Nurses Caring for Patients: Who They Are, Where They Work, and What They Do1
An organization’s workers and their work environment have a reciprocal relationship, each influencing the other in an ongoing, dynamic interplay that affects the level of safety within the organization (Cooper, 2000). To construct a nursing work environment that maximizes patient safety, the characteristics of the nursing workforce, the settings in which they provide care, and the nature of their work, as well as the implications of these elements for patient safety, need to be considered. This chapter does so, focusing predominantly on the role of nurses in hospitals and nursing homes, where the greatest amount of study has been conducted on patient safety.
WHO IS DOING THE WORK OF NURSING?
“When average citizens report that ‘I saw the nurse,’ or ‘I talked to the nurse,’ they could mean any of a vast array of workers” (Ward and Berkowitz, 2002:44). The word “nurse” is often used to refer to registered
nurses (RNs), licensed practical nurses/licensed vocational nurses (LPNs/ LVNs), or nursing assistants (NAs). In this report, we refer collectively to all three of these groups of personnel as nursing staff.
There are over 5 million nursing staff in the United States. Of these, 2.2 million are actively employed as RNs2 and 683,800 as LPNs/LVNs. RNs and LPNs/LVNs are licensed by the state in which they provide nursing care. Another 2.3 million unlicensed health care workers (Bureau of Labor Statistics, undated) supplement the work of licensed nurses by performing basic patient care activities under the supervision of an RN or LPN/LVN. These unlicensed health care personnel hold a variety of job titles, including nurse assistants, nurse aides, home health aides, personal care aides, ancillary nursing personnel, unlicensed nursing personnel, unlicensed assistive personnel, nurse extenders, and nursing support personnel. In this report, we refer collectively to these workers as NAs. Jobs for NAs are expected to be among the most rapidly expanding in the workforce as the overall U.S. population ages, and the need for postacute and chronic care increases. Indeed, the number of employed NAs increased by 40 percent between 1980 and 1990, more than twice the growth rate of the overall U.S. workforce. The greatest growth was in aides working in home care, whose numbers more than doubled from 1988 to 1998. From 1998 to 2008, a 36 percent increase in NA jobs is predicted, compared with a 14 percent increase in all workforce jobs (GAO, 2001b).
Variations in Education and in Experience and Expertise Among Members of the Nursing Workforce
Each type of nursing personnel is educated differently. An overview of the education received by each is provided below.
Education for RNs Basic RN education can be attained through three routes: 3-year diploma programs, 2-year associates degree (AD) nursing programs, and 4-year baccalaureate degree programs. In addition to any of these three types of academic preparation, individuals must pass a state examination to be licensed as an RN.
The route chosen to receive entry-level, prelicensure RN education has changed considerably over the past two decades, with decreasing use of 3-year diploma programs and increased use of AD and baccalaureate programs. Between 1980 and 2000, the proportion of nurses receiving their
basic education from a diploma program decreased from 60 to 30 percent, while the proportion of those receiving basic education from AD or baccalaureate programs increased from 19 to 40 percent and 17 to 29 percent, respectively. However, these data do not fully characterize the educational level of the RN workforce, as many RNs pursue additional education after being licensed. In 2000, the distribution of RNs according to their highest degree was as follows: diploma preparation (23 percent), AD (34.3 percent), baccalaureate degree (32.7 percent), and master’s or doctoral degree (10 percent). The educational level of RNs varies by place of employment. RNs in nursing homes generally have a lower level of education than those in other settings. In 2000, only 27 percent of RNs employed by nursing homes were prepared at the baccalaureate level, compared with 43 percent in hospitals. Nurses with advanced-practice credentials are also less well represented in nursing homes: 7.6 percent of hospital nurses were prepared at the masters or doctorate level, compared with 4.3 percent of nursing home nurses (Spratley et al., 2000).
Research on the effect of different educational paths to RN licensure on nurse performance and patient outcomes has been inconclusive. Such research has examined the characteristics, abilities, and work assignments of nurses with and without baccalaureate degrees, but has not been as thorough in examining the quality of the care they provide (including patient safety) (Blegen et al., 2001). However, an analysis of educational preparation and years of experience in the nursing workforce from the National Sample Survey of Registered Nurses (NSSRN) suggests that baccalaureate-prepared nurses have tended to stay in the workforce longer and accrue more years of work experience than those not thus prepared (Sochalski, 2002). Further, limited data from studies of magnet hospitals (i.e., hospitals characterized by their ability to attract and retain nurses) indicate that those hospitals have higher percentages of baccalaureate-prepared nurses (50 percent) as compared with the national hospital average of 34 percent (Aiken et al., 2000a).
Education for LPNs/LVNs LPN/LVN training programs are shorter than those for RNs, taking 12 to 18 months, and emphasize technical nursing tasks such as monitoring vital signs, administering medications, and completing treatments (GAO, 2001b). In 2000, approximately 1,100 state-approved programs provided LPN/LVN education. Students attending these programs were enrolled predominantly in vocational/technical schools and community and junior colleges. A state licensing examination also must be completed successfully following the LPN/LVN training program (Bureau of Labor Statistics, 2003).
Education for NAs Training for NAs depends on their place of employment. Those working in Medicare- or Medicaid-reimbursed nursing homes
(the majority) and home health agencies must meet certain minimum training requirements and competency standards and acquire state certification to become certified nurse aides (CNAs). An individual may become a CNA either by completing a nurse aide training program and a competency evaluation (a written or oral test and skills demonstration) or by passing a competency evaluation alone. A minimum of 75 hours of training is required through a state-approved CNA program, although many state programs exceed the minimum. At least 16 of the 75 hours must be practical training under the direct supervision of an RN or LPN. For CNAs working in nursing homes, states are required to keep a registry of those who have passed their competency evaluations (GAO, 2001b). There are no similar federal requirements regarding training, certification, competency evaluation, or registries for NAs working in hospitals (GAO, 2001b).
Experience and Expertise
Experience and expertise refer to the knowledge and skill obtained apart from (often subsequent to) formal preparation in an academic institution. Experience is acquired when an actual practice situation “refines,” “elaborates,” or “disconfirms” knowledge that has been acquired previously through the study of theory or principles or participation in events. Expertise is the result of an individual’s accumulation of knowledge and skill from such experiences (Benner, 1984:3–5). Thus, workers with similar formal education can possess varying degrees of expertise. A new graduate and a seasoned nurse of 20 years are both nurses, but their experience and expertise are very different.
The varying levels of expertise and skill acquired by learners have been identified through studies of different types of workers and learners within and outside of health care. These levels have been labeled as “novice,” “advanced beginner,” “competent,” “proficient,” and “expert” (Dreyfus and Dreyfus, 1986). As applied to nursing, they have been described as (1) novice—beginners who have no experience with the situations in which they must perform; (2) advanced beginners—individuals who have marginally acceptable performance based on a foundation of experience with real situations; (3) competent—individuals with 2 or 3 years in a similar situation; (4) proficient—wherein perception allows meanings to be understood in terms of the “big picture” rather than as isolated observations; and (5) expert—based on a wealth of experience enabling an intuitive grasp of situations and quick targeting of problem areas (Benner, 1984). According to this framework, expertise is subject matter–specific; thus, for example, RNs may be expert in one area of practice, such as critical care, but not in another, such as psychiatric nursing, just as a highly expert obstetrician may be less than proficient in managing an adult with neurological problems.
The levels of experience and expertise of nursing staff have not been well measured. Experience is typically assessed using a proxy measure—the number of years an individual has been employed in nursing. This measure may capture exposure to opportunities for experience and the gaining of expertise, but as noted above, such exposure is not always a guarantee of expertise. Using years of nursing work as a proxy measure, however, experience has been associated with better patient care. In an analysis of data from two studies (involving 42 inpatient units in one large tertiary-care hospital and 39 patient care units in 11 other hospitals), nursing units whose nurses had more years of experience were found to have lower rates of medication errors and patient falls (Blegen et al., 2001). Likewise, a 1996–1998 analysis of nurses and errors in a Japanese cardiology ward found that nurses with less than 3 years of experience made significantly more rule-based and skill-based errors than those with more than 3 years of experience (Narumi et al., 1999).
Further support for the beneficial effects of years of experience and expertise in providing nursing care to individuals with particular clinical conditions can be inferred from similar studies of physicians. Such studies have revealed better patient outcomes when clinical procedures are carried out by physicians who have performed greater numbers of those procedures and when care of patients with certain clinical conditions, such as AIDS, is rendered by physicians with more experience in treating those conditions. The Agency for Healthcare Research and Quality’s (AHRQ) recent evidence-based report on the effect of health care working conditions on patient safety presents evidence that in a number of types of clinical care, greater experience of health professionals is associated with better patient outcomes (Hickam et al., 2003).
