1
Study Activities

Two major information-gathering activities were conducted by the Institute of Medicine (IOM) in the course of its congressionally mandated study of the adequacy of nurse staffing in hospitals and nursing facilities. The first activity was the committee's wide-ranging request for written and oral testimony, and the second was a series of four site visits by small subgroups of the committee.

Written And Oral Testimony Submitted To The Committee

Many IOM studies use requests for testimony to elicit a broader expression of views on the main topics of the project than would otherwise be available from committee members, published literature, and site visits. Providing testimony is an opportunity for interested parties to express their views and for committee members to obtain, firsthand, an extensive range of opinion on matters under consideration. Written testimony is solicited from a wide group of respondents and, based in part on the testimony received, selected groups and individuals may then be invited to present their testimony before the committee at a public hearing.

Because of the high level of interest among many organizations and individuals, the IOM committee requested testimony in the early stages of its study to help identify issues and resources. Following general guidance received from the committee and other IOM staff, the study staff developed a mailing list of organizations and individuals from whom written testimony related to the committee's mandate could be requested. In addition, some of the study's liaison panel



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 241
--> 1 Study Activities Two major information-gathering activities were conducted by the Institute of Medicine (IOM) in the course of its congressionally mandated study of the adequacy of nurse staffing in hospitals and nursing facilities. The first activity was the committee's wide-ranging request for written and oral testimony, and the second was a series of four site visits by small subgroups of the committee. Written And Oral Testimony Submitted To The Committee Many IOM studies use requests for testimony to elicit a broader expression of views on the main topics of the project than would otherwise be available from committee members, published literature, and site visits. Providing testimony is an opportunity for interested parties to express their views and for committee members to obtain, firsthand, an extensive range of opinion on matters under consideration. Written testimony is solicited from a wide group of respondents and, based in part on the testimony received, selected groups and individuals may then be invited to present their testimony before the committee at a public hearing. Because of the high level of interest among many organizations and individuals, the IOM committee requested testimony in the early stages of its study to help identify issues and resources. Following general guidance received from the committee and other IOM staff, the study staff developed a mailing list of organizations and individuals from whom written testimony related to the committee's mandate could be requested. In addition, some of the study's liaison panel

OCR for page 241
--> members, nursing and nursing home associations, labor unions, other interest groups, and study sponsors provided names or sent their mailing lists for the committee's use. Selections were made from these and other lists, with the goal of representing all points of view. A general announcement, containing the committee's mandate, its purpose in requesting testimony, a guide to assist in preparing written statements, and ''key questions" around which the testimony could be organized, was then developed. (See Exhibit 1.1, at the back of this appendix, for a facsimile of the announcement/request for testimony.) In all, 511 announcements were mailed during July 1994; responses were requested by September 26, 1994. Some organizations and individuals who received the announcements also distributed them further to their memberships and acquaintances. By May 1995, staff had received and reviewed 108 testimonies. (See Table 1.1 for an alphabetical listing of the organizations and individuals that responded; for those that presented oral testimony, the site of the hearing is indicated.) In addition to the request for written testimony, the mailed announcements also included information about 2 half-day public hearings at which the committee would hear oral testimony from a smaller group of individuals. The announcement specifically stated that if testimony were received by the September 1994 deadline, the organization or individual would be considered for one of the two hearings. After that deadline, potential testifiers for the two hearings were contacted. Because travel costs could limit the ability of some groups and individuals to testify, the committee deliberately held one public hearing on each coast. This strategy also made it easier to distinguish broad, region-based differences across the country. The first public hearing was held in Washington, D.C., on October 19, 1994, in conjunction with committee's second meeting; 23 witnesses appeared before the committee. The second public hearing was held in Irvine, California, on January 22, 1995, in conjunction with the third committee meeting; 21 witnesses presented testimony. To the extent feasible, the preferences for dates and location of those invited to testify were honored. Those presenting oral testimony were grouped into panels, asked to confine their remarks to 5 minutes, and requested to be prepared to respond to committee members' questions. In addition to those invited and scheduled to testify, at both public hearings the meetings were opened to general comments at the end of the day and were not adjourned until all those who wished to speak had done so. Written and oral testimony received equal weight in the committee's deliberations. The written testimony ensured input from all interested parties, and the information, references, referrals, and suggestions provided in the statements were of considerable benefit to the study. The public hearings were convened to give committee members an opportunity to engage in discussion with—or to observe discussions among—an extensive range of health care providers, consumers and consumer advocates, professional organizations, and others. Both

OCR for page 241
--> TABLE 1.1 Organizations Submitting Written Statements Name of Organization Presented Testimony at Public Hearing Academy of Medical-Surgical Nurses   Affiliated Organization of Nurse Managers   Aging Services for the Upper Cumberlands, Inc.   Alcanter, B.J.   American Association of Colleges of Nursing DC American Association of Homes and Services for the Aging DC American Association of Occupational Health Nurses   American Federation of State, County and Municipal Employees DC American Health Care Association DC American Nephrology Nurses' Association   American Nurses Association DC American Organization of Nurse Executives DC American Psychiatric Nurses Association DC American Public Health Association   American Radiological Nurses Association   American Society for Parenteral and Enteral Nutrition   Association of Child and Adolescent Psychiatric Nurses, Inc.   Association of Operating Room Nurses CA Association of Rehabilitation Nurses   Baptist Hospital of East Tennessee   Belew, John   Bureau of Aging and In-Home Services   California Advocates for Nursing Home Reform CA California Association of Hospitals and Health Systems CA California Nurses Association CA Career Nurse Assistants' Programs DC Catlett, Carter Williams   Commonwealth of Pennsylvania, Department of Aging   Connecticut Nurses Association   Danbury Hospital Professional Nurses Association   Davenport, Jennie CA Davis, Feather Ann   East Tennessee Human Resource Agency   Emergency Nurses Association DC Federation for Accessible Nursing Education and Licensure CA Federation of Nurses and Health Professionals DC Florida Nurses Association DC Gerontological Nursing Consulting Services CA Graves, Ruby   Hannigan, Hank CA Harvard Medical School, Center for National Health Program Studies DC Harvard School of Public Health   HBO & Company DC Healthcare Association of New York State  

