The Number of Nurses for the Safety and Better Care Towards Patients - Report Example

Increase the Number of Nurses for the Safety and Better Care Towards Patients An Evidence-Based Paper Submitted by April 2008 Introduction The problem on quality health care provision on patients has been increasingly recognized in recent years due to the shortage of nurses as a trend now in western countries. Recruitment of nurses from other countries is now being done to fill in the shortage. However, there are not enough new recruits to the profession to meet the demand. Even hospitals that were once known for the quality of their nursing care now struggle to fill the vacant positions, like Boston’s Beth Israel Deaconess Medical Center as described by Dana Beth Weinberg in her book Code Green. And she argues that hospital restructuring, to retain profit margins, in the 1990s is to be blamed. Her book carefully looked into the effects of hospital restructuring on nurses’ ability to plan, evaluate, and deliver excellent care to the patients. With this, it is better to examine the problem based on the researches and reports of other authorities regarding the problem, not only based on the book of Weinberg, to clearly see the cause of the problem and the effect it resulted to the patients, nurses, and to the community since it started. Thus, this paper will thoroughly examine the impact of hospital restructuring and cost reduction to the staff nurses and on nursing practice at a merged hospital. In addition, this paper will create suggestions on solving the problem regarding the shortage of nurses and on improving the health services that will be provided by the nurses in merged hospitals. Discussion Restructuring Many hospitals in the United States of America merged during the 1980s and 1990s in an effort to retain their profit margins. According to Dr. Bazzoli (2002) (with the American Hospital Association's Health Research and Educational Trust and now with the Department of Health Administration, Virginia Commonwealth University) and her co-researchers, on their study “Hospital reorganization and restructuring achieved through merger,” it was found out that hospitals merges during 1983 to 1988 and 1989 to 1996 due to three primary reasons. These reasons were to strengthen financial position, achieve operating efficiencies and consolidate services. During 1994, there was this study performed by the Hay Group, a consulting firm, which surveyed one thousand (1000) hospitals and found out that fifty-five percent (55 %) were actively involved in reorganization. Eight percent (8 %) of the surveyed hospitals have completed redesign initiatives as cited in Pierson and Williams (1994). On Modern Healthcare on February 1996, a report made by Greene noted that there was an average of one hundred seventy-one (171) dismissed of workers per hospital from 1993 through January of 1996. In addition, the administrators of the hospitals explained that they intended to save money through reduction of staff rather than by limiting capital improvements or research and development. The American Nurses Association surveyed on nurses in year 1997 and result showed that seventy (70) percent of all respondents said that their employers were reducing staff by leaving the unfilled vacant positions. Still on the survey result, sixty-six (66) percent said that hospitals had already laid-off nurses or were planning to do so and sixty-seven (67) percent of registered nurses said that there is an increase in the number of patients assigned to them (American Nurses Association, 1997). Furthermore, restructuring have not only led to dismiss or reduction of nurses but also registered nurses were replaced with aides. To support this statement, a study conducted by Rothschild, Middleton, and Berry (1997) showed that of the seven thousand three hundred fifty-five (7, 355) nurses surveyed in a separate 1997 study, sixty percent (60 %) said that there were fewer registered nurses available for direct patient care. In addition, the result also showed that there were forty-two percent (42 %) nurses who said that there is an increasing substitution of unlicensed assistive personnel (UAP) for registered nurses. According to the study conducted by Margaret Sovie in 1999, using data collected in fiscal years 1997 and 1998, it showed that the responsibilities of chief nursing executives and university teaching hospitals increased in selected or in all patient services. Her study also showed that there was an indirect relationship in the number of nurse managers as to their span of control. In addition, her study also reported a declining number of registered nurses in direct patient care while there is an increasing number of an unlicensed assistive personnel participating in caring the patients. Still on the findings of Sovie, it was found out that although the reductions in the number of registered nurses were to reduce costs and increase profit of the hospital, the costs per day/discharge were influenced by hours worked per patient day and paid fulltime equivalents. Furthermore, as RN percentage went down, both the hours worked per patient day and paid fulltime equivalents rose since. With this, it took more people and more hours to deliver care because of the reason that there were fewer RNs and more unlicensed personnel on staff. And the reengineering does not necessarily improve the performance of a hospital but instead can be destructive or fatal, if there will be not enough care that will be given to the patients from the registered nurses, not from the aides. Nurses in many hospitals were questioned if they will still remain in nursing profession and it showed that more than half of the nurses rated “poor” or “very poor” to the question (American Nurses Association, 1997). Nurses are usually loyal to the institutions where they belong, with this, this finding of American Nurses Association is significantly important. In