Currently, the experience level of nursing staff is threatened by high turnover rates in all health care delivery settings. Nationally in 2000, an estimated 21 percent of all acute care hospital nurses left the position in which they were practicing. Most hospitals reported turnover rates of 10 to 30 percent, but some experienced even higher rates (The HSM Group, 2002). The turnover rate is even higher in long-term care facilities. A 2001 national survey of the American Health Care Association (AHCA) revealed turnover rates of 78 percent for NAs, 56 percent for staff RNs, 54 percent for LPNs/LVNs, and 43–47 percent for directors of nursing and RNs with administrative duties (AHCA, 2002). If all these nursing personnel left their positions to take new positions in settings offering similar clinical services, the level of expertise of the nursing workforce would not be threatened.3
However, NSSRN data show that a number of these nurses are leaving the field of nursing altogether. In 2000, 18.3 percent of licensed nurses were not working in the field of nursing. Evidence indicates that these are not just retired older nurses. Almost 3 percent of women and 2 percent of men graduating from nursing schools between 1988 and 1991 were not working in nursing within the first 4 years following graduation. By 9 to 12 years after graduation, 11 percent of women and 6 percent of men had departed from the profession. More recent graduating classes have higher departure rates. Among 1996–1999 graduates, 4.1 percent of women and 7.5 percent of men left the profession within 4 years of graduating (Sochalski, 2002). This loss of experienced nurses can represent a threat to patient safety.
Unique Demographic Characteristics of the Nursing Workforce
Most data on the nursing workforce are collected on RNs; less is known about LPNs/LVNs and NAs, who together make up 42.6 percent of nursing staff. It is known, however, that nursing staff overall are predominantly female and ethnically different from the workforce at large and those they serve. RNs are older than the total U.S. workforce and aging more rapidly. NAs are often poor and without health insurance—unable to receive the services they provide to others. A small portion of nursing staff are not employees of the health care organizations (HCOs) in which they work, but provide care to patients as “contingent” workers.
Predominance of Women
The RN workforce is predominantly female (94.6 percent), although the small proportion of male RNs rose from 2.7 percent in 1980 to 5.4 percent in 2000 (Spratley et al., 2000). The NA workforce is similarly largely female. Women are estimated to make up 79.6 percent, 90.9 percent, and 89.2 percent of hospital, nursing home, and home care aides, respectively (GAO, 2001b). Although data are unavailable on the gender of LPNs/LVNs, they are likely predominantly female as well.
The high proportion of women in the nursing workforce has a number of implications. Conflicts in nurse–physician relationships have been attributed in part to gender conflicts and inequalities in society at large (McMahan and Hoffman, 1994). In addition, responsibilities at home, such as caring for children or older family members and performing household chores, may contribute to the commission of errors in two ways. First, family obligations may add to the long hours worked by many nurses in their professional workplace and contribute to the sleep deficits and fatigue that are associated with the commission of errors. Of nurses employed in the field in 2000, 55 percent had children living at home (Spratley et al., 2000).
Nursing home and home health aides are also two to three times more likely than other workers to be unmarried and to have children at home (GAO, 2001b). Second, while research has shown that men and women both experience stress in balancing work and family obligations, multiple studies on the division of household tasks have found that women continue to perform far more chores than do men (Wentling, 1998).
An Older and More Rapidly Aging Nursing Workforce
The entire U.S. workforce is aging, largely as a result of the aging of baby boomers. As noted, however, the RN workforce is already older than the total U.S. workforce and is aging more rapidly. The average age of the RN workforce was 37.4 in 1983 (Buerhaus et al., 2000), but had increased to 45.2 years by 2000 (Spratley et al., 2000). In the 1980s, the majority of nurses were in their twenties and thirties; by 2000, this distribution had changed substantially, with four times more 40-year-old than 20-year-old nurses. The average age of RNs is projected to increase and peak at 45.5 years in 2010 (Buerhaus, et al., 2000). In contrast, the Department of Labor forecasts the age of the overall labor force to reach only 40.7 years by 2008 (Bureau of Labor Statistics, 1999).
The more rapid aging of the RN workforce is attributed to three factors. First, large cohorts of the existing RN workforce are in their fifties and sixties—a function of the baby boom. Only when RNs born in the 1950s reach retirement age in approximately 2020 is the age distribution of the RN workforce projected to shift back toward younger ages (Buerhaus et al., 2000). Also, fewer young people are choosing to become RNs, so the proportion of younger nurses among all RNs is declining (Buerhaus et al., 2000; Spratley et al., 2000). Finally, in recent years, new graduates of basic nursing programs have tended to be older, and thus the average age of entrants into the RN workforce has been higher (Spratley et al., 2000).4
This aging workforce has implications for nurses’ work environments. The loss of strength and agility that often accompanies aging affects the ease with which nurses can perform patient care activities that require them to turn, lift, or provide weight-bearing support to patients. Focus groups of nurses have revealed that among nurses who plan to stay in the field, many are concerned that they will be unable to do so as they age because of the heavy physical demands of the job (Kimball and O’Neil, 2002). Ergonomic
patient and staff furniture and work tools will be needed to decrease the risk of injuries to patients (and nurses as well). Changes in hearing and vision also have implications for the design of work and technology used in patient care—for example, the need for increased lighting and larger size of print material (Curtin, 2002). There could be implications as well for shift lengths and rotations. Research has shown that adapting to shift work is more difficult for workers over age 40. A recent study of the effect of age on performance found that older individuals (mean age 43.9) had less ability to maintain performance on standard neurobiological tests across a 12-hour shift compared with younger individuals (mean age 21.2) (Reid and Dawson, 2001).
A Workforce That Does Not Yet Fully Reflect the Racial and Ethnic Diversity of the U.S. Population
The U.S. population is becoming more racially and ethnically diverse. At the beginning of the 1900s, one of every eight Americans identified himself or herself as a race other than “white.” At the end of the century, one of four did so, as the white population had grown more slowly than every other racial/ethnic group. This increase in diversity accelerated in the latter half of the century. From 1970 to 2000, the population of races other than “white” or “black” grew considerably, and by 2000 was comparable in size to the black population. The black population represented a slightly smaller share of the total U.S. population in 1970 than in 1900, while the Hispanic population more than doubled from 1980 to 2000. In the 2000 census, 36 percent of the population reported belonging to “two or more” races (the 2000 census was the first to include this reporting category). The racial/ ethnic composition of the U.S. population according to the 2000 census was as follows: 75.1 percent white, 12.3 percent black, 3.8 percent Asian or Pacific Islander, 0.9 percent American Indian or Alaska Native, 2.4 percent claiming two or more races, and 5.5 percent claiming a race other than those already cited. Individuals (of any race) claiming Hispanic origin constituted 12.5 percent of the U.S. population (Hobbs and Stoops, 2002).
The nursing workforce does not yet fully reflect this diversity. In 2000, a higher proportion of RNs (88 percent) than the general U.S. population (75.1 percent) was white; however, the 12 percent of racial/ethnic minority RNs was an increase from the 5 percent of 1980. Significantly, the increase in the overall RN population between 1996 and 2000 is attributed largely to the growth in the numbers of RNs from racial/ethnic minorities (Spratley et al., 2000). In contrast, the NA workforce has a higher proportion of such minorities than the U.S. population overall. Approximately 40–50 percent of NAs working in hospitals, long-term care facilities, and home health care are nonwhite racial/ethnic minorities (GAO, 2001b).
This phenomenon is not unique to nursing. Differences in the racial/ ethnic and cultural composition of the health care workforce and the patient population have been a source of concern across all health professions. Such differences can be obstacles to fully understanding patient care needs. Language differences, in particular, can be a major barrier to care delivery. If nursing staff cannot communicate with patients effectively, health assessment, explanations of alternative treatments, informed consent, health education, involvement of patients in self-care, and discharge instructions are all compromised. Patients cannot be full partners in monitoring for threats to their safety if they do not understand the interventions being applied on their behalf. Other implications of racial/ethnic and cultural differences include, for example, limited understanding of the use of alternative therapies and other health- and illness-related practices of patients and their families, and the effects of those practices on planned care. In a previous study, the Institute of Medicine (IOM) found that greater racial and ethnic diversity in the health professions strengthens patient–provider relationships. The benefits of this diversity are believed to accrue broadly to the health professions and help expand their ability to conceptualize and respond to the health needs of the increasingly diverse U.S. population (IOM, 2003).
Hospital RN Salaries Might Be Increasing; Many NAs Live at or Below Poverty Level
The U.S. Department of Labor characterizes the earnings of licensed nurses as “above average” (Bureau of Labor Statistics, 2003). Although there is documentation of the need or desire of some RNs for higher salaries (Kimball and O’Neil, 2002), other studies of RNs find a lack of substantial dissatisfaction with their salaries (GAO, 2001a). Of 13,471 RNs surveyed in Pennsylvania, 57 percent reported their salaries were adequate (Aiken et al., 2001b). Only 26 percent of a national random sample of nurses identified “not making enough money” as a great concern when reflecting on their own experience (Kaiser Family Foundation and Harvard School of Public Health, 1999). The average annual salary in 2000 for RNs employed full time in their principal position was $46,782, although this figure varied by setting of care and position. RNs working full-time in hospitals5 earned on average about $47,759 per year, while those working in nursing homes earned less—about $43,779 per year. In contrast to nurses working in administrative, research, or educational positions, staff nurses providing di-
rect care to patients (the majority of employed nurses) earned an average of $42,133 annually in 2000 (Spratley et al. 2000). These salaries, when adjusted for inflation, have not changed greatly since the 1980s (Health Resources and Services Administration, 2002). However, recent data indicate that hospital nurses received base salary increases of approximately 8 percent in 2002 (Bolster and Hawthorne, 2003). LPNs/LVNs are paid, on average, about two-thirds of what RNs in staff positions earn (Bureau of Labor Statistics, undated).