OCR for page 241
--> Name of Organization Presented Testimony at Public Hearing Illinois Nurses Association   Intravenous Nurses Society   Kaiser Permanente Medical Care Program CA Kansans for Improvement of Nursing Homes, Inc.   Kentucky Nurses Association   Kroposki, Margaret   Legal Services of South Central Tennessee, Inc.   Lewis, Nancy   Marshall, Sarah   Massachusetts Hospital Association DC Massachusetts Nurses Association DC Miller, Maura Farrell   Minnesota Alliance for Health Care Consumers   Minnesota Nurses Association CA Montana Coalition for Nursing Home Reform CA Mount St. Vincent CA Nagy, Mary   National Association for Practical Nurse Education and Service, Inc.   National Association of Hispanic Nurses CA National Association of Neonatal Nurses   National Citizens' Coalition for Nursing Home Reform DC National Committee to Preserve Social Security and Medicare DC National Council of State Boards of Nursing, Inc. DC National League for Nursing DC New York City Substate Long-Term Care Ombudsman Program   New York State Nurses Association   Nurses Organization of Veterans Affairs   Nursing Home Advisory and Research Council, Inc.   Nursing Home Community Coalition of New York State   Ohio Board of Nursing   Ohio Nurses Association   Oliver, Pauline   Oregon Federation of Nurses and Health Professionals CA Oregon Nurses Association CA Organization of Nurse Executives-California Organization for Nurse Leaders CA Parma School of Practical Nursing   Peer Review Systems CA Pennsylvania Nurses Association   Rehabilitation Care Consultants, Inc.   Revolution   Service Employees International Union DC Smith, Judy   Stanford University Hospital   Streeter, Janyce   Tennessee Hospital Association  

OCR for page 241
--> Name of Organization Presented Testimony at Public Hearing Tennessee LTC Ombudsman Program   Texas Nurses Association   The Children's Hospital, Denver, Colorado   The University of Tennessee Medical Center at Knoxville DC Town of Amherst LTC Ombudsman Program   Turner Healthcare Associates, Inc. CA Unicare Health Facilities DC University of California, Irvine, California Strategic Planning Committee for Nursing CA University of Missouri-Columbia   Vermont Ombudsman Project   Villa, Marina CA Walsh, James F. (Ombudsman, Indiana Area II) DC Wilder Foundation Residence West CA forms of public participation in the study were vital parts of the committee's fact-finding efforts. The following section presents an overview of the concerns and issues raised in the testimony submitted to the committee. The testimony is divided into four categories: hospitals, nursing homes, nursing education, and individual comments (e.g., from academics, self-employed geriatric nurse practitioners, a nursing journal). The testimony is usually grouped by the affiliation, membership, or area of concern of the testifying organization (e.g., professional nursing organizations, hospital industry, resident advocacy groups). The concerns of the relatively few individuals and organizations that testified about both settings are included in both categories. Hospital-Related Testimony Nursing Personnel Testimony presented by nursing personnel, including unions, state nurse associations, and nursing organizations formed around clinical specialties, careers, or ethnic groups, is discussed below. The following section addresses testimony from institutional providers of health care such as hospitals and hospital associations. Unions and Union Members With the exception of one association, all of whose members are registered nurses (RNs), the unions that testified have memberships

OCR for page 241
--> that include RNs, licensed practical and licensed vocational nurses (LPN),1 and nurse assistants (NA). All unions providing statements for this study noted that in their opinion, patient acuity levels are increasing and managed care is delaying hospital admissions and shortening hospital lengths of stay. In general, the unions do not take issue with the cost containment goals of restructuring hospital care, but they are concerned that these changes are being poorly implemented. Many anecdotes were provided describing the perceived negative effects of understaffing on the quality of patient care and on nurses' stress and health. Other reports involved changes such as the sudden elimination of all positions at a certain level (e.g., all LPNs). The staff currently in those positions are told they no longer have a job, but they may apply for newly created positions at an hourly wage several dollars lower than their current wage and essentially provide the same care. Several examples of such practices were supplied in the testimony and in the committee's site visits (see later discussion). The unions reported that, in a time of greater patient needs and shorter hospital stays, a variety of changes in staffing patterns have made it more difficult for licensed nurses to provide direct patient care. Many hospitals have established higher ratios of patients to licensed staff; others have reduced the number of supporting ancillary nursing personnel (ANP) or have replaced more highly skilled ANP with those having less training. At other locations, according to testimony, specialized nursing is being replaced with "generic" nursing: intravenous care teams are disbanded, scrub nurses in operating rooms are replaced with cursorily trained technicians, and nurses are sent to provide care on short-staffed, specialized units (e.g., pediatrics) without training or experience in that area. In addition to concerns about the quality and safety of patient care, the unions expressed concern about the safety and quality of the workplace. Many nursing personnel stated that their work environment is unsafe for employees as well as for patients. Hospital nurses, in particular, report that rates of injuries (e.g., needlesticks, back strains) and illness (e.g., hypertension) have increased due to overwork, stress, and the need to work even if sick. These nurses also had strong feelings that hospital management is not responding to the increases in injury, illness, and stress. Some testimony did provide examples of successful cooperation between unions and hospitals in addressing concerns. The testimony from a nurses' union and from the administration of one hospital was presented jointly. After significant difficulties over a restructuring initiative, the union and the administration used federal "mutual gains bargaining" to resolve some of their differences, with the result that they are now more able to focus, together, on patient care. 1   As noted in Part I of the report, for simplicity's sake both licensed practical nurses and licensed vocational nurses will be referred to as LPNs.

