Forging a link with patient safety movement
Patients are at a heightened risk of nosocomial infections and other adverse outcomes as the nation’s nursing shortage worsens, health care accreditors warn. Federal money earmarked for patient safety issues must be used to bolster nursing recruitment and retention efforts, says Dennis O’Leary, MD, president of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
"We need to put new federal money into nurse staffing, and that should be driven off of the patient safety platform," he tells Hospital Infection Control. "The fact of the matter is that public policy-makers have been subtracting resources from hospitals for 25 years and it is starting to have its effect. It’s time to put some of it back, quite frankly."
How bad is the shortage? More than 126,000 nursing positions are unfilled today. That number is expected to continue increasing even as 78 million aging "baby boomers" begin placing unprecedented demands on the health care system.
Contributing factors to the nursing shortage include job dissatisfaction, an aging work force, cost cutting and stress from increased patient care assignments, and extra work shifts. The staffing problem translates into emergency department overcrowding, cancellation of elective surgeries, discontinuation of clinical services, and the limited ability of the health system to respond to any mass casualty incident, the Joint Commission warns.
O’Leary and other health care officials held a recent telephone press conference to announce release of the Joint Commission report Healthcare at the Crossroads.1 The far-reaching report calls for transforming the nursing workplace, creating a clinical foundation for nursing education, and providing financial incentives for health care organizations to invest in high-quality nursing care. Failure to address the problem aggressively, the Joint Commission warns, is likely to result in increased deaths, complications, length of stay, and other adverse patient outcomes.
A threat to patients and workers
The report cites studies showing the association between adequate nurse staffing levels and patient outcomes, including lower rates of mortality, lower catheter-related bloodstream infections, and lower nosocomial infection rates in a pediatric cardiac intensive care unit.1 "Insufficient staffing not only adversely impacts health care quality and patient safety," the Joint Commission report states, "it also compromises the safety of nurses themselves. The risk of having a needlestick injury is two-to-three times higher for nurses in hospitals with low staffing levels and/or poor working climates."
Health care epidemiology studies have previously linked increased infections with staffing problems that include increased use of "pool" nurses to fill in for regular staff.2-6 (See HIC June 1999 under archives at www.HIConline.com.) "Having nurses who are full-time and are familiar with that setting makes a lot of difference," O’Leary says. "When you are busy, you don’t take time to wash your hands, which is probably the single most important problem underlying the rise of nosocomial infections."
Exacerbating the shortage, is a trend that finds experienced nurses — those that have mastered multitasking — leaving hospitals to work in less stressful medical settings, adds Sally A. Sample, RN, MN, FAAN, moderator of the nurse staffing session.
"When you are dealing with newer nurses, temporary nurses, how you manage IV lines, how you manage urinary catheter lines — that which is second-nature to the experienced nurse who has worked many years on a single unit — is lost," Sample says. "It increases the potential risk to patients when you have a continuing stream of nurses who are just moving into the profession, or who are doing a six-week term at this hospital and will be going to another hospital and another commitment through a temporary agency."
While nursing groups have been warning about the problem for years, the link with patient safety is now irrefutable, says Mary Foley, MS, RN, immediate past president of the Washington, DC-based American Nurses Association (ANA). "There is a direct correlation between safety, quality, and nurse staffing," she says. "We do have knowledge now in nursing to be able to show that quite convincingly. I think the nosocomial studies are another affirmation that there are potentials for breakdown in procedures."
Meeting the crisis
The Joint Commission report identified three key strategies to fight the problem:
• Transform the workplace to give nurses the independence and support they need to do their work well, thereby creating a culture of professional satisfaction and encouraging retention. Setting staffing levels that take into account the complexities of patient needs and nurses’ skills and competencies also must be part of the solution. So, too, is adoption of zero-tolerance policies for abusive behaviors by physicians and other health care practitioners.
• Bolster nursing education to ensure that new graduates are better prepared to care for fragile patients. This means re-invigoration of nursing schools by funding new faculty positions and encouraging nurses to seek advanced degrees. It also means the creation of standardized postgraduate nursing residency programs. Increased federal funding for nursing education also is needed to encourage greater interest in the profession.
• Make new federal money available to motivate hospitals to invest in nursing services. Continued receipt of these monies should be conditioned on achievement of evidenced-based, nursing-sensitive goals, including patient outcomes.
(Editor’s note: For a complete copy of the Joint Commission report, go to www.jcaho.org/news+room/news+release+archives/health+care+at+the+crossroads.pdf )
References
1. Joint Commission on Accreditation of Healthcare Organizations. Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Oakbrook Terrace, IL; 2002.
2. Fridkin SK, Pear SM, Williamson TH, et al. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17:150-158.
3. Haley RP, Bregman DA. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis 1982; 145:875-885.
4. Kidd F, Heitkemper P, Kressel A. A neonatal intensive care unit outbreak of S. aureus associated with inadequate staffing. Abstract S74. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.
5. Cunney RJ, Thornley D, Bialachowski A, et al. Environ-mental and nursing staff levels: Relationship to nosocomial acquisition of methicillin-resistant Staphylococcus aureus (MRSA). Abstract M29. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.
6. Duncan RA, Levine A, Willey S, et al. Nursing staffing and central venous catheter-related bloodstream infections (CVC-BSIs) in a changing surgical intensive care unit (SICU). Revised Abstract. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 1999.
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