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Healthcare Organizations
5.1 Staffing shortages will increase despite higher wages and bonuses.
What is the scope of the nursing shortage now and for future projections? What is being done to remedy the nursing shortage?
What is being done to address patient safety and medication errors?
How serious is the safety issue in terms of American risk in hospital care? What are important case management implications for these issues?
The work environment for nurses these days can be characterized as challenging and at times, rewarding (Underwood, 2000). One of the most critical issues facing nursing today is that hospitals have tried to influence their financial problems by reducing RN staff. During these years of staff cutting, patients have become more ill and need more critical judgments made by professional nursing staff.
In the U.S. and in California in particular, we are heading for the largest shortage of nurses that his country has ever seen. It will affect bedside nursing units most seriously and also other areas needing well educated nurses including nursing faculty and other nursing staff. The next three to five years in particular will not be easy. Healthcare providers will need to adjust their operations and strategies in response to Medicare's Budget cuts, managed care, and new reimbursement patterns (American Hospital Association, 2000).
The nursing shortage, which most of us know now, has spread to all regions of the United States. Demand for RNs is rising fast, and will continue. The Bureau of Labor Statistics projects that the U.S. will have 2,530,000 jobs for registered nurses in 2008, an increase of 2 1.7 percent from 2,079,000 jobs in 1998 (Braddock, 1999). The current supply of nurses in training programs will not meet the future needs. The lack of RN staff leads to many problems and concerns, which are discussed further in this chapter. One that has been with nursing for a long time is the overworked RNs who get burned out and leave staff roles as a result. In addition, those left to man the understaffed units are more likely to be stressed and likely to be involved in medical mistakes or medication errors.
It is now called "let's make a deal." Nurses in specialty areas are being wooed to all areas of America to take RN roles in the ICU, OR, OB-GYN units as fast as is possible. To attract nurses, hospitals are trying ads with promises of bonus for signing on, bonuses for staying at least a year, as well as paying for their apartment and other needs. Some believe that we do not have a real shortage of all nurses, just those who must take ICU and high-stress areas in hospitals, as reported in a recent article (Busman, 2000).
The issues discussed in earlier chapters-aging of American patients, hospital monetary shortfalls, and other cost issues-add to this problem and will continue to be issues for many years. The Bureau of Health Profession's Division of Nursing, within the U.S. DHHS is conducting surveys on the nursing workforce. In addition, the American Organization of Nurse Executives is also following statistics on recruitment and retention. Information on these efforts can be accessed at information provided in Table 1.
The AHA report asserts that staffing shortages will continue despite attempts to attract nurses with higher salaries and bonuses. The aging RN workforce, the concomitant Baby Boomer aging, and jobs that attract women and men to other fields all have a factor in the ongoing shortage of nurses (AHA). As Boomers get older, we will also have a critical need for case managers and special training to handle elder needs, acute and chronic healthcare conditions and innovative therapies, long-term care, and other issues. Legal guidelines and general documentation considerations in acute care, home care, and long-term care elder care are listed in Table 2.
Other leaders are encouraging nurses to think of other delivery models to meet the needs of older patients, the younger workers, and nursing shortage in the near future. Ed O'Neil, a leader in healthcare issues, recently spoke to American nursing leaders and made the call for new ways to work, rather than trying to fit the past models of care and nursing roles on a new and unique healthcare future (O'Neil, 2000). This new approach may well be needed to survive and be successful in teaching roles and practice areas in the near future. It may also be the only way to meet the needs of patients' rights to safe care.
As the shortage matures, more nurses in all areas find themselves besieged with overtime-often mandatory in nature. In Several states, legislation has had to be passed to stop mandatory overtime expect for emergency times. In California, nonunion workers do not have to work overtime at the manager's discretion, and if overtime is due to an emergency, the worker has the right to leave at the end of four hours.
In addition to overtime, poor staffing is now blamed for lawsuits in places not expected. For example, a hospital in Kansas was sued due to inadequate staffing that lead to a women stopping breathing and then suffering brain damage and partial paralysis (American Nurse, 2000). Other areas of the country also have stories of similar outcomes of poor staffing.
