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Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

1
Study Activities

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

Written And Oral Testimony Submitted To The Committee

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

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

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

members, nursing and nursing home associations, labor unions, other interest groups, and study sponsors provided names or sent their mailing lists for the committee's use. Selections were made from these and other lists, with the goal of representing all points of view.

A general announcement, containing the committee's mandate, its purpose in requesting testimony, a guide to assist in preparing written statements, and ''key questions" around which the testimony could be organized, was then developed. (See Exhibit 1.1, at the back of this appendix, for a facsimile of the announcement/request for testimony.) In all, 511 announcements were mailed during July 1994; responses were requested by September 26, 1994. Some organizations and individuals who received the announcements also distributed them further to their memberships and acquaintances. By May 1995, staff had received and reviewed 108 testimonies. (See Table 1.1 for an alphabetical listing of the organizations and individuals that responded; for those that presented oral testimony, the site of the hearing is indicated.)

In addition to the request for written testimony, the mailed announcements also included information about 2 half-day public hearings at which the committee would hear oral testimony from a smaller group of individuals. The announcement specifically stated that if testimony were received by the September 1994 deadline, the organization or individual would be considered for one of the two hearings. After that deadline, potential testifiers for the two hearings were contacted.

Because travel costs could limit the ability of some groups and individuals to testify, the committee deliberately held one public hearing on each coast. This strategy also made it easier to distinguish broad, region-based differences across the country. The first public hearing was held in Washington, D.C., on October 19, 1994, in conjunction with committee's second meeting; 23 witnesses appeared before the committee. The second public hearing was held in Irvine, California, on January 22, 1995, in conjunction with the third committee meeting; 21 witnesses presented testimony. To the extent feasible, the preferences for dates and location of those invited to testify were honored.

Those presenting oral testimony were grouped into panels, asked to confine their remarks to 5 minutes, and requested to be prepared to respond to committee members' questions. In addition to those invited and scheduled to testify, at both public hearings the meetings were opened to general comments at the end of the day and were not adjourned until all those who wished to speak had done so.

Written and oral testimony received equal weight in the committee's deliberations. The written testimony ensured input from all interested parties, and the information, references, referrals, and suggestions provided in the statements were of considerable benefit to the study. The public hearings were convened to give committee members an opportunity to engage in discussion with—or to observe discussions among—an extensive range of health care providers, consumers and consumer advocates, professional organizations, and others. Both

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

TABLE 1.1 Organizations Submitting Written Statements

Name of Organization

Presented Testimony at Public Hearing

Academy of Medical-Surgical Nurses

 

Affiliated Organization of Nurse Managers

 

Aging Services for the Upper Cumberlands, Inc.

 

Alcanter, B.J.

 

American Association of Colleges of Nursing

DC

American Association of Homes and Services for the Aging

DC

American Association of Occupational Health Nurses

 

American Federation of State, County and Municipal Employees

DC

American Health Care Association

DC

American Nephrology Nurses' Association

 

American Nurses Association

DC

American Organization of Nurse Executives

DC

American Psychiatric Nurses Association

DC

American Public Health Association

 

American Radiological Nurses Association

 

American Society for Parenteral and Enteral Nutrition

 

Association of Child and Adolescent Psychiatric Nurses, Inc.

 

Association of Operating Room Nurses

CA

Association of Rehabilitation Nurses

 

Baptist Hospital of East Tennessee

 

Belew, John

 

Bureau of Aging and In-Home Services

 

California Advocates for Nursing Home Reform

CA

California Association of Hospitals and Health Systems

CA

California Nurses Association

CA

Career Nurse Assistants' Programs

DC

Catlett, Carter Williams

 

Commonwealth of Pennsylvania, Department of Aging

 

Connecticut Nurses Association

 

Danbury Hospital Professional Nurses Association

 

Davenport, Jennie

CA

Davis, Feather Ann

 

East Tennessee Human Resource Agency

 

Emergency Nurses Association

DC

Federation for Accessible Nursing Education and Licensure

CA

Federation of Nurses and Health Professionals

DC

Florida Nurses Association

DC

Gerontological Nursing Consulting Services

CA

Graves, Ruby

 

Hannigan, Hank

CA

Harvard Medical School, Center for National Health Program Studies

DC

Harvard School of Public Health

 

HBO & Company

DC

Healthcare Association of New York State

 

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

Name of Organization

Presented Testimony at Public Hearing

Illinois Nurses Association

 

Intravenous Nurses Society

 

Kaiser Permanente Medical Care Program

CA

Kansans for Improvement of Nursing Homes, Inc.

 

Kentucky Nurses Association

 

Kroposki, Margaret

 

Legal Services of South Central Tennessee, Inc.

 

Lewis, Nancy

 

Marshall, Sarah

 

Massachusetts Hospital Association

DC

Massachusetts Nurses Association

DC

Miller, Maura Farrell

 

Minnesota Alliance for Health Care Consumers

 

Minnesota Nurses Association

CA

Montana Coalition for Nursing Home Reform

CA

Mount St. Vincent

CA

Nagy, Mary

 

National Association for Practical Nurse Education and Service, Inc.

 

National Association of Hispanic Nurses

CA

National Association of Neonatal Nurses

 

National Citizens' Coalition for Nursing Home Reform

DC

National Committee to Preserve Social Security and Medicare

DC

National Council of State Boards of Nursing, Inc.

DC

National League for Nursing

DC

New York City Substate Long-Term Care Ombudsman Program

 

New York State Nurses Association

 

Nurses Organization of Veterans Affairs

 

Nursing Home Advisory and Research Council, Inc.

 

Nursing Home Community Coalition of New York State

 

Ohio Board of Nursing

 

Ohio Nurses Association

 

Oliver, Pauline

 

Oregon Federation of Nurses and Health Professionals

CA

Oregon Nurses Association

CA

Organization of Nurse Executives-California Organization for Nurse Leaders

CA

Parma School of Practical Nursing

 

Peer Review Systems

CA

Pennsylvania Nurses Association

 

Rehabilitation Care Consultants, Inc.

