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--> Nursing Staff in Hospitals and Nursing Homes Is It Adequate? Gooloo S. Wunderlich, Frank A. Sloan, and Carolyne K. Davis, Editors Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes Division of Health Care Services INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1996
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--> National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the National Institute for Nursing Research through an interagency agreement with the Bureau of Health Professions of the Health Resources and Services Administration, U.S. Department of Health and Human Services. The views presented are those of the Institute of Medicine Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes and are not necessarily those of the funding organization. Library of Congress Cataloging-in-Publication Data Nursing staff in hospitals and nursing homes : is it adequate? / Gooloo S. Wunderlich, Frank A. Sloan, and Carolyne K. Davis, editors. p. cm. “Division of Health Care Services, Institute of Medicine.” Includes bibliographical references and index. ISBN 0-309-05398-6 1. Nurses—Supply and Demand—United States. 2. Nurses’ aides—Supply and demand—United States. 3. Hospital care—United States. 4. Nursing home care—United States. I. Wunderlich, Gooloo S. II. Sloan, Frank A. III. Davis, Carolyne K. [DNLM: 1. Nursing Staff—supply & distribution. 2. Nursing Staff, Hospital. 3. Nursing Homes. WY 125 N9748 1996] RT86.73.N886 1996 331.12′91362173′0973—dc20 DNLM/DLC 96-117 for Library of Congress CIP Copyright 1996 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.
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--> COMMITTEE ON THE ADEQUACY OF NURSE STAFFING IN HOSPITALS AND NURSING HOMES CAROLYNE K. DAVIS,* (Chair), National and International Health Care Advisor, Ernst and Young, Washington, D.C. FRANK A. SLOAN,* (Cochair) J. Alexander McMahon Professor of Health Policy and Management and Professor of Economics, Center for Health Policy Research, Duke University, Durham, North Carolina DYANNE D. AFFONSO,* Dean and Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia JAMES F. BLUMSTEIN,* Professor, Vanderbilt University School of Law, Nashville, Tennessee DONALD L. CHENSVOLD, President, Healthcare of Iowa, Inc., Cedar Rapids, Iowa LINDA HAWES CLEVER,* Chair, Department of Occupational Health, California Pacific Medical Center, San Francisco, California JOYCE C. CLIFFORD, Vice President for Nursing and Nurse in Chief, Beth Israel Hospital, Boston, Massachusetts EDWARD J. CONNORS,* President Emeritus, Mercy Health Services, Morrisville, Vermont ARTHUR COOPER, Chief of Pediatric Surgical Critical Care, Division of Pediatric Critical Surgery, Harlem Hospital Center, New York City, New York ALLYSON ROSS DAVIES, Health Consultant, Newton, Massachusetts ERIKA SIVARAJAN FROELICHER, Professor, Department of Physiological Nursing and Adjunct Professor, Department of Epidemiology and Biostatistics, University of California, San Francisco, California CHARLENE A. HARRINGTON, Professor and Chair, Department of Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California MARK C. HORNBROOK, Program Director, Center for Health Research, Kaiser Permanente, Portland, Oregon RONALD E. KUTSCHER, Associate Commissioner, Bureau of Labor Statistics, U.S. Department of Labor, Washington, D.C. SUE LONGHENRY, Surveyor, Joint Commission on Accreditation of Hospitals, Columbus, Ohio ELLIOTT C. ROBERTS, SR., Professor, Louisiana State University Medical School, New Orleans, Louisiana * Member, Institute of Medicine
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--> Division of Health Care Services Study Staff Gooloo S. Wunderlich, Study Director Holly Dawkins, Research Assistant Annice Hirt, Senior Project Assistant Kathleen N. Lohr, Division Director H. Don Tiller, Division Administrative Assistant
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--> Acknowledgments The Institute of Medicine (IOM) Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes acknowledges with appreciation the many persons and organizations, not all of whom can be individually identified, who contributed to the success of this study. Support for this study was provided by the Division of Nursing, Health Resources and Services Administration of the U.S. Department of Health and Human Services. We particularly wish to thank Evelyn Moses, Division of Nursing, who served as the government project officer for this study. She was always available for participating in all the committee meetings open to the public and the public hearings, and providing guidance and data to the committee throughout the period of its deliberations. We would like to thank Patricia Moritz, National Institute of Nursing Research, where the original request for the study was directed by Congress, for