Leaders within the American Nurses Association assert that there is a critical need for research that examines the impact of staffing levels and skill mix on patient safety and the incidences of terrors by nurses and others. Related to this is the need to address research on patient safety while including an examination of the relationship between continuous hours worked by personnel involved in direct patient care and their ability to work safety and without error (Underwood, 2000).
Patient safety has become a major concern in the U.S. One study from early 90's found that an estimated one million patients nationwide are injured by errors during hospital therapy each year, and 120,000 die as a result (Brennan, Leape, et aI, 1991). In late 1999, a report found that 44,000 to 98,000 Americans die in hospitals each year from preventable medical error, to which some in the medical community reacted with anger and denial (McDonald, et aI, 2000). Hospital errors have now been identified as the number 1 problem facing the U.S. Lucien Leape is the nation's leading expert on hospital deaths and adverse drug events caused by medical errors.
Leape has found that 1 of every 200 patients die as a result of a hospital mistake and that errors accounted for 69 percent of injuries caused by medical therapy that lengthened hospital stays or led to a disability upon discharge (Brennan, Leape). Serious injury and death caused by medical errors are well-known in the medical community but Care Delivery Models and Shortages, and Squeal are rarely reported to the public.
On the other side, some experts believe that most patients admitted to hospitals have high disease burdens and high death risks even before they enter the hospital (McDonald). In other words, some deaths are preventable, but most will happen no matter how much we work to avoid accidents with patients. Leape argues that it is not a guilt ridden issue, but a symptom of system errors that lead to excess mortality that can be lessened if we work on system problems.
Mistakes can occur at hospitals for complex reasons. Several potential causes have been addressed as issues in safety problems. Fragmentation of care due to shift changes, tired, overworked, hungry, bored, anxious, frightened, pressured staff are many of the possible causes (Bureaus’, 1999). Most notable for nurses are staffing shortages, redesigned care models in hospitals, and overtime that is mandated at some hospitals. Leape calls such issues "latent errors" that result from system defects that eventually lead to medical errors. One example of such a latent error is when a hospital decides that a nurse can take care of twice as many patients in the same amount of time. This practice results in an overworked nurse subject to fatigue and thus to medical errors.
Dishonesty among healthcare professionals-don't tell and don't report errors-has been cited as a problem with patient safety (Bureaus’, 1999). Also, many report that they have hidden the truth from patients for fear of retribution or legal ramifications. In addition, hospitals currently self-regulate themselves by preparing and sending data on errors to lab. Unfortunately, the number of errors reported is believed to be far below the level of errors actually occurring in the U.S.
Research lately has shown that although adverse events during hospitalization are common, few of the malpractice claims involved negligence (Thomas, et aI, 2000). This study was a review of records in Utah and Colorado and supported the fact that errors are occurring, but not the reason patients sue. The researchers suggest that the low income level of the patients studied prevented them from securing an attorney (Thomas).
Medication errors are far too common in hospital settings. Some of the potential factors leading to these errors include:
lllegible orders are a serious issue, and it has been said that "people die of penmanship errors" according to Arthur Caplan, Director of the Center for Bioethics the University of Pennsylvania Health System. Most nurses can relate to the difficulty of reading some medical orders and the risks they have had to negotiate to avoid patient harm through wrong dosages or wrong medications.
The Catholic Healthcare Association (CHA) said in April of 2000 that they would support a national mandatory medical-errors reporting system, but only if certain conditions to protect the providers from legal liability are met (Reuters Health, 2000). The CHA was the first national hospital organization to take a public position in the ongoing medical errors debate. CHA said it would support a national mandatory reporting if it would improve clinical care and have clear guidelines and terms.
The American Hospital Association has also taken action on patient safety. Faced with a growing awareness that medical error contributes to a decline in public confidence in the healthcare system, AHA supported six national initiatives aimed at reducing and preventing medical errors. These six initiatives are listed and described in Table 3.
Close on the heels of AHA news came the news that the House of Representatives opened hearing on medical errors in early 2000, with the goal of hearing several proposals for addressing serious healthcare errors trends. In addition, the National Committee for Quality Assurance (NCQA) release modified accreditation standards that would force health plans to focus on reducing medical errors and improving patient safety (Reuters Health, 2000). Beginning in 2001, managed care organizations would be required to show that they have developed patient safety programs. NCQA is the largest HMO accrediting body and is building on existing accreditation requirements in the areas of clinical performance, practitioner credentia1ing, coordination of care and utilization management (Reuters Health).