 

Revolution

 

Service Employees International Union

DC

Smith, Judy

 

Stanford University Hospital

 

Streeter, Janyce

 

Tennessee Hospital Association

 

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

Name of Organization

Presented Testimony at Public Hearing

Tennessee LTC Ombudsman Program

 

Texas Nurses Association

 

The Children's Hospital, Denver, Colorado

 

The University of Tennessee Medical Center at Knoxville

DC

Town of Amherst LTC Ombudsman Program

 

Turner Healthcare Associates, Inc.

CA

Unicare Health Facilities

DC

University of California, Irvine, California Strategic Planning Committee for Nursing

CA

University of Missouri-Columbia

 

Vermont Ombudsman Project

 

Villa, Marina

CA

Walsh, James F. (Ombudsman, Indiana Area II)

DC

Wilder Foundation Residence West

CA

forms of public participation in the study were vital parts of the committee's fact-finding efforts.

The following section presents an overview of the concerns and issues raised in the testimony submitted to the committee. The testimony is divided into four categories: hospitals, nursing homes, nursing education, and individual comments (e.g., from academics, self-employed geriatric nurse practitioners, a nursing journal). The testimony is usually grouped by the affiliation, membership, or area of concern of the testifying organization (e.g., professional nursing organizations, hospital industry, resident advocacy groups). The concerns of the relatively few individuals and organizations that testified about both settings are included in both categories.

Hospital-Related Testimony
Nursing Personnel

Testimony presented by nursing personnel, including unions, state nurse associations, and nursing organizations formed around clinical specialties, careers, or ethnic groups, is discussed below. The following section addresses testimony from institutional providers of health care such as hospitals and hospital associations.

Unions and Union Members With the exception of one association, all of whose members are registered nurses (RNs), the unions that testified have memberships

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

that include RNs, licensed practical and licensed vocational nurses (LPN),1 and nurse assistants (NA). All unions providing statements for this study noted that in their opinion, patient acuity levels are increasing and managed care is delaying hospital admissions and shortening hospital lengths of stay. In general, the unions do not take issue with the cost containment goals of restructuring hospital care, but they are concerned that these changes are being poorly implemented. Many anecdotes were provided describing the perceived negative effects of understaffing on the quality of patient care and on nurses' stress and health.

Other reports involved changes such as the sudden elimination of all positions at a certain level (e.g., all LPNs). The staff currently in those positions are told they no longer have a job, but they may apply for newly created positions at an hourly wage several dollars lower than their current wage and essentially provide the same care. Several examples of such practices were supplied in the testimony and in the committee's site visits (see later discussion).

The unions reported that, in a time of greater patient needs and shorter hospital stays, a variety of changes in staffing patterns have made it more difficult for licensed nurses to provide direct patient care. Many hospitals have established higher ratios of patients to licensed staff; others have reduced the number of supporting ancillary nursing personnel (ANP) or have replaced more highly skilled ANP with those having less training. At other locations, according to testimony, specialized nursing is being replaced with "generic" nursing: intravenous care teams are disbanded, scrub nurses in operating rooms are replaced with cursorily trained technicians, and nurses are sent to provide care on short-staffed, specialized units (e.g., pediatrics) without training or experience in that area.

In addition to concerns about the quality and safety of patient care, the unions expressed concern about the safety and quality of the workplace. Many nursing personnel stated that their work environment is unsafe for employees as well as for patients. Hospital nurses, in particular, report that rates of injuries (e.g., needlesticks, back strains) and illness (e.g., hypertension) have increased due to overwork, stress, and the need to work even if sick. These nurses also had strong feelings that hospital management is not responding to the increases in injury, illness, and stress.

Some testimony did provide examples of successful cooperation between unions and hospitals in addressing concerns. The testimony from a nurses' union and from the administration of one hospital was presented jointly. After significant difficulties over a restructuring initiative, the union and the administration used federal "mutual gains bargaining" to resolve some of their differences, with the result that they are now more able to focus, together, on patient care.

1  

As noted in Part I of the report, for simplicity's sake both licensed practical nurses and licensed vocational nurses will be referred to as LPNs.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

State Nurse Associations State nurse associations are membership organizations of RNs; many of them also act as collective bargaining units or unions for their members. The testimony in this category was almost completely about acute care and, because of the membership composition, consisted of RN-specific experiences, perceptions, and concerns.

The widespread restructuring and downsizing within hospitals, as well as some implementations of patient-focused models of acute care delivery, are not well regarded by some RNs. Experience with these models has led them to question the value of such changes because the restructuring does not seem to benefit patients or improve the delivery of care. In the testimony, RNs' primary concerns, like those of the unionized health professionals, were about their job performance and security and their patients' safety and quality of care. Many reported being at "the end of their rope," either because they are trying to maintain the quality of care at enormous personal cost or because they are trying very hard simply to maintain a uniform level of safety. They argued that restructuring efforts are often poorly planned and implemented, and are seldom evaluated for the quality of nursing care; furthermore, there is sometimes no consultation with nurses about these changes.

Registered nurses are also unhappy with having less patient contact and more delegating and supervisory responsibilities. Several witnesses noted that the educational preparation for such managerial responsibilities is inadequate. Others pointed out that opportunities for learning on the job are now greatly reduced because many hospitals have fired their clinical nurse specialists, given their charge nurses patient care loads (sometimes full loads), and eliminated or reduced orientation programs for new nurses.

One general perception was that changes are cost driven and poorly and hastily planned; another was that no data support such changes, whereas data suggesting that higher levels of RNs improve the quality of care are felt to exist. The growth of for-profit institutions; the trend toward business, rather than medical and nursing, leadership in hospitals; and the profitability of the hospital industry were also matters for comment. Registered nurses believe they are bearing the brunt of financially motivated cost-saving efforts.

Concern was also expressed about "a loss of understanding that nursing is not a series of tasks, but an integrated process which may include a series of tasks to achieve a [patient] assessment and a [care] plan." Some witnesses worried that inflexible, task-oriented, top-down systems were being imposed on care givers who are educated to make judgments and who are ultimately responsible for care. Acuity systems for determining staffing levels, for instance, were seen as valuable tools but not more valuable than RNs' clinical judgment. Some testifiers also expressed concern that hospitals are altering the threshold on their acuity systems as a means of justifying lower staffing levels.