addition, the widely discussed topic today involves the conflict the nurses feel between administrative loyalty and loyalty to the patient. Nurse Dissatisfaction Nurses in United States nowadays are the most dissatisfied professions. The Department of Health and Human Services reported that slightly more than two-thirds or the RNs (69.5%) said that they are moderately satisfied with their jobs (Spratley et. al, 2001). In contrast, about 85 percent workers and 90 percent professionals were reported to be satisfied with their jobs according to the National Opinion Research Center, General Social Survey (1999). Similarly, the Nursing Executive Center on year 1999 conducted a survey which reported that there were only 21 percent registered nurses said that they are very satisfied with their job while the rest were either satisfied or somewhat or very dissatisfied with their job. But after two years, the registered nurses who said they are very dissatisfied increased to 51 percent. Same with the studies above, according to Spratley et. al (2001), staff nurses have sixty six percent (66%) satisfaction lower satisfaction as compared with other type of nurse. In terms of work place, hospital nurses have sixty seven percent (67%) satisfaction percentage which is the second lowest satisfaction, just ahead of nursing homes which have sixty five percent (65%) satisfaction while all other type of nurses have higher levels of satisfaction. And the greatest or the one having the highest satisfaction rate is the nursing education with eighty three percent (83%) satisfaction. Even though this is the highest satisfaction rate, it remains low if compared to other professionals in other occupations. In hospital units, it showed that the highest rate of dissatisfied nurses was on the ICU and medical/surgical units of the hospital with a 29.2 percent and 31.9 percent, respectively, according to the Nursing Executive Center (2000). Nurse dissatisfaction on their job has nothing to do with personal factors such as age, years of experience, or education, according to Blegen (1993), but rather due to the job itself. Due to over workload given to the nurses, they feel like they are not giving the quality care the patient needs and after work they feel exhausted. A study conducted by the American Nurses Association in year 2001 was intended to survey nurses on how they felt at the end of the work (day’s work). The survey showed that nearly 50 percent were “exhausted and discouraged,” 40 percent felt “powerless to affect change necessary for safe, quality patient care,” 26 percent felt frightened for their patients while 24 percent felt frightened for themselves. Recent Reports on Nurse Shortage In the year 1999, there were many reports on nurses dealing with ratios of one is to ten (1:10), RN to patients ratio on the day shift and one is to fifteen (1:15) or even one is to twenty (1:20) ratio on some shifts. The working conditions of nurses in hospitals have negative view of the public on nursing profession which makes it more difficult for many nursing schools to recruit or encourage new students to enroll in such profession. The shortage of nurses has also another reason aside from deteriorating working conditions that could add up to the problem and that is nursing profession failed to attract the younger generation, according to Wieck (2003). On his study “Faculty for the millennium: changes needed to attract the emerging workforce into nursing,” he discussed that there is a decline in interest among college students to consider nursing as a probable career and more than half of the currently working nurses would not advice their children on taking nursing as a course in college. This study of him is supported by the other studies. A 1999 survey conducted in New York State found that only 28 percent registered nurses would choose a career in nursing if given the chance of starting their work lives again while the rest were disappointed on the remaining as a nurse. Thirteen percent of nurses, on the other hand, stated that they would prefer another clinical health care profession (not nursing) while 31 percent stated that they would prefer non-clinical health care as a career. With this finding, we can say that the nurses have no problem on what is their work as health care but the problem, as we can see, is on the working conditions which is dissatisfying them (Nursing Executive Center, 2000). On the report entitled The 2007 State of America's Hospitals - Taking the Pulse reported by the American Hospital Association in July 2007, US hospitals need approximately one hundred sixteen thousand (116,000) registered nurses to fill-in the vacant positions nationwide, which mean that there is a national vacancy rate of 8.1%. The report also found that 44% of hospital CEOs had more difficulty recruiting RNs in 2006 than in 2005. By year 2016, according to the latest projections from the U.S. Bureau of Labor Statistics published in the November 2007 Monthly Labor Review, there will be more than one million new and replacement nurses will be needed due to the issue now on nurse shortage. The government analysts that there will be more than 587, 000 new nursing positions to be filled (a 23.5% increase). Similarly, the report or statement of The Council on Physician and Nurse Supply on March 2008 stated that “an independent group of health care leaders based at the University of Pennsylvania, has determined that 30,000 additional nurses should be graduated annually to meet the nation's healthcare needs, an expansion of 30% over the current number of annual nurse graduates.” With this increasing demand of nurses, could a nurse give her/his full patient care if she/he has many patients to look for? With this ratio, could a nurse meet the needs of the patient? Well, the answer is obviously no. Quality of Care due to Nurse Shortage There are many studies examining on the work of nurses, adverse effects, satisfaction