The Impact of Nursing Shortage on Patient Care - Case Study Example

The Impact of Nursing Shortage on Patient Care The vast gap between what skilled nurses really do and what the public thinks they do is a fundamental factor underlying most of the more immediate apparent causes of the shortage. These causes include nurse short-staffing, poor working conditions, inadequate resources for nursing research and education, the aging nursing workforce, expanded career options for women, nurses’ predominately female nature, the increasing complexity of health care and care technology and the rapidly aging populations in developing countries. Because studies have shown that an inadequate quantity of skilled nurses in clinical settings has a significant negative impact on patient outcomes, including mortality, the nursing shortage is literally taking lives, and impairing the health and well-being of many millions of the world’s people. “It is a global health crisis”(ICN 2004). Hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, ( “there is also a considerable financial cost to be considered, for example, the cost of care for patients who developed pneumonia while in the hospital rose by 84 percent. Treating pneumonia raised total treatment costs by $22,390 - $28,505, while the length of stay increased 51 -54 days and the probability of death rose 4.67 – 5.5 per cent. Pressure ulcers, another category of adverse patient event sensitive to nursing care, are estimated to cost $8.5 billion per year”(Buerhaus, Needleman, 2000), also shock, cardiac arrest, and urinary tract infections’(AHRQ 2004) A broad array of research on this topic has found association between lower nurse staffing levels and higher rates of some adverse patient outcomes. A new evidence report entitled “The effect of Health Care Working Conditions on Patient Safety”, produced by an AHRQ funded Evidence based Practice Center, reviewed 26 studies on the relationship between nurse staffing levels and measures of patient safety( Needleman et al 2000). Most of the studies examined nurse staffing levels and adverse occurrences in the hospital setting, including in hospital deaths and nonfatal adverse outcomes such as nosocomial infections, pressure ulcers, or falls, the EPC researchers found that lower nurse to patient ratios were associated with higher rates of nonfatal adverse outcomes’(Hickman 2003). The finding were constant at the hospital and the nursing unit levels. When addressing in-hospital deaths, the evidence does not show across the board that lower nurse staffing is associated with higher mortality. In hospitals with high RN staffing, medical patients had lower rates of five adverse patient outcomes (UTIs, pneumonia, shock, upper gastrointentinal bleeding, and longer hospital stay), than patients in hospitals with low RN staffing. In a study done by Patricia Stone, Cathy Mooney-Kane, Elaine Larson, teresa Hovan, Laurent Glance, Jack Zwanzinger, and Andrew Dick, and published in Medical Care, these researchers found that “hospital units with higher nurse-to-patient staffing ratios had significantly lower incidences of Central line IV bloodstream infections, pneumonia associated with ventilators, death within 30 days, and bed sores. Increased overtime of nurses was associated with higher rates of catheter-associated urinary tract infections and bed sores, but slightly lower rates of central line blood stream infections”(Stone et al 2007). When nurse staffing is improved from 8 patients per nurse to 4, lives are saved in a cost efficient manner. The adequate nurse staffing intervention cost is $136,000 per life saved. Common life saving measures such as the use of thrombolytic therapy for myocardial infractions and PAP smears for routine cervical cancer screening cost $182,000 and $432,000 respectively per life saved”( Rothberg, Abraham, Lindenaver & Rose, 2005). In an American Journal of Nursing article titled, “Failure to Rescue: Needless Deaths are prime examples of the need for more nurses at the bedside”, nurse researchers Sean Clarke and Linda Aiken, describe how patients deteriorate unnoticed and die when hospitals under-staff nurses. The article shows why the “failure to rescue” rate increases by 7% for each additional patient assigned to a nurse and why this is the best indicator of a hospital’s quality”(Clark et al 2003). More RN direct care time per resident per day..was associated with fewer pressure ulcers, hospitalizations, and [urinary tract infections] less weight loss, catheterization, and deterioration in the ability to perform [activities of daily living] and greater use of oral standard medical nutritional supplements. RN staffing time and outcomes of long-stay nursing home residents; pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care”( Horn, Buerhaus, Bergstorm & Smout 2005) In its latest report on patient safety, The Institute of Medicine identified workforce deployment patterns in the typical work environment of nurses as contributing to many serious threats to patient safety. Among various measures it called for was the involvement of the direct care nursing staff in determining and evaluating the approaches used to determine appropriate unit staffing levels for each shift”( Buerhaus et al 2000). “The implications of doing nothing to improve nurse staffing in low staffed hospitals are that a large number of patients will suffer avoidable adverse outcomes and patients will continue to incur higher costs than are necessary”(idid) The fact of the matter is “more accurate and consistent measures of acuity and quality and more complete data on staffing for all types of nursing personnel are needed to explain the complex relationship between nurse staffing for all types of nursing personnel are needed to explain the complex relationship between nurse staffing and the quality of care”(Jones, Zhan 2002). The National Quality Forum, a private, not for profit group of public and private health care organizations created to develop and implement a national strategy for health care quality measurement and reporting, has