Many NAs, in contrast, are among the working poor. In particular, NAs working in nursing homes and home care are much more likely than other workers to live below the poverty level, to be uninsured, and to receive public benefits such as food stamps and Medicaid. A U.S. General Accounting Office (GAO) analysis of 1998, 1999, and 2000 data from the Current Population Survey (CPS) of the U.S. Census Bureau and the Bureau of Labor Statistics found that the average wages of full-time, full-year NAs in hospitals, nursing homes, and home health care agencies ranged from $19,216 to $21,432. These wages place 17.8 percent, 18.8 percent, and 8.1 percent of NAs working in nursing homes, home health care, and hospitals, respectively, at or below the federal poverty level. Additionally, 13.5 percent, 14.8 percent, and 5.3 percent, respectively, receive food stamps, while 25.0, 32.1, and 14.2 percent, respectively, are uninsured (GAO, 2001b). The stresses and distractions caused by their poverty, insurance status, and related conditions undoubtedly have an adverse effect on these workers’ ability to provide maximal attention to work requirements and adapt to new workplace practices.
RNs Employed as “Contingent Workers”
“Contingent workers” are those who provide their services to an organization on a short-term or periodic basis. They include temporary staff, independent contractors, and seasonal hires (Rousseau and Libuser, 1997). In 2000, only 2 percent of RNs working in their principal nursing position did so through a temporary employment service; most were employed by the organization in which they worked. However, this 2 percent represented a 36 percent increase over that reported in 1996 and reversed a declining trend observed between 1988 and 1996. Further, in 2000 an additional 71,490 RNs reported working through temporary service agencies in positions that were in addition to their principal positions. Taken together, the total number of nurses employed through a temporary employment service was 110,994—a 65.6 percent increase over 1996 and considerably higher than 1988 and 1992 estimates (Spratley et al., 2000).
It is not clear whether this one-time measurement indicates a trend in nursing; the proportion is close to that observed nationally across all indus-
tries, where contingent workers constitute 3 percent of the workforce. The national use of contingent workers in all employment settings has remained relatively stable since the mid-1990s (Employment Policy Foundation, 2000). However, a 2001 survey of nurse executives in 693 acute care U.S. hospitals found that temporary staff or travelers were used by 54 percent of the respondents to fill vacancies (The HSM Group, 2002). Moreover, a 1997 survey of 187 employers of nurses in the District of Columbia found that 9.6 percent of hospital nursing staff were not hospital employees, but secured through nurse staffing agencies (Mailey et al., 2000). If the present high rate of vacancies in nursing positions (discussed below) continues, use of contingent workers may persist or even increase. Furthermore, the proportion of NAs who are employed by temporary agencies may be higher than the corresponding proportion of RNs: 35 percent of NAs report working in positions other than hospitals, home health agencies, and nursing homes; this large category of “other” includes temporary staffing agencies (GAO, 2001b).
Although use of temporary employees can increase the number of nurses available to care for patients, it can also represent a threat to patient safety because these temporary staff are unfamiliar with a nursing unit and an HCO’s overall structure, policies, and practices. Temporary employees are less familiar with an organization’s information systems, patient care technology, facility layout, critical pathways, interdependency among work components, ways of coordinating and managing its work, and other work elements. Permanent nursing staff in hospitals and nursing homes describe the use of agency nurses as hindering continuity of care and reducing quality of care (Anderson et al., 1996; Bowers et al., 2000).
These subjective impressions are supported by some objective analyses of patient safety indicators. Medication errors have been shown to increase with the number of shifts worked by temporary nursing staff and to decrease when permanent staff work overtime to ensure adequate staffing (Roseman and Booker, 1995). An observational cohort study in eight hospital intensive care units (ICUs) participating in the Centers for Disease Control and Prevention’s National Nosocomial Infections Surveillance System found that, after controlling for other risk factors, care by a “float” RN for more than 60 percent of central line days was independently associated with an increased risk for central line–associated blood-stream infections, and the risk increased in proportion to “float” days of care (Jackson et al., 2002). These observations in health care are consistent with those made regarding the use of contingent workers in other industries. The latter studies have found that increased use of contingent workers results in higher accident rates due to decreasing familiarity with on-site personnel and equipment, undercuts teamwork, and impairs communication. It also is associated with poor labor–management relations when contingent workers are
used in an attempt to bypass labor–management conflicts (Rousseau and Libuser, 1997). The International Atomic Energy Agency cites use of contract personnel to replace traditionally hired employees as a symptom of incipient weakness in an organization’s safety culture. While hiring contract personnel has some benefits to the employer, it often comes at the expense of safety—either directly as a result of lower contractor standards or indirectly as a result of effects on permanent employees (Carnino, undated).
WHERE NURSES WORK6
RNs, LPNs/LVNs, and NAs are employed in a wide variety of inpatient, home health, and ambulatory HCOs. Many of these organizations have undergone turbulent changes in response to the rapid evolution of the U.S. health care system over the last 20 years. The relationships between these organizations and their nurse employees have been turbulent as well. Many of these HCOs report large vacancies in nursing positions and serious difficulties in securing enough nursing staff to care for patients.
Wide Variety of Health Care Settings for Nursing Staff
While RNs are employed primarily in hospitals (see Table 3-1), LPNs/ LVNs are about equally employed in hospitals and nursing homes (28 and 29 percent, respectively). Another 14 percent of LPNs/LVNs work in physicians’ offices and clinics (Bureau of Labor Statistics, undated). Nursing homes employ the largest proportion of NAs (see Table 3-2). The populations served in these settings have some differences in their health care needs. These differences, changes in the U.S. health care system, and changes in the ways nursing care is delivered have shaped all nurses’ work environments, but especially hospitals, nursing homes, home care and community-based organizations, and public health agencies.
Hospitals have historically been the largest employer of the nursing workforce and continue to be so today, although there has been a decline in
Licensed nurses function in a variety of capacities in a diverse array of locations, including serving as educators, researchers, managers, lawyers, public policy analysts, and government officials. In this section and the next, we do not describe all nursing roles, but focus on those nurses who provide direct clinical care to patients within HCOs (often referred to as “staff nurses”) and their supervisors. Chapter 4 addresses some aspects of the work of nurse managers and nurse executives in HCOs.
TABLE 3-1 Primary Employment Settings of RNs Employed in Nursing, 2000
Percent of RNs Employed
Community/public health setting
Nursing home/extended care facility
Student health service
aTotal not equal to 100 percent because of rounding.
SOURCE: Spratley et al. (2000).
the last two decades. The proportion of the RN workforce employed in hospitals peaked in 1984 at approximately 68 percent. By 2000 the proportion had declined to 59 percent as the result of a shift in care and nurse employment to noninstitutional settings (Spratley et al., 2000). Most hospital nurses work on inpatient units; 53.7 percent of hospital RNs work in ICUs, step-down/transitional units, or general/specialty bed units (see Table 3-3) (Spratley et al., 2000). The deployment of nurses by hospitals has changed dramatically over the least two decades as hospitals themselves have changed.
TABLE 3-2 Employment Settings of NAs, 1999
Percent of NAs Employed
aIncludes a range of employment settings, such as residential care, social services, and temporary staffing agencies.
SOURCE: GAO (2001b).
TABLE 3-3 Types of Work Units in Which Hospital-Employed RNs Spend More Than Half of Their Direct Patient Care Time
Type of Work Unit
Percent of RNs Employed
General/specialty bed unit
Intensive care unit (ICU)
Step-down/transition from ICU
Post-anesthesia recovery room
No specific area
SOURCE: Spratley et al. (2000).
Fewer hospitals, fewer inpatient beds, and fewer (but more acutely ill) inpatients In the last two decades, hospitals have been under tremendous pressure to remain financially solvent in the face of a widely acknowledged oversupply of hospital beds, cost-containment measures resulting in changes in reimbursement from public and private payors, and demands for greater accountability for the quality of the care they provide. Between 1980 and 2000, the number of hospitals in the United States declined by 17 percent, the number of hospital beds by 28 percent, the number of hospital admissions by 10 percent, and the average length of patients’ hospital stays from 7.6 to 5.8 days (American Hospital Association, 2002).7 Over about the same period, outpatient visits increased by more than 150 percent. By 1999, outpatient surgery constituted 50 percent of all hospital-based surgery—an increase from 16 percent in 1980 (American Hospital Association and The Lewin Group, 2001). As a result of this downsizing and technological advances in care, patients admitted to the hospital today are more acutely ill than was the case in the previous decade (Medicare Payment Advisory Commission, 2001).
During this same period, the number of RNs working in hospitals increased substantially,8 although this increase was not uniform across all hospitals (Unruh, 2002), and not all of it should be assumed to represent an increase in RNs providing direct patient care. Data also indicate that many of the above downsizing initiatives were accompanied by reductions in unlicensed support staff, such as NAs (Aiken et al., 1996). These changes were accompanied by changes in the ways nurses deliver care to patients and have been perceived as leading to an increased workload for nurses (as discussed further below).
Changes in approaches to care delivery As described in Chapter 1, many hospitals attempting to respond to the pressures of the last two decades have undertaken efforts to reengineer or redesign patient care processes to make them more efficient. Because nurses are the largest category of hospital workers, these reengineering efforts have often involved changing the ways in which nursing care is provided—typically through personnel reductions; cross-training of personnel to perform additional duties; changes in the mix of nursing staff (RNs, LPNs/LVNs, NAs); reassignment of support services (e.g., laboratory, radiology) to nursing units; redistribution of patients across nursing units; redesign of patient care processes; use of clinical pathways; and other changes in organization structure, decision-making processes, and responsibilities of management and patient care staff (Aiken et al., 2000b; Norrish and Rundall, 2001; Ritter-Teitel, 2002; Walston et al., 2000; Walston and Kimberly, 1997).
