JCAHO's View on the Bedside Nurse Shortage

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Statement by

The Joint Commission on Accreditation of Healthcare Organizations

Hearing on Addressing Direct Care Staffing Shortages

before the Senate Committee on Health, Education, Labor and Pensions

May 17, 2001

The Joint Commission on Accreditation of Healthcare Organizations, whose mission is to improve patient safety and quality of care, applauds the leadership of Chairman Jeffords and the members of this Committee in holding a Congressional hearing on nurse shortage issues. We would like to take this opportunity to provide our views on this important subject and to offer the Joint Commission as an expert resource to the Committee as you continue to deliberate over possible solutions.

It is important to underscore the significance of the problems that exist today because of the increasing shortage of nurses. While we have had crises in the availability and distribution of nurses before, this shortage is unprecedented in its complexity and future implications. Consequently, it will take an array of solutions and the concerted efforts of many stakeholders to rectify the issues that contribute to an inadequate supply of nurses.

Furthermore, solutions must be crafted with a recognition that the nursing shortage occurs in a health care system that is already overstressed.

Nurse shortage issues are not limited to the difficulties that hospitals are currently having recruiting and retaining nurse caregivers. The entire spectrum of the health care system is affected by patient care issues that relate to worker fatigue, inadequate support for the professional staffs, and insufficient training in the use of new drugs and technology. Insufficient nursing capacity can cause delays in emergency room treatment and hospital admission, cancellation of surgery leading to queues for elective surgery or exhausted teams performing urgent operations well after midnight, lack of crucial patient education, and inadequate patient care management. Moreover, nurses are the primary caregivers in many settings, such as home care, hospice, and long-term care. Nurses render services that are vital to the ability of many individuals to receive basic preventive care and they frequently serve as the only access point to needed treatment. Nurses stand watch over this nation's healthcare system 24 hours per day, 7 days a week. If a nurse is not available to provide care, an institution must limit the number of patients to whom it provides care.

The Joint Commission is in a unique position to witness first hand the effects on the health care system when there is a shortage of nurses. We accredit approximately nineteen thousand health care organizations, including facilities housing nearly 95% of all hospital beds, as well as home health agencies, nursing homes, ambulatory care facilities, hospices, assisted living organizations, behavioral health organizations, and managed care

organizations. In its performance of accreditation evaluations, the Joint Commission assesses compliance with professionally based state-of-the-art standards on-site in health care organizations. We have front-line objective knowledge of the state of health care in America and a keen understanding of the complexities of delivering quality care in today's environment. The observations and data collected by the Joint Commission have long served as

bell-weathers for emerging issues and offer a potentially important substrate for future public policy development.

Issues involving educational preparation, competency, availability, and deployment are often identified as key contributing factors to problems in the delivery of effective care. This is supported by a recent review, analysis and follow-up of patient care complaints received by the Joint Commission. Concerns over nurse competency and nurse availability frequently arise. Further, the Joint Commission has a growing database of sentinel events that are voluntarily reported to the Joint Commission by accredited organizations. Sentinel events are unanticipated, serious events that result in death, injury or permanent loss of function. In keeping with Joint Commission requirements, each of these sentinel events has undergone a thorough and credible "root cause" analysis by the health care organization of the causal factors that led to the undesirable outcome. Analyses of root causes indicate that in

24% of these serious events, nursing issues were raised as one of the major underlying factors. Sentinel event and complaint data complement information gleaned from our on-site evaluations, and underscore the need to make the decreasing availability of nurses a public policy priority.

The Joint Commission is currently developing an enhanced set of accreditation standards that will focus on nurse staffing effectiveness. We want to stress that staffing adequacy is not simply measured by applying numbers and ratios, but rather by evaluating a constellation of factors, such as staff turnover, the number of hours a hospital is not able to receive and treat emergency patients because of staff shortages, delayed or cancelled surgeries, and the number and types of medical errors related to staffing issues.

The quality of care and access issues that attend reductions in nursing capacity present a complex set of challenges that will require a coordinated, multi-faceted set of solutions crafted to work synergistically. While there are unprecedented recruitment difficulties, we must also take a careful look at the job of nursing itself, including what nurses do and are expected to do, and consider the reasons for the growing dissatisfaction among nurses in all settings.

Nursing is a very diverse occupation. Issues of job satisfaction are often a function of job expectations that can vary significantly among care-giving settings. Nevertheless, some consistent themes have emerged that bear mentioning here. These include the heavy workload; higher average intensity of illness; overtime requests and/or requirements; paperwork requirements that create a burden while detracting from patient care; the lack of appropriate education, orientation and training to manage increasingly sophisticated care; the general lack of delegated authority; erosion of prestige; and the role definition of nursing with respect to other care-givers and ancillary staff. Serious nursing job satisfaction issues are occurring at a time when there are many more attractive opportunities in the workforce which offer clear cut economic, work schedule, and advancement opportunities. We must also acknowledge the reality that nursing is not a gender-neutral profession. There has been inadequate progress in attracting men to nursing careers.

There is no simple or single solution to this rapidly worsening problem. An amalgam of strategies designed to address this issue at each of its contributory factors is needed. We are pleased that members of this committee are taking the leadership to propose incentives for nursing as a career choice and are providing attention to retention challenges. Substantial efforts must also be undertaken to address the factors that define or affect the role of the nurse in today's health care environment. We must ensure that nurses are not just viewed in terms of their numbers, but in terms of their profession, including their training, their support, and their use. The adequacy of nursing services is among the greatest threats to the future of quality health care. It will require multiple and very creative solutions. The future of patient care safety is at stake. The Joint Commission stands ready to assist the Committee in whatever manner it deems appropriate.

http://www.jcaho.org/news/0517stmnt.html

[oramar]

I have very little use for the Joint Commission. Like most bureaucracies it exist to perpetuate itself. A nice place for a bunch of nurses and physicians to park their butts and collect pay checks without working very hard. All these desk job types should be forced back to the bedside. I would like to stand and watch their panic. It would be the first time I had a good laugh in about a hundred years.