Nursing shortage imperils patients http://www.usatoday.com/news/healthscience/hsphoto.htm By Kathleen Fackelmann, USA TODAY 6-28-01 The day started out like most others for Barbara Carey, a hospital nurse from Glendale, Calif.: a heavy patient load and not enough staff. That usually just meant that Carey had to work harder and faster. But on this particular day in 1989, short staffing led to tragedy. Carey began to check in on her patients but had so much to do that it took 45 minutes to get to patient No. 4. Carey walked into the room and realized the liver cancer patient was dead. She still wonders if the delay, caused by short staffing, might have hastened the woman's death. Carey says now "if I had walked in at the beginning of the shift," the patient might have been revived long enough to see a favorite relative who planned to visit that day, or could have lived even months longer. Read more On Wednesday, a subcommittee of the Senate Governmental Affairs Committee will hear testimony from other nurses who echo Carey's worry about the quality of care provided on short-staffed hospital wards. New research supports their concerns, suggesting that many U.S. hospitals have shifted work once done by aides to registered nurses, forcing them to answer phones, transport patients around the hospital and run samples to the laboratory. Researchers say such non-nursing work can leave nurses with little time to check on patients, a trend that can have dire results. A study by researchers at the Harvard School of Public Health and Vanderbilt University suggests short staffing at US hospitals puts people at risk for dangerous, even deadly complications. A study by a team at the University of Pennsylvania suggests overwork has burned out a record number of nurses who say they are unable to provide many aspects of essential nursing care. "The problem of low staffing is very serious at many US hospitals," says Jack Needleman, one study author and an economist at the Harvard School of Public Health in Boston. "And the consequences for patients can be severe." The Harvard-Vanderbilt study shows that one out of five people who developed serious complications after surgery died. A check of records suggested that people died because an overtaxed nurse didn't catch a deadly problem, like pneumonia or an infection, until it was too late, Needleman says. Preliminary estimates by the team suggest that if hospitals beefed up staff they could save an estimated 75,000 people from heart attacks, pneumonia and other serious problems related to short staffing. That number, based on limited data, almost certainly underestimates the problem, Needleman says. The nursing crisis started in the 1980s when cutbacks in Medicare and other sources led hospital managers to lay off employees, including nursing staff. Then nurses began to leave hospitals for less stressful jobs. Now the American hospitals cope with a shortage of 126,000 registered nurses. From the start, nurses had voiced concerns about quality problems but there had been few studies of the issue, Needleman says. That's why he and Peter Buerhaus at the Vanderbilt University School of Nursing in Nashville began their study of 799 hospitals in 11 states. The team looked at health problems that resulted from inadequate nursing care tied to staffing shortages. For instance, an overworked nurse might not have time to clean a urinary catheter frequently and the patient develops a urinary tract infection. Or a nurse doesn't have time to turn a bedridden patient, so secretions build up in the lungs and pneumonia develops. This study found that when hospitals at the lowest staff levels beefed up their nursing staff, they reduced the risk of such complications by up to 12% and the risk of dying after surgery by up to 6%. Post-surgical patients often need close monitoring, Needleman says. The improved staffing for people who had surgery could save at least 500 people a year in the USA. The researchers reported their findings earlier this month at the Academy for Health Services Research and Health Policy meeting in Atlanta. For Sally Evers, a 59-year-old emergency room nurse at St. Mary's Hospital in West Palm Beach, Fla., short staffing is a daily reality. She says nurses used to rely on technicians and other staff to do jobs like drawing blood or answering the phone. But St. Mary's eliminated many of those jobs, forcing Evers to do those tasks in addition to her usual duties. A research team led by Linda Aiken at the University of Pennsylvania School of Nursing in Philadelphia surveyed more than 43,000 nurses in the USA and Europe and found that many hospitals require nurses to do a whole lot more than nursing care today. Her survey of U.S. nurses found that: 42% had to deliver and retrieve food trays. 34% had to clean rooms and do other janitorial tasks. 46% had to transport patients. Only 33% of the 13,000 U.S. nurses surveyed in Aiken's study said that their unit had enough staff on hand to get the work done. Just 35% described the care they provided on their ward as excellent. Not surprisingly, the Aiken study documented widespread dissatisfaction: 23% of U.S. nurses were so frustrated that they planned to quit within a year. Other nurses experiencing burnout have walked out on hospitals. That's what 800 nurses in Youngstown, Ohio, did on May 1 to protest Forum Health hospital system's policy of mandatory overtime. Linda Warino, a nurse on the picket line, says Forum and many other hospitals around the nation force nurses to work overtime instead of hiring additional staff. She says that policy leads to nurses who must work shifts of up to 16 hours at a time. "That's a risky way to provide care," she says. Forum Health's Evonne Woloshyn says the hospital has been hit with a severe shortage of nurses, and like other hospitals, uses mandatory overtime to ensure enough nurses are on hand for quality care. The Service Employees International Union (SEIU), the nation's largest health care union, has called on Congress to ban the practice of mandatory overtime. SEIU and other nursing advocates want Congress to enact legislation that would establish safe staffing standards for all U.S. hospitals. California has already adopted such a law, which is now being implemented, says Charles Idelson of the California Nurses Association. Nursing shortage Hospital managers say they're dealing with a severe shortage of hospital workers. Right now, the American Hospital Association says that U.S. hospitals have 168,000 unfilled positions, including 126,000 vacancies for registered nurses. Managers simply can't find enough qualified people to fill those job slots, says Pamela Thompson, a nurse executive at AHA. In some cases, that means the nurses that are on staff must work overtime or perform other jobs. "Nurses do have one of the toughest jobs in the hospital today," Thompson says. To address the shortage, managers have created ties with nursing schools to recruit young nurses, she says. And some hospitals recruit nurses from other countries, particularly the Philippines. Hospitals may be importing quality problems because they can't be sure foreign nurses are trained to U.S. standards, says Connie Helmlinger of the American Nurses Association. She and other nurse advocates say that hospitals won't solve the shortage until they raise the pay and improve working conditions in U.S. hospitals. Hospital CEOs must also deal with the reality of reduced payments from Medicare and other sources, says Laura Thevenot of the Federation of American Hospitals, representing for-profit hospitals. She and other industry advocates say staffing difficulties have not affected the quality of care. These early studies do suggest that severe staffing shortages may lead to problems, says Rick Wade, senior vice president of the AHA. But he and others say by and large hospitals don't let staffing difficulties affect the level of care. "Hospitals are doing what they need to be doing to care for patients," Wade says. He says that many nurses are frustrated because the pressure to provide care has left little time for comforting patients, a job that provides nurses with a lot of emotional satisfaction. Future shortage The nurse shortage will become even more severe in the next two decades, Buerhaus predicts. The average age of a nurse today is 45; by 2010 the average age will be pushed up to 50, he says. That aging workforce will not get many young, new recruits coming up through the ranks, Buerhaus says. During the 1980s and 1990s, many young women decided against nursing school and chose to pursue studies in higher-paying careers, he says. At the same time, Buerhaus says that the aging baby boomers will be flooding hospital wards. There will be an influx of aging patients, just at a time when the studies predict a catastrophic shortfall: By 2020, the shortage is expected to total 400,000 registered nurses. Carey is one who has already left the hospital ranks, going to work as a school nurse. She said she just couldn't take the marathon work shifts. The lack of support staff. The crushing loads of very sick patients. And the constant worry that her patients were in danger. "Who wants to work in hospitals under such conditions?"