been actively developing national voluntary consensus standards for nursing sensitive performance measures. Such measures can help to evaluate the extent to which lack of qualified nursing staff if affecting the quality of health care. They can also help to identify opportunities to improve nursing. A shortage of nurses is a factor in one-fourth of patient injuries or deaths in hospitals (JCA 2004). According to a 2002 report by the Joint Commission on Accredation of Health Care Irganizations, inadequate nurse staffing has been a factor in 24 percent of the 1609 cases involving patient death, injury or permanent loss of function reported since 1997. An article in the Arkansas City Star on March 29, 2004, stated that researchers at Harvard and Vanderbilt Universities found preventable deaths and patient complications were up to nine times higher in hospitals when the most care was given by licensed practical nurses and aides, not RNs(Arkansas City Star 2004). More than eight in ten hospital-employed RNs (84%) reported that they had frequently or often observed the nursing shortage negatively impact the timeliness of care, and omly 1 % believed the shortage had never influenced this aim. Roughly three- quarters of RNs reported the patient centerdness (74%), effectiveness (74%), and efficiency (72%) of care was affected by the shortage frequently or often; only 3%, 2%, and 2% indicated the shortage was never a problem for these aims. Almost two-thirds of the RNs perceived the shortage impacting the safety (65%) and equity (63%) of care frequently or often. (Medscape). The purpose of this study is to determine nursing care which is regularly missed on medical-surgical units and to highlight the reasons for the missed care. This study will examine nine elements of regularly missed nursing care ( hygiene, patient teaching, intake and output documentation, emotional support, surveillance, delayed or missed feedings, emotional support, ambulation, and turning.) Clarke and Aiken pointed out that nurses serve the surveillance function in hospitals to prevent errors and ensure quality care, and too few staff lead to insufficient surveillance.(Clarke et al 2003). Research Questions There are specific indices which the author would like to gauge and since the research will take on the form of an oral interview, the exact wording of the following questions will be asked of each respondent; (1) From your observations, what nursing care would you consider to be the most consistently missed activity on medical-surgical units in acute care hospitals? (2) In your conversations, and you may have experienced these activity misques, what would you say are the reasons cited by nursing staff for their non-adherence to these specific aspects of patient care? Research design This will be a qualitative study which will use a focus group format and the conduct of verbal interviews with nursing staff from medical-surgical units from at least two hospitals; one of which will be a 312 bed facility which is situated in an urban medical center setting, and a 375 bed facility situated in a suburban medical complex.. Research Setting The conduct of the focus groups will be situated in venues such as meeting halls of hotels, which are conventienly located in both the urban and suburban setting. The key word here is convenient, which will be designed to accommodate the respondents. Participants Attention will be given to recruit a total of one hundred registered nurses as respondents. This group of respondents will hopefully yield a mix of personnel, which will include head nurse, nursing supervisors and duty nurses. Additionally, it is hopeful that this group will represent a cross section of age groups and a considerable amount of diversity, both along the lines of ethnicity and gender. The total will also be comprised of 35 Licensed Practical Nurses, and fifteen Nursing Assistants. Again the author is looking for a similar type of mixture, as stated in the group of RNs. In that the respondents will comprise three different types of skill groups and specific hierarchical orders, the interviews will be conducted to accommodate homogeneity to preserve these delineations. Given the number of projected participants, it is feasible to maintain the number of focus groups at a minimum of fifteen. While the author will cross seniority lines, It will be critical to maintain professional and supervisory separation. This is critical to the credibility of the process. And for an earnest attempt of eliciting candor, without the possible thought of retribution. Data Collection The focus group interviews will be conducted at a neutral location for both the urban and the suburban hospitals. The focus group interviews will be of a semistructured design. Given the numbers of individuals which the author will be interviewing from each type; the RNs individual grouping (one set of respondents), should consume approximately 45 minutes. The other individual (focus) groups are considerably smaller and it should take no more than 30 minutes per group. Ethical Considerations (1)Psychological and other risks to the participants In the initial stages of the interview, it is important that the understanding be established that a commitment of confidentiality be engendered by all parties participating. This is essential to the aire of candor and paramount for the establishment of the study’s validity. It is this authors contention that each participant must be empowered with the will to answer all questions as they earnestly perceive them. That to enable this to be an actuality, the groups must be designed so they are in a setting with those who are considered (to the fullest extent possible) in fact, their peers within their professional and respective job responsibility levels. In other words, the RNs will comprise a specific focus group-the delineation here will be supervisors, who will be in a separate focus group whose make up will consist only of supervisors. The head nurses will also be accommodated similarity, and the duty nurses will also receive a like accommodation, forming three distinct group types. The same type of delineation will be designed to accommodate the two remaining groups of Licensed Practical Nurses and Nursing Assistants. These types of groupings will ensure that lingering inhibitions surrounding the idea of whistleblowing will be suppressed, as peers share their thoughts, feelings, and frustrations about their daily work environment and conditions. Every effort will be made by the author to assure the participants that the information which they are being requested to provide is professional input, which will serve as a catalyst to improve the present working environment on a macro level. 