WHEN CARE BECOMES A BURDEN: Diminishing Access to Adequate Nursing

Article sent to me by the Florence Project listserve. A must read for all. Karen

WHEN CARE BECOMES A BURDEN:

Diminishing Access to Adequate Nursing

By Claire M. Fagin http://www.milbank.org/010216fagin.html

Table of Contents

Foreword

Acknowledgments

Executive Summary

Introduction

*The First Cause: Changes in the Nature of Hospitalization

Professional versus Personal Care

Patients' Concerns

*The Second Cause: Hospital Reorganization

Restructuring, Adverse Effects, and Other Outcomes

Magnet Hospitals

*The Third Cause: Lack of Accepted Expectations about Caregiving

Family Caregivers

Care at Home

A Nursing Shortage?

*Summary

*When Care Becomes a Burden: What Can Be Done?

Regulation and Licensing

Financing

Organization of Nursing Services in Hospitals

Role of Governing Boards

Recruiting and Educating Nurses

Caregiving by Family Members and Friends

References

The Author

EXECUTIVE SUMMARY

This report synthesizes research studies, recent journalism, and the author's personal experience to address the problem of the increasing burden of care placed on nurses, patients, and families. The author drew the following conclusions from this work:

The burden of care for nurses, patients, and families has demonstrably increased since 1990.

Pressures on families are particularly severe when a patient has been sent home from the hospital after a shortened stay or has received outpatient care for problems that were formerly dealt with in hospitals.

There is considerable evidence that nurses and families are very concerned about the erosion of care and fearful about hospital safety.

Nurses report increasing dissatisfaction with their work in hospitals that have cut staff, that require frequent overtime, and that have replaced nurses with assistive personnel. Research has shown that these phenomena are related to adverse nurse and patient outcomes.

The supply of nurses is tightening, and a severe shortage will occur should present conditions persist. Supply is tightening because the nursing workforce is aging, and the number of students enrolling in nursing programs in 1999 declined for the fifth straight year. Moreover, there is currently a shortage of faculty in nursing schools, leading to an inability to accept enough qualified and interested students. In addition, the average age of full-time nursing faculty has increased. The graying of the nursing workforce, coupled with the declines in enrollment in nursing schools, makes a serious shortage inevitable.

Experts in nursing reviewed a draft of the analytic section of this report. These experts then convened in conference calls to answer the major question raised by the analysis in this report: What can be done to alleviate the actual or potential harm to patients as a result of lack of access to adequate nursing care?

The experts' recommendations for policy initiatives designed to prevent harm by improving patients' access to nursing care fell into six broad categories:

Regulation and licensing

Financing

Organization of nursing services in hospitals

Role of governing boards

Recruiting and educating nurses

The experts addressed their recommendations to a variety of audiences. The principal audiences for the recommended strategies are within the health care sector and include administrators of health services, physicians, nurses themselves, and hospital trustees as well as members of state boards of nursing. Other important audiences are state legislators and members of the U.S. Congress, public- and private-sector collective purchasers of health services, leaders of education in nursing and medicine, foundation executives, and officials of the federal agencies that subsidize higher education for the health professions as well as clinical and health services research. Some of the recommendations may also be of interest to journalists.

The experts' recommendations for action in the six categories can be found on pages 27-31.

RE: Organization of Nursing Services in Hospitals

The experts concurred that a major problem hindering both the recruitment and the retention of nurses is professional nurses' loss of control over the circumstances of their practice, even as they are being held accountable for the quality of nursing care provided. In this environment, it is particularly important, the experts said, to have a strong chief nurse executive with the formal power to act as an advocate for both patients and nurses. The experts noted that while the actual number of nurses is at an all-time high, many nurses choose to work in health care settings other than hospitals or, indeed, in other sectors of the economy.

The experts emphasized that problems in hospital management and organization can lead to clinical errors. Where surveillance systems are inadequate, the experts said, clinical errors are more likely to occur. Nurses have been an important resource to patient care teams that have been successful in improving hospital systems. Achieving an optimal balance between management responsibility for costs and the effectiveness of systems, staffing, and oversight of nursing services and creating working conditions in which nurses can exercise their professional judgement and skill is an important goal.

The experts offered the following recommendations to address these issues:

Adopt the ANA Principles of Nurse Staffing, either as an industry standard or by regulation.

Require hospitals to report nurse-to-patient ratios publicly on a regular schedule. (Note: This is not a recommendation of required nurse-to-patient ratios.)

Establish protocols to prevent the circumvention of technologies designed to prevent medical errors (for example, turning off alarms that would alert staff to problems).

Establish a more effective standard hierarchy of expertise in nursing service; in particular, establish as a norm the strong presence of persons with substantial recent clinical experience at the highest levels of management as well as in team leadership in patient care areas.

Provide opportunities for education and career progression for all hospital positions. Encourage hospitals to improve working conditions in order to be eligible for Magnet Hospital Recognition, awarded by the American Nurses' Credentialing Center.

null When the hospitals eliminated nurse educator/clinical nurse specialist positions (in the late 80's and 90's) and reimbursement of continueing education programs, the administrators shot themselves in the foot. These were means for nurses to communicate with one another re best practices, renew interest in our nursing careers and reenergize ourselves. We learned what was occuring in different hospitals/healthcare settings, and were somtimes able to make changes within our own settings. That was lost when the cuts occurred. Thankfully with the internet, we can now regain our profession, control over our practice and learn to say NO to harmful practices! Karen