In addition, redesign and reengineering have changed the way nursing staff are organized to provide patient care. Restructuring initiatives often have been marked by a departure from primary nursing and a return to variants of team nursing (Norrish and Rundall, 2001). As initially conceptualized, the latter approach involved a team of RNs, LPNs/LVNs, and NAs, with an RN serving as the team leader. The RN team leader determined assignments for team members consistent with their abilities and performed activities for which other team members were not qualified. At a daily team conference led by the team leader, patient care plans were reviewed. Ideally, the same team was assigned to care for the same group of patients each day. In practice, however, teams might include only a single RN. While team nursing was designed in part to make the most efficient use
of RNs, it was criticized both for being overly task oriented and for resulting in fragmentation of care (Mark, 2002).9
Partly in response to this fragmentation of care, primary nursing became popular in the 1970s. This model of care delivery is characterized by the establishment of a direct relationship between an RN and a patient (Pontin, 1999). The patient’s primary nurse is responsible for all aspects of the patient’s care, 24 hours a day, during the entire course of the hospitalization. This is achieved through a 24-hour plan of care created and implemented by the primary nurse, along with the use of associate nurses who care for the patient according to the plan in the absence of the primary nurse. Although primary nursing was not intended to require an all-RN staff, it was often interpreted in this way. The approach was viewed favorably by nursing staff because it emphasized the nurse–patient relationship and was perceived as most consistent with the practice of professional nursing (Norrish and Rundall, 2001).
Primary nursing still is often cited as the best way of organizing nursing care, although research on the effects of primary nursing has been hindered by the lack of a clear conceptual model (Pontin, 1999), and studies to date comparing team and primary nursing have had significant methodological weaknesses and yielded only equivocal results (Mark, 2002). Moreover, some now assert that the question of which model is best is moot. Because levels of nursing expertise, support personnel, patient acuity and needs, and resources vary across nursing units, it is likely that the best nursing model in one unit is not the best for another. For example, a nursing unit with a high proportion of novice nurses is more likely to require a care delivery model that affords higher levels of clinical nursing supervision, such as a modified team approach, than a unit whose staff is stable and possesses higher levels of expertise. According to this view, care delivery models tailored to each nursing unit’s structures, processes, and resources are most desirable (Deutschendorf, 2003).
Changes in workload Nurses in hospitals also report increasing workload as a result of the above changes (Aiken et al., 2001b; Hurley, 2000), and some have linked this increased workload to diminished patient safety (Kimball and O’Neil, 2002; Service Employees International Union, 2001; Sochalski, 2001). Nurses’ workload is discussed most often in terms of the number of patients assigned to each nurse (see also the discussion of staffing levels in Chapter 5). In numerous surveys, nurses report inadequate
numbers of nursing staff to accomplish their work (Kaiser Family Foundation and Harvard School of Public Health, 1999) and provide high-quality care (Aiken et al., 2001b). Although evidence indicates that nurses’ perceptions of staffing adequacy can be influenced by structural characteristics of hospitals and units, such as the number of beds in a nursing unit and higher levels of patient technology (Mark et al., 2002), the hospital industry itself reports difficulties in securing the number of RNs it needs to care for patients (AHA Commission on Workforce for Hospitals and Health Systems, 2002; American Organization of Nurse Executives, 2000; JCAHO, 2002). Emergency room diversions, closures of nursing units, cancellation of elective surgeries, and other restrictions on service delivery have been documented as resulting from insufficient nurse staffing (First Consulting Group, 2001; Kimball and O’Neil, 2002; The HSM Group, 2002).
Staffing levels have been shown to vary considerably by hospital (Unruh, 2002). This variation is illustrated by data for 1998–2000 from the California Nursing Outcomes Coalition, which maintains a statewide database of nurse staffing levels from California hospitals. Although these data constitute a convenience sample of 52 California hospitals voluntarily contributing staffing data, the data are useful because they were collected at the level of the nursing unit (as opposed to the aggregate hospital level), because common data definitions and reporting were used, and because ongoing verification was performed to ensure the data’s accuracy. Data reported on 330 critical care, step-down, and medical–surgical units in these hospitals across nine calendar quarters revealed that RNs provided 92 percent of the care in ICUs, 87 percent of the care in step-down units, and 57 percent of the care in medical–surgical units. The RN–patient ratios across these facilities were as follows:
ICUs—a range of 0.5–5.3 patients for each RN (average 1.6)
Step-down units—a range of 1.5–11.6 patients for each RN (average 4.2)
Medical–surgical units—a range of 2.7–13.8 patients for each RN (average 5.9)
These findings did not vary over the nine quarters or by the size of the hospital (Donaldson et al., 2001).
Data from a fiscal year 2002 national convenience sample survey of hospitals on staffing, scheduling, and workforce management of nursing department employees further document this variation in staffing levels. The 135 hospitals responding showed variation in nurse staffing levels even with the shift and type of patient care unit being held constant. Although the average RN-to-patient ratio in medical–surgical units on the day shift was 1:6, the range was from 1:3 to 1:12. Twenty-three percent of hospitals
reported that nurses in their medical–surgical units on the day shift were each responsible for caring for between 7 and 12 patients. On the night shift, 7 patients on average were assigned to each nurse, but 34 percent of hospitals reported between 8 and 12 patients assigned to each nurse. For critical care units, the average number of patients assigned to each nurse was 2 for both the day and the night shifts, but 7.4 percent of hospitals reported having nurses care for 3 or 4 ICU patients during the day shift, and 11 percent reported nurses caring for 3 or 4 ICU patients during the night shift (Cavouras and Suby, 2003).
In addition to staffing levels, work environment factors that have been identified as affecting nurse workload include RN expertise, patient acuity, patient turnover, physician availability, work intensity, unit physical layout, degree of teamwork, and available support staff (Pinkerton and Rivers, 2001; Salyer, 1995; Seago, 2002). Many of these factors also have been affected by hospital reengineering and redesign initiatives. Workload factors for which there is a strong evidence base with regard to their effects on patient safety, as well as strategies for modifying the work environment to address these factors, are examined in the succeeding chapters of this report.
As patients move more quickly through acute inpatient settings or undergo complex procedures in outpatient settings, their needs for long-term care follow-up escalate. Further, as older adults increasingly constitute a larger proportion of the U.S. population, there is a concomitant increased demand for services for older patients who have higher dependency needs. As a result, nursing homes (sometimes called long-term care or nursing facilities) and the populations they serve have changed significantly in recent years.
Like hospitals, nursing homes are seeing an increase in the dependency and acuity levels of their residents (as described in Chapter 1) and an expansion of the nursing facility workforce. In contrast to hospitals, however, there has been an increase in the number of nursing homes and nursing home beds. Between 1987 and 1996, the number of nursing home beds in the United States increased by 19 percent, from 1.48 to 1.76 million, reflecting in part a 20 percent increase in the number of nursing homes nationwide (from 14,050 to 16,480) (CMS, 2000, 2002). During this period, the percentage of nursing home patients whose care was paid for by Medicare increased from 3 to 9 percent, and the proportion of nursing homes certified to receive Medicare reimbursement increased from 28 to 73 percent, indicating that the number of nursing facilities planning to take residents with more acute illness or more complex needs rose substantially.
Concurrently, the number of nursing home residents over age 85 increased from 49 to 56 percent for women and from 29 to 33 percent for men (Rhoades and Krauss, 2001).
Caring for individuals in nursing homes also involves some other special safety considerations. For many nursing home residents, the nursing facility is the home where they live as well as where they receive services. Patient safety in these facilities therefore requires consideration of patients’ long-term living environment, as well as their clinical care needs. Further, many long-term care clients have some degree of cognitive impairment. Data from the 1996 Nursing Home Component of the Medical Expenditure Panel Survey (MEPS) revealed that nearly three-quarters (70.8 percent) of nursing home residents had some form of memory loss. About the same proportion had problems with orientation, such as knowing where they were or the identity of staff members. Many residents (80.6 percent) had difficulties in making daily decisions, and almost one-third (30.2 percent) exhibited at least one form of inappropriate or dangerous behavior—including wandering off or resisting care (12.5 percent). Overall, nearly half of all nursing home residents had some type of dementia. These conditions make residents less able to participate in increasing their own safety, and in fact can cause behaviors that create their own threats to safety. Forgetfulness and disorientation in particular can be dangerous problems, requiring 24-hour supervision to provide for an individual’s safety and well-being (Krauss and Altman, 1998).
This increase in resident dependency and acuity has important implications for staffing, oversight, work complexity, workload, and the overall nature of the work in nursing facilities. For example, the staff time required to meet basic needs of residents (such as feeding, toileting, and ambulation) increases with the overall dependency levels of residents (CMS, 2002). Further, since Medicare residents often have complex health conditions or are recovering from serious health events, a more sophisticated knowledge base is required to care for these residents, as are higher levels of vigilance and monitoring and of professional staffing. Consistent with this observation, a higher ratio of RN staff to residents in nursing homes has been demonstrated to reduce adverse health care events for residents (CMS, 2000, 2002).