OCR for page 241
--> State Nurse Associations State nurse associations are membership organizations of RNs; many of them also act as collective bargaining units or unions for their members. The testimony in this category was almost completely about acute care and, because of the membership composition, consisted of RN-specific experiences, perceptions, and concerns. The widespread restructuring and downsizing within hospitals, as well as some implementations of patient-focused models of acute care delivery, are not well regarded by some RNs. Experience with these models has led them to question the value of such changes because the restructuring does not seem to benefit patients or improve the delivery of care. In the testimony, RNs' primary concerns, like those of the unionized health professionals, were about their job performance and security and their patients' safety and quality of care. Many reported being at "the end of their rope," either because they are trying to maintain the quality of care at enormous personal cost or because they are trying very hard simply to maintain a uniform level of safety. They argued that restructuring efforts are often poorly planned and implemented, and are seldom evaluated for the quality of nursing care; furthermore, there is sometimes no consultation with nurses about these changes. Registered nurses are also unhappy with having less patient contact and more delegating and supervisory responsibilities. Several witnesses noted that the educational preparation for such managerial responsibilities is inadequate. Others pointed out that opportunities for learning on the job are now greatly reduced because many hospitals have fired their clinical nurse specialists, given their charge nurses patient care loads (sometimes full loads), and eliminated or reduced orientation programs for new nurses. One general perception was that changes are cost driven and poorly and hastily planned; another was that no data support such changes, whereas data suggesting that higher levels of RNs improve the quality of care are felt to exist. The growth of for-profit institutions; the trend toward business, rather than medical and nursing, leadership in hospitals; and the profitability of the hospital industry were also matters for comment. Registered nurses believe they are bearing the brunt of financially motivated cost-saving efforts. Concern was also expressed about "a loss of understanding that nursing is not a series of tasks, but an integrated process which may include a series of tasks to achieve a [patient] assessment and a [care] plan." Some witnesses worried that inflexible, task-oriented, top-down systems were being imposed on care givers who are educated to make judgments and who are ultimately responsible for care. Acuity systems for determining staffing levels, for instance, were seen as valuable tools but not more valuable than RNs' clinical judgment. Some testifiers also expressed concern that hospitals are altering the threshold on their acuity systems as a means of justifying lower staffing levels. Both the state nurse organizations and the unions were concerned about licensed nurses' professional, legal, and ethical responsibility—and liability—for

OCR for page 241
--> providing safe and adequate care. Under the nursing practice acts of each state, nurses are responsible for all care delivered under their supervision; furthermore, they are liable for patient abandonment if they do not accept reasonable assignments, but they must not accept unreasonable work assignments. Many state nursing organizations and unions have responded by encouraging their members to use "assignment despite protest" forms to document their concerns; this is not, however, considered a solution to the concerns about patient safety and quality of patient care. Furthermore, according to one union, some hospitals are pushing for "reinterpretation or revisions in state nurse practice acts so as to allow unlicensed personnel to perform significant nursing duties, while leaving ultimate responsibility and legal liability in nurse hands." Most of the testimony noted the current challenges of delivering nursing care: higher levels of patient acuity; an aging population; shorter lengths of stay in which to deliver care and teach patients self-care; the use of ANP in place of RNs; and sometimes the loss of support services. Many RNs expressed concern that ANP are replacing RNs rather than supporting them, and a few mentioned that at their institution new and less knowledgeable ancillary personnel were replacing those with greater skills and better training. Others spoke of a general "de-skilling" of nursing practice. Specific concerns about the quality of patient care included less preventive care; more "near misses," considered by many RN organizations to be a critical "invisible" indicator; inappropriate transfers to other units or to the home; and more unsafe patient loads. Another perception was reduced continuity of care, especially with the growth of cross-training, and increased reliance on floating and per diem nurses. Cross-training and floating,2 it should be noted, are regarded as appropriate solutions for both hospitals and nurses if implemented properly, but many testifiers believe that these tactics are often poorly implemented and, as a consequence, the risks to quality of care are high. Specific problems involving injuries, illness, and stress were also mentioned. Violence, back injuries, and the risk of infectious diseases are all serious occupational hazards. One example raised was that equipment that could prevent or minimize injuries is not being used because of cost considerations. In addition, strains on family life and personal time, job security worries and layoffs, and either mandatory overtime or days without work are significant sources of stress. Some complaints about increased stress and risks to their health came from experienced nurses who have been providing care for decades. By and large, most representatives of the state associations expressed con- 2   Cross-training is on-the-job training of nursing personnel to deliver specialized clinical care in an area outside their primary expertise and experience. Floating is the temporary assignment of nursing personnel to a clinical unit other than the one to which they are usually assigned.