Both the state nurse organizations and the unions were concerned about licensed nurses' professional, legal, and ethical responsibility—and liability—for

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

providing safe and adequate care. Under the nursing practice acts of each state, nurses are responsible for all care delivered under their supervision; furthermore, they are liable for patient abandonment if they do not accept reasonable assignments, but they must not accept unreasonable work assignments. Many state nursing organizations and unions have responded by encouraging their members to use "assignment despite protest" forms to document their concerns; this is not, however, considered a solution to the concerns about patient safety and quality of patient care. Furthermore, according to one union, some hospitals are pushing for "reinterpretation or revisions in state nurse practice acts so as to allow unlicensed personnel to perform significant nursing duties, while leaving ultimate responsibility and legal liability in nurse hands."

Most of the testimony noted the current challenges of delivering nursing care: higher levels of patient acuity; an aging population; shorter lengths of stay in which to deliver care and teach patients self-care; the use of ANP in place of RNs; and sometimes the loss of support services. Many RNs expressed concern that ANP are replacing RNs rather than supporting them, and a few mentioned that at their institution new and less knowledgeable ancillary personnel were replacing those with greater skills and better training. Others spoke of a general "de-skilling" of nursing practice.

Specific concerns about the quality of patient care included less preventive care; more "near misses," considered by many RN organizations to be a critical "invisible" indicator; inappropriate transfers to other units or to the home; and more unsafe patient loads. Another perception was reduced continuity of care, especially with the growth of cross-training, and increased reliance on floating and per diem nurses. Cross-training and floating,2 it should be noted, are regarded as appropriate solutions for both hospitals and nurses if implemented properly, but many testifiers believe that these tactics are often poorly implemented and, as a consequence, the risks to quality of care are high.

Specific problems involving injuries, illness, and stress were also mentioned. Violence, back injuries, and the risk of infectious diseases are all serious occupational hazards. One example raised was that equipment that could prevent or minimize injuries is not being used because of cost considerations. In addition, strains on family life and personal time, job security worries and layoffs, and either mandatory overtime or days without work are significant sources of stress. Some complaints about increased stress and risks to their health came from experienced nurses who have been providing care for decades.

By and large, most representatives of the state associations expressed con-

2  

Cross-training is on-the-job training of nursing personnel to deliver specialized clinical care in an area outside their primary expertise and experience. Floating is the temporary assignment of nursing personnel to a clinical unit other than the one to which they are usually assigned.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

cern about the deteriorating quality of patient care, job safety and security for their members, and nurses' abilities to meet their professional, legal, and ethical responsibilities in their current situations.

Nursing Organizations Formed Around Clinical Specialties, Careers, or Ethnic Groups Although most of these organizations are national in scope and organized around areas of RN clinical specialization, they form a somewhat varied group and their testimony reflected this variety. As an example, two organizations affiliated with state-level hospital associations represent the interests of nurse executives and managers. Understandably, the positions taken by these associations differ somewhat from those of the nurses in clinical specialty organizations. The testimony of the former, for instance, exhibit greater awareness of the cost pressures on hospitals and the tensions between clinical and administrative responsibilities that can be felt by nurse managers. The American Organization of Nurse Executives, which represents nurse executives and managers at the national level, made three points: (1) the "[a]dequacy of nurse staffing in hospitals and nursing homes needs to be determined in the context of the future, restructured health care delivery system—not in the context of today's needs"; (2) "[n]urse and other staffing needs are and will continue to be unique to each health care delivery organization and the community it serves. No single approach fits the needs of each situation in determining appropriate staffing levels"; and (3) "[c]urrent data on the number of nurses in institutional settings and on nursing's impact on the quality of patient care is limited.''

Of the 17 organizations testifying in this group, the majority represent nurses who have a specific clinical specialization. Some organizations expressed concerns similar to those noted previously; for instance, reductions in staffing are seen as hazardous to patients and, over the long-term, debilitating to nurses' abilities and health. Clinical specialty organizations tended, however, to add a broader perspective to the discussion of concerns and issues, often paying more attention to the movement of patients across sites of care delivery and the need to track patients after discharge. The need for continuity of care was a strong theme in some of the testimony and several organizations expressed confidence that cost-effectiveness considerations would demonstrate the value of nursing once factors such as rehospitalization and increased morbidity after discharge are taken into account. Some also expressed greater approval of the concept of team nursing—perhaps because nurses with clinical specialties are more likely to function as part of an established nursing team and thus to have had positive experiences with team nursing.

Finally, several of the organizations in this subgroup, such as the National Association of Neonatal Nurses and the National Association of Hispanic Nurses, noted the need for more minority RNs and higher-level nurses. This was seen as particularly important because of demographic predictions that cultural diversity and patient acuity will continue to increase nationally.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×
Institutional Providers of Acute Care

Organizations representing providers of acute care included two hospitals; the national association representing hospitals; three state-level chapters of the same; one health maintenance organization (HMO); and one organization with both hospital and nursing facility membership that was reporting on behalf of its hospital members.

The hospital associations, HMO, and dual membership organization provided analyses of recent changes in the delivery of acute care. This testimony was generally in agreement on two issues. First, that there have been significant changes in hospital utilization. This is a time of retrenchment, when the movement of inpatient care into outpatient settings is resulting in lowered census and fewer beds. In many states, the growth in managed care has been dramatic and some acute care hospitals have either closed or merged. Second, hospital associations were able to provide some data suggesting that despite declines in hospital utilization and the high costs of nursing labor to hospitals, RN utilization in hospitals—that is, the total number of RNs employed—has either remained constant or increased.

In general, hospital associations did not see notable changes in the levels stress felt by nursing personnel, patient satisfaction, or mortality rates. Most organizations in this category noted the lack of data on the number of nurses in institutional settings and the effect of nursing on quality of patient care. This information is not uniformly collected or linked, and often is not collected at all. Several of these organizations urged that valid and reliable patient care outcome data, particularly outcome data associated with nursing care, be collected.

Nursing Homes-Related Testimony
Resident Advocacy Groups and Long-term-Care Ombudsmen

Testimony from nursing home resident advocacy groups, family members, and long-term-care (LTC) ombudsmen exhibited great concern about poor-quality care and inadequate staffing.3 This testimony is useful because these insights are often not available directly from residents.