organizing a special session for the committee in conjunction with the 1994 annual meetings of the Gerontological Society of America where she brought together researchers to discuss completed and ongoing research on staffing and quality of care issues in nursing homes. We recognize with gratitude Janet Heinrich, director of the American Academy of Nursing, for organizing with Patricia Moritz a workshop to discuss completed and ongoing research on the relationship between quality of care and nurse staffing and organizational variables in hospitals. This workshop was held in conjunction with the annual meeting of the American Academy of Nursing. Dr. Heinrich's assistance to staff throughout the period of the study is appreciated. In addition we would like to acknowledge the help provided by many other federal government officials. In particular the committee appreciates the time
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--> and efforts of staff of the Health Care Financing Administration for providing the committee and staff with relevant information and participating in committee meetings. We thank the staff of the Bureau of Labor Statistics for providing the committee and staff with special tabulations and other information on employment statistics in the health industry, and on injuries in the workplace. An important part of the committee's work was analysis of national databases and extensive review of literature. The committee wishes to thank the Health Statistics Group of the American Hospital Association and Marjorie Beyers, executive director, American Organization of Nurse Executives, for making available special detailed tabulations for the committee's use. We recognize with gratitude Scott Bates and Peter Kralovec of that office for preparing the tabulations, some on very short notice, and for patiently answering the many questions for clarification. Many individuals shared unselfishly with the committee the results of their work, and some carried out special focused projects on behalf of the committee. The committee particularly wishes to thank its Liaison Panel, which comprised representatives of professional associations of nurses, related professional groups, hospitals and nursing homes, unions, and organizations that serve as advocates for nursing home residents (see Appendix B). Several members of the panel also provided the committee with results of special surveys, informational material, and other background information from their organizations throughout the period of the study. The committee also wishes to thank the staff of various interested organizations, including Margaret Peisert and Arvid Muller of the Service Employees International Union and Karen Worthington and David Keepnews of the American Nurses Association, who were responsive to many committee requests; Sarah Burger of the National Citizens' Coalition for Nursing Home Reform, who organized meetings and provided information that helped the committee understand the specific concerns of nursing home residents and the elderly; Martha Mohler of the National Committee to Preserve Social Security and Medicare, who ably served a double duty as both the Liaison Panel member and the staff contact; and Marcia Richards of the American Health Care Association (AHCA), who organized a meeting with the AHCA long-term care nurse council and was always available to answer questions and provide data. Although we agreed not to identify these individuals and organizations, we want to express our gratitude to the many site visit hosts who welcomed the committee graciously and shared their thoughts, experiences, insights, and time. The committee also appreciates the efforts of the large number of persons who submitted written testimonies and letters to share their views and experiences, as well as several individuals who provided oral testimony at the public hearings held by the committee. Organizations and individuals who presented oral statements at the public hearings are listed in the Study Activities in Part II of this report.
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--> We are grateful to the authors of commissioned papers prepared for this study. These papers were used extensively by staff and committee in drafting the report. They are included in Part II of the report. In addition the committee had access to a preliminary draft of a paper on "Utilization of Unlicensed Assistive Personnel in Nursing Care Delivery: Examination, Evaluation, and Recommendations for the Future," which was prepared for the committee's use by Greta Krapohl and Elaine Larson, Georgetown University School of Nursing, in fulfillment of a graduate student assignment with the IOM committee. The committee expresses its appreciation to Ms. Krapohl and Dr. Larson, her advisor for the scholarly project. During the first year of its work, the