How Hospitals CREATED A Shortage of Nurses

  1. March-April. 2000 Vol.1 - No.2
    http://www.revolutionmag.com/newrev2/engineering.html

    By Don DeMoro

    Don DeMoro, director of the Institute for Health & Socio-Economic Policy, has authored numerous studies critiquing health care industry policies, including "California Health Care: Sicker Patients, Fewer RNs, Fewer Staffed Beds" (1999) and "A Methodological Critique of the East Bay Hospital Capacity Study" (2000).

    The health care industry and its proponents, including investment banks and management consulting firms, have had much to say in recent years about the origins of RN shortages and solutions. However, nearly all of their analysis has focused on causes that leave the industry itself invisible and devoid of responsibility for its own role in causing the nursing shortage.

    Nursing shortages are certainly not a new phenomenon. Like other market and labor trends, the supply of nurses has historically been uneven, and nurses have entered or re-entered the workforce to stave off national crises of care.


    But the nursing shortage that has grabbed headlines across the country in recent years, and left scores of unfilled vacancies on hospital bulletin boards, is unique and threatens to be far more enduring.


    Increasingly, trends indicate that many RNs simply have lost trust in the industry; they've left the hospital setting and they are not readily coming back.


    The health care industry and the numerous management consultants it employs have a catalog of explanations for the current shortage.


    They cite an aging workforce - the average age of RNs is now 46 - and opportunities for women in other professions as long-closed doors in business, law and other male-dominated venues begin to slowly crack open. They note drops in nursing school enrollments and declining graduation rates. They blame the "invisible hand" of the market, which in supposedly neutral fashion dictates supply and demand, as well as changes in medical technology and patient care trends that require fewer nurses.


    Not coincidentally, the industry analysts paint these factors as beyond their control. Notably absent from these clarifications is any recognition or accountability for the industry's own actions.


    An assessment can begin with a brief look back at the last major nursing shortage in the mid-1980s. As noted by Judith Shindul-Rothschild, RN, assistant professor at the Boston College School of Nursing, that shortage was reversed when hospitals abandoned fragmented models such as team nursing and turned to primary care nursing, which enabled RNs to provide a patient's total care. The result was what Shindul-Rothschild calls a "renaissance in nursing," and RNs returned to the workforce.


    Within a few years, however, virtually everything had changed. Nursing care no longer was prioritized as the health care industry had begun to systematically deskill, displace and deprofessionalize nursing.


    Guided by market-driven goals of cost-cutting and profit-making rather than assurance of quality care, corporate health care firms began to implement restructuring programs in the corporate, clinical and technological arenas.


    On the corporate level, large-scale mergers and acquisitions intended to increase market share and build economies of scale resulted in an unprecedented concentration of health care resources in the hands of a shrinking number of very large companies.


    In the past six years, mergers and acquisitions have consumed an astonishing $453 billion in health care, concurrent with a rise in profits and executive stock portfolios, resources that could have been better spent elsewhere ......
    (See Slide Show)
    The binge was fueled by a 1994 change in U.S. anti-trust law (ironically, the only major change adopted by Congress in response to the Clinton administration's 1993 health care plan) that granted extraordinary latitude to merging health care corporations, reputedly to encourage competition.


    The anti-trust law was reflective of the increased political clout of the industry. It was also a harbinger of vigorous lobbying against any policy legislation, including scores of health care reform proposals, that would inhibit its corporate expansion and profit generation.


    Similarly the industry was successful in manipulating tax laws - for example, shifting assets from for-profit to non-profit entities to avoid taxation and regulations, such as moving patients to hospital units or other areas with lesser regulatory oversight.


    To accumulate the cash needed for their expansion, and to pay off the staggering debt load they incurred, hospital corporations increasingly turned to squeezing labor costs - and nursing care in particular, their main source of expenditures.


    At the bedside, management consulting firms like McKenzie, Booz Allen & Hamilton, American Practices Management (APM), Andersen Consulting and the Hunter Group, were paid hundreds of millions of dollars to implement work redesign models.


    Carrying pleasing-sounding names such as Patient Focused Care or Population Based Care, the re-engineering was premised on models first introduced in the manufacturing sector of the economy and forced onto the health care workplace and direct caregivers.


    The emphasis was on "just-in-time" production techniques that cut staff to dangerously low levels and only provided care for patients when they reached the periphery of crisis and presented a legal liability if they were not treated.