Mandated tasks in a nursing home include, at a minimum, turning bedbound residents every 2 hours and keeping them clean; getting wheelchair residents up

3  

Long-term care ombudsman "advocate to protect the health, safety, welfare, and rights of the institutionalized elderly" (IOM, 1995, p. 1). For more information on long-term care ombudsmen see the IOM report from which this quotation was taken: IOM. Real People, Real Problems: An Evaluation of the Long-term Care Ombudsman Programs of the Older Americans Act. J. Harris-Wehling, J.C. Feasley, and C.L. Estes, eds. Washington, D.C.: National Academy Press, 1995.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

to exercise; giving residents adequate food and water; and assisting them in toileting. Often, however, NAs do not have time to get all of this done: "There are times I have been there when there has been only one aide on the floor with the charge nurse and the med nurse. … One aide isn't enough for, roughly, I would say sixty-two beds." The equipment for delivering care may also be inadequate.

Basic care is sometimes not given frequently or quickly enough—patients are often left in dirty diapers or on the toilet for extended periods of time, baths may be given infrequently, and basic dental care is sometimes forgotten. Neglect is sometimes so extreme as to become abuse. Other concerns are the lack of dignity accorded to residents in terms of not leaving them naked or exposed in public areas or respecting their wishes about daily activities such as eating and dressing. Even such simple things as providing sufficient water are often neglected. Water pitchers may be missing or out of reach. Many residents need to have water handed to them or must be reminded to drink.

Residents' family members expressed high levels of concern about neglect, unnecessary pain, endangerment, loss of health or life, and abuse. Testimony from family members sometimes mentioned unreported falls; errors such as a nondiabetic resident being given an insulin shot; and the widespread loss of bladder and bowel control by residents because aides do not have the time to toilet them.

Although much of the testimony from resident advocacy groups and LTC ombudsmen concerned examples of poor quality of care and poor quality of life for residents, overall points specific to nurse staffing levels were also made. Most of the problems with the delivery of long-term care were felt to be tied, in some way, to inadequate staffing or to inadequately trained staff.

One national organization estimated that almost half of all hospitalizations of nursing home residents could be eliminated with adequate staffing, which would save more than $942 million per year. This same organization calculated, in addition to less morbidity and pain, substantial savings of both money and time from improved levels of care and staffing. Citing annual national costs from more than $3 billion for the care of urinary incontinence to between $1.2 billion and $12 billion for preventable pressure sores, this organization argued that many of these expenses are preventable and that higher-quality care would be more cost-effective than the current approach to long-term care.

Nursing Personnel

Unions and Union Members Union concerns about nursing homes are somewhat different from those about hospitals. Structural changes and managed care do not pose immediate issues in nursing facilities; consequently, union testimony tended to focus more on concerns in acute care than in long-term care. Nevertheless, in the words of one union, "Nurses and nurse aides in nursing homes,

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

already laboring under chronic understaffing, inadequate training, and other adversities, face growing numbers of persons discharged from hospitals, with new and more intensive needs."

Some individual union members provided examples of their concerns. One noted that at her institution an NA is typically responsible for 10 residents during the day shift. The evening shift has one NA for 13 to 18 residents, and on the overnight shift the ratio is usually one NA for 22 residents. She described how impossible it is to provide for the needs of all residents—even in such basics as turning them to prevent bed sores and providing hot food on time—with staff-to-patient ratios that low. Nevertheless, she noted, these ratios are deemed sufficient under the state's minimum required staffing levels for nursing facilities. Some of those presenting testimony attributed injuries such as back strain to inadequate staffing levels, because when facilities are understaffed nursing personnel often attempt difficult physical tasks (e.g., lifting and turning patients) with insufficient help.

Compensation levels for RNs and NAs in long-term care are low compared to those in acute care. Certified nurse assistants, in particular, are paid low wages for arduous work; consequently, turnover is high. This contributes to poor continuity of care, working short staffed, and high injury rates compared to most other occupations. To summarize, the unions appear to believe that "[w]hile adequate staffing levels in themselves do not guarantee good care, consistently good care is not possible in their absence."

Professional Nursing Organizations Formed Around Clinical Specialties or Careers Although there were 17 testifiers from professional nursing organizations for the hospital testimony, only 1 such organization focused on nursing home care. The Career Nurse Assistants' Programs "promotes recognition, education and peer support development for experienced nurse assistants in long-term care settings."

The Career Nurse Assistants' Programs (CNAP) made three points in its testimony. First, being realistic about the number of tasks any NA can perform, and therefore the number of bodies needed to provide care. The organization believes that guidelines must be developed for assigning NAs on the basis of acuity level and complexity of care, and that no NA should be required to perform more than 40 to 50 different tasks, each requiring 5 minutes or more, within a 4-hour period. The second recommendation related to NA supervision. NAs want daily direct access to a clinical supervisor who has the responsibility and time to help prompt, shape, coach, and adapt care for patients. The third recommendation concerned the issue of responsibility and authority, particularly as it relates to the new NA. Career NAs want to complement the role of trainer, not usurp it. Their tasks associated with training new nurse assistants must be clearly defined, properly assigned, and supervised.

In summary, CNAP noted, the quality-of-life experience of the resident is

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

largely determined by the person who provides the hands-on, daily care. If the issue of quality is to be addressed, the experienced career nurse assistant should be recognized as a valuable resource and provided with a supportive work environment and the supplies necessary to the provision of care.

Providers of Care in Nursing Facilities

Three associations representing nursing facilities (two are national and one is on the state level), are discussed first. The testimony of a national chain of nursing facilities and of two individual nursing facilities is discussed later.

The three nursing facility associations agreed on several points, specifically on the challenges faced by nursing facilities and their strong opposition to mandatory minimum staffing ratios. On the first topic, the associations noted the numerous regulations and expectations confronting nursing facilities and the low reimbursement rates that make meeting those tasks so difficult. They also noted the increase in resident acuity levels, the challenges of providing subacute care, and how the levels of nursing skills and the documentation required have grown with the increase in acuity and regulation.

