Do You Know What Patient Safety Looks Like?

[NRSKarenRN, BSN, RN]

From Hawaii Nurses Association, downloaded on 1/3/02:

Stephani Monet, JD, RN

HNA Director Education & Practice

http://www.hinurse.org/

Recently there have been many comments and numerous articles in various publications as to why nurses in Hawaii chose to leave the patient's bedside and walk the picket line. This was an exceedingly difficult choice for the nurses to make and they did not come to this conclusion without much soul-searching and considerable debate. The primary reason the nurses are on the picket line is to ensure patient safety, something they do each and every day in this state. Patients rely on nurses to ensure their safety but do you really know what patient safety looks like or what unsafe conditions could mean to you, the potential patient.

Ensuring patient safety is at the very heart of the nursing profession. Patients are in the hospital because they need complex care, observation and monitoring by skilled registered nurses who can detect potential problems and intervene in a timely manner. This ability is so crucial that the Journal of the American Medical Association (JAMA) recently published research from the University of Pennsylvania that showed that each additional patient in a nurse' s workload translated to a corresponding seven (7%) increase in the death rate. For example, the difference between four and six patients per nurse translated to a fourteen percent (14%) increase in mortality, while the difference between four and eight patients increased the likelihood of dying by thirty one percent (31%).1 This is one of the first research projects to actually document the problems with insufficient staffing but it is not the first time nurses have attempted to address these issues. In Hawai`i, and across the country, staff nurses have tried on many occasions to address these issues to no avail.

Nurses have been speaking out for over a decade now. They have brought these problems to the attention of management again and again using a variety of strategies. Nurses have filed numerous unsafe staffing reports, served on labor-management committees, negotiated principles of safe staffing, and drafted legislation, yet none of these strategies have worked. In the last two labor negotiations, the nurses' primary issue was "safe staffing and quality patient care." Nothing is more important to nurses than to be able to go home at the end of the day feeling that he or she gave their patients good safe quality care. The sad truth is nurses can no longer say that they are always providing that level of care we have all come to expect. The number of registered nurses per patient is dropping at the same time that the acuity of the patients is increasing. (Acuity measures the seriousness of the patient's condition and the level of nursing care needed) Patients are sicker than ever before, hospital stays have been shortened so that nurses have less and less time to deal with a myriad of issues and the technology is becoming increasing complex. There is only so much one person can do, and for years now, nurses have been told that they will "just have to manage." We have to understand that nurses are at the absolute breaking point. They are saying, "No more, we can't do this" and as a community, we need to listen. The one thing that no nurse can live with is harming patients due to their inability to provide care because they were placed in situations that were not in their control.

Our nurses in Hawaii are standing up for patient safety. Normally, they attempt to address these issues out of the public eye because they do not want to erode the confidence you have placed in their hands. Consequently, you may not know how many times nurses have tried to address these issues on both a local and a national level.

We have even taken these issues to our State Legislature. Legislation has been introduced adding language to the whistleblower bill to allow nurses to report health and safety concerns without fear of losing their job. We have tried to prohibit mandatory overtime to make nursing more attractive (In the event of a major disaster, nurses have always volunteered, mandatory overtime is not an issue in those situations). Bills were introduced to provide for scholarship and loans to nursing students and to create a Center for Nursing that could address many of these issues. All of this legislation failed to pass. A Center for Nursing, already a reality in some other states, could assist us in getting data on our workforce, addressing recruitment and retention issues, and assist us in obtaining the research that we need to identify and correct these problems. Health care is in a crisis and we must find a way to address this problem, it is not addressed by cutting nursing staff.

Unfortunately, because poor staffing has led to bad outcomes, many consumer groups have focused on more regulation. This solution is counterproductive because the monies for regulation take needed health care dollars from clinical practice and shift those dollars to clerical and administrative activities. Suzanne Gordon, a leading health policy analyst and author of "Life Support: Three Nurses on the Front Line quotes a 1996 study by Steffie Woolhandler and David Himmelstein, at Harvard Medical School. They point out that it is not the patient care sector of health care that is growing; it is administration.

"Between 1968 and 1993, administrative and clerical staff grew by 692percent -or a sevenfold increase. In 1968, administrative and clerical occupations comprised 18.1percent of healthcare full-time equivalents (FTEss), and in 1993 the figure was 27.1 percent. In 1968, nursing personnel comprised 40.6 percent of FTEs, and in 1993, that figure had declined to 36.3 percent." 2

Since that period of time, nurses have seen the staffing situation grow even worse.