OCR for page 241
--> cern about the deteriorating quality of patient care, job safety and security for their members, and nurses' abilities to meet their professional, legal, and ethical responsibilities in their current situations. Nursing Organizations Formed Around Clinical Specialties, Careers, or Ethnic Groups Although most of these organizations are national in scope and organized around areas of RN clinical specialization, they form a somewhat varied group and their testimony reflected this variety. As an example, two organizations affiliated with state-level hospital associations represent the interests of nurse executives and managers. Understandably, the positions taken by these associations differ somewhat from those of the nurses in clinical specialty organizations. The testimony of the former, for instance, exhibit greater awareness of the cost pressures on hospitals and the tensions between clinical and administrative responsibilities that can be felt by nurse managers. The American Organization of Nurse Executives, which represents nurse executives and managers at the national level, made three points: (1) the "[a]dequacy of nurse staffing in hospitals and nursing homes needs to be determined in the context of the future, restructured health care delivery system—not in the context of today's needs"; (2) "[n]urse and other staffing needs are and will continue to be unique to each health care delivery organization and the community it serves. No single approach fits the needs of each situation in determining appropriate staffing levels"; and (3) "[c]urrent data on the number of nurses in institutional settings and on nursing's impact on the quality of patient care is limited.'' Of the 17 organizations testifying in this group, the majority represent nurses who have a specific clinical specialization. Some organizations expressed concerns similar to those noted previously; for instance, reductions in staffing are seen as hazardous to patients and, over the long-term, debilitating to nurses' abilities and health. Clinical specialty organizations tended, however, to add a broader perspective to the discussion of concerns and issues, often paying more attention to the movement of patients across sites of care delivery and the need to track patients after discharge. The need for continuity of care was a strong theme in some of the testimony and several organizations expressed confidence that cost-effectiveness considerations would demonstrate the value of nursing once factors such as rehospitalization and increased morbidity after discharge are taken into account. Some also expressed greater approval of the concept of team nursing—perhaps because nurses with clinical specialties are more likely to function as part of an established nursing team and thus to have had positive experiences with team nursing. Finally, several of the organizations in this subgroup, such as the National Association of Neonatal Nurses and the National Association of Hispanic Nurses, noted the need for more minority RNs and higher-level nurses. This was seen as particularly important because of demographic predictions that cultural diversity and patient acuity will continue to increase nationally.

OCR for page 241
--> Institutional Providers of Acute Care Organizations representing providers of acute care included two hospitals; the national association representing hospitals; three state-level chapters of the same; one health maintenance organization (HMO); and one organization with both hospital and nursing facility membership that was reporting on behalf of its hospital members. The hospital associations, HMO, and dual membership organization provided analyses of recent changes in the delivery of acute care. This testimony was generally in agreement on two issues. First, that there have been significant changes in hospital utilization. This is a time of retrenchment, when the movement of inpatient care into outpatient settings is resulting in lowered census and fewer beds. In many states, the growth in managed care has been dramatic and some acute care hospitals have either closed or merged. Second, hospital associations were able to provide some data suggesting that despite declines in hospital utilization and the high costs of nursing labor to hospitals, RN utilization in hospitals—that is, the total number of RNs employed—has either remained constant or increased. In general, hospital associations did not see notable changes in the levels stress felt by nursing personnel, patient satisfaction, or mortality rates. Most organizations in this category noted the lack of data on the number of nurses in institutional settings and the effect of nursing on quality of patient care. This information is not uniformly collected or linked, and often is not collected at all. Several of these organizations urged that valid and reliable patient care outcome data, particularly outcome data associated with nursing care, be collected. Nursing Homes-Related Testimony Resident Advocacy Groups and Long-term-Care Ombudsmen Testimony from nursing home resident advocacy groups, family members, and long-term-care (LTC) ombudsmen exhibited great concern about poor-quality care and inadequate staffing.3 This testimony is useful because these insights are often not available directly from residents. Mandated tasks in a nursing home include, at a minimum, turning bedbound residents every 2 hours and keeping them clean; getting wheelchair residents up 3   Long-term care ombudsman "advocate to protect the health, safety, welfare, and rights of the institutionalized elderly" (IOM, 1995, p. 1). For more information on long-term care ombudsmen see the IOM report from which this quotation was taken: IOM. Real People, Real Problems: An Evaluation of the Long-term Care Ombudsman Programs of the Older Americans Act. J. Harris-Wehling, J.C. Feasley, and C.L. Estes, eds. Washington, D.C.: National Academy Press, 1995.

