Hospital Staffing Issues
Panel 3: Particular Systems Issues
Presented by Patricia W. Underwood, PhD, RN
American Nurses Association
Testimony for the National Summit on
Medical Errors and Patient Safety Research
September 11, 2000
The American Nurses Association (ANA) appreciates the opportunity to share the nursing profession's perspective on areas for priority consideration in developing a research agenda related to public safety and medical errors. As you know, nurses are the largest group of health care providers and the largest group at the sharp end of health care error. As front-line health care workers, registered nurses (RNs) have substantial observations and contributions to make in order to target efforts to reduce health care errors.
Health care practice in hospital and other health care settings is changing daily. Nurses, physicians and others are asked to do more with less. As hospitals have reorganized and put fewer nurses at the bedside, as more and more hospitals have come to rely on use of overtime as a "solution" to inadequate staffing, the most common complaint we hear from our members is their belief and concern that these changes are fundamental factors putting patients at risk.
Although we know from experience to trust our own assessment skills, and often even our hunches, we also know that hunches are not always enough in establishing the relationship between staffing levels, skill mix, continuous work hours and the incidence of errors. We also know that hunches and anecdotes have been insufficient to affect changes in policy, legislation and regulation that protect patients and provide optimum environments for health care delivery.
The organization of health care within a hospital depends on interdisciplinary teams of professionals and auxiliary workers, all of whom have defined areas of expertise and responsibility. Provision of safe care demands that there be adequate numbers of each of these health care team members and that their deployment be appropriate to their training. Any consideration of medical errors that does not look at a full range of staffing issues is missing a crucial element that lies at the center of safe patient care. This critical element of a systems' perspective on health care error was, unfortunately, largely missing from the recent Institute of Medicine study, To Err is Human: Building a Safer Health System (IOM, December 1999).
ANA believes that there is a critical need for research that examines the impact of staffing levels and skill mix on patient safety and the incidence of errors by nurses and others. In other words, what is the relationship of variations in the number and mix of health care workers providing direct patient care to the incidence of medical errors?
While such research would optimally show the impact of health system change on error rates, we face some practical problems in this regard, primarily, the fact that there is no research on error prior to health system reorganization over the past decade. But variations in staffing patterns across hospitals, and often across units in the same hospital, will allow for some examination of the relationship between staffing levels and the incidence of errors.
Research has been done to demonstrate the linkage between nurse staffing and patient outcomes. ANA's most recent study, Nurse Staffing and Patient Outcomes in the Inpatient Hospital Setting (March 2000), tracks five adverse outcomes measures that can be mitigated if adequate staffing is provided. Those measures include: length of stay in the hospital, pneumonia contracted while in the hospital, postoperative infection, pressure ulcers (bed sores), and urinary tract infections contracted while in the hospital. With sufficient nurse staffing, time is available for more thorough patient assessment and interventions to improve outcomes. We believe that adequate time is also critical to implement the range of safety checks and activities necessary to improve patient safety and reduce the likelihood of medical error and would like to see that theory tested in research.
As stated earlier, part and parcel of concerns about the rate of medical errors related to the sufficiency of staffing in health care facilities today is the alarming incidence of overtime work currently being used to fill gaps in staffing. ANA believes that any research on patient safety must also include an examination of the relationship between continuous hours worked by personnel involved in direct patient care and their ability to work safely and without error.
While specific research in this area is critical, we don't believe we can wait to take action until all the findings are in. Don't we know enough about the impact of fatigue on human judgment, and on cognitive abilities, to recognize that having a 47-year-old nurse working 16-hour shifts for three or four days in a row is dangerous? And, we can draw on existing research-such as research on the impact of fatigue on residents-to help guide both future research and public policy initiatives.
In order to take immediate action to alleviate overtime use and still provide sufficient staffing, we must be able to recruit and retain all health care workers -and registered nurses in particular- into health care facilities. Anyone in this audience will tell you this is a difficult, if not impossible task. Talk of nursing shortages abound. Yet, in another "shortage" not so very long ago, we noticed that, despite the crisis, some hospitals had no problems recruiting and retaining a sufficient nursing staff.
In order to more fully understand that phenomenon, the American Academy of Nursing (AAN) -- an affiliated arm of the ANA -- conducted research to identify what made those facilities different. What was discovered in the early research done in the 1980s by Linda Aiken, and reaffirmed in more recent studies, is that specific organizational variables create a milieu that not only attracts nurses, but create practice environments that provide better outcomes for patients. Known as "magnet facilities," these hospitals have higher nurse-staffing levels and lower morbidity and mortality rates, as well as shorter lengths of stay and lower utilization of ICU days, than do non-magnet facilities. (In the 1999 research, a lower incidence of needlestick injuries among nurses was also noted.)
What can we learn from these magnet facilities, what organizational and cultural variables can we identify, that we can apply to creating better care environments across all health care facilities? ANA believes that one further focus for research related to patient safety is the examination of such variables as relationships between nurses and physicians; RN control over the practice environment; and professional autonomy for RNs, which all contribute to better professional practice and safer delivery of patient care.
And lastly, let's not forget the necessary tools with which to do research. Much of the work that will take place on the heels of this summit will require that researchers have data that is readily accessible and standardized. Staffing data, in particular, is extremely difficult to access and is currently not standardized. For these reasons, the ANA has long advocated for the collection and public reporting of standardized data, on nurse staffing and patient outcomes in particular. It is imperative that all involved in ensuring patient safety and reducing medical errors support this last priority.