Nursing Shortage Fuels Concerns About Compromised Care, Patient Outcomes

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Nursing Shortage Fuels Concerns About Compromised Care, Patient Outcomes

As the nursing shortage continues, healthcare professionals who work in infection control are keeping a nervous eye on hospital-acquired infections that may be linked to decreased staffing levels. While the employment of nurses is expected to grow much faster than average for all occupations through the year 2008, according to the US Bureau of Labor Statistics, more nurses are leaving the field than entering it. As many as 450,000 nurses may be needed in the next decade, according to government projections.

RNs Brenda Nevidjon and Jeanette Ives Erickson, in their paper “The Nursing Shortage: Solutions for the Short and Long Term,” state that the aging of nurses, as well as changes in patient-care models, and shortages in ancillary professions and support labor, are factors that exacerbate the nursing shortage and can aggravate patient outcomes. They point to a study published in the Journal of the American Medical Association (JAMA) that predicted approximately 40% of nurses will be 50 years old or older by the year 2010. Additionally, the average age of a full-time nursing faculty is 49 years old, and one-third of the nursing workforce is already 50 years old. Nevidjon and Erickson say the physical demands of the profession have taxed older nurses, and that hospitals should accommodate them through increased flexibility in scheduling, offering increased time off, and utilizing technology to lighten their workloads.

“A survey of nurses conducted by the University of Pennsylvania Department of Nursing revealed nurses were concerned about the perceived diminishment of patient care, and they didn’t believe patients were being given the same level of care as in the past,” says Carolyn Williams, president of the American Association of Colleges of Nursing (AACN). “We need to fix that because while (the nursing shortage) is bad in some places, it’s likely to get much worse. More people than ever need care and we simply don’t have adequate numbers of people entering nursing.”

A factor in the nursing shortage is the decreased number of individuals entering the profession in the first place. The AACN reports that enrollment of nursing students in entry-level bachelor’s degree programs fell by more than 2% last year, while master’s degree enrollments declined by almost 1%. This decline, while smaller than last year’s figures (declines of 4.6% and 1.9%, respectively), comes even as demand for nurses accelerates in hospitals and surgicenters.

Exacerbating the problem is the bad reputation the nursing profession gets– the result of a negative image of nursing as a low-paying, back-breaking occupation. Many potential nursing students may still see nurses as having a lower status than doctors, and many more are wary of entering the field due to still feeling the repercussions of the nursing staff consolidations of the 1990s.

“Image is an issue,” Williams admits. “As a group, nurses are not as well educated as many of us would like them to be, with a minimum of a baccalaureate degree. With such varying ranges of educational requirements, nursing sometimes is not seen as a demanding field. It doesn’t draw from the pool of talent other fields do. People will say, ‘My parents expect me to do better than nursing.’ It’s a perception that hurts our profession,” she said. “What nurses really want to do is be able to do a good job, and it upsets them if they can’t. Yes, it would be nice to have more money or benefits or flexible scheduling to avoid burnout, but it’s often about wanting more respect, too. We hear a lot about verbal abuse of nurses by physicians who act in an unprofessional manner, which is unconscionable.”

Williams adds nurses need personal and professional autonomy. “Nurses want control over their lives. They want to work in hospitals that have a strong nursing presence; they want an office of nursing affairs to represent them and their issues; they want to participate in nursing decisions, and they want to be respected by other staff members. Nurses get waylaid with things that don’t relate to nursing and then they don’t feel very satisfied if they are not doing things for patients that they ought to be doing. They are tired, disgruntled, then add things like being asked to do too much overtime, and it just adds up and pretty soon they walk.”

While hospital administrators dangle incentives like sign-on bonuses and premium packages in front of prospective recruits and hope they can swell their nursing ranks, Nevidjon and Erickson say more pro-active solutions are essential because these kinds of economic strategies simply redistribute the supply of nurses, not increase it. Their suggested solutions include encouraging healthcare organizations to work together to elevate the image of nursing; reaching new pools of nursing talent through improved recruiting techniques; identifying what benefits keep nurses in the profession; and encouraging hospitals to provide intensive training programs for nurses in specialized areas of care, among other strategies.

  • One bright spot, according to Williams, is the fact that many nursing specialties, like infection control, are better staffed because of the opportunity to develop a more advanced body of knowledge and ability.
  • “I honestly think specialties may be in better shape than general staff nursing,” she says. “I know there are some infection control nurses who learn on the job, while others are certified, and I think individuals who can gain educational credentials and recognition for their specialty helps keep them on the job. Nurses want to be thought of as professionals, so specialties can be attractive.”

Endoscopy is one specialty that is rapidly gaining recruits because of the prestige often associated with it, according to Dr. Michael B. Kimmey, past president of the American Society for Gastrointestinal Endoscopy (ASGE), the 60-year-old professional organization dedicated to

Advancing the practice of endoscopy.