    At their core, the redesign plans were intended to deskill and disempower direct caregivers. Most of the models featured the carving up of the care process into assorted "tasks," and shifting RNs away from hands-on patient care to serve as "team leaders" of unlicensed assistive personnel who would perform the tasks. It would mean replacing direct care RNs with unlicensed staff and RNs with advanced degrees who would supervise them.


    New technologies also played a major role in the deskilling process, such as computerized diagnostic and treatment protocols that some institutions began to use in areas from bedside care to telephone advice.


    Large numbers of RNs were simply laid off - Kaiser Permanente alone laid off 1,600 RNs in Northern California from 1994 to 1997, and a 1997 survey by the California Board of Registered Nursing found that 5 percent of respondents had left nursing due to downsizing.


    Health care had been "transformed," the industry and its consultants proclaimed. With fewer RNs ostensibly needed in hospitals, hospital-based education and training programs for RNs were dropped. As hospitals signaled to nursing schools that fewer nurses were needed, education curricula and expenditures were cut back. Enrollments in entry-level bachelor's degree programs had fallen by 4.6 percent in the fall of 1999, although advanced degree programs were growing, according to the American Association of Colleges of Nurses. The Boston College School of Nursing was among the healthiest programs, with admissions flat rather than declining, Shindul-Rothschild said.


    The restructuring programs had a huge economic cost. Kaiser Permanente alone spent about $100 million in only one year on its top four consultants - enough to insure at least 80,000 people.


    Results for patients also have been disastrous. In an examination of more than 18.2 million patient discharge records from 1993-1997, a study by the Institute for Health & Socio-Economic Policy found that the proportion of patients admitted to a hospital in a given year who were well enough to be discharged home dropped 5.2 percent.


    Industry attempts to limit admissions and reduce costs have forced many patients to seek the ER as their only means of access to a hospital bed of any kind. California ERs now account for almost 34 percent of all hospital admissions statewide.


    And hospital-based errors leading to the deaths of up to 98,000 Americans every year have become a national scandal. Notably, the Institute of Medicine, which produced the findings, studied every conceivable variable except RN staffing ratios and deteriorating patient care conditions to explain the shocking numbers.



    Patients are sicker than ever, and there are fewer RNs at the bedside.


    Some states, such as New York, Massachusetts and Pennsylvania, have experienced steadily declining numbers of full-time RNs, coupled with a rising uninsured population. As more patients use the emergency room as their entry point to health care, RNs struggle with higher nurse-to-patient ratios and higher acuity levels of patients.


    Click here to view charts of RN numbers in
    Massachussetts, New York and Pennsylvania

    In Maryland, the nursing shortage is reaching epidemic proportions. Dr. John Burton, director of geriatric medicine at Johns Hopkins Bayview Medical Center told a Baltimore Sun reporter that the staffing problems are "having a dramatic impact, and it's likely to get worse. We're headed for a crisis." Maryland hospitals are suffering nurse vacancy rates of 10 percent to 12 percent, with some hospitals facing a 20 percent shortage. The Professional Staff Nurses Association of Maryland, which represents nurses in six of the state's 55 institutions, reports that complaints on unsafe assignments or mistakes have doubled since the beginning of the new year.


    Although Maryland hospitals are offering higher salaries and extra benefits like tuition or day care provisions, they aren't finding takers. The state's Board of Nursing reports that the number of registered nurses available for work dropped by about 2,300 from 1998 to 1999.


    In other states, hospitals are also offering signing bonuses of $6,000 or more, seemingly to little avail.


    A closer look yields disturbing information. According to the American Hospital Association, the number of California full-time employed hospital RNs peaked at about 63,700 in 1994 and has not quite attained that level since. But figures obtained from the California Board of Registered Nursing this year reveal that 266,800 RNs are licensed statewide and, of that number, about 248,000 are actively licensed.



    So, where have all the nurses gone?


    "All you have to do is talk to a direct care nurse to find out what the conditions are like," said Echo Heron, RN, and author of Tending Lives: Nurses on the Medical Front. "Forced overtime, working double shifts, having far too many patients to care for, then being asked to 'delegate' your work to a person with very little training, well, it all adds up. The hours. The strain. The stress on you, not to mention your family.


    "And too many RNs feel that they aren't safe and their patients aren't safe," Heron said. "When nurses are overworked and exhausted, run ragged by too many patients, mistakes happen."