The Agency for Health Care Policy and Research (AHCPR) is also focusing on improving quality. They report that errors in care are prevalent and often preventable by addressing system errors, as reported by Dr. Leape in his studies (AHCPR, 2000). Dr. Leape led a study of utilizing pharmacists within intensive care units (lCU) to avert medication errors during 1999 (Leape, et aI, 1999). This study found that the presence of a pharmacist on rounds as a full member of the patient care team was associated with substantially lower rate of adverse drug events caused by prescribing errors (Leape).
In July of 2000, the ANA reported concern with errors, and that nurses continuously contribute to efforts to reduce medical errors as shown by the efforts mentioned in a recent U.S. News & World Report Article (Nursing world, 2000).
The ANA asserts that nurses are pivotal to improving patient outcomes and excellent evaluators of the work environment for deficits and solutions for quality improvements (Nursing world).
Protection from abuse
Each patient has the right to be protected from abuse in any setting. Abuse can take many forms, including:
Any of these types of abuse may be noticed in various care settings. Case managers, nurses, and other care providers are obligated to be alert to signs of suspected Abuse, including assessment of risk factors the patient may have. While young children may be the victims of emotional, verbal, physical, or sexual abuse, or neglect, elders are at risk for any type of abuse. For example, financial abuse may be take the form of family members or caretakers using patient's social security income or savings for personal purchases unrelated to the patient's needs. Reports of elder abuse and neglect have. been seen in the media and may be familiar to nurses in emergency departments or home health care who are witness to substandard care or questionable care.
Nurses and case managers in school health roles, clinics, home care, or hospital pediatrics need to be aware of children at risk for abuse or neglect, and the agency's protocol for reporting such information. This is a vital aspect of patient advocacy for minors-a group who often are not able to self-report abuse or harm to care providers.
The elder portion of our citizenship is the fastest growing age group in our country. It is important for nurses and case managers to understand the needs of this age group and how to minimize risk with elders in all healthcare settings, as is discussed in Table 2.
You are the nurse case manager for several intensive care units in a large hospital. While making morning rounds, an 80-year-old patient, Mr. Jensen, who was admitted from the local prison with complications secondary to his emphysema, seems upset. He looks familiar, and may have been in the hospital before. You listen to his descriptions of how horrible the conditions are in the prison for the aging convicts like him.
Listening to his story you recall other elderly prisoners who have been in the intensive care units during the past few months who have presented with some signs of neglect. Mr. Jensen tells you that he will do anything to get admitted to the hospital for "long-term" therapy, and that most of the other elderly prisoners would too. "Not even a dog should have to live the way we do," he says. You sense he is probably being honest. Case Questions:
References
Table 1
| Information on Staffing, Salaries, and the Nursing Workforce Bureau of Health Profession's Division of Nursing Abstract of 1996 survey available at: http:\\www.hrsa.gov 2000 data will be online soon.
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| American Organization of Nurse Executives Recent statistics on recruitment and retention at: www.aone.org or call 312.422.2800 |
| Care Planning: |
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| Medications: |
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| Policy and procedures: |
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| Teaching: |
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| Safety and protection: |
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Table 2. Source: adapted from American Health Consultants, 1998, in reference list.
Table 3
National Initiatives Aimed at Reducing/Preventing Medical Errors |
| Institute for Healthcare Improvement (IHI): Convened forty organizations from 1996 to 1997 that looked into reducing adverse drug events. AHA may replicate this study format.
Institute for Safe Medication Practices (ISMP): A nonprofit organization that provides education about adverse drug events and prevention. National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP): Co-founded by the AHA in 1995 to address interdisciplinary causes of error and to promote the safe use of medications. National Patient Safety Foundation (NPSF): A non-profit organization founded by the American Medical Association to measurably improve patient safety in the delivery of health care. National Patient Safety Partnership (NPSP): A public-private partnership that is led by the Veterans Administration. The purpose is to improve patient safety by reducing preventable adverse events and untoward outcomes of healthcare related processes United States Pharmacopeia (USP): Private, not-for-profit public service organization that develops standards and disseminates authoritative information for healthcare professionals, patients, and consumers about the use of medicine and other healthcare technologies. |