OCR for page 241
--> to exercise; giving residents adequate food and water; and assisting them in toileting. Often, however, NAs do not have time to get all of this done: "There are times I have been there when there has been only one aide on the floor with the charge nurse and the med nurse. … One aide isn't enough for, roughly, I would say sixty-two beds." The equipment for delivering care may also be inadequate. Basic care is sometimes not given frequently or quickly enough—patients are often left in dirty diapers or on the toilet for extended periods of time, baths may be given infrequently, and basic dental care is sometimes forgotten. Neglect is sometimes so extreme as to become abuse. Other concerns are the lack of dignity accorded to residents in terms of not leaving them naked or exposed in public areas or respecting their wishes about daily activities such as eating and dressing. Even such simple things as providing sufficient water are often neglected. Water pitchers may be missing or out of reach. Many residents need to have water handed to them or must be reminded to drink. Residents' family members expressed high levels of concern about neglect, unnecessary pain, endangerment, loss of health or life, and abuse. Testimony from family members sometimes mentioned unreported falls; errors such as a nondiabetic resident being given an insulin shot; and the widespread loss of bladder and bowel control by residents because aides do not have the time to toilet them. Although much of the testimony from resident advocacy groups and LTC ombudsmen concerned examples of poor quality of care and poor quality of life for residents, overall points specific to nurse staffing levels were also made. Most of the problems with the delivery of long-term care were felt to be tied, in some way, to inadequate staffing or to inadequately trained staff. One national organization estimated that almost half of all hospitalizations of nursing home residents could be eliminated with adequate staffing, which would save more than $942 million per year. This same organization calculated, in addition to less morbidity and pain, substantial savings of both money and time from improved levels of care and staffing. Citing annual national costs from more than $3 billion for the care of urinary incontinence to between $1.2 billion and $12 billion for preventable pressure sores, this organization argued that many of these expenses are preventable and that higher-quality care would be more cost-effective than the current approach to long-term care. Nursing Personnel Unions and Union Members Union concerns about nursing homes are somewhat different from those about hospitals. Structural changes and managed care do not pose immediate issues in nursing facilities; consequently, union testimony tended to focus more on concerns in acute care than in long-term care. Nevertheless, in the words of one union, "Nurses and nurse aides in nursing homes,

OCR for page 241
--> All participants in the 4-week competency-based training module received large amounts of training in team building skills, including conflict resolution. Some RNs had negative responses to the proposed changes before the new patient care model was implemented. Registered nurse tenures at the 2 campuses in this facility were 7 and 10 years, respectively, and some RNs did resign before implementation of the model. The RNs, LPNs, CNAs, and SAs with whom committee members spoke, however—whether already delivering care in teams or anticipating this change—appeared genuinely enthusiastic about the new model. The consensus, among both nursing and administrative staff, was that the new approach, along with many specific organizational or structural changes, allowed nursing staff to concentrate on patients and provide better-quality care. Each team with an LPN was typically assigned 7 or 8 patients, while a team with a CNA would be assigned 6 patients; on a 12-hour shift, the total number of patients would go no higher than 10. Members of the care teams almost always work together and plan their shifts together, deciding among themselves whether to work four 12-hour shifts or five 8-hour shifts. They report knowing each others' capabilities well, trusting in and relying on each other, and cooperating to accomplish tasks. The satisfaction and enthusiasm of team members were most impressive, as was their acknowledgment of each individual's part in providing care. The administrative staff with whom committee members met were cautiously optimistic, while the nursing personnel were extremely enthusiastic. Morale was high, and there appeared to be a pervasive conviction that the quality of patient care had improved. Even though the plan was staff-neutral, nursing staff spoke of feeling as though there were more staff than before implementation of the new model. All levels of team members reported feeling less stress and being more confident about the care delivered, because of the trust and communication among the three members of the team. More patient teaching was reported, and RNs reported feeling secure that in a time of crisis with a patient, other patients would be taken care of and they would be notified if an additional patient needed their attention. In terms of patients' responses to the change, staff related anecdotes of patients returned to the hospital demanding "their" care team and of positive comments from patients who had been on the unit prior to implementation of the new approach and could therefore compare the two models of care delivery. Administrative staff confirmed that patient responses were positive. In conclusion, this new patient care model was instigated by the top levels of the health care system to improve the quality of care delivered. The leadership appears to have successfully created a system and environment in which a reorganization of patient services could take place that improved both the quality of patient care and the morale. Key factors identified by participants in this process were keeping staff aware of planned changes, involving them in decision making aspects of the new model, empowering the care giving staff, and leadership from top levels. The patient care model is still being improved; anxiety about the new

OCR for page 241
--> model no doubt remains for some personnel, as do the stresses of transition. Additional facets of the plan have to be improved or clarified, such as ways of increasing communication along some lines (e.g., among teams or between teams and charge nurses). Nevertheless, care giver satisfaction with, and commitment to, the new patient care delivery model appear extremely high, and preliminary indications are that patient satisfaction has also noticeably improved. At the time of the site visit, the entire hospital system was expected to have converted to the new care model by 1 to 2 years after the first unit-level test of the new model began. Pre-implementation evaluations and two evaluations conducted during the implementation process should eventually provide data upon which to base an assessment of the model's success. The level of involvement of nursing personnel in the shaping and implementation of change seems to account for some of the critical differences in the success of institutional restructuring. Based on insights provided by the site visits, hospitals appear more likely to be successful in restructuring when all or most of the following is true: the top management levels of the institutions provide a strong vision, clear goals, and steady commitment to the reorganization; nursing staff have the time and the opportunity to discuss with management both the goals of restructuring care and the ways in which these might be met; nursing staff have autonomy and accountability in the delivery of care; top management is open to discussion and suggestions and negotiates in good faith; and reorganizations focus on improving the quality of patient care rather than on cost-cutting measures (e.g., are budget- and staff-neutral). Collaborative change, where successful, resulted in visible confidence among the nursing staff in their ability to deliver quality care, unusually high levels of trust and teamwork, and clearer responsibility for the quality of patient care. In situations where relations between administration and health professionals appeared particularly bad, top-level administrators may have given insufficient value to nursing and not included nursing staff in the strategic plan processes at a decision making level. Quality of Patient Care and Patient Life in Nursing Facilities One factor that can positively affect the quality of patient care in long-term care is RN clinical leadership. Physicians have a minimal presence in most nursing homes, and the number of RNs in a facility is extremely low compared to other nursing staff; despite the high levels of acuity in most nursing homes, nationally RNs comprise less than 10 percent of the total nursing staff in long-

