Nurses Voice Concerns about Patient Care in the Wake of Cost-cutting (11/1/96)

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CONTACT: Sara Foer [202-651-7023]

Nurses Voice Concerns about Patient Care in the Wake of Cost-cutting

Almost two out of five nurses would not recommend their facility to a family member

WASHINGTON, DC --The voices of nurses--their feelings, observations, and frustrations--are recorded in the final results of an American Journal of Nursing survey of more than 7,500 nurses about their perceptions of health care and nursing practice. The remarks by the respondents bear witness to the stories being reported by the media about hospital errors and unsafe patient care that may result when facilities increase the use of unlicensed, minimally skilled technicians to provide direct patient care and reduce the number of RNs.

ANA President Beverly L. Malone, PhD, RN, FAAN, hailed the survey, stating that it "provided valuable insights into the perceptions of nurses about their work environments and the impact of cost-saving decisions on patient care and the nursing profession."

"The public needs to be aware of how changes in health care delivery impact the safety and quality of care they receive," said Malone. "When RN staff is decreased in today's hospitals, patient care suffers because there are either not enough nurses to deliver care or the few nurses who remain have such large patient loads that care may be compromised."

One of the survey's key findings is that almost two out of five nurses would not recommend that a family member receive care in their facility. This finding indicates that nurses share the public's growing concern about the safety and quality of care available in hospitals today.

Use of Unlicensed Assistive Personnel

More than 85% of the respondents said that the increased use of unlicensed assistive personnel (UAP) did not improve patient care at their facility. Here are some of the comments provided by nurses completing the survey about the increased use of UAPs, also called care partners; patient care technicians, patient aides; patient care associates; nurses aides; nursing assistants; the list is virtually endless.

"One incident I observed occurred when an aide disconnected an IV to help a patient change gowns. The patient lost a large amount of blood before I got to the room to clamp the tubing."

--A forty-year-old pediatric staff nurse from Alabama.

"Unlicensed assistive personnel on the wards are called patient care attendants, while in the PICU, NICU, and ED, they're called, critical care support technicians. UAPs in our hospital had about 11 days training."

--A forty-one-year-old pediatric ICU nurse in California

"I have seen a decrease in patient satisfaction with the emergence of care partners'"

--A thirty-one-year-old ICU/CCU pediatric/neonatal
staff nurse from Ohio

"This home hires most anyone off the street to do aide work. The turnover in aides is unbelievable and the quality of care the resident gets is poor to fair."

--A fifty-nine-year-old Missouri staff nurse in a nursing home

The media are increasingly uncovering cases where errors made by unlicensed aides have resulted in harm to patients, including death. Most recently, Time magazine reported the case of Rebecca Strunk, a 46-year-old who died following a routine hysterectomy in 1994. Her family's lawsuit, which was recently settled out of court for $3 million, charged the Cincinnati, Ohio hospital with substituting nursing care with unlicensed technicians who lacked the knowledge, judgment, and skills to adequately assess and monitor Strunk's condition.

In Indiana, Attorney General Pamela Carter discovered that unlicensed and untrained staff, even housekeeping and janitorial staff were providing medical services and performing patient care procedures at several Indiana hospitals. She stated that "it is imperative that hospitals understand that this practice is unacceptable and that I will use the full power of my office to protect the citizens of this state."

In Akron, OH, emergency room nurses sent a letter to that state's Board of Nursing requesting an investigation of the emergency room departments of Summa Health System. The letter complained of understaffing and cited specific cases in which care may have been compromised because of reduction in RN staff. This letter is similar to one sent recently by a group of doctors to Summa administrators charging that Summa officials cut nurses and other personnel to the point that it was negatively affecting emergency care. The incidents cited in the letter include: a patient admitted with a possible heart attack was not assessed for 45 minutes; another patient waited three hours for an ultrasound because no one was available to transport her to the radiology department; and patient charts are not thoroughly reviewed.