    A Maryland nurse, who refused to give her name to a reporter for the Baltimore Sun for fear of losing her job, said that a nurse missed a very unsafe cardiac arrhythmia with one of her patients because she was busy with another one. Yet a number of Maryland hospitals assign ICU nurses three patients instead of the standard ratio of one nurse to two ICU patients.


    Nurses across the nation are extremely concerned about the quality of care in their hospitals. A survey conducted by Fingerhut Granados Opinion Research revealed that 66 percent of RNs believe that "staffing levels are inadequate at the place where they work." Sixty-nine percent of them worried that "patients aren't getting the care they need." And 75 percent of RNs were concerned that "because of short staffing, a mistake affecting a patient will occur."


    If we look at the evidence, we are forced to a conclusion about the nursing shortage.


    Nurses are losing trust in their institutions and in their management. They are losing trust in the entire health care industry.


    Nurses see speed-up at the expense of patient care while executives in the hospital chains where they work sit on wealth undreamed of only a few years ago. They see inner city hospitals closed while the companies shift services to more affluent communities, and they see the most vulnerable patient populations, including the poor, seniors, and some minorities, medically redlined and deprived of needed care.


    They see ever-decreasing lengths of stay while acuity levels skyrocket, and sicker patients moved to the new patient dumping ground of "sub-acute" care. They see implementation of computer programs that reduce skills to tasks and unlicensed staff performing increasingly complex procedures.


    They have so little faith in hospitals today that increasing numbers will not even recommend hospitals they work in to family members because they are not sure the facility will care for them properly.


    "Our profession is mostly women, and it's true that there are more alternatives for women wanting professional careers," says Shindul-Rothschild. "But then, those slots aren't being filled by men, either. So you have to ask the question, 'Why aren't men coming into the field?' Whether male or female, people aren't entering the profession because of money. The salaries are competitive. And during the last nursing shortage in the '80s, nurses came back to the profession. We aren't seeing that happen today. So that leads me to the conclusion that it must be the working conditions."


    Despite the negative consequences of the transformation of health care the past few years, the industry is gearing up for a new stage of deskilling and restructuring programs. They will be prompted by industry attempts to cope with the huge debt load created by the mergers and acquisitions, fallout from the 1997 cuts in Medicare reimbursements, and the recent wave of pharmaceutical mergers and the resulting increases in formulary prices as HMOs seek to pass costs to hospitals.


    Most critically, the industry will use the excuse of the devout refusal of actively licensed RNs to enter a workplace they consider unsafe for themselves and their patients.


    The mysterious workings of the market and employment opportunities for women elsewhere can not begin to explain the current shortage of RNs.


    More likely, the industry shortage is a self-inflicted wound brought about by years of market- and industry-led restructuring programs that led to indiscriminate downsizing, increased patient complaints about the quality of care, deteriorating RN-to-patient ratios, and most critically, a marked loss of RN trust.


    Just as the industry has created this crisis, it can help to resolve it. The industry can do its part to alleviate the RN shortage by adopting in word and practice a few simple principles:


    * Value patients as human beings and not as "covered lives."
    * Rather than expending resources fighting RNs and patients on safe staffing ratios, use those resources to enhance the ratios. The market is not able to set ratios that are safe for patients or that will assure adequate numbers of RNs.
    * Trust in the professional judgment and skills of the bedside nurse to advocate for the patient.
    * Terminate all contracts with management consultant deskilling programs and invest those hundreds of millions into preventative care and improving nurse-to-patient ratios.
    * When RNs testify that many health care restructuring programs are a form of patient endangerment - listen.
    * Accept that a profession dominated by women can and should earn a living wage commensurate with skills and dedication.
    * Promote direct caregiver role models as opposed to nurse executive models. The archetypal nurse executive may appeal to an MBA student but is decidedly less appealing to those who value nursing as a noble and hands-on calling.
    * Adopt RN work schedules that allow RNs some semblance of a normal life.
    * Provide RNs with adequate retirement and health benefits.
    * Provide increased funding for RN scholarships.
    * Expand educational and training opportunities for generalist RNs to learn specialty skills, and for LPNs, LVNs and aides to become RNs.
    * Work with nursing unions on projects to develop new programs for the future of nursing.




    Most importantly, do whatever it takes to restore the traumatic loss of RN faith in the industry that they see as having forsaken both them and their patients in the pursuit of private wealth over and above public health.