Along with the growth in the number of nursing homes, nursing home beds, and patient acuity has come a significant expansion of the nursing home workforce. There has been not only an overall increase in the total number of workers to care for the increased population of residents, but also an increase in the ratio of all categories of nursing staff to residents (CMS, 2000). This increase is attributable in large part to the passage of the Nursing Home Reform Act in 1987, which mandated coverage by at least one RN for 8 hours a day, 7 days a week for all nursing homes accepting
Medicare or Medicaid reimbursement. Additional legislation required facilities to have a licensed nurse (RN or LPN/LVN) on duty at all times. As discussed in Chapter 5, however, evidence indicates that levels of staffing above these minimums are necessary to ensure an adequate level of patient safety.
NAs make up 60–70 percent of the total nursing staff in nursing facilities. They spend the most time with residents and provide 80–90 percent of direct patient care, working under the supervision of RNs and LPNs/LVNs (CMS, 2000; GAO, 2001a). LPNs/LVNs constitute approximately 25–30 percent of all nursing staff and approximately two-thirds of licensed nursing staff. RNs represent the smallest proportion—10–15 percent—of nursing staff in nursing facilities (CMS, 2000). In contrast to the hospital setting, physicians are less frequently on site in nursing homes.
There has also been an increase in the percentage of nursing homes that are large for-profit chains or networks of not-for-profit facilities, as opposed to being individually owned. The significance of this shift is unclear. However, a 1998 national study of 13,693 nursing homes10 comparing those owned by investors with nonprofit and public nursing facilities found higher rates of deficiencies in the quality of care provided and lower staffing levels among the former. Chain ownership also was found to be associated with higher rates of deficiencies in quality of care. In both instances, the analysis adjusted for case mix, location, percentage of patients covered by Medicaid, whether the facility was hospital based, and whether it served only Medicare residents (Harrington et al., 2001, 2002).
Home Care and Community-Based Organizations
Home care and community-based organizations encompass a wide variety of noninstitutional long-term care settings, ranging from an individual’s own home to various types of congregate living arrangements. The boundaries between institutional and noninstitutional care settings are blurring, however. Many assisted-living “board and care” facilities are large buildings that resemble nursing facilities. Other residential care sites are small and homey. In contrast to nursing homes, which are licensed and regulated by the federal government as a condition of Medicare and Medicaid reimbursement, residential care facilities are generally licensed and regulated by states and local jurisdictions. Consequently, there is no single definition of “residential care” or tally of the number of such facilities nationwide. A 1999 national study counted 11,472 assisted-living facilities
with approximately 650,500 beds. Other community-based long term-care settings include adult day care programs, in which disabled elderly individuals receive supervision, personal care, and social integration in a group setting, usually during the work week and normal work hours (Stone and Wiener, 2001).
Home health care was the fastest-growing employment setting for all nursing personnel throughout the 1980s and 1990s (Buerhaus and Staiger, 1999). As of 2001, there were more than 20,000 home care agencies, approximately 7,000 of which were Medicare-certified. Free-standing, for-profit agencies represented 40 percent of that total and experienced the greatest growth. Hospital-based agencies made up another 30 percent of the total.
These free-standing and facility-based (usually hospital-based) Medicare-certified agencies, home care aide organizations, and hospices employ licensed nursing staff (as well as physical, occupational, and speech therapists) to provide such skilled services as illness management, medication management, infusion therapy, wound care, ostomy instruction, and end-of-life care to clients in their homes and other locations. Licensed home care nurses also supervise home care aides who provide such personal care services as assistance with bathing, eating, and ambulation, as well as monitoring of vital signs and patient status. NAs make up 54 percent of the nursing personnel working in home health care (GAO, 2001b).
The home care industry has experienced substantial turbulence. Since the 1960s, the National Association for Home Care (the home care industry association) has documented periods of rapid expansion and decline in the numbers of home care agencies (National Association for Home Care, 2001). In particular, the Balanced Budget Act of 1997 changed the way the Medicare program pays Medicare-certified home health agencies from a cost-based method to a prospective payment system of fixed, predetermined rates. Subsequently, the number of Medicare-certified home health agencies decreased by 32 percent—from 10,556 in 1997 to 7,715 in 2000 (Office of Inspector General, 2001). As with nursing home care, however, demands for home health services are expected to continue to grow because of reduced lengths of stay in acute care hospitals, advances in technology, and the aging of the U.S. population.
Public Health Agencies
Public health agencies comprise state, county, and local health departments that provide such health care services as immunizations, health education, case management for frail elders, and community assessment. All states have a public health structure and staff at the state level; some also have such a structure and staff in all counties or regions. Although many
cities still have local health departments, the trend is toward decreasing duplication and cost by merging city and county units (Martin, 2002). RNs employed in public health and community health settings increased by 155 percent between 1980 and 2000 (Spratley et al., 2000).
During the 1990s, various factors, such as substance abuse and its impact on high-risk pregnancies and newborns and the incidence of HIV/AIDS, stimulated growth in the public health sector and caused these agencies to reassess their mission and purpose. An earlier IOM study found that the public health system was in disarray and incapable of fulfilling the fundamental core functions of assessment, policy development, and assurance (IOM, 1988). Following the events of September 11, 2001, and associated concerns about bioterrorism, the public health infrastructure began receiving additional attention.
Problems with Recruitment and Retention of Nursing Staff Across Clinical Settings
Hospitals, nursing homes, home health agencies, and other community-based long-term care organizations all report difficulties in securing enough RNs and NAs to provide needed patient care (AHA Commission on Workforce for Hospitals and Health Systems, 2002; GAO, 2001b; Stone and Wiener, 2001). For 2001, the American Organization of Nurse Executives (AONE) reported nationwide hospital RN vacancy rates11 of 10.2 percent, with the highest rates being in critical (14.6 percent), medical–surgical (14.1 percent), and emergency room (11.7 percent) care (The HSM Group, 2002). Similarly, an AHCA national survey of long-term care facilities found vacancy rates of 18.5 percent for staff RNs, 14.6 percent for LPNs/LVNs, and 12 percent for NAs (AHCA, 2002). Some have expressed the view that this inability to attract and retain a sufficient number of nurses is the result of inhospitable working conditions. Others assert that, while work conditions may not be favorable, recruitment problems are due to an underlying shortage of nursing personnel. Evidence indicates that both factors are at work.
A Nationwide Nursing Shortage
The national employment of RNs per capita and the national unemployment rate for RNs have both declined. The national unemployment rate for RNs in 2000 (1.0 percent) was at its lowest level in more than a decade. At the same time, total employment of RNs declined by 2 percent
between 1996 and 2000, reversing steady increases since 1980 (GAO, 2001a). Data provided by the Health Resources and Services Administration (HRSA), the federal agency responsible for providing information and analysis on the supply of and demand for health professionals, show that this decline reflects a present and growing discrepancy between the supply of and demand for RN services. HRSA estimates that a 6 percent undersupply (110,000) of nurses existed in 2000 and projects a growing shortfall in nursing personnel, up to a 29 percent deficit by 2020. This undersupply of RNs is more the result of a growing demand for nursing than of a decreasing supply of RNs (HRSA, 2002).
Although the supply of RNs will grow, this growth will be limited by the aging of the RN workforce discussed previously and declining enrollments in nursing schools. Since 1973 there has been an approximately 40 percent drop in the percentage of college freshman who indicate that nursing is among their top career choices. The most prominent factor contributing to this decline appears to be the expansion of opportunities for women in formerly male-dominated professions, such as medicine, law, and business (Staiger et al., 2000). For example, in 1971–1972, women comprised 13.7 percent of the entering class of U.S. medical schools; in 2001–2002, they comprised 47.8 percent (Barzansky and Etzel, 2002).
The higher demand for nurses will be fueled by a projected 18 percent growth in the U.S. population between 2000 and 2020 and a 65 percent growth in those over age 65, who require a disproportionately larger share of health care services (HRSA, 2002). This workforce deficit is not unique to the United States; similar data from other countries indicate a global shortage of nurses (Buchan, 2002).
A similar shortage of NAs also has been documented (GAO, 2001b; Stone and Wiener, 2001), and the demographic changes cited above are predicted to worsen that shortage. With the aging of the population, the demand for NAs is predicted to increase greatly; however, the available supply is expected to increase much less. Between 2000 and 2030, the number of persons over age 85—those most in need of NA services—will more than double from 4.3 million to 8.9 million. At the same time, the population of women aged 20–54—the traditional pool of NAs—will increase by only 9 percent. The ratio of women aged 20–54 to the population aged 85 and older (sometimes referred to as the “elderly support ratio”) will decline from 16.1 in 2000 to 8.5 in 2030 (GAO, 2001b).
Working Conditions That Discourage Nursing Staff from Remaining in the Workforce
The difficulties HCOs are having in attracting and retaining nursing staff are also linked to those individuals’ dissatisfaction with their work
environment. According to GAO (2001a:13), “Efforts undertaken to improve the workplace environment may both reduce the likelihood of nurses leaving the field and encourage more young people to enter the nursing profession.”
Numerous surveys indicate the dissatisfaction of nursing staff with their work conditions (Aiken et al., 2001b; ANA, 2001; Spratley et al., 2000). Sources of that dissatisfaction include inadequate staffing to perform the work, heavy workloads, increased overtime, lack of sufficient support staff (GAO, 2001a), and the resulting stress (ANA, 2001). In the 2000 NSSRN, just 69.5 percent of all RNs reported being satisfied in their current position. Satisfaction levels varied by place of employment. Nurses working in hospitals and nursing homes reported the lowest levels of satisfaction—67 and 65 percent, respectively. Staff nurses (as opposed to nurses in administrative or management positions) consistently reported the lowest levels of satisfaction across hospital, nursing home, ambulatory care, and public/ community health settings. This level of satisfaction is significantly lower than that seen in the general employed U.S. population. Data from the General Social Survey of the National Opinion Research Center indicate that from 1986 through 1996, 85 percent of workers in general and 90 percent of professional workers expressed satisfaction with their job (as cited by Spratley et al., 2000).
