,’ which I think is a little bit where we are now."
JCAHO’s measures and standards also are under review, he notes. The Joint Commission has had internal discussions with the advisory committees that O’Leary says have included a lot of noise from unions and a lot of emotional debate. "We are trying to push that stuff to the side to make this as objective as we possibly can."
The California Hospital Association argues the nurse/patient ratio should be 1:10 while the nursing association wants 1:3, O’Leary says. There are now a dozen states that have legislation in the hopper to create mandated ratios, and that number is growing, he adds. "When we reach that point, that is just stupid. The only mandate that you will reach is that you will have all the same problems that you had before."
He calls the proposal the Joint Commission has on the table a modest one. "We don’t assume that there are staffing problems in an individual organization. We are going to measure it first." To that end, the Joint Commission has engaged a panel of about 120 experts from various walks of health care to come up with the standards framework as well as a series of specific screening measures.
O’Leary says the clear consensus is that these should be clinical measures and human resource-related measures. He says organizations should be required to pick from the evidence-based measures that JCAHO has assimilated plus measures that would address issues particular to their own environment and to apply them.
"These are screening measures, and the organizations will get good at doing pattern reading to identify the potential existence of the problem," he explains. "But as a screening measure the potential problems you identify may be related to nursing and may not be."
These measures will be associated with staffing but there are no one-to-one relationships and even a good matrix of measures year after year will still require root-cause analysis, O’Leary maintains.