of nurses on their jobs, and the quality of care the patients receive from the nurses. In a New York State Education Survey, it was reported that half of the RNs reported that there were reduction in the number of RNs in their workplaces and that two-thirds of the nurses who had been charged with medication errors reported decreased RN staffing. The survey also showed that the nurses with only an associate degree as their basic preparation were more likely to be charged with violations as compared to those with Bachelor of Science degree. These findings were also the findings by the state of Texas conducting the same study (State Education Department/University of the State of New York 1996; Green 1996). Another study conducted by Gil Preuss (1998) on nurses showed that “the broadening of the responsibilities given to the nurses such as bathing, feeding, and conducting sterile procedures on nursing units leads to medication errors.” Furthermore, his study showed that there is a positive correlation between the labor-management cooperation and the hospital’s capacity to respond to the changes around it especially in competition. Still on the study of Sovie in 1999, her research showed that an increase in registered nurse staff was associated with the “decrease in nosocomial pressure ulcers, an increase in patient satisfaction, and an increase in information exchange on patient status.” Satisfactions from the patients, reduction in serious injuries as a result of falls and quality care were met when there was an increased in registered nurses and better nurse/physician collaboration. While, patients have negative approach towards unlicensed assistive personnel; low satisfaction with the hospital and low satisfaction with the information they received. Suzanne Gordon (1999) investigated the broadening or expanded management responsibilities of the health professionals and also investigated the increased number of patients assigned to health professionals in six hospitals. She interviewed the nurses, physicians, and some hospital administrators in four community hospitals and in two teaching schools. And based on her report, she verified that there is an eroding quality of care for the patients. All the health professionals she had interviewed agreed that they could no longer provide the level of care they usually give in the past due to the increased in the number of responsibilities they are facing. They also said that due to many responsibilities, some nurses and physicians postpone or miss some tasks and they find it hard to find time in providing even the basic physical care due to the responsibilities. In addition, due to busy schedules, many patients to look and care for, and poor staffing, they find little or no time to educate the neophyte nurses. On the study done by Aiken et, al. (2001), titled “Nurses’ reports on hospital; care in five countries,” their paper presented reports from forty-three thousand (43000) nurses from more than seven hundred (700) hospitals in US, Canada, England, Scotland, and Germany in 1998-1999. And based on their report, it showed that nurses from countries with distinctively different health care systems report similar inadequacy in their work environments and the quality of hospital care and the core problems in work design and workplace management threaten the provision of care. The findings of the study also showed that job dissatisfaction, burnout, and intent to leave were the major factors of the current context of nurse shortage. One of the most important findings of the study was that 33 percent of nurses under the age of 30 were planning to leave the job within the year. With the fact that many young nurses are now dissatisfied with their job and the older nurses are going to leave the profession, shortage on nurses in America is greatly prevalent. And they suggested that this problem should be solved for the safety and quality care of patients. On the study of Tang et. al (2007), in Taipei, Taiwan, titled “Nurses relate the contributing factors involved in medication errors,” results showed that of the seventy-two (72) female nurses who responded on the study, 76.4 percent nurses believed that there is more than one factor that contributes to medication errors. Three main factors in medication errors were identified and it is as follows: 86.1 percent “personal negligence”, 37.5 percent on “heavy workload”, and 37.5 percent too on “new staff.” In addition, medical wards and ICU were the two most error-prone units in the hospital with 36.1 and 33.3 percent respectively. This statement is a bit similar to the study conducted by Nursing Executive Center (2000) on what units of the hospital have the most dissatisfied nurses which resulted to ICU and medical/surgical units. Furthermore, the common errors committed by the nurses on the study of Tang et al., were wrong dose and wrong drug. United States could relate with this study conducted in Taiwan because the study showed that heavy workload is one of the major factor in medication error, what more here in US where the nurses have many patients to look for. This study just only showed that medication error will increased if there will be many workloads given to the nurses in a hospital due to small number of nurses available as compared to the patients needing the care. The preceding statement is similar to the study of Stone et al. (2004). According to him, the shortage of nurses has many effects such as increase in nurses workloads, increase the risk of error, increase the risk of spreading infection to patients and staffs, increase risk for occupational injury, deaths, nursing turnover, increase in perception of unsafe working conditions, contributing to increase shortage, and hindering local or national recruitment efforts, and lastly, increase the nurses chance of getting psychiatric help because of massive amounts of stress. Interview I have interviewed a nurse that is gone