This dissatisfaction is linked to the departure of RNs from the nursing workforce. In an Internet survey of RNs conducted by the American Nurses Association (ANA) in 2001, 75.8 percent of 4,826 self-selected nurse respondents stated that concerns about their personal health and safety resulting from their work environment affected their decisions about the kind of nursing work they did and their continued practice as nurses (ANA, 2001). In a survey of 50 percent of RNs working in acute care hospitals in Pennsylvania between 1998 and 1999, 41 percent reported being dissatisfied with their jobs. Only 33–34 percent of nurses reported that there were enough RNs to provide quality care and enough staff to get the work done; only 29 percent reported that their administration listened and responded to nurses’ concerns; and a minority of 43 percent reported having enough support services. Not surprisingly, 43 percent also had high scores on a well-validated and widely used tool for measuring levels of employee burnout, and 22.7 percent reported plans to leave their job within the next year. Of nurses younger than age 30, 33 percent stated their intent to leave their present job within the year (Aiken et al., 2001b).
The work environment of NAs also is highly stressful. NAs’ work is physically demanding, often requiring them to provide partial weight-bearing support to help feeble individuals turn in bed, sit, transfer from bed to chair, stand, and walk. They spend long hours on their feet and bathing, dressing, feeding, and toileting patients who may be disoriented or other-
wise cognitively impaired and uncooperative in their own care. In 1999, the occupational injury rate for nursing home employees was 13 injuries per 100 employees, compared with 8 injuries per 100 employees for construction workers (GAO, 2001b). Heavy workloads, poor supervision, low wages and benefits, lack of involvement in work-related decisions, and a job that society holds in low regard cause significant stress among the NA workforce and contribute to difficulties in recruitment and retention of NAs in nursing homes, home health care agencies, and other long-term care settings (Parsons et al., 2003; Stone and Wiener, 2001). Evidence indicates that such stress contributes to errors in health care delivery (Campbell and Cornett, 2002).
WHAT NURSES DO
The work of direct-care nursing staff includes both visible and invisible activities (Star and Strauss, 1999). The visible activities are those physical actions observable by patients and others and often portrayed in the media, such as assisting a patient to walk, administering medications and treatments, and educating patients about their disease and therapies. The invisible or cognitive work incorporates knowledge learned from formal education and subsequently acquired expertise. It includes such processes as assessing a patient’s health condition, monitoring and detecting when a change in therapy is needed, and integrating an individual patient’s health care needs with the interventions of a variety of different health care providers to formulate a plan of care tailored to the particular patient. While certain assessment, monitoring, and care planning actions may be visible (e.g., a nurse watching a cardiac monitor or listening to a patient’s chest), these cognitive processes are not. Often when a nurse appears to be carrying out a visible activity, such as bathing a patient, he or she is actually performing numerous invisible tasks, such as assessing the patient’s skin color for evidence of poor oxygenation, evaluating skin integrity for signs of skin breakdown, engaging the patient in conversation to assess mental status, or educating the patient about his or her disease and its management.
These visible and invisible nursing activities are performed by all RNs, LPNs/LVNs, and NAs in all settings of care. The specific activities performed by a particular nurse depend on patient needs, the nurse’s education and expertise, the setting of care in which the nurse practices, how nursing care services are organized and delivered within that setting of care, and the nurse’s licensure status and scope of permitted practice as delineated in state licensure laws.
There is not always agreement across HCOs and even across nursing units within an HCO about whether less complex activities, such as bathing
a patient or taking vital signs, should be performed by RNs or NAs (McCloskey et al., 1996; Pedersen, 1997). While NAs are clearly trained and competent to perform these activities, removing RNs from performing them may diminish the RNs’ opportunities to simultaneously monitor other aspects of patient status, such as color, character of breathing, mental status, and manifestations of pain. Use of NAs to perform these less complex activities has been cited as creating opportunities for gaps and discontinuities in care (Cook et al., 2000). Available evidence is unclear as to whether assigning routine tasks to lower-skilled nursing staff enhances patient safety by allowing RNs to concentrate on tasks requiring more knowledge, or separating the RN from the patient while routine tasks are being performed results in greater opportunities for critical changes in patient condition to go unnoticed, unreported, or addressed less effectively.
There is agreement, however, that the preponderance of critical thinking and other cognitively complex work is in the domain of the RN. These cognitive processes are taught to every RN student in nursing school, using as a template the six components of clinical nursing practice: assessing, diagnosing, identifying outcomes, planning, implementing, and evaluating. This cyclical, interactive method of thinking forms the foundation for clinical decision making by RNs (ANA, 1998).
Variety of Ways in Which Direct-Care Nursing Staff Provide Patient Care12
Direct-care nursing staff (i.e., those nurses providing hands-on patient care as opposed to nurses in administrative or educational positions) perform a variety of interventions when delivering patient care. These interventions are used to monitor patient status, administer physiologic therapies, help patients compensate for loss of function, provide emotional
support, and educate patients and families. Nursing staff perform these basic functions in all care delivery settings in which they practice. While some of these direct patient care activities implement treatments ordered by physicians, a substantial amount of nursing care is not provided in response to a physician’s treatment order, but is performed independently by nurses based on nursing’s professional practice standards and the nurse’s clinical judgment. In addition, nursing staff perform a variety of indirect-care functions, such as documenting patient care, integrating care across settings and providers (discussed further below), and supervising other nursing staff.
RNs also are frequently required to carry out a variety of non-nursing activities, such as performing clerical tasks (e.g., transcribing physician orders); transporting blood products and laboratory specimens; and locating and retrieving patient care supplies, such as bed linens and medical equipment when these are not at hand. Time spent in these non-nursing activities prevents RNs from providing patient care.
Monitoring of Patient Status (Surveillance)
Monitoring of patient status (also called patient surveillance) encompasses the first four of the six components of the nursing process noted above: assessing the health condition of the patient, diagnosing patient needs, identifying desired outcomes, and planning for necessary remedial or enhancing therapeutic interventions. Surveillance differs from assessment in that an assessment is typically performed at a single point in time; for example, an initial assessment of health is often made upon hospital admission or at the time of first contact with a practitioner. In contrast, surveillance is defined as the “purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision-making [emphasis added]” (McCloskey and Bulechek, 2000:629). While novice and other less experienced nurses may understand and rely upon the performance of assessment, diagnosis, outcome identification, and planning as sequential activities, nurses with greater expertise perform these cognitive processes concurrently, repeatedly, and in a back-and-forth manner as they size up a situation (Benner et al., 1999).
The goal of surveillance is the early identification and prevention of potential problems, which requires both behavioral and cognitive skills. When RNs perform surveillance, they typically use a variety of means to gather patient data, including direct inspection, palpation, percussion, and auscultation of the patient. They also use noninvasive and invasive patient monitoring devices to measure such patient status indicators as temperature, pulse, blood pressure, respiration, tissue oxygenation, blood electrolytes, cardiac function, intracranial pressure, and neurologic status. These monitoring devices, such as those for invasive hemodynamic monitoring,
are becoming progressively more sophisticated and complex. As new and more powerful monitoring devices are invented, nurses are the personnel primarily responsible for their use in patient care.
The cognitive aspect of surveillance involves studying, interpreting, analyzing, and evaluating the data and information produced by the above methods. These cognitive processes require a high level of knowledge (Dougherty, 1999). When done well, surveillance leads to recognizing problems early, initiating actions to intervene, and preventing complications (see Box 3-1) (Benner et al., 1999). When surveillance is not done or done poorly, changes are not recognized early, complications or adverse events
The following excerpt from Benner et al. (1999:92–95) illustrates the vital role played by RNs’ surveillance of patients in recognizing problems and preventing them from causing complications:
Rita was an unsuspecting patron at a local restaurant one evening. As she was leaving … stranger ran after her … and stabbed her.… The blade passed through the left ventricle of her heart.
The restaurant was about four blocks from the hospital … and … was a gathering place for paramedics, firefighters, and police officers…. Rita got to our trauma center emergency department within about two minutes…. A few minutes later Rita was being wheeled down the hall toward the operating room, with three units of blood running, her chest already open and Dr. R doing open heart massage…. Rita survived the surgery and was in the intensive care unit the next afternoon when I arrived at work. My orientee (Anna) and I were assigned to care for Rita
… I … [took] hold of Rita’s foot. It was warm. Her heart rate, rhythm, and blood pressure looked good. The ventilator gave her each breath with ease. A few drops of light red fluid trickled through the tube that drained her chest. There was clear light yellow urine in her drainage bag. “Well, Anna,” I said, “Things are looking pretty good here.”
Anna and I spent the first couple of hours tracking down each line and tube from end to end...taking note of what was running in and what was coming out. We checked each IV bag, and I explained what effects the different drugs were supposed to have and how to calculate the doses and IV rates. We zeroed and calibrated the pressure transducers, and I explained how to recognize the waveforms on the monitor, and how to make sure that the measurements we took were accurate. We evaluated the physical findings—lung sounds, heart sounds, pulses, skin color, and temperature, etc. When I looked at the monitor tracings
develop or progress, and the patient’s health status is adversely affected—a phenomenon described as “failure to rescue” (see Chapter 1) (Silber et al., 1992).