2. Steps to Ensure Protection As stated above, the groups will be separated according to their professional titles and job status. In such a grouping, the probability is high that the issues or circumstances which exist in the respective hospital settings have frequent or common incidence occurrences in most, if not all hospital settings. Consequently, the focus group sharing by the participants will not take on the status of “the airing of dirty laundry”. By the authors continued insistence that this input will serve as the blanket which will cover and eradicate unfavorable conditions on a macro level, the participants will actualize that this is an attempt to “clean up their environments and relieve them of unwanted and unnecessary job stress. In other words, by participating in this effort, they become a part of a win, win situation. Consequently, the sharings of one individual, is the input of the group, because everyone stands to gain. (3) Communicating Aims of the Study This can effectively and most appropriately be achieved by recruiting a core group(three nurses) from each hospital-one nurse from each professional category. The author will present these individuals with documents which highlight a small volume of incident reports, covering the nine indices, as well as information on the nurse to patient ratio, as recorded within each hospital. These persons will be appraised of the target numbers of persons desired, and provided with a cut off date to report on the prospective participant total. They will be requested to inform the prospective respondents of the overall objective and the form of the studys’ design. Close coordination with these individuals will be maintained to ensure a smooth process, and to clarify all issues which may be of concern by the prospective respondents. Once the fifty per cent mark is achieved, the author will present the coordinators with an additional communiqué, which will include the questions and the projected venue for the sessions. (4) Ensuring Informed Consent of Participants Subsequent to providing all of the prospective respondents with the questions and informing them of the venue, we will now be ready to fully expose to them the overall aim, which will enable them in making a definite commitment to the study. The author will make it crystal clear, the reason for the study and will provide all assurances as may be necessary or demanded. (5) Withdrawing From the Study All prospective respondents will receive assurances that they reserve the right to participate or to withdraw their participation, at any time during the process. The author will inform the team of coordinators to explicitly state this circumstance to all of the prospective participants. Also, before the commencement of each session, the group will be informed of their right to discontinue or withdraw, at any point. (6) Measures to ensure confidentiality of the participants The sessions will be conducted in the focus group format. In so being and because these groupings will consist of individuals from two different hospitals, the interviews will be tape recorded. However, the only identifying marks which will be a matter of recorded record is that each person will receive an identifying marker (either hospital “A” or hospital “B”) to identify their place of employment, and they will be asked to indicate the level of their employment. In that the sessions will be conducted according to group or professional types, the identification of the professional type will be at the heading marker on the tape. At no time will any individual be asked to disclose, their names. (7) How to ensure confidentiality of collected data This data will be collected, and analyzed exclusively by the author. Data Analysis The interviews of the various focus groups will be recorded on tape, and subsequently totally transcribed and analyzed by the author. The author will then employ a qualitative analysis software. Works Cited Buerhaus, P., Needleman J., Policy implications of research on nurse staffing and quality of patient care, Pplicy Politics Nurse Practice 2000, 1 (1) 5-15 Clarke, S., Aiken, L., Registered Nurse staffing and patient and nurse outcome relationships: A guide for change in care delivery: Nurse Econ, 2003; 21 (4):158-166 Hickman DH, Severance, S., Feldstein, A., The Effect Of Health care Working conditions on patient safety. Evidence Report/Technology Assessment number 74 (prepared by Oregon Health & Science University under contract no. 290-97-0018) AHTQ publication no. 03-E031. Rockville MD Agency for Health Research & Quality May 2003 International Council of Nurses (2004) ICN Report Joint Commission on Accreditation of Health Care Organizations. Kover,C., Jones,C., Zhan,C., Nursing Staff and Post surgical Adverse Outcomes, analysis of administrative data from a sample of U.S. hospitals, 1990-1996, HSR, Health Service Res 2002, 37 (3), 611-29 Medscape, retrieved on line on 17 October 2007, from www.profreg.medscape.com National Quality Forum, Project Brief: Core Measures for nursing care performance, May 2003 Needleman,J., Buerhaus,P., Mattke,S., Nurse staffing levels and patient outcomes. Final Report for health resources and services administration. Contract no. 230-99-0021. Harvard School of Public Health, Boston, MA Susan Horn, Peter Buerhaus, N ancyBergstorm & Randall Smout (Nov. 2005) American Journal of Nursing 105 (11) 58-70 Read More