due to the merging of the hospitals. Let us just call her in the name of Ms. Ann for confidentiality. Ms. Ann was once a staff nurse in a known hospital but due to the merging of her hospital with the other hospital, Ms. Ann felt that she is unable to give the patients quality care and just decided to leave the nursing profession in a hospital and is now working as a school nurse in her locality. Ms. Ann completed her nursing degree in a prestigious university in Europe and have been a nurse for seven years. I asked her if she have heard or read the book of Dana Weinberg, the Code Green, and she said, “Yes I’ve read that book and it’s a good book describing how nurses, like me, affected by the merging of the hospitals. For me, the research of Weinberg is good and reliable for she herself is also a product and experienced what we experienced after the merging of hospitals.” I asked her questions regarding her experiences before and after the merging of the hospitals and her is what she had stated, “before, we, the nurses has manageable time for all our activities and that we can really say that we are giving our patients the care and satisfaction they needed but when the merging happened, my co-nurses and I were not the same as before. After the merging, we find ourselves confused and always thinking on how our assigned patients are doing. We have about three to five patients assigned on us, imagined that one! And after a day of work, we find ourselves exhausted from work. Because of this reason, some of my colleagues intended to leave, resigned in the hospital and to look for a better hospital.” With these statements of her, I was really convinced on the effect of the merging of hospitals on the quality of care given to the patients, the satisfaction they needed. Ms. Ann experienced working on a for-profit and on a not-for-profit hospitals and she said that as compared to for-profit hospital, not-for-profit hospitals have a good quality of care given to the patients. She added that for-profit hospital have low quality care for the patients because of the small number of nurses available as compared to the patients needed to be cared of in not-for-profit hospital. On the other hand, Ms. Ann’s view of cost-cutting in healthcare is negative. She said that just like in the book of Weinberg, she has seen that there is an increase in the demand of nurses here in our country and the number of incident reports is also increasing. Cost cutting in healthcare resulted to the many incidents in patients too because they come in and out of the hospital quickly or very fast and it also resulted to low quality of nursing care now in our state. With the issues faced by many hospitals now regarding on the nursing leadership, I asked Ms. Ann on the effect of lack of nursing leadership to them while they were in merged hospitals and she said that, “The lack of nursing leadership does affect the nursing staff. Without a nursing leadership, the staff nurses will not feel autonomy to make clinical decisions within our areas of competence and to control our own practice in the hospital. With this, this would really affect the patients because we will not be able to confidently give them the needs they need.” Then I asked her about primary nursing and team nursing and which is better for the patient and for the nurse and she answered that she preferred primary nursing is better than team nursing. She said so because for her, primary nursing will greatly help the patient; and the nurse looking for that patient will have enough and good time for her patient and she is an expert on what her patient needs. One-to-one ratio of nurse and patient is the best way of caring the patient, according to her. On the other hand, for her, team nursing is disadvantageous because not all nurses in that team will be that expert in caring the patient and the patient will, she thinks, will be really confused of so many nurses that are attending for him/her. In addition, “team nursing also has communication problems which could led to medication errors,” as what she stated. I questioned her again on her satisfaction as a nurse in that hospital after the merging happened and she said that due to the exhaustion in over working to meet the demand of the hospital, she was unable to relax herself as compared when the hospitals were not merged. Ms. Ann was very disappointed when the hospital she had worked with reduced the number of nurses. According to her, “for me, the hospital administrators are not thinking on the security and on the need of the patients when they planned the merging of the hospitals. They only think on the profit they will have! I was very disappointed with that idea! Money driven healthcare system could be detrimental. It could lead to many serious problems to patients and to nurses.” While our conversation flowed well, I finally asked her what positive changes to nursing she have seen and why she is still a nurse, not in a hospital but in a school clinic and then she answered that, “The positive changes I’ve seen so far are the thorough and strict education on nursing nowadays. Also, the community now is valuing the nurses and they now know how important our job for them, especially to the patients! I’ve chosen nursing as my course or profession because I want to help the doctors in caring the patients, especially those patients with serious illness. Because of my desire to help others, I’m still a nurse, not in the hospital but here in this school. I’m also fond of children and I’m teaching them on some knowledge on nursing so that they will appreciate the nurses’ role in the community.” Suggestion There are many studies on the effect of merging hospitals on the quality of care the nurses were giving and suggestions to the problem were also proposed by these researchers. Gil Preuss (1998) who studied on the effect of broadening the responsibilities of nurses on the quality care given to the patients