As frontline providers who provide round the clock care, nurses are concerned about the deterioration of safety and quality in today's health care environment. For nurses, safe, quality care means having enough time to monitor the status of patients, detect critical changes in patient conditions, provide lifesaving interventions, educate and counsel patients and their families, prepare treatment plans, and offer compassion and caring to patients. These measures, historically a part of nursing care, point to the true value of registered nurses. Furthermore, a decade of research demonstrates that when there are more nurses, patients will experience shorter lengths of stay, fewer complications, lower mortality rates and even lower costs. A nurse's median weekly salary is just slightly more than the median cost of one day in the hospital. With nurses' positive impact on patient outcomes and a significant correlation between high RN staffing and shorter lengths of stay, hospitals save money by using highly skilled nurses in adequate numbers.

The Speed-Up Phenomenon

More than 60% of the nurses reported a reduction in the number of RNs providing direct patient care and an increase in the number of patients assigned to RNs. These combined factors result in a labor trend known as "speed-up"-- expecting fewer workers to work harder and be more efficient than during the period before staffing reductions.

"Some of the units in our hospital are so understaffed I don't trust them even when I transfer patients from my unit out to the floor."

--A forty-year-old ICU/CCU nurse in Michigan

Negative Effects on Patient Care

Fifty-five percent of nurses across the United States reported that there's less continuity of and an overwhelming number of nurses reported having less time to provide all aspects of nursing care. For example, most RNs reported less time to comfort and talk to patients (74%), teach patients and their families (73%), provide basic nursing care (68%), document care (66%), and consult with other members of the health care team (57%).

"I seem to spend more time apologizing to my patients for the lack of care they receive."

--A forty-year-old staff nurse from Massachusetts

"I would recommend a family member or a friend to watch over the care provided to their significant others who are hospitalized."

--A forty-two-year-old Minnesota ICU/CCU staff nurse

Retention Rates for RNs Declining

Unfortunately, the number of nurses who report that they will remain in the nursing profession appears to be dropping. In 1986, University of Texas researchers found that 86% of nurses indicated that they planned to remain in nursing. In the AJN study, the retention rate dropped ten points to 76%. According to the AJN survey, the lowest retention rates are in the Pacific region (70%) and the highest are in the West/North Central region (80%).

"I worked as a hospital RN until three months ago. I quit due to severe RN cutbacks, increased UAP use and what I felt were unsafe working conditions. I am currently working as a case manager, not directly involved in patient care. I miss direct patient care. But I don't miss being stretched so thin that I hardly had time to think, let alone provide quality patient care."

--A thirty-five-year-old case-manager from Utah

"In 22 years of nursing I have always loved the profession. For the first time, I am doubting whether I will stay with it."

--A forty-two-year-old staff nurse in California

The 1996 AJN Patient Care Survey was conducted by Judith Shindul-Rothschild, RN, CS, PhD, and commissioned by AJN, whose staff reviewed the survey questions along with ANA. Shindul-Rothschild is an assistant professor at Boston College School of Nursing and a member of the ANA Congress on Nursing Economics. The final results which were released today are based on the responses of 7,560 RNs, whose average age is 43 years, the same as the national average for RNs. The survey population is representative of the demographics of the RN population nationwide in every category. Most of the respondents practice in hospital settings and have medical/surgical specialties, which is also reflective of RNs nationwide. The survey was conducted from March through June 1996 and was designed to investigate nurses' perceptions of the safety and quality of patient care that is currently being delivered. According to Shindul-Rothschild, the AJN study is the first to identify the speed-up trend in nursing. The margin of error for the survey findings is less than 2%.

Reporters may request a free copy of the AJN survey and final results article (available November 1) by calling Martin DiCarlantonio, AJN Editorial Director, at 212-582-8820, ext. 411. The general public may order reprints by calling 212-582-8820, ext. 203.