    That trust must be earned. It cannot be purchased with sign-on bonuses and certainly not with broken promises. The path back to that lost trust will be difficult. Common decency, an industry reaffirmation of the centrality of patient health in its mission and a commitment to the nursing profession that has made the industry one of the wealthiest in the nation demand it.


    Click here to read how
    nurses are fighting back against short staffing
    •  
  2. 18 Comments

  3. by   bellehill
    Excellent article.
  4. by   webbiedebbie
    The evidence clearly points to hospitals and the media talks to administration of hospitals. The hospital where I work is expanding and there is no money for this...so, they made it clear to the employees that benefits were being changed and raises were being reduced. Nurses are the hospital scapegoat.
  5. by   BBFRN
    Loved this article! Thanks for posting it!
  6. by   Katnip
    Now if we can only get this news out to the general public where all can see.
  7. by   suzanne4
    Great article.........
  8. by   Sheri257
    I'm not trying to discount anything mentioned in the article. But I always wonder another key factor that's always missing in this discussion. And that is ...

    It's hard as hell to become a nurse.

    Pre-req failure rates at my community college are at 80 percent. Similar stats are posted on the student board almost daily. A lot of people want to become nurses, and the classes are overloaded with students, but the vast majority can't make it through the academic requirements.

    And, of course, there are a lot of poeple who don't make it through nursing school either. (Currently about a third of the freshman class at my school.)

    I'm just wondering why this never seems to be mentioned in a lot of these discussions. With all of these young people flunking out of nursing, couldn't that also explain why the average age of RN's is 46?

    Certainly this has to contribute to the shortage as well. It's only logical, yet nobody talks about it.

    Last edit by Sheri257 on Apr 3, '04
  9. by   Brownms46
    Thank you guys, I thought the article did a good job of supporting what I and I am sure many others have know, or felt all along.
  10. by   Tweety
    Yes, a very good article.
  11. by   Brownms46
    Thank you Tweety! I was doing a search, and felt it was the first article I have read, that covered the whole problem for the nursing shortage.
  12. by   mattsmom81
    Thanks Brownie...it said it all for me too. Now...shall we bombard our local newspapers with it and challenge them to investigate???
  13. by   Brownms46
    Welcome mattsmom! Hey great idea, and I am definitely game! But I also feel that nurses need to get organized, and treat this more seriously than they have in the past. Recently the doctors in this area have taken to the airwaves to let the public know how they feel about lawsuits, and malpractice insurance. They have a least a 30 min promo telling the public how they are being pushed out of practice, and how this is affecting the health they receive.

    I think it is high time that nurses get together and do the same thing. I mean can nurses afford to get proactive? For far too long nurses have allowed the PTB, to take away their voices. Why have nurses allowed this to happen? Why have nurses not taken a stand, and said enough is enough? How bad does it have to get before they decide to stand up, and say I am not going to allow myself, or my fellow nurses to be used and abused, and then casted aside??

    For much too long nurses have been a silent, or whispering voice in the healthcare profession. Taking whatever tidbits the PTB are willing to caste from their table of plenty. Letting others speak for them, and tell them how to solve the problem, by the same forces who created the problem in the first place! Yes, there have been achievements, but they are too little, and I feel only bandaids on the real problems that face nurses today.

    I feel that there is a war going on, and nurses are sitting on the sidelines, waiting for someone else to take up their plight, hoping someone else will do the right thing! But if nurses don't step to the forefront, and take the reins in this war, no adequate solutions will come about. And none that will bring relief to the unending nightmares they face in the workplace daily!

    Everyone is looking to solve the shortage with more nurses, whether it is throwing grants into the mix, bringing in foreign nurses, paying high priced recruiters, loan forgiveness programs...yada...yada...yada.

    But the real problem in on the battleground....the floors and units where nurses work...or slave! Until there is better working conditions, flexible schedules, R-E-S-P-E-C-T for the knowledge that nurses have, they are not belittled, or ill treated by the MDs they work beside. Until they are no longer relegated to being the hand maidens to the "GODS", then there is little any of the forementioned solutions will accomplish.

    If you have a weeping sore, heaping ABX on top of it will not heal it! If you don't get to the root or crust of the problem, the sore will continue to fester, and enlarge...invading the areas surrounding it.

    A good example is the lack of nurses in education. Not enough educators is not only because nurses see little or no value in taking a teaching prosition, d/t poor return on their educational investment, but because too many of the best and the bightest, leave nursing before they can even gain the creditials needed to pursue a career in education.