On the second topic, the associations articulated several arguments against minimum required staffing ratios. Both national organizations expressed the view that the use of mandatory staffing ratios would be, essentially, a step backwards: "the shift from process to outcomes embodied in OBRA [the Omnibus Budget Reconciliation Act of] 1987 was supported by both consumers and providers. Establishing required staffing ratios would reverse this and shift the emphasis back to processes." These associations expressed their general belief that there is no proven correlation between higher staffing levels and positive care outcomes. The American Health Care Association (AHCA), for instance, noted that available data suggest that staffing levels explain only a very small portion of the variation in number of "outcome-related" deficiencies issued to facilities. The following were additional arguments against minimum staffing levels:

  • The leadership and management of a facility are more important to the delivery of quality care than having a specific minimum number of staff.
  • It is difficult to determine what particular measure could be used to assess nurse staffing levels and skill mix in all facilities because of myriad differences in areas such as structure, patient mix, acuity levels, and state requirements.
  • The health care environment continues to change every day, making it likely that any preordained staffing levels would poorly address the needs and care environments of the future.

In addition to the areas in which all three nursing home associations agreed, each individually made points that were useful to the committee's work. Califor-

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

nia has more than 400 surveyors who conduct 200 to 300 hours of inspections, annually, in each nursing facility. Despite this, the California Association of Health Facilities (CAHF) reported that reliable data about quality of care are difficult to find, especially since there is no general agreement on a definition of quality of care. Furthermore, surveys performed by state and federal surveyors provide only partially reliable information because no two surveyors perform their function in the exact same way. The California Association of Health Facilities urged that any changes to the workforce in nursing facilities take into consideration growth projections, educational opportunities, and actual workplace dynamics.

Testimony from the American Health Care Association stated that the number of nursing staff in nursing homes is adequate. Rather, turnover among NAs is the real problem. It does not believe such expenditures should be recommended by the IOM committee without supporting information that shows a correlation between greater numbers of nursing staff and higher levels of quality of care.

The American Association of Homes and Services for the Aging (AAHSA) asserted that a mission, philosophy, and principles must be established within nursing facilities; also, that care should be delivered through a team approach that relies on education, training, coaching, checking, and correction and clearly communicates the expectations of staff members. AAHSA believes that the goal of high-quality, individualized long-term care can be achieved only through "(1) continued movement toward quality of care assessment based on resident outcomes rather than process; (2) ongoing efforts to define positive outcomes within the context of [resident] populations; (3) maintenance of facilities' ability to achieve these outcomes while determining staffing needs and targeting resources based on the populations they serve; (4) the development of valid, reliable quality monitoring systems that incorporate not only clinical indicators, but also resident perceptions and satisfaction; (5) the assurance of adequate reimbursement rates by State Medicaid programs and an increase in Medicare cost limits, specifically for nurse staffing; and (6) by increasing academic awareness and opportunities for nursing experience in these long-term care settings."

Unicare Health Facilities (UHF) currently operates 160 health facilities in 14 states. Their services include skilled nursing care, therapeutic and rehabilitative care, dementia units, and subacute care, as well as services in assisted living and retirement settings. Their testimony identified three challenges: (1) the need to increase staffing in skilled nursing facilities, in terms of both numbers and skill mix, as patient acuity levels continue to rise, and (2) the difficulty of considering quality-of-care outcomes across the clinical settings of hospitals and nursing homes. Computerization of the minimum data set, as mandated by the Health Care Financing Administration, should provide an opportunity to analyze a variety of factors in relation to quality outcome indicators. UHF also recommended that new studies be conducted to provide data to help design staffing models (e.g., time-motion studies based on resident acuity within the long-term-care setting).

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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(3) current reimbursement systems have lagged behind the delivery of care, and this has had a prohibitive effect on facilities' use of higher staff-to-residents ratios.

The testimony from UHF also reported that the organization has not seen a significant correlation between current staffing levels and either quality of care or work-related injuries and stress, probably because its facilities responded to the needs of higher-acuity residents with higher staffing ratios. UHF believes that a great deal of additional research and analysis of existing data are needed.

Two different examples of restructured nursing facilities, both of which reported that these changes were essentially cost-neutral, were provided in testimony to the committee. The first was from Robert Ogden, representing the Mt. St. Vincent Nursing Home; the second was from Jan Olson, speaking on behalf of Wilder Residence West.

Robert Ogden described how a 200-bed nursing facility at the Mt. St. Vincent Nursing Home was restructured both physically and programatically to shift the emphasis toward "resident-directed" services. He believes that long-term-care services should meet the needs and wants of residents, not of regulations, facility management, or physicians. He noted that this may not sound radical but that it is, in fact, a major change for staff to truly internalize and act on this new perspective.

Ogden believes that the use of nurse assistants or aides is a critical aspect of long-term care and stressed that nurse aides are the key to both quality of life and quality of care. He believes that the ratios of NAs need to be changed, and he also strongly urged that their title in nursing facilities be changed from nurse aides, or nursing assistants, to resident assistants. Along with such a change, he recommends training. At his facility, NAs are required to have 12 hours of continuing education each year. To make this possible, the facility brings in replacement staff. Ogden concluded by noting that at present, when acuity cannot really be used to set staffing levels, he and his facility feel the need for regulations that require some kind of minimum staffing levels of resident assistants or nurse assistants.

Jan Olson described a new model of care delivery that was implemented on the 50-bed Wilder Residence West unit. It changed nursing care from a task-oriented system to a resident-oriented system by assigning primary nurses and their associates ongoing responsibility to care for a designated group of residents. The number of hours of care did not increase, but the skill mix did; the percentage of licensed staff coverage over a 24-hour period increased from 24 to 38 percent at the time of implementation and to 45 percent when the testimony was submitted. Olson noted that the increase of licensed staff is perceived as having improved quality of care and of life for residents and quality of work for staff, while remaining cost-effective. Ongoing data collection supports this assertion, documenting notable reductions in the use of restraints and antipsychotic drugs; a dramatic decrease in hospitalization rates; high resident satisfaction rates, along

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

with reduced staff turnover rates; and high levels of success with various forms of rehabilitation despite a continuously rising acuity level and an average resident age of 91 years.

Education-related Testimony

Most education-related testimony either was site neutral or focused on the hospital setting. In general, if organizations discussed hospital restructuring, cost containment efforts, and the use of ANP, they agreed with the concerns raised in testimony from other hospital-focused nursing groups. Unlike the prior grouping of testimony, however, the seven organizations in this category have fairly varied perspectives on nursing education and practice. None of these education-focused groups addressed the training needs of NAs and ANP, probably because these health care workers are not among their membership. Testimony provided by the Career Nurse Assistants Program did provide the committee with general comments on the educational and training needs of NAs and LPNs and suggestions on how to organize and provide continuing education to NAs.