As the case example in Box 3-1 shows and as physicians in the American College of Critical Care Medicine note:
Critical care nurses do the majority of patient assessment, evaluation, and care in the ICU … critical care nursing staff … spend several hours per patient per shift collecting and integrating information and incorporating it into meaningful patient care. Through their caring practices, they improve the ICU experi-
and the chest tube drainings, I could see that her heart was OK. The pericardium was not filling up with blood and there were no signs of tamponade….
A short time later, while I was out of the room at the nurses desk, the ventilator alarm began to sound. I reached her bedside immediately and could see that all that was calm moments ago was in chaos now. “What’s going on?” I thought. “Is she seizing?” Her head was lifted off the pillow with convulsive coughing. The needle on the pressure gauge was hitting the red zone and the high-pressure valve was venting with loud hiss with each breath the ventilator tried to give. But the motions were not really seizure-like. My mind was racing…. Is the ET tube blocked? No. Has the ET tube moved? Can’t tell. What do the lungs sound like? Right side OK, LEFT SIDE NOTHING!! What’s going on here?” … As I was taking her off the vent and connecting the Ambu bag I’m thinking, “No breath sounds on the left … could be the ET tube is in the right main stem.” … It took both hands on the Ambu bag to force a breath through the ET tube. Rita was dusky and tachycardic and her neck looked funny. I reached over and palpated, her trachea was shifted way over to the right….
I gave the Ambu bag to a respiratory therapist that had come in and said, “Anna … go get a Pleur-Evac, a couple of sizes of chest tubes, and a bottle of sterile water.” I beeped … the resident on call. “Come to ICU stat.” Dr T. called me back…. I said, “Get down here now. This lady with stab wound through her heart has no breath sounds on the left, we can hardly bag her, her trachea is deviated to the right, she’s turning blue….”
Dr T. arrived and … took the 18 gauge needle and stuck it in Rita’s chest wall…The Pleur-Evac was ready and Dr. T put the chest tube in. I listened to her lungs, “breath sounds both sides now.” Rita’s breathing was calmer, and we could put her back on the vent…. Things went smoothly for the rest of the evening.
ence for both patients and their families, and through their critical thinking skills, experienced nurses readily recognize clinical changes to prevent further deterioration on these patients. They are familiar with the complications that may be seen in these patients and attempt to prevent them (Brilli et al., 2001:2011).
A competent RN is able to assess and monitor a given patient’s health status as compared to age-appropriate norms, baseline health status, and the expected effects of treatments using a variety of techniques and instruments in a systematic and ongoing manner (ANA, 1998). Newly licensed RNs report that they spend the greatest amount of time in patient assessment and evaluation (Smith and Crawford, 2003). A skilled NA, while not educated to assess normative health status across multiple dimensions of health using a variety of assessment tools and skills, is trained to monitor health status using basic devices that measure a more limited number of indicators, such as temperature, heart rate, and blood pressure. NAs also assess patient status based on their ongoing knowledge of the patient’s “normal” health status. In this way, they serve as the foundation for the monitoring and surveillance system in nursing homes, and nurses are dependent upon NAs to bring abnormal findings to their attention. The low proportions of RN and LPN/LVN staff in most nursing homes means that NAs are the nursing staff in most frequent contact with patients and that they often possess information not available to anyone else in the nursing home (Henderson, 1994).
The one resource required by all types of nursing staff to perform patient monitoring is time (Dougherty, 1999). This also is the resource that many nursing staff identify as dangerously low, as a result of the high numbers of patients assigned to individual nursing staff.
Licensed nurses perform a wide array of interventions on patients to treat the physiological effects and mitigate the health consequences associated with a disease. The very broad spectrum of such therapies includes such interventions as managing the patency and functioning of artificial airways; changing dressings on traumatic wounds or surgical incision sites; providing care to women during childbirth; providing surgical assistance; participating in resuscitation activities during cardiac or respiratory failure; inserting intravenous, urinary, gastric, or other body catheters or tubes; providing bodily care to comatose patients, such as mouth care and range-of-motion exercise to prevent the formation of contractures; peritoneal dialysis; mechanical ventilation and weaning; and administration of medications and blood products (McCloskey and Bulechek, 2000).
As explained earlier, the exact types and frequency of interventions performed by nurses across different setting of care have not been quantified. However, it is consistently observed that administration of medication—oral, enteral, intrapleural, parenteral, topical, or through a ventricular reservoir (McCloskey and Bulechek, 2000)—is the most frequently performed physiologic therapeutic intervention (Bulechek et al., 1994).
Helping Patients Compensate for Loss of Functioning
Illness is accompanied by a loss of functioning with a variety of manifestations and with varying degrees of debilitation. Loss of functioning and resulting dependency can range from mild temporary weakness and malaise that accompanies the flu; to a temporary acute loss of strength and capacity to perform activities of daily living (ADLs) (i.e., bathing, dressing, eating, or other personal care activities) after major surgery; to a temporary inability to perform essential life functions, such as breathing, eating, or moving, as a result of more serious illnesses or injuries; to permanent disabilities, such as paralysis of extremities.
Most of the services provided by nursing staff in long-term care organizations (both institutional and home and community based) are designed to minimize, rehabilitate, or compensate for the loss of independent physical or mental functioning, and include assistance with basic ADLs (Stone and Wiener, 2001). An ethnographic report by an investigator who worked for 13 months as an NA to obtain an insider’s view of NAs’ work experiences found that NAs’ day shift tasks can be categorized as follows: (1) getting patients in and out of bed; (2) providing food services, especially feeding; (3) checking patients for incontinence and making and cleaning beds; (4) shaving patients; (5) walking to and from the linen closet; (6) helping patients shower; and (7) performing miscellaneous tasks, such as rinsing dirty linen and fixing sinks. NAs spent the most time helping patients shower; followed closely by providing food services, and checking, making, and cleaning beds (Henderson, 1994).
More telling than the official tasks performed by NAs, however, is their unofficial work. For example, Henderson (1994) found that each aide knew a great deal about the personal habits of the residents, which allowed care to be individualized and rendered more efficiently. These details included such things as removing a napkin from the tray of a resident who could feed herself but was known to eat paper, or placing a juice glass on the left side of a tray to make the glass more visible and accessible to a stroke patient (Henderson, 1994).
RNs also perform these types of activities, as well as activities intended to prevent further deterioration (e.g., fall prevention)—typically when they are providing care to a hospitalized patient who has more acute health care
needs. The extent to which these activities should be performed by RNs has been the subject of much discussion and has not been resolved in the health care literature (Kovner, 2001). Under the primary model of nursing care delivery discussed earlier in this chapter, an RN assigned to a patient provides total care for that patient, including bathing and ambulatory support. Under a team or functional nursing care approach, a mix of RNs and NAs coordinates their skill set in the provision of care to the patient.
Providing Emotional Support
Providing emotional support is recognized by nursing staff and patients as an essential part of nursing practice. Quality hospital nursing care has been described by patients as “accepting, empathetic, compassionate … and respectful,” as well as technically competent (Miller, 1995:31). A survey of individual nurses in clinical practice conducted in 1992 to validate the content of the Nursing Interventions Classification (NIC) system and determine the frequency with which nurses performed each of 336 nursing interventions identified provision of emotional support as one of the six most frequently used nursing interventions and the one reported most often by nurses as being used in their patient care activities (Bulechek et al., 1994). Rather than a vague, intangible attitude, caring—showing kindness, preserving dignity, explaining with empathy, and being patient—is recognized as requiring actions that impose their own time requirements as illustrated in the case of Ana in Box 3-2.
Emotional support is a key feature of the care provided by NAs in a variety of long-term care settings (Stone and Wiener, 2001). Providing such support necessitates establishing, nurturing, and sustaining relationships with residents, as well as responding to and effectively managing disruptive, aggressive, or uncooperative resident behavior. Indeed, responding to aggressive residents has increasingly become an aspect of CNAs’ work. In studies describing the epidemiology of workplace violence, NAs in long-term care facilities have been found to represent the occupation most at risk of workplace assault. NAs frequently are subjected to residents’ hitting, scratching, pinching, biting, pulling hair, twisting wrists, spitting, and throwing objects. Verbal assaults include threats of physical harm, cursing, racial slurs, demeaning remarks, screaming, and yelling. In focus groups with NAs and nursing directors at six nursing homes, NAs reported such physical and verbal incidents as occurring on a daily basis, resulting in their feeling “hurt, angry, frustrated, resentful, sad, … violated … fearful” (Gates et al., 1999:17). Unless a physical attack requires medical attention, most violent incidents are not reported for several reasons, including the acceptance of such violence as part of the job; a lack of receptivity and follow-up on the part of administration; and, in five of the six nursing
homes, a requirement that individuals involved in an incident report submit to drug testing. NAs generally reported little training or support from management in dealing with such incidents. Separate focus groups with nursing directors from the six nursing homes confirmed that many incidents likely are not reported and that there is little support for NAs after such incidents occur. Directors of nursing cited resistance to drug testing and fear of job loss as reasons for failure to report incidents. Violence by residents against NAs was not viewed as a priority by administrators (Gates et al., 1999).