    Before an educator can teach, they have to experience, and too many who start out in nursing, leave all too quickly once they get out and see what is out here. So they leave for more fulfilling careers with pharmaceuticals, or go into anything else but bedside care. How can you expect someone who feels that a career in a hospitals is the last place they want to be, to be williing to assist others to come along behind them?? Or if they go into teaching, they must take a vow of proverty, or kiss up to whomever to get significant funding for the programs that are needed.

    Until nurses get serious about doing whatever it takes to bring their profession into the forefront of the public, the policticans.....and not just for better wages, but for better working conditions, improved educational assistance, and recognition for their expertise, the problem will never improve.

    The doctors have taken their plight to the public, so why haven't nurses? So again I ask....when are nurses going to join this war? Why are nurses content to let someone else speak for them? When are nurses going to say, we have had enough, and we are NOT going to take this anymore??
  14. by   Brownms46
    I just found this article, and I feel it embodies the first article, and my thoughts also.

    The Shortage of Care


    A Study by the SEIU Nurse Alliance
    EXECUTIVE SUMMARY

    The rising rate of medical errors in hospitals is fast becoming a national crisis. Ever since the Institute of Medicine released its shocking report in the fall of 1999 showing that medical errors are responsible for 44,000 to 98,000 deaths in hospitals a year, public officials have been studying the crisis and ways to solve it.

    According to hospital administrators, the problem was not inadequate staffing but rather technological changes and other factors. Only recently have they begun to concede that they don't have enough nurses on staff - which they attribute to a growing nursing shortage brought on by demographic changes. In their view, the solution is to expand recruitment and education
    programs to bring more people into the nursing profession.

    But what these initiatives fail to take into consideration is that understaffing was a problem long before a nursing shortage began to emerge. In fact, the industry itself created the shortage by cutting staffing levels to the point where nurses - increasingly unable to meet the needs of their patients - began to leave hospitals for less demanding and more rewarding jobs.

    Recruitment initiatives may treat the symptoms, but they won't cure the disease. As long as hospitals are free to cut staffing levels to bare-bones minimums, patients will continue to be at risk - and nurses will continue to leave. Only when hospitals are bound by enforceable safe staffing standards will nurses stay in the profession.

    Too few nurses are caring for too many patients in the nation's hospitals.
    Nurses in hospitals and related facilities are caring for many more patients today than they did a decade ago. And because of restrictions on hospital admissions and lengths of stay imposed by managed care, the patients in hospitals are more acutely ill and in need of greater care.

    As a result, nurses across America are sounding the alarm: staffing levels are too low to provide the quality of care their patients need. To determine the extent to which understaffing is having an impact on medical errors and
    the emerging nursing shortage, the SEIU Nurse Alliance - more than 110,000 nurses represented by the Service Employees International Union, the nation's largest health care union -commissioned an independent polling firm to conduct a nationwide survey of registered nurses in acute care facilities.

    In December 2000 and January 2001, The Feldman Group - a
    Washington, D.C.-based opinion research firm - conducted extensive telephone interviews with a nationally representative sample of 800 registered nurses, as well as over-samples in six states.

    The survey confirmed that understaffing is taking its toll on nurses and patients alike. Nurses don't have enough time to meet the basic needs of their patients. In hospitals and other acute care facilities, nurses bear the primary responsibility for the care and well-being of patients. It's up to them to continually assess patients, monitor their conditions, modify interventions accordingly, and teach patients to care for themselves.

    However: 1- 58 percent of nurses say that at least once a week on their units, nurses do not have time to provide patient teaching and education.

    2- 37 percent say that at least once a week on their units, nurses do not have time to assess and monitor patients' conditions. When nurses are overloaded, mistakes happen - and patients suffer. As nurses have less and less time to spend with their patients, medication errors and other adverse incidents have become a regular occurrence:

    3- 34 percent of nurses say that patients on their units experience missed or delayed medication or treatments at least once a week.

    4 - 8 percent report that the wrong medication or dosage, which can lead to serious complications, is administered to patients on their units at least once a week.

    5- 10 percent say that patients on their units acquire infections, which are often the result of delayed medication or treatment, at least once a week.
    Most medical errors are caused by insufficient staffing. A majority of nurses identify understaffing as the cause of medical errors. And the situation, they say, is not improving.

    6- 54 percent of nurses say that half or more of the errors they report are the direct result of inadequate staffing.