OCR for page 241
--> term-care facilities. Some site visit hosts believed that RNs' administrative and documentation responsibilities reduce the quality of patient care because RNs spend the majority of their time on paperwork rather than with residents. Combined, these factors lead to a deficiency of clinical expertise, minimal direct resident care by RNs or physicians, and lack of RN supervision and clinical leadership for LPNs and NAs. One facility seen by a site visit team used clinical nurse specialists to address these concerns and to implement programs such as a restraint reduction effort. The extremely high turnover of NAs also exacerbates quality-of-care problems. NAs are the residents' primary care givers. According to some NAs with whom committee members met, LPNs provide little supervision and are unable to deliver adequate clinical support and care. Despite the fact that NAs spend the most time with residents and know them best, they have little or no input into residents' care plans. Resident comfort is also an element of high-quality care. When one group of residents was asked what they valued, they cited security, medical care and the availability of physicians, and private rooms. (Residents may share a room with as many as three other people.) Other residents wanted more staff and more experienced staff on the night shift. At most of the sites visited by committee members, residents with whom the site visit teams met reported the care to be either good or adequate. Yet another issue in the areas of quality of care and quality of life involves the assumptions and expectations of family members. Some care givers pointed out with frustration that a demanding individual or active family member can result in fairly elaborate attention being devoted to one resident, while someone who cannot speak up or has no family nearby—but who requires more care—may be shortchanged on basic care. On the other hand, site visit teams were sometimes informed that scheduled visits by inspectors or family members typically present a reassuring picture but that unannounced visits can be a different matter. If visitors are not expected, care may be limited or inadequate. Yet residents and family members are often afraid to complain for fear—whether realistic or not—of retaliation from care givers. At a meeting with LTC ombudsmen, site visit team members heard some grim stories of neglect, intimidation, abuse, and theft. The stories pointed out the many ways in which both the quality and the quantity of staff in nursing facilities can directly affect the quality of care and quality of life for residents. Another quality-of-care point that was raised frequently in nursing home visits is that the current survey process and standards can override the clinical judgment of care givers and negatively affect the quality of patient care and quality of life. In at least one example recounted to the site visit team, the problem seems to have been rote enforcement of the OBRA guidelines without permitting the facility to explain the rationale for the restraint or discuss the resident's care plan and without consultation with the resident's family members.

OCR for page 241
--> Finally, a few of the larger, more diversified long-term-care facilities are starting to use outcome measures of quality of care that will be meaningful to managed care entities; these include admissions to the hospital or emergency room, length of stay, and resident and family satisfaction. Injuries and Stress In general, discussions during site visits were more about stress than injuries. Information on injuries is equivocal. Some hospitals and nursing homes are maintaining or reducing rates of problems such as back injuries, needlestick incidents, and nosocomial infections. Other facilities expressed concern that injury rates have been reduced through education and training but will soon rise again because of the physical demands of nursing the current resident populations. Nursing personnel are more subject to injuries than other workers; this is particularly true of NAs who work in nursing homes where many residents must be turned, lifted, or assisted in their toileting. Nevertheless, a noticeable number of facilities and nursing personnel did not seem to be concerned about traditional work-related injuries, probably because they are taking steps to reduce these. Such steps include the use of back supports when lifting, as well as educational programs, and the results seem to indicate that such efforts are often effective in reducing back injury rates. A possible solution to the physical demands of providing long-term care is the provision of equipment and the use of technology. When NAs at one site were asked to list the equipment they would like to have, their wishes appeared surprisingly modest: hospital beds, bathtubs, shower chairs, bedside commodes, bed linen with rubber backing, and adult diapers were all mentioned as equipment that staff needed but often did not have. At first glance, these technologies might seem relatively unlikely to affect injury rates but the NAs explained that many of them do reduce the physical strain of caring for and lifting residents. Aides were open to the possibility of more technologically sophisticated equipment but were more aware of the basic tools they lacked. Stress appears to affect nursing staff in a variety of ways. In acute care settings at least, anger, frustration, and confusion about restructuring and cost-cutting measures were often evident. It appeared to committee members that lack of empowerment or participation in the planning and implementation of restructuring, combined with uncertainty about their jobs or new responsibilities, clearly increased the stress level among nurses. Many licensed nurses in acute care were concerned about the use of ANP, particularly since they are held responsible for the care provided by these unlicensed staff whether or not they are the ANP's supervisors. Committee members also heard reports of mandatory overtime and double shifts being common on weekends. "Floating" from one unit to another and reduced staffing levels be-