The increased workloads associated with hospital reorganization and redesign initiatives, as discussed earlier, and hierarchical and bureaucratic management styles that overemphasize efficiency also have been identified as creating obstacles to the provision of emotional support (Miller, 1995). “Physical tasks can be recorded in medical records, used for reimbursement purposes, and easily quantified. Caring for patients’ psychological needs, which is not charted or paid for as a special service item, is missing from the usual litany of tasks and activities for which aides are responsible” (Foner, 1995:231), as was illustrated in Box 3-2.
Educating Patients and Families
Education of patient and families is another of the primary responsibilities of RNs. This education is aimed at providing patients and families with appropriate information so they can make informed decisions about their health care and treatments, and develop the knowledge, skills, and abilities needed to perform self-care (ANA, 1998, 2001). Surveys of individual nurses in clinical practice conducted in 1992 to validate the content of the NIC system and determine the frequency with which nurses performed each of the 336 nursing interventions identified teaching patients as an intervention used by more than 90 percent of nurses (Bulechek et al., 1994). However, shorter hospital stays challenge nurses to find the time to provide effective patient education. In a survey of 50 percent of RNs living in Pennsylvania and working in acute care hospitals between 1998 and 1999, 27.9 percent of respondents stated that they had left necessary patient or family teaching undone (Aiken et al., 2001a).
Additional Activities Related to Hands-on Patient Care
Integrating care The increasing complexity of health care often requires that patients be cared for by multiple providers with specialized expertise in diverse roles for a single or across multiple episodes of care (Shortell et al., 2000b). A patient may also be cared for by multiple HCOs or units within one organization, such as ICU, step-down unit, general medical–surgical unit, skilled nursing facility, and home health agency. The coordination of
Foner (1995:232–235) describes the following example of a situation in which the time needed to provide emotional support to patients is undervalued relative to speed and efficiency in accomplishing the physical tasks of nursing:
Gloria James and Ana Rivera (pseudonyms) were exact opposites. Ms. James … was mean and verbally abusive of patients…. Ana was gentle, considerate and kind. Yet Gloria was the nurses’ favorite, while Ana was constantly criticized by the nursing coordinator in charge of the floor….
Why was Ms. James so favored by the nurses? Mainly for being quick, efficient, and neat…. Ms. James’ rooms … were immaculate. By lunchtime the beds were neatly made … items in the drawers were properly in place and neatly folded. The yellow trays by the sink were sparkling, lined with paper towels to keep toothbrushes and other toilet articles clean. Ms. James was typically the first nursing aide in the day room at lunchtime getting residents ready to eat. She was a fast worker. She … was punctilious about getting her paperwork done neatly and on time….
Ms. James’ attitude toward dressing, bathing, and feeding patients was much the same as her attitude toward her other chores. She was determined to get them done quickly whether patients liked it or not…. She had no tolerance for patients’ resistance which slowed her down. Besides, she could get in trouble if, for example, their nails were not cut or their weights not done…. Ms. James’ behavior to patients was far from gentle … she bullied and taunted them; she badgered and yelled…. Ms. James humiliated and verbally abused patients … in front of nurses, administrators, doctors and visitors. Yet she received the best evaluation on the floor and had privileges denied other aides … when the two nurses were away from the floor, it was Ms. James whom they left in charge.
Ana is an expert in … the emotional work of caring: holding, cuddling, calming, and grieving. My first view of Ana was typical…. Ana
patient care services across these people, functions, activities, and sites over time is referred to as “clinical integration” (Shortell et al., 2000a).
RNs spend a large amount of time integrating patient care as part of planning for patients’ discharge from hospitals or other health care facilities to enable continued care in the home, school, or long-term care facility; educating the patient and family about the patient’s disease, course of
quietly fed a frail and weak resident, cradling her with one arm and gently calling her “Mama” as she coaxed her to eat…. One of her residents, Ms. Calhoun, was a witty, sarcastic woman with Parkinson’s disease whose mental status, as the problem book noted, fluctuated from alert and oriented to disruptive and verbally abusive. One afternoon she went out of control, screaming and shaking when a new rehabilitation aide mistakenly put a restraint on her chair. Ana gently removed the restraint and gently stroked Ms. Calhoun’s head for several minutes as she calmed her down. “She [the rehabilitation aide] didn’t know, its her first time,” she tried to explain to Ms. Calhoun. “Calm down now, calm down. You’re better now.”
With completely disoriented and unresponsive patients, Ana assumed a maternal air; with the alert, she chatted and joked as an equal, asking them what they wanted to wear, explaining the tasks she was doing or was about to do, and trying to reassure them about the anxieties they had…. Ana empathized with the residents’ situation and was aware of their family and personal histories. “It’s not just a job,” she explained. “Some of them are lonely. They have nobody; they need love and understanding.” Beyond emotional work, Ana was fastidious about keeping residents clean. She was careful about the way she gave baths and made sure to wash and lubricate residents before changing their undergarments.
But … her efforts were unappreciated by the coordinating nurse…. One day she was berated for not doing tasks in the right order; another for not having a resident dressed on time for lunch…. Slowness was part of the problem. Though Ana maintained a steady even pace throughout the day, she was sometimes late in completing her tasks … sometimes behind schedule weighing patients; and she did not always have her paperwork finished on time. Sometimes she ended up staying late just to complete her basic chores….
Ana’s trouble, paradoxically, was that she had the misfortune to work on what the administration then judged to be the best floor, under the best registered nurse in the facility…. At every level of the nursing department, from aides to registered nurses, efficiency and organization were valued over compassion to residents.
therapy, medications, self-care activities, and other areas of concern to the patient; and preventing gaps in care delivery, or discontinuities in care that can result in a loss of information relevant to patient care or interruptions in care. Patient transfers—e.g., from unit to unit, facility to facility, or hospital to home—are a common occurrence resulting in a high potential for
gaps in care. Gaps also occur from shift to shift or from provider to provider (Cook et al., 2000b).
Integrating activities to prevent these gaps requires that nursing staff communicate and coordinate with a wide variety of health care workers who participate in a patient’s health care, including multiple physicians, other nursing personnel, pharmacists, social workers, nutritionists, housekeeping and maintenance personnel, and community care providers. Communication, collaboration, and interactions between physicians and nurses have been shown to result in better patient care (Knaus et al., 1986; Mitchell and Shortell, 1997; Shortell et al., 1994).
The activities that RNs perform in integrating and coordinating patient care have sometimes been classified as “indirect” patient care13 (McCloskey et al., 1996), and the amount of time nurses spend integrating or coordinating care is indicated, in part, by the amount of time they spend on indirect as opposed to direct patient care. Although the location of some indirect-care activities may be shifting to the bedside (as is the case with automated patient records), the numerous work sampling studies of hospital nursing care that have been performed (with varying degrees of divergence from the standard definitions of “direct” and “indirect” care), have found that RNs spend as much as 25–45 percent of their time in indirect-care activities (Hendrickson et al., 1990; Prescott et al., 1991).
Documentation Documenting nursing work and other activities to meet facility, insurance, private accreditation, state, and federal requirements, as well as to furnish information needed by other providers, is uniformly cited across all care delivery settings as imposing a heavy demand on nurses’ time. See Chapters 1 and 6 for a discussion of the demands placed on nursing staff by various documentation requirements.
Supervision RNs also supervise other nursing personnel—LPNs/LVNs and NAs, as well as other RNs. Supervision activities include assigning and scheduling work, collaborating with staff to make patient care decisions, overseeing nursing staff performance and patient care quality, resolving problems, and evaluating performance. In addition, as non-nursing patient care services have been decentralized and located at the nursing unit as part
of hospital reengineering initiatives, nurses have taken on responsibility for supervising non-nursing personnel (McCloskey et al., 1996).
Effective supervision is associated with nurses’ satisfaction, recruitment, and retention (Aiken et al., 2001b), as well as with patient care quality. The impact of supervision is particularly clear in studies of nursing homes, where, as discussed earlier, NAs provide most of the care. Poor supervision is often a source of work dissatisfaction among NAs and associated with NA staff turnover (Parsons et al., 2003).
Workplace Characteristics That Hinder Safe Nursing Care
It has long been documented that, in addition to providing nursing care, RNs spend a significant portion of their time performing non-nursing activities. In 1954, the first work sampling study of nursing in three general hospitals in Michigan documented that 11–22 percent of nursing time was spent on activities typically the responsibility of other departments, such as housekeeping, dietary functions, and errands off the unit (Abdellah and Levine, 1954). Subsequent work sampling studies and surveys of nurses have documented the continuation of this phenomenon. Large proportions of nurses continue to spend substantial amounts of time performing non-nursing activities, including delivering and retrieving food trays; performing housekeeping duties, such as cleaning patients’ rooms; transcribing physicians’ orders; transporting patients; and ordering, coordinating, or performing ancillary services, such as delivery of medical equipment or supplies, blood products, or laboratory specimens (Aiken et al., 2001a). These tasks often prevent nurses from performing the patient care activities detailed above (Aiken et al., 2001b; Prescott et al., 1991; Upenieks, 1998). Other characteristics of the work environments of nurses have been documented as creating obstacles for their provision of appropriate patient care. These characteristics include low staffing levels, poor collaboration across health professions, inadequate decision support, poorly designed work and workspaces, and organizational cultures that inhibit nurses and other health care workers from raising patient safety concerns to management and creating mechanisms to prevent health care errors and adverse events. These problems and recommendations for their resolution are described in Chapters 4 through 7.
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