The American Association of Colleges of Nursing (AACN) represents nursing education programs at universities and 4-year colleges, so its concerns are baccalaureate and graduate education, nursing research, and the development of academic leaders. In its testimony, AACN explicitly considered the bachelor's degree in nursing "the critical first step to a professional nursing career" and supported it as "the minimum educational requirement for professional nursing practice." The AACN also offered an agenda for nursing education in the twenty-first century, noting that schools of nursing must redefine the role and rewards of nursing scholarship to include nursing practice in an expanding array of settings, as well as nursing theory. The movement from delivering services in acute care settings to delivering them in outpatient and home-based settings also implies a need to retrain and redeploy health care professionals in the future.

The Federation for Accessible Nursing Education and Licensure (FANEL) represents the educational interests of "nurses" defined more broadly to include LPNs and RNs with associate degrees or diplomas. In contrast to the AACN, FANEL advocates recognition of the value of different, coexisting levels of education: "There is a wide spectrum of health care needs which can be met more cost efficiently if there is a choice of educational programs to enable anyone, regardless of economic or social condition, to enter the program that best fits that person's situation. Then, upon entering the workforce they can render valuable services and through articulation can go on into advanced nursing, if they so choose [emphasis in original]." Expressing concern that funds for diploma and associate degree programs for educating nurses might be diverted into baccalaureate programs, FANEL noted that this would be "highly unjustified" and provided information to demonstrate that nurses without RN baccalaureate degrees,

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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as well as those with them, can provide critical types of care and meet high levels of competency and responsibility.

Testimony from the Parma School for Practical Nursing seconded FANEL's point, adding that practical nursing programs also provide "experienced, prescreened" individuals a way to finance their RN education. The National Association for Practical Nurse Education and Service (NAPNES), an organization with the mission of promoting the standards of practical nursing education and practice, also noted that "[m]ultiplicity of choice in nursing programs will continue to attract citizens from all backgrounds and educational preparation. This diversity will reflect the broad spectrum of patients and nursing needs."

The National Council of State Boards of Nursing (NCSBN) and the Ohio Board of Nursing (OBN) are organizations charged with the regulation of nursing practice. State boards of nursing are created by statute to administer the licenses of RNs and LPNs in accordance with a state's nurse practice act, and complaints against licensed nursing personnel would be filed with state boards. The NCSBN testimony emphasized the value of licensing as "a mechanism to assure the public of the competence of the licensee to practice safely and effectively." The testimony from OBN agreed with this and also noted that the concept of delegation is becoming critical. According to OBN, boards of nursing "must define and regulate delegation by rule language and enforce disciplinary action when there is non-compliance."

The National League for Nursing (NLN) considered nursing practice from a policy and research perspective rather than a regulatory one. Expressing concern about the effects on nursing practice of staffing models that are task oriented and prescribed, NLN urged the articulation of a "clear and universal definition of nursing practice" and the development and use of outcome measures of nursing practice, rather than of nursing tasks or process. The design of staffing models should recognize the "central role and accountability of the clinical nurse in achieving optimal outcomes for patients and families."

A few unions raised the issue of education; they expressed concern that the swift national movement from inpatient to outpatient care leaves many nursing personnel unprepared to provide care in the settings where it will have to be provided. Reeducation and retraining in primary and preventive care, and advanced education at the clinical specialist or nurse practitioner levels, were seen as solutions. Other issues were a lack of qualified faculty in some regions and salary levels for faculty that are lower than hospital salaries. As far as continuing their education, some instances were cited in which staff RNs have been unable to attend mandatory in-service programs because of low staffing levels and were (understandably) very unhappy later to be rebuked in performance reviews for those absences.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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Testimony from Observers

Other observers include individual testifiers and a nursing journal; academics and representatives of universities; self-employed nurses, such as gerontological nurse practitioners; and consulting groups. Individual testifiers—for the most part either nursing personnel or people whose relatives were in nursing homes—expressed some of the same concerns as the state nurse associations, unions, resident advocates, and consulting groups. The nursing journal testimony provided a critique of the current changes in nurse staffing, including mandatory floating, mandatory overtime, unsafe nurse-to-patient ratios, retaliation against nurses who object to changes, and increased use of unlicensed assistive personnel.

The testimony from four academics or university representatives made several different points. One presented information on a state-level strategic plan for summarizing data about the current nurse supply and predicting the future need for RNs in California. Another argued strongly that current staffing levels for direct care are insufficient while staffing levels for administrative tasks are excessive. Testimony from another academic presented information on the implementation, at a large nursing facility, of a professional practice and participatory management model for nursing. This model resulted in reduced mortality, despite increases in resident acuity, as well as high levels of job satisfaction for staff nurses and nurse managers. The final academic testimony emphasized the effects on decisions about nurse staffing of the changing economic incentives experienced by hospitals.

Testimony from consulting groups addressed several broad areas. Two consulting firms were data-focused organizations whose primary clients were acute care institutions. One of these firms emphasized the value of data analysis, while the other discussed the opportunities provided by sophisticated information and documentation systems. This second firm argued that in addition to the goal of cutting costs, a true restructuring of hospital care requires a deep commitment to reinventing delivery processes and to removing inefficiencies and redundancies so as to improve patient care.

The remaining three consulting groups are nurse consultant organizations concerned with long-term care. One articulated the need for skilled management, upgrading of employee education and supervision, and role modeling. The second argued that nurses are complaining without data to back them up and that there are no data or correlations between staffing ratios and any of the following concerns: poor patient outcomes, decreased quality of care, or decreased well-being of nurses. Rather, this testimony strongly stated, an evolving health care environment is requiring nurses to take responsibility for decisions about, and the implementation of, change. The final testimony from a consulting group offered the committee a research-based staffing methodology and urged the use of case-mix classifications systems to determine the nursing needs of specific nursing

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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facility residents. This testimony also argued for reimbursement based on resident classification systems that (1) are evaluated systematically for the adequacy of nursing time and (2) require facilities to use funds allocated on the basis of high acuity to increase staffing.