OCR for page 241
--> cause some staff are out on sick leave were frequently mentioned sources of stress, even at institutions with fairly satisfactory staffing levels. Even under good conditions and with sufficient training to establish the familiarity and competence of floating nurses, nursing personnel usually hate floating, often because of strong concerns about the quality of patient care that they can deliver when they are shifted from one location and one type of care to another. Many of the complaints to LTC ombudsmen about care delivered in nursing facilities concern the inadequacy of staff, particularly at night and on weekends. Other complaints involve patient abuse. Many of those interviewed believed that abuse is most likely when nursing personnel are understaffed or are taking care of unfamiliar residents. Complaints to ombudsmen often result in formal surveys by the state units that handle licensure and certification; the survey process is a mechanism for identifying inadequate care that can result in the issuance of statements of deficiencies against facilities. More generally, patient acuity levels are up in long-term-care facilities, and staffing levels are insufficient; this situation is compounded by turnover rates that leave staff habitually working shorthanded. Not surprisingly, overall staff stress is high. Specific sources of stress for NAs are lack of time, constant turnover of staff, inadequate time to orient and help new staff, and the addition of unpredictable, poorly prioritized tasks to their responsibilities. As noted earlier, many facilities and staff in highly urban areas are concerned about the vulnerability of nursing staff to increased stress and injury inflicted by patients. The increase in patient violence toward nurses seems to be more prevalent in settings where a general societal increase in violence and other social ills is evident (e.g., emergency rooms, municipal hospitals, psychiatric units, and nursing home dementia units). The increased violence appears most likely to occur when care is being provided to prisoners, drug abusers, the homeless, and the mentally ill. The level of experience and training of the care provider becomes an issue in these situations. Sometimes the danger is augmented because a less prepared provider is unable to control a situation or does not have the assessment skills to identify such a situation far enough in advance to avoid conflict. A few facilities reported that nonviolent crisis intervention is taught to all emergency room staff. Reimbursement Issues Most reimbursement issues raised to committee members were concerned with long-term care. Medicare and Medicaid reimbursement rates are seldom sufficient to cover the actual costs of providing care and can easily be half the average costs. For this reason, private-pay residents are preferred. The rates charged private-pay residents differ widely by facility, region, and resident, but they ranged in just one facility from $27,600 to $59,000 per year. Inadequate

OCR for page 241
--> reimbursement from Medicaid also makes it difficult for administrators to get physicians into the facilities for routine, required visits to Medicaid patients. The response of one facility to financial concerns was to set a goal of converting the entire facility into a subacute unit, which yields better (Medicare) reimbursement rates that the current (Medicaid) payments for long-term-care residents. Two facilities, in contrast, were very diversified; they offered many services such as a profitable home health agency or assisted living facility; educational programs, consultations, and workshops; on-site, ongoing NA training; and a day care center. Such facilities may also be seeking more managed care contracts, which some facility administrators consider critical for future financial stability. Some hosts argued that the current system for reimbursement needs to be improved because it offers no motivation or reward for providing restorative or preventive nursing care. They recommended that the base reimbursement rate be tied to acuity (e.g., activity-of-daily-living factors) and that incentive payments be given for achieving positive outcomes. These outcomes should not necessarily be limited to improvements in health; the avoidance of poor outcomes (e.g., low decubitus, incontinence, or hospitalization rates) should also be considered. Education Throughout the site visits, the topic of education—whether initial, continuing, clinical, academic, or managerial—was frequently raised. The majority of those interviewed on site visits felt that the educational preparation of new RNs is insufficient. Assessment skills may be adequate but judgment, experience, knowledge of medications, and leadership and delegation skills are lacking. The need for baccalaureate-prepared RNs was noted by both educators and nursing leaders. Some spoke of the need for nurses in intensive care units to be trained with 6-month internships after graduation. Many mentioned that new graduates need more rehabilitation and geriatrics in their educational program, and some expressed the opinion that 2-year associate degree programs are inadequate to prepare nurses for their roles in the current evolving health care system. Adequate preparation is especially necessary when nurses have to plan the care for patients who require exceptional assessment. According to some staff nurses in hospitals, one difficulty facing new RN graduates is that they simply have not been prepared for the work. Their schooling is mostly theoretical, and these staff nurses felt that neither associate degree nor bachelor's degree RNs have received the necessary preparation and orientation. Educators, in contrast, point out that changes in the delivery of acute care have exacerbated the difficulty of the transition from school to work because facilities no longer have time to teach new staff, and often those who used to teach them (e.g., staffing coordinators, clinical nurse specialists) have heavy patient loads or have been dismissed.

OCR for page 241
--> The need for clinical leadership for nursing personnel and for educational preparation and training was a topic that recurred several times and across settings. Registered nurses' difficulties in delegation and the importance of being good nurse managers were noted. Some nurses spoke of the role of the RN ''becoming expensive" and the need to maximize these nurses by delegating functions to others such as LPNs and NAs whom RNs would then supervise. It was suggested at more than one site visit that RNs need to be explicitly instructed in delegation, management, and supervision and that these subjects ought to be in the curriculum of the educational program. On the topic of NA training, several CNAs who had worked as uncertified NAs while attending certification classes believed that this combination of learning and experience prepared them better than only attending classes would have. They also pointed out that it might be an efficient way to "weed out" those student NAs who would not continue working in long-term care once they experienced the day-to-day work. The disadvantage is that this double load of work and learning can be tiring. They also identified a need for additional training and, most particularly, additional supervision of newly certified NAs after they have started working; this is the time when new CNAs need explicit guidance and reinforcement in translating their training into clinical care. Concluding Remarks About Site Visits The site visits were a vital part of the IOM committee's information gathering efforts. They provided committee members with opportunities to learn about a variety of staffing issues in acute and long-term care and to ground their discussions and deliberations in an appreciation of the complex ways such issues play out in the actual delivery of bedside care. Furthermore, the site visit teams benefited from the opinions, expertise, and experiences of a number of individuals and organizations in the areas of health care delivery and policy; nursing care and nursing administration; hospital and nursing home administration; labor relations; state-level regulation and oversight of nursing facilities; nursing education; resident advocacy; business concerns; and health care policy. Despite the fact that committee members often had quite different experiences on site visits, analysis of all this information enabled them to reach several overarching conclusions: Issues such as increased patient acuity, difficulties in recruiting and retaining NAs, and the effects of reimbursement systems and rates on the ways in which care is delivered are increasingly crucial factors influencing the quality of care and the safety of the workplace. Hospitals are restructuring the delivery of health care in many diverse ways, and gathering and using data on these changes are difficult challenges for hospitals, nursing personnel, consumers, payers, and other concerned groups.

