Closer link made between nursing shortage, safety: comprehensive study, JCAHO panel say lives may be in danger

HealthCare Benchmarks and Quality Improvement, Oct, 2002

Ever since the nursing shortage came to the fore in health care circles, concerns have been raised about its possible impact on patient safety. But even experts have not been able to agree as to whether the evidence of such a linkage was conclusive.

However, the most comprehensive scientific look at the subject to date and a white paper from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in Oakbrook Terrace, IL, have drawn a direct link between the nursing shortage and serious complications--even death.

A study by the Harvard School of Public Health in Boston and Vanderbilt University's School of Nursing in Nashville, TN, has shown that the size and mix of nursing staffing at U.S. hospitals has a direct impact on the outcome of patient health.

The Harvard/Vanderbilt study, published in the May 30, 2002, issue of the New England Journal of Medicine, represents a re-examination and refinement of the co-authors' previous analysis released last year by the Health Resources and Services Administration in cooperation with the Department of Health and Human Services, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare & Medicare Services, and the National Institute for Nursing Research.

Specifically, the researchers confirmed their initial findings that low levels of RNs among a hospital's nurses were associated with rates of serious complications such as pneumonia, upper gastrointestinal bleeding, shock, and cardiac arrest, including deaths among patients with these three complications, as well as sepsis or deep vein thrombosis. These complications occurred 3% to 9% more often than in hospitals with higher RN staffing.

"In some subtle ways this article is different, but the fundamental conclusions hold up," says Jack Needleman, PhD, assistant professor at the Harvard School of Public Health, a co-author of the article with Peter Buerhaus, PhD, RN, FAAN, of Vanderbilt. Needleman noted that the sample size (his study used data from 799 hospitals in 11 states, and 6 million patients discharged) helped underscore the validity of his findings.

The main difference, says Needleman, is that in the original HRSA presentation "we were somewhat equivocal--there was no consistent evidence of an association between [licensed practical nurses] and aide staffing and these outcomes, but some evidence of a total effect. When we looked more and harder, we determined that all we really see on these data is a registered nurse effect."

The growing shortage of nurses in America's hospitals is putting patient lives in danger and requires immediate attention, according to an expert panel put together by JCAHO. The panel was convened to discuss a recent white paper report by JCAHO, via expert roundtable, designed to address the growing nursing shortage crisis. Failure to address this problem aggressively, the panel members warned, is likely to result in increased patient complications and deaths, greater lengths of stay and other undesirable outcomes.

According to JCAHO, more than 126,000 nursing positions are unfilled today, and that number is expected to skyrocket just as 78 million baby boomers begin placing greater demands on America's health care system.

Today, this nurse-staffing problem is a major factor in 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, it said.

According to Dennis O'Leary, MD, president of JCAHO, the organization found that almost 25% of all medical error reports can be traced to inadequate staffing, and clear evidence suggests that high nursing turnover is associated with increased patient mortality.

"The need for solutions to this problem is particularly urgent," O'Leary says. "We must, as a country, understand not simply what needs to be done but who specifically is responsible for getting each task done. Otherwise, we face a future in which patient safety and health care quality will be significantly compromised." He termed nurses "the frontline of health care."

`Perfect storm' brewing

Current forces in place spell bad news down the road for patient safety unless something is done; all the elements are in place for "a perfect storm brewing," warned Marilyn Chow, RN, vice president of patient care services at Kaiser Permanente in Oakland, CA, and a JCAHO roundtable panelist. She said an aging nursing population--average age just over 43--and fewer coming into the profession, along with the rapid increase in aging baby boomers needing increased health care, all contribute to darkening clouds hanging over not just nursing but the entire health care sector.

Chow said that the proposals set forth in the JCAHO white paper will spur action on the issue, but that it will require effort from all parties involved. "We believe there are solutions, but making these solutions happen will require a commitment from leaders across the industry and government and for all those who care about how America's patients are cared for," she said.