Concluding Remarks on Testimony

The IOM committee did not look to the testimony for quantitative data. Indeed, many of those affected by proposed or implemented staffing changes—hospital patients, nurse assistants, hospital and nursing home administrators, managed care organizations, licensed practical nurses, and others—were not necessarily represented through the submitted testimony in numbers commensurate with their potential interests. Rather, as noted above, the testimony provided the study with a rich set of materials representing a broad range of opinions, expertise, and experience in the matters under consideration. The hearings additionally represented an opportunity for interested parties to express their views directly to committee members, respond to committee members' requests for clarification or additional information, and reply to other panelists with different positions on some of the issues.

The submitted documents and statements enriched and broadened the study by greatly informing the committee's deliberations, helping committee members to understand better the concerns of specific groups, and alerting them to additional issues. The committee is grateful for the insights provided, and it acknowledges the generosity of time and effort of those who prepared and contributed to the testimony.

Site Visits Conducted By The Committee

This section describes site visits conducted by the IOM committee. Because members bring diverse backgrounds and experience to the committee, site visits are often used to educate them, give them common reference points, and help them develop some collective understanding on a variety of issues. Site visits also provide vivid circumstances and specific instances that can be extremely useful during committee discussions. During the fall and winter of 1994–1995, therefore, site visits were a central activity of the IOM committee.

A principal objective of these visits was to increase the committee's understanding of the issues of nurse staffing levels and skill mixes, quality of patient care, and nurses' work-related stress and injuries. The visits were an opportunity for committee members to benefit from the experiences and opinions of those directly involved in the questions posed by the study's mandate. Because individual locales (as well as organizations and individuals) were chosen for the insights they could provide, the site visits were not intended to result in a broad, quantitative analysis of national nurse staffing patterns. Rather, the visits sensi-

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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tized committee members to a broad range of issues and informed them, in rich detail, about myriad points of view.

Approach

The committee conducted intensive site visits in Mississippi, Missouri, New York, and Oregon between November 1994 and March 1995. Site visit teams were usually composed of four committee members and one staff member, and the visits usually consisted of 2 full days of meetings with host facilities, agencies, and individuals in specific regions. The states to be visited were chosen by committee members at the first committee meeting. The specific organizations and individuals with which the site visit teams met were chosen on the basis of suggestions from members of the committee, various interest groups, and the liaison panel, and on the basis of staff research. An effort was made to achieve representation of

  • geographic areas of the country (e.g., urban, suburban, and rural areas and the four census regions);
  • a range of health care delivery environments in hospitals and nursing facilities (e.g., from areas with high rates of managed care to those in which managed care is minimally present);
  • a variety of facilities and institutions in terms of size, ownership and governance, organization of health care delivery, and other characteristics; and
  • a wide sampling of local professional groups, associations, and individuals concerned about the issues in the committee's mandate.

Overall, the committee heard a broad range of perspectives, including (but not limited to) staff and management at hospitals and nursing homes; representatives and members of labor unions, professional organizations, and the business community; state-level hospital and nursing home associations; federal and state government officials; nursing home residents, their family members, and resident advocacy groups; and nurse educators in a range of educational institutions.

A ''typical" site visit would include (1) 2 1/2-hour visits to 2 hospitals and 2 nursing homes and (2) shorter appointments with others such as health care professionals, state regulators, patients, and educators.4 The committee members held a total of 41 meetings and spoke with approximately 350 people in a variety of settings. During site visits the committee members referred to an interview guide developed by staff but were also led by their own interests and those of the groups being visited.

4  

The specific facilities, organizations, and individuals visited by the site visit team were promised confidentiality. For this reason, descriptive information rather than names and locations is used here.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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General Issues in Health Care Delivery

Information derived from site visits documented several broad issues: increasing patient acuity-of-care needs; an aging population; the movement from inpatient to outpatient delivery of care; and cost containment approaches to the delivery of care, which ranged from managed care to low Medicaid reimbursement rates to the "restructuring" being undertaken in many hospitals.

Both acute care and long-term-care settings reported increased acuity levels and the need for higher intensities of services in the past few years. This change in the needs of the patient populations was attributed to several factors, including the aging of the U.S. population. For acute care settings, a primary reason cited in the facilities visited was the change in lengths of stay and the incentives to delay admissions. A significant change in the kinds of illness presented has also altered hospital acuity levels. In some regions, many cases of AIDS and drug-resistant tuberculosis and an increase in the numbers of trauma patients have compounded the general increases in acuity levels.

Similar issues—changes in the kinds of residents, their acuity of illness, and age and comorbidities—were also described in nursing facilities. The staff at some facilities pointed out, first, that many or most of their residents have been in the facility for a while and are "aging in place," and, second, that they are getting more short-term rehabilitative patients discharged from the hospital and more patients classified as "subacute." This means that nursing homes are now receiving people with such care needs as in-house kidney dialysis, tracheotomy care, and intravenous pain management; 10 or 15 years ago, these patients would have remained in an acute care setting.

Alternative models for delivering long-term care, such as increased placement of the elderly in community-based care settings, are extensively used in some areas. This also increases the acuity level in nursing homes because the existence of alternate forms of long-term-care services essentially results in the selection of relatively healthier persons for placement elsewhere. Consequently, higher concentrations of severely ill or debilitated individuals can be found in nursing facilities.

In some urban areas, the age groups served appear to be expanding. Urban facilities are providing chronic, but intense, care to younger populations, in part because of AIDS and violent trauma. Another specific reason for the increased acuity is the closing of mental hospitals. Whatever the various causes, however, the concentration of high-acuity residents—those who need extensive help with eating and elimination and are less mobile; those who have greater psycho-behavioral problems; and those with intravenous pumps, oxygen concentrators, and other such devices—is straining the staff and, at times, the physical plant of nursing facilities.

Managed care and other cost containment efforts are also greatly affecting the environment in which health care is delivered. Hospitals are currently feeling

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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the immediate effects of these pressures, but managed care for Medicaid patients is starting to affect nursing home residents. Committee members heard some concern that managed care for Medicaid patients may mean, for long-term care, more focus on cost, a lower priority for quality, and, therefore, the possibility of further reductions in staffing levels.