“There is certainly a nursing shortage overall, but I think we don’t have a problem finding GI nurses because it’s such a great field,” Kimmey says. “It’s an attractive job with more normal hours of 8 to 5, and weekend call is minimal. Plus, GI nurses get to do more technical-oriented things, like manipulating a guidewire, than what they would normally do, yet they are still an integral part of patient care. This experience not only makes a difference in treatment, but it also extends their nursing skills.”

Kimmey reports that many ICU nurses have been joining endoscopy suites nationally.

  • “ICU nurses like endoscopy because they see this as a great lifestyle as well as a way to use their skills,” Kimmey adds. “Endoscopy is a marvelous field–it has so many possibilities. It’s an extension of the trend toward more non-invasive or less-invasive treatment modalities,” he said.
  • “We’re going to be using endoscopes to treat many things surgeons have traditionally treated by open procedures, which is much better for patients in terms of a quicker recovery. We’re just beginning to scratch the surface of what we can do. GI nurses are challenged by the knowledge and abilities required of them.”
  • One such area of challenge is sedation, according to Kimmey. “I would like to see GI nurses trained specifically to administer to and monitor patients who are receiving deep sedation with propofol. It’s a new and emerging way to make people sleepy and get them in and out of the hospital or procedure unit quickly. I think having a nurse involved would be a bridge between GI nurses and CRNAs, that’s where I’d like to see the nursing area develop.”

Kimmey says that endoscopy requires advanced knowledge on the part of nurses and that since most departments do not recruit new nursing school graduates, the nursing shortage hasn’t impacted the field greatly.

  • “GI nurses need to be already proficient in general nursing skills, like monitoring patients,” Kimmey says. “Before they take on the additional training required to be a GI nurse they have to have pretty good basics, so we’re not looking for new graduates. We want experienced nurses, and my own view is that ICU nurses are ideal people to recruit to GI,” he said. “The acuity of our patients, many of whom have had GI bleeding, can be significant, and they require special monitoring. I think we have to ask that much more from our nurses trained in GI than general nurses. Having someone with ICU-type skills is the ideal GI nurse.”
  • No matter if it’s ICU or endoscopy, infection control is one practice that unites all specialties within the healthcare facility. As hospitals cope with an acute shortage of nurses, ICPs fret about the potential breakdown in the adherence to universal precautions and the threat of compromising patient outcomes.
  • “Shortage of staff means that whatever staff you do have is worked harder and longer, says Pat Tydell, RN, MSN, MPH, and risk manager at North Chicago Veterans Administration Medical Center in North Chicago, Ill. “This results in fatigue and loss of mental acuity. Errors occur when this happens to people. These errors are those of decreased vigilance to patients’ signs and symptoms, they are more easily distracted, and they have decreased coordination in performing manual tasks. Needlestick injuries could increase, as sleepy nurses lack the fine motor coordination to perform skills such as injections or starting IVs.”

Specific IC practices may be curtailed when HCWs feel pressured to perform their duties swiftly due to staffing shortages on the floor. “Shortages mean that everyone is pressed for time and they tend to rush through tasks,” Tydell adds. “People take shortcuts that are not always safe, like wearing gloves for too long, or not washing their hands between patients.”

A recent study, “Nurse Staffing and Patient Outcomes in Hospitals,” conducted by the US Department of Health and Human Services (HHS) in 799 hospitals in 11 states revealed that facilities with adequate staffing are likely to have lower rates of hospital-acquired pneumonia and urinary tract infections among patients.

The report stated that by increasing the number of nurses, healthcare facilities could reduce their UTI rate by up to 25%, and reduce their pneumonia rate up to 17%. The study, directed by Jack Needleman, Ph.D. and assistant professor of economics and health policy at Harvard School of Public Health, found that the total amount of daily nursing time per patient averaged 11.4 hours, with approximately 7.8 hours of RN time, 2.4 hours of aide time, and 1.2 hours of LPN time.

Patient outcomes also can be affected by hospitals’ environmental practices, as many HCWs must act beyond their normal realm of responsibilities during a staffing shortage.

  • “Healthcare staffing shortages in general means that whoever is left on the unit is doing more than his or her primary job,” says Tydell. “They may have to empty the trash or clean an item, and not being specialized in the hospital’s housekeeping policies may mean less than optimal cleanliness.”

She says that nursing personnel who float have similar challenges. “Nurses who are floated to other units where they may not be familiar with the special requirements of that unit, and there may be little to no time or staff to provide them with orientation.”

One solution to nursing shortages in the past was the use of unlicensed personnel for cost-cutting purposes; however, the fear of medical errors in the face of increasing patient acuities pose great concern for hospital administrators and medical staff alike. “Many hospitals are using nonprofessional persons to take over some aspects of care while still requiring the nurse to supervise that individual. This could lead to breaks in technique the nurse may not know about,” Tydell says.

The AACN’s Williams agrees. “Continuity of staffing as it relates to patient care is very important in areas such as infection control,” she says. “Lapses in policies and procedures happen when nurses are rushed or forced to work overtime, and that could put everyone at risk.”

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Category: Practice Management

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