OCR for page 241
--> The links between reimbursement and patient acuity levels or case-mix could be strengthened. In both nursing homes and hospitals, flexibility in staffing arrangements and in nursing personnel's approaches to work can result in improved morale and quality of care. High-level leadership and direction within a facility are critical for maintaining and improving the quality of patient care. The committee is grateful to the individuals and organizations that hosted its visits. In addition to the information conveyed in person, many sites and individuals provided information before and after the visits. It is impossible to document the myriad forms of assistance that were provided, but the committee wishes to express here its recognition of the expenditure of time and energy on the part of all those who helped committee members.

OCR for page 241
--> EXHIBIT 1.1 Request by the Committee on the Adequacy of Nurse Staffing for written testimony. INSTITUTE OF MEDICINE 2101 Constitution Avenue, Washington, D.C. 20418 Division of Health Care Services TEL (202) 334-1321 Committee on the Adequacy of Nurse Staffing FAX (202) 334-2031 The Adequacy of Nurse Staffing: Stress, Injury, and Quality of Care Request For Testimony The following is an open invitation to prepare written testimony for submission to the Institute of Medicine (IOM) Committee on the Adequacy of Nurse Staffing, with the opportunity for oral presentation before the committee at a later date. Any organization or individual may submit testimony to the committee, but written statements are to be received no later than September 26, 1994. Please read further for more details. Background The Congress of the United States, following 1993 hearings on the current state of staffing of nursing personnel in hospitals and nursing homes, directed the Secretary of the Department of Health and Human Services to request a study from the Institute of Medicine, National Academy of Sciences, to determine whether and to what extent there is a need for an increase in the number of nurses in hospitals and nursing homes in order to promote the quality of patient care and reduce the incidence among nurses of work-related injuries and stress. For the purposes of this legislative mandate "nurses" includes registered nurses, licensed practical and vocational nurses, and nursing assistants and aides. The Congress has requested a formal report at the conclusion of this study. Providing Testimony To respond to this request, the IOM has established a committee of 15 experts representing a wide range of expertise (the committee roster is attached). As part of the committee's activities, written testimony is being solicited from organizations and groups representing all points of view on the subject, with the opportunity for oral presentation before the committee and to respond to the committee's

OCR for page 241
--> questions. Two invitational sessions, each one-half-day long, will be convened — one in Washington, D.C., and the other in Irvine, California. The committee will make every effort to accommodate as many oral presentations as possible within the very limited time available for each session. Those organizations and individuals asked to present oral statements will be grouped in panels, asked to confine their remarks to about 5-7 minutes summarizing their written testimonies, and requested to be prepared to respond to committee members' questions. These sessions will be open to the public for observation. Reporters interested in attending the oral presentation sessions should contact the Office of News and Public Information at 202-334-2138, or through Internet at NEWS@NAS.EDU. These hearings are an opportunity for the committee members to obtain firsthand an extensive range of opinion on the matters under consideration. Written and oral statements will be summarized by staff for the committee after they are completed. The topics to be addressed in the written testimony are provided in the following Guide to Preparing Testimony. Guide to Preparing Testimony First, as background, briefly describe your organization and its activities; existing brochures or publications are acceptable. Then, to the extent possible, please address at least the topics listed below. Your written statement may be as long as you choose and you may confine your remarks to only hospitals or only nursing homes, if you prefer. Please note that, in accordance with the legislative mandate for this study, the term "nurses" is used to cover registered nurses, licensed practical and vocational nurses, and nursing assistants and aides. All testimony should include a one-page executive summary and a cover letter identifying the name, affiliation, address, and telephone number of the contact person. Your experiences with and conclusions about the current status of nurse staffing and its adequacy (both for numbers and skill mix), effects on the quality of patient care, and effects on nurses' work-related well-being. The gaps in knowledge and documented evidence in the areas that the committee is studying, and priority areas and concerns. The measures that are or should be used to assess the impact of nurse staffing levels and skill mix on the quality of nursing care and patient well-being. The measures that are or should be used to assess the impact of nurse staffing levels and skill mix on nurses' work-related well-being (including stress and injuries).

OCR for page 241
--> Beyond anecdotes, what data are available to support the committee's analysis? What resources and mechanisms exist to confirm and strengthen anecdotal information? Can you provide any of these resources or data? The appropriateness and adequacy of current nursing undergraduate, graduate, and in-service education and training in addressing the changing delivery and organization of health care. What data or information are available relating to the institutional cost-benefits, quality of patient care, and nurses' work-related well-being associated with restructuring of the delivery of nursing care utilizing different skill mixes? What information is available about patients' satisfaction with different skill mixes in nursing care? Keeping in mind the current national environment for cost containment, please note any suggestions you have for the committee. Please note that all written statements are to be received no later than September 26, 1994. Feel free to distribute this announcement to others who may wish to submit written testimony. Questions regarding the written statements may be directed to Gooloo S. Wunderlich, Ph.D., Study Director, at Institute of Medicine, 2101 Constitution Avenue, NW, Washington, DC 20418.