suggested that extensive cooperation should be implemented. He explained that “extensive cooperation allowed more flexibility in staffing and led to higher staffing intensity and better financial performance.” He also postulated that “cooperation may enable hospitals to adopt better-performing work practices, decentralize supervisory responsibilities to include employees, and respond flexibly to evolving patient demands, reducing overall patient care costs.” Other researches suggested a way for the hospitals to recruit and retain nurses. A study commissioned by the American Academy of Nursing in the early 1980s and intended to provide information that would help to solve the shortage of nurses identified the following organizational attributes which made some hospitals a good place for nurses to work (McClure, Poulin, Sovie, et al. 1983): Nurses' high status in the organization, as reflected in the formal organizational structure (i.e., a "flat" organization, with few supervisors, in the nursing department and a chief nurse executive with a strong position in the hospital's hierarchy). Nurses' autonomy to make clinical decisions within their areas of competence and to control their own practice. Nurses' control over the practice environment, including decentralized decision-making at the unit level. Adequate staffing and a limit to the proportion of nurses who were new graduates. Established mechanisms to facilitate communication between nurses and physicians. Organization of nurses' clinical responsibilities at the unit level to promote accountability and continuity of care (e.g., primary nursing and relatively infrequent use of floating nurses). An established culture signifying the importance of nursing in the overall mission of the institution, as reflected in the practice of paying nurses on a salary rather than an hourly basis, institutional investment in nurses' continuing education, and supervisory personnel who supported nurses' decision-making responsibilities. As for my suggestion on solving this problem, this shortage of nurses which resulted to the low quality of care given to the patients, I will strongly suggest that the role of nurses in caring the patients should be well explained and known by most of the people in the population. With the knowledge that these people will acquire about the important role of nurses in the community, many children will be encourage to take nursing courses or many people will value the nurses in the community. I will also suggest that after explaining to the people what important role the nurses play on our community, the hospital administrators must think of the future of the hospital and of the patients in there, and must only consider the profit they will have. In addition to this, since many current nurses nowadays are not recommending nursing course to be taken up by their children, I think it would be better if the nursing colleges will establish career-orientation or promoting nursing on high school students so that they will be encouraged to engage in nursing course. The government must also impart some actions on this issue, encouraging most hospitals to stop the merging for the sake of the patients and of the nurses. Increasing the number of nurses for the better quality of care given to the patients should be done in many hospitals now. Summary The paper examined the impact of hospital restructuring and cost reduction to the staff nurses and on nursing practice at a merged hospital. Based on the researches done by the authorities, the effect of merging hospitals could lead to detrimental state. Due to the cost-cutting in nurses, decreased in registered nurses resulted to the low quality given to the patients and there were medication errors reported. There was also a great increase in the rate of dissatisfaction of nurses on their jobs while the substitution of registered nurses by the aides also affects the satisfaction of the patients on the hospital, on the care given to them and on the education/information given to them while they are in the hospital. Therefore, the increase in the number of nurses in a given hospital should be implemented, especially to for-profit hospitals, to give quality care to the patients. Based on the interview that I have done, Ms. Ann, once a nurse in a known hospital, was disappointed on the idea of merging the hospitals. She leaved the nursing profession in a hospital due to the merging of her hospital with another hospital. She said that they were very exhausted from the responsibilities or works bombarded to them by the hospital after the merging due to the lack of nurses or small number of nurses while there was an increase in the number of patients to look for. With all the data I have gathered, I suggest that to solve the problem on shortage of nurses and on giving quality care, there must be an explanation or information on the role of nurses on the community. People should better know the role of nurses in the community so that they will value the nurses. In addition to this, there should be a better career-orientation on high school students so that they will be encouraged to engage in nursing course. Government should impart actions to the issue. Increasing the number of nurses in the hospitals should also be considered by most hospitals that are merging. With an increase number of registered nurses in a hospital, the hospital will be able to meet the needs of the patients and will also be able to meet the satisfactions the nurses needed. References Aiken, L. H., S. P. Clarke, D. M. Sloane, J. A. Sochalski, R. Busse, H. Clarke, P. Giovannetti, J. Hunt, A. M. Rafferty, J. Shamian. (2001). Nurses' reports on hospital care in five countries. Health affairs: the policy journal of the health sphere. Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, USA. American Association of Colleges of Nursing. (2008). Nursing Shortage. 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