Staffing Issues

The ability of institutions to recruit and retain nursing staff has changed in recent years. In both acute care and nursing facilities, positions for RNs and, to some extent, LPNs are generally filled without much problem. Retention rates for nurse assistants, however, particularly in nursing facilities, are often poor. The sections below draw a picture of recruiting and retention issues in hospitals and nursing homes.

Staffing Issues in Hospitals

Hospital staffing ratios are usually determined by the administrative staff of an individual facility or of the health care system with which the hospital is affiliated. Consequently, in acute care, many approaches are used in determining the levels of staff needed and scheduled. These approaches can be broadly divided into census-based systems and acuity-based systems, although most staffing systems combine aspects of both. A true census-based system for determining staffing is one in which the number of patients determines staffing levels. An acuity-based system is one in which the patient's health status and needs are rated to help determine staffing levels.

In general, most of those with whom the committee met were not in favor of across-the-board mandated minimum staffing ratios (i.e., ratios based only on census levels) not only because individual patients' health status and needs can differ broadly, but also because each hospital differs in terms of the population served and organizational variables. The number of nursing staff required, for example, will be affected by available support systems as well as by patient acuity levels and medical practices. These systems include such components as medication administration technology, transportation and messenger services, and computerized information systems. During site visits the development and use of patient classification systems based on acuity levels were frequently mentioned as the most desirable approach to determining staffing levels. Site visit teams also heard concerns from several different groups of hospital nursing staff about the fact that some hospitals have "backtracked" from an acuity-based system to a census-based system for determining staffing levels.

In urban areas, RN positions are infrequently vacant because of a number of changes in recent years, not the least of which are various cost containment and efficiency models that have resulted in the downsizing and restructuring of hospitals and comparatively high RN salaries in acute care settings. Those salaries

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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have led the administrative levels of hospitals to put pressure on nursing management to find and use care providers, such as NAs, who are cheaper than RNs. Several hospitals reported experiencing high turnover rates among NAs.

Committee members saw a variety of alternative models for delivering care and reengineering the delivery of nursing services. These included cuts in staff positions (either direct cuts or through attrition), implementation of team nursing, movement of some RNs into float pools, and use of "flexing"—(e.g., sending nurses home or calling them in partway through a shift). Until recently, facilities in some areas relied heavily on recruiting foreign-trained RNs. With one notable exception among the group of hospitals visited, these facilities are no longer actively recruiting from other countries to fill their positions and are not experiencing great difficulties in recruiting and retaining RNs. In fact, the overall supply of LPNs and RNs in hospitals appears sufficient, and new RN graduates are having difficulty finding jobs because facilities prefer to hire experienced RNs.

RNs and LPNs reacted to the changes in the way acute care is delivered—the restructuring and new models of patient care delivery—with strong concern about the quality and safety of future care. For some of those interviewed, this concern extended to the belief that current levels of care are a threat to the quality of patient care. Others believed that the overall quality of patient care is being maintained, but at a high personal and professional cost to nursing staff that cannot be sustained indefinitely.

Staffing Issues in Nursing Facilities

Three staffing issues for nursing facilities are notable: turnover and retention rates for NAs; adequacy of staffing levels, particularly in light of increasing patient acuity; and reimbursement levels for care. These issues did not differ dramatically from site to site because federal regulations have a significant and fairly uniform effect on both staffing and reimbursement levels. Nevertheless, labor markets, regulatory environments, and state reimbursement policies did differ by site; consequently, recruitment and retention also vary somewhat.

Almost all nursing facilities visited reported high turnover rates among NAs. As mandated by federal regulations, states and facilities provide training and certification for nursing-home-based NAs. Once trained and certified, however, these NAs often chose to leave long-term-care for positions in hospitals, which can afford to pay a little more per hour. Still other NAs leave the health care industry entirely when other jobs become available. Committee members heard reports of NAs leaving health care for retail jobs when a K-Mart opened or to waitress or clean in locations where the tourist industry was growing. In some areas the redesign of hospital staffing is causing NAs to move into acute care at a greater rate, which is increasing the demand for NAs in long-term care.

The need for more staff, particularly NAs, was expressed almost universally.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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Many NAs try to provide good care but there are not enough of them, particularly on weekends when staffing ratios are lower and getting people out of bed, giving baths, and other care tasks may be omitted. The same kinds of problems noted in the written and oral testimony were reported during some of the site visits: patients not being turned as required to prevent bed sores, being left on the toilet for prolonged periods, or not having their physiological needs attended to on time. Furthermore, the staffing levels mandated in some states were reported to have little relevance to the level of patient needs and work at most of the facilities visited.

In economically depressed areas, many of the NAs in nursing facilities hold permanent second jobs, either as NAs in other facilities or in retail settings. Their incomes as NAs are sometimes less than those they could receive as welfare recipients. Frequently, NAs must worry about child care. At one site, NAs could not afford health insurance coverage offered by the facility because it would cost approximately 75 percent of their salary; they were better off if they and their children were eligible to receive Medicaid.

Working as an NA is physically and emotionally grueling; it is hard physical labor for comparatively low compensation. Not surprisingly, NA turnover is one of the most pressing issues facing those who deliver long-term care. Even at facilities where NAs were fairly satisfied with working conditions, turnover rates were still 50 to 70 percent. Nationally, some facilities have annual turnover rates as high as 200 percent, and at most facilities a cycle of recruiting, hiring, and providing the mandated training to new NAs never ends. Consequently, facilities are not always very selective and do not always perform such quality control measures as criminal record checks on applicants.

In general, what site visit teams seemed to hear was that delivering care was much more difficult because of the increase in patient acuity and other factors, including the higher concentrations of extremely ill residents in nursing homes resulting from new care options such as board and care, home health, and hospital subacute units. Nevertheless, many NAs were doing what they could to deliver, despite static staffing levels and rising needs, at least a basic level of care.

Site visit teams heard reasons NAs continue to work at a facility. By and large, retention of NAs occurs despite low salary levels and little opportunity for advancement. Of those who stay, a personal commitment to the residents is often one of the primary reasons for doing so. Leaving is not, however, only a response to salary levels or to physical and emotional demands—"life events," such as the NA moving or seeking further education, are also factors. Nevertheless, it seemed as though those who stay have found sources of satisfaction and pride