committee held meetings at which experts made thoughtful presentations on various aspects of the committee's mandate. The presenters and the topics of their talks are listed in Appendix A; their contribution of time and knowledge is appreciated. We acknowledge with gratitude the contributions of the committee's staff, to whom an important debt of gratitude is owed. The committee is aware of the enormous commitment and effort of our study director, Gooloo Wunderlich. Her organizational skills, as well as her sense of humor assisted the committee throughout its deliberations. Her professionalism and expertise in health care policy development coupled with her excellent writing skills advanced the progress of this report throughout its many reviews and revisions. Coordinating the research and assimilating disparate views was a major undertaking. A disproportionate share of any credit due this report is because of her perseverance, skill, knowledge, and the incredible amount of time she devoted to organizing and writing the report. Holly Dawkins, who served as research assistant, worked closely with the study director on various aspects of the study. She took primary responsibility for organizing the various site visits, guiding committee members through each site visit, and drafting the site visit reports. We recognize and appreciate the substantial staff effort that went into organizing the site visits. Annice Hirt served ably as the senior project assistant. She efficiently managed the logistical and administrative arrangements for the many committee meetings and orchestrated the smooth operation of two public hearings involving large numbers of people. She organized the voluminous research material that committee and staff generated over the course of the study, handled the large volume of correspondence and inquiries, and cheerfully and competently coped with the various drafts of the report under very tight deadlines. Other IOM staff made valuable contributions to the success of the committee's efforts. Kathleen N. Lohr, director, Division of Health Care Services, was always available to answer questions, provide assistance to committee and staff, and explain to members of the committee the operations of the IOM and the National Research Council. Nina Spruill helped keep our budget in order. Claudia Carl managed the logistics of an extensive report review process, and
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--> Mike Edington shepherded the report through the editing and production process. Sally Stanfield at the National Academy Press was supportive as always. Finally, we would like to thank the members of the committee for their generous contribution of time and effort in the preparation of the report. Carolyne K. Davis, Chair Frank A. Sloan, Cochair
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--> Contents SUMMARY 1 PART I: REVIEW AND RECOMMENDATIONS 1 INTRODUCTION 19 Immediate Origins of the Institute of Medicine Study 20 Committee Charge 21 Definitions 22 Study Approach 25 Underlying Assumptions and Values 27 Organization of the Report 28 2 IMPLICATIONS OF POPULATION CHANGE 31 Introduction 31 Growth of the Population 32 Diversity of the Population 34 Health Status and Disabling Conditions 38 Conclusion 41 3 EVOLVING HEALTH CARE SCENE 42 Overview 42 Private Insurance and Public Payers for Health Care 46 Managed Care 47
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--> Ownership Structure 50 Hospitals 51 Nursing Homes 58 Implications for Nursing Services 66 4 NURSING PERSONNEL IN A TIME OF CHANGE 68 Supply of Nursing Personnel 69 Changing Demand for Nursing Personnel 79 Is Supply Adequate for the Demands of the Next Century? 87 Summary 91 5 STAFFING AND QUALITY OF CARE IN HOSPITALS 92 Restructuring in the Hospitals 94 Measuring Quality of Care in Hospitals 106 Relationship of Nursing Staff to Quality of Patient Care 116 Legislative and Regulatory Requirements 124 Summary 126 6 STAFFING AND QUALITY OF CARE IN NURSING HOMES 128 Measurement of Quality 129 Status of Quality of Care in Nursing Facilities 132 Has Quality of Care Improved Since OBRA 87? 136 Relationships Among Nursing Staff, Management, and Quality of Care 146 Effects of Reimbursement and Other Factors on Nursing Staff 162 Residents, Families, Volunteers, and Ombudsmen 165 Conclusion 167 7 STAFFING AND WORK-RELATED INJURIES AND STRESS 169 Overview 169 Incidence of Work-Related Injuries and Illness 170 Violence, Abuse, and Conflict 177 Work-Related Stress 183 Summary 187 8 EPILOGUE 189 APPENDIXES A Presentations Made to the Committee 195 B Liaison Panel 197 C Separate Statement, James F. Blumstein 199 Responses by Committee Members 202 D Acronyms 205
