Unsafe Workforce Deployment

Despite the strong and accumulating evidence that higher nurse staffing levels in hospitals and nursing homes result in safer patient care, there is wide variation in nurse staffing levels across hospitals and nursing homes. Data from 135 hospitals contacted in 2002 show that although a nurse working in a medical–surgical unit on the day shift typically is assigned six patients to care for, that number is sometimes much higher for individual nurses. Fully 23 percent of hospitals reported that nurses in their medical–surgical units on the day shift were each responsible for caring for 7 to 12 patients (Cavouras and Suby, 2003). Nursing homes also vary in the number of patients assigned to nursing staff.

Currently available methods for achieving safer staffing levels in hospitals, such as authorizing nursing staff to halt admissions to their unit when staffing is inadequate for safe patient care, are not employed uniformly by hospitals or nursing homes. Federal regulations governing nursing home staffing are over a decade old and do not reflect new knowledge on safe staffing levels. Minimum standards for registered nurses require only the presence of one licensed nurse in a nursing home, regardless of its size. Moreover, the regulations do not specify minimum staffing levels for nurse assistants, who provide most of the nursing care in these facilities.

Additionally, not all HCOs have taken steps to compensate for the widely acknowledged fact that, like newly licensed physicians, newly licensed nurses need additional training and education once they enter the workforce, and that experienced nurses similarly need ongoing education and training to keep up with the continuing growth of new medical knowledge and technology. Surveys of nursing administrators from acute care hospitals and nursing homes and newly licensed nurses themselves report the same finding: many newly licensed nurses do not possess the overall educational preparation to provide safe, effective care. Registered nurses (RNs) are viewed as especially lacking skills in recognizing abnormal physical and diagnostic findings and responding to emergencies (Smith and Crawford, 2002a,b).

Despite these findings, hospitals are reported to have scaled back orientation programs for newly hired nurses, as well as ongoing in-service training and continuing education programs, as a result of financial pressures (Berens, 2000). A federally sponsored study of staffing in long-term care facilities similarly found that current initial certification education for nurse assistants is insufficient (CMS, 2002). The committee found evidence that all health care professionals (nurses and physicians alike) need better training, as well as organizational practices that promote and support interdisciplinary collaboration and teamwork. Decision support technology is also needed in all nursing work environments.

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