    7- Despite the growing attention focused on medical errors, most nurses say the rate of incidents has remained unchanged during the last year - while fully 30 percent of nurses say the errors have actually increased. The sicker the patient, the greater the risk. Hospitals are expected to allocate nursing staff in such a way that the patients with the highest acuity level - that is, the patients who are most seriously ill - receive the most care. But that is not always the case.

    8- 55 percent of nurses say the methods their hospitals use to measure patient acuity do not do a good job of telling management the number of staff needed in their units.

    9- 58 percent of nurses caring for mostly high-acuity patients identify short-staffing as the cause of most medical errors, compared with 46 percent of nurses with mostly low-acuity patients. The problem is systemic understaffing, not a shortage of nurses.

    The nursing shortage is not causing understaffing. Instead, systemic understaffing is causing the nursing shortage. For more than a decade, managed care led hospitals to hold down nurse staffing levels, even as the average acuity level of patients rose sharply.

    As a result:
    - The number of hospital employees on staff for each patient discharge, adjusted to reflect the rise in acuity levels, declined by more than 13 percent between 1990 and 1999. Deteriorating working and patient care conditions led nurses to leave hospitals. As far back as 1992 (when there was actually a growing surplus of nurses), understaffing was already damaging working and patient care conditions in hospitals.

    A national survey by SEIU revealed that, stretched to the limit and increasingly unable to provide the quality of care their patients needed, nurses were experiencing high levels of stress, chronic fatigue, and workrelated injuries. Nurses began to leave hospitals for less demanding jobs.

    - The proportion of registered nurses working in hospitals declined from 68 percent in 1988 to 59 percent in 2000.

    - Many nurses left the profession altogether, and fewer young people are entering it. Nursing school enrollment has declined in each of the last six years. As a result, the average age of working RNs has increased 7.8 years since 1983 to 45.2 today.

    The industry's response to the growing shortage of RNs is making it worse.
    The emerging nursing shortage promises to get much worse. By the year 2020, when baby boomers will be in most need of care, there will be a projected shortage of 400,000 nurses.

    But the industry's response to the growing shortage is exacerbating the problem. Nurses are increasingly required to work excessive amounts of mandatory overtime and "float" or transfer to units where they lack the experience and training. These practices are driving more nurses out of hospitals. According to the recent survey:

    - Nurses in acute care hospitals work an additional 8 weeks of overtime on average per year.
    - Only 55 percent of acute care nurses plan to stay in hospitals until they retire.
    - 68 percent of nurses say they would be more likely to stay in acute care if staffing levels in their facilities were adequate.
    The crisis will not be solved by recruitment and education initiatives alone.
    Current initiatives to ease the nursing shortage by expanding tuition assistance and nursing school recruitment programs are a step in the right direction. But putting resources into recruitment and education alone will only create a revolving door.

    As long as they are overloaded and unable to provide quality care for patients, nurses will continue to face high levels of frustration, stress, and injuries - and look elsewhere for careers that provide greater
    rewards and satisfaction.

    In today's health care industry, the financial incentives to understaff hospitals and other health facilities are as intense as they've ever been. And yet, with remarkably few exceptions, the nation's hospitals are unregulated and oversight of the quality of care is weak. To make matters
    worse, no federal "whistleblower" protections or mandatory overtime restrictions exist to specifically address the concerns of nurses and other health care employees.

    The only true solution: safe staffing standards all hospitals must follow.
    To address systemic understaffing and improve working and patient care conditions in the industry, the nation needs laws and policies to:
    - Set enforceable minimum staffing standards linked to the acuity of patients to ensure good quality care in hospitals, emergency rooms, and outpatient facilities.

    Safe staffing standards should be accompanied by a ban on mandatory overtime and set maximum hours for nurses, as well as protections for nurses who blow the whistle on staffing problems.

    - Establish meaningful oversight and inspection procedures for the nation's hospitals and other facilities. The industry's self-monitoring system under the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) must be reformed, and the oversight and regulations of the Health Care Finance Administration (HCFA) must be strengthened.

    - Ensure that direct-care nurses and other caregivers have a voice in the development of hospital staffing plans and in the oversight and enforcement of staffing standards.

    - Promote retention - not just recruitment - in the nursing profession with initiatives to mprove working conditions and strengthen the nation's job safety laws.

    Ultimately the nation must also address the growing ranks of the uninsured - and guarantee affordable, quality care for everyone.

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