In the 1999 contract negotiations, nurses put issues of patient safety at the forefront of their negotiations. Language related to safe staffing and labor/management committees was negotiated; unfortunately, the nurses feel that this contract language has not adequately addressed the issue. Nurses have not been given the autonomy and control over their practice that they need if they are going to provide safe care. It is simply not enough to set up committees to study the issues and to list principles of nurse staffing if the nurses have no real say over these issues. Control over nursing practice is the bottom-line issue. Nurses are highly educated professionals who are expected to make, and do make, critical decisions every day, yet when these same professionals relay concerns about staffing or the number of hours they are expected to work, they are treated like children who do not like to clean their bedroom. Most healthcare services are provided and reimbursed as separate itemized procedures, yet nursing care is included as part of room and board. At a recent forum, Edward O'Neil, the former Executive Director of the Pew Health Profession Commission, spoke to this need to change the attitude towards nurses. He stated that nurses are viewed as "a commodity. We need to think of them as the strategic asset that the hospital of health system deploys." 3

This view of nurses as a commodity has been a long-standing problem. It started at a time when women were seen as second class citizens and had very few career choices open to them, primarily teaching, nursing, secretarial or social work. Health care did not have to compete with other professions for highly skilled workers; particularly for nurses. Unfortunately, this led to attitudes and practices that devalued the nurses' role and left nurses with little say about their own practice.

The introduction of business principles during an era of "healthcare reform" has made this situation intolerable. Business principles from manufacturing and other industries cannot be easily applied to patient care. Nurses now have less say than ever about their work environment, to the point that it now extends into their personal lives with a new concept called "mandatory overtime."

Mandatory overtime occurs when hospitals have not adequately staffed for a particular shift. It works like this. A registered nurse who is scheduled to work from 7:00 A.M. to 3:00 P.M. is approached one to two hours before the end of their shift and told that no one can be found to work the next shift so they will have to work another four to eight hours. Many nurses fear that if they refuse, they may be charged with patient abandonment even though several State Boards of Nursing have taken official stands that this does not constitute abandonment. The nurse must now cancel all plans they had for that evening, try to make arrangements for the care of any dependents they are responsible for, and face another four to eight hours of exhausting shift work when they are already fatigued. We limit the hours pilots and other transportation employees work because we know how dangerous it is to be working in those occupations when a person is fatigued. Yet, nurses are frequently required to work mandatory overtime. A study by ANA of some 5000 nurses revealed that two thirds (2/3) of them are required to work unplanned overtime on a monthly, if not weekly basis. 4. A survey by Hawai'i Nurses Association's also showed that mandatory overtime is being used by several facilities in our state.

Health care facilities would have you believe that they have no choice but to use mandatory overtime because of the shortage of nurses. This is simply not true. Mandatory overtime actually started during the early nineties when health care facilities were lying off registered nurses. It allows them to hire fewer nurses and to save money on wages and benefits. It is less expensive than paying overtime but it is a very short term strategy that is leading to the exodus of nurses from the profession and making it even more difficult to recruit new nurses.

Currently, there are 2.7 million nurses in the United States. The Health Resources and Services Administration reports that more than one half (1/2) million nurses with active licenses are no longer working in nursing. 5. In 1980, 47.1 percent on nurses in the United States were over 40, in 1999, that figure rose to 68.3 percent. In Hawai`i, the situation is even worse, 75.4 percent of all registered nurses are over the age of 40. 6. A 1998 study by Community Initiative on Nursing of Hawai`i (CINH) showed that we would have to graduate 400 nurses a year for the next fifteen years just to replace our current workforce.7 At the time, we graduated approximately 280 nurses per year and this need for nurses does not include the additional numbers of nurses that will be needed to care for our rapidly aging population.7. Nursing schools have steadily increased the number of nursing students and are projected to graduate approximately 367 students in 2003- 2004, yet this increase will not keep up with the projected need. 8

Sadly, the current working environment has been so demoralizing to nurses that the ANA survey of 7000 nurses showed that nearly fifty five percent (55%) would not recommend nursing as a profession to friends and family and twenty three percent would actively discourage anyone from choosing the profession. 9 Nationally, the RN population under thirty (30) dropped from 25.1 percent in 1980 to 9.1 % in 1999. Again, the picture in Hawai`i is even more dismal; only 6.3% of our nurses were under the age of thirty in 1999. 10

We must solve these problems that have made nursing seem to unattractive to today's generation. The wages and benefits have to be comparable to other professions in order to attract this new generation of men and women. (Nursing is no longer a profession for women only). The image of nursing needs to be addressed, particularly in the mass media, but most of all, nurses need control over their own practice.

You can help by supporting the nurses on the picket line, give them a friendly wave, (we ask you not to honk because it is disturbing some hospitalized patients and the community). Write letters of support to our Governor, your legislators, and the local news media. The nurses want to return to the bargaining table and to their patients. We appreciate your support.

1 CBS News.com. Busier Nurses, Riskier Hospitals? October 22, 2002

2 Suzanne Gordon, Life Support Three Nurses on the Front Line Little Brown and Company, Boston, NewYork, Toronto and London, 1997,284, 285, quoting from Steffie Woolhandler and David Himmelstein.

3 Kaisernetwork.org, Alliance for Health Reform, The Nursing Shortage: Today and Tomorrow, October 17, 2002, p. 12

4 Id., p. 21

5 Id., p. 16

6 HMSA Foundation, Health Trends in Hawai`i, 5th Ed. 2001, Honolulu, Hawai`i p. 100

7 Community Initiative on Nursing of Hawai`i, Nursing Workforce Supply Data Trends, 1997,

1999, and 2001

8 Id.

9 Ibid., Kaisernetwork.org, p. 18

10 Ibid., HMSA Foundation, p. 100