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--> REFERENCES 209 BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS 230 PART II: RESOURCES FOR THE STUDY 1 STUDY ACTIVITIES Written and Oral Testimony Submitted to the Committee 241 Site Visits Conducted by the Committee 259 2 STATISTICAL RESOURCES 277 3 COMMISSIONED PAPERS Quality of Care, Organizational Variables, and Nurse Staffing Joyce A. Verran 308 Professional Nursing Education—Today and Tomorrow Angela Barron McBride 333 Nursing Staff and Quality of Care in Nursing Homes Meridean Maas, Kathleen Buckwalter, and Janet Specht 361 Quality of Care and Nursing Staff in Nursing Homes Jean Johnson, C. McKeen Cowles, and Samuel J. Simmens 426 Nursing Facility Quality, Staffing, and Economic Issues Charlene A. Harrington 453 Nursing Injury, Stress, and Nursing Care Bonnie Rogers 503 INDEX 533
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--> Tables And Figures Tables 3.1 Inpatient Activity in Community Hospitals, Total Patients and Patients 65 Years of Age or Older, United States, Selected Years, 1983–1993 54 3.2 Percent Change in Inpatient Community Hospital Utilization, United States, 1994–1995 55 3.3 Trends in Outpatient Visits and Other Selected Services Offered in Community Hospitals, United States, Selected Years, 1983–1993 56 3.4 Percent Change in Outpatient Community Hospital Utilization, United States, 1994–1995 57 3.5 Number of Licensed Nursing Home Beds per 1,000 Population Aged 85 and Older, by Region, Selected Years, United States, 1978–1993 59 3.6 Number of States by Medicaid Nursing Facility Reimbursement Method and by Number Using Case-Mix Reimbursement, United States, 1979 and 1993 62 3.7 Number of Licensed Long-Term Care Facilities, United States, 1992 and 1993 64 4.1 Number of Full-Time and Part-Time Employees in Nursing Occupations, United States, Selected Years, 1983–1993 72 4.2 Unemployment Rates, Nursing and Other Selected Occupations, United States, Selected Years, 1983–1994 73 4.3 Number of Full-Time and Part-Time Employees in Hospitals and Nursing Homes, United States, Selected Years, 1988–1994 78 4.4 Percent Change in Nurse Staffing in Community Hospitals, United States, 1994–1995 81 5.1 Illustrative Measures of Quality of Care in Inpatient Hospital Settings, with Specific Attention to Nursing Care 110 6.1 Illustrative Measures of Quality of Care in Nursing Homes 130 6.2 Deficiencies in Certified Nursing Facilities from the Federal On-Line Survey Certification and Reporting System, United States, 1993 137 6.3 Resident Characteristics in Nursing Facilities from the Federal On-Line Survey Certification and Reporting System, United States, 1993 139 6.4 Nurse Staffing Levels for All Certified Nursing Facilities from the Federal On-Line Survey Certification and Reporting System, United States, 1991–1993 143 6.5 Average Turnover Rates in Nursing Facilities by Staff Category, United States, 1990–1994 160 6.6 Nursing Facility Hourly Wages by Staff Category, United States, 1990–1993 161
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--> 7.1 Trends in Occupational Injury and Illness Incidence, United States, 1980–1993 171 7.2 Percent Distribution of Nonfatal Occupational Injuries and Illnesses Involving Days Away from Work, for Selected Occupations and Worker Characteristics, United States, 1993 172 Figures 2.1 Average annual percent change in population 65 years and older, United States, 1900–2040 (middle series projections) 33 2.2 Number of people 85 years and older, United States, 1900–2050 (middle series projections) 33 2.3 Percent of population 65 years and older by race and hispanic origin, United States, 1900 and 2050 35 2.4 Parent support ratio, United States, 1950–2050 (number of people 85 years and older per 100 persons 50–64 years old, middle series projections) 37 3.1 Employment in hospitals, United States, 1969–1994 44 3.2 Nurses as a percent of total full-time-equivalent (FTE) personnel in community hospitals, United States, 1979–1993 45 3.3 Sources of funds for medical care expenditures, United States, 1993 46 3.4 Number of people receiving care in HMOs, United States, 1976–1995 48 4.1 Estimated active supply of registered nurses (RN) per 100,000 population, United States, 1960–1993 71 4.2 Age distribution of employed registered nurses (RN), United States, 1988, 1993, and 2000 74 4.3 Highest educational preparation of registered nurses (RN), United States, 1992 75 4.4 Percent of registered nurse graduates by type of educational program, United States, 1958–1993 76 4.5 Number of licensed practical nurse (LPN) graduations, United States, 1983–1993 77 4.6 Ratio of registered nurse full-time-equivalents (FTE) to adjusted patient days, United States, 1983–1993 80 4.7 Percent change in registered nurse employment in selected areas, United States, 1988–1992 82 4.8 Median weekly earnings of nursing occupations, United States, 1983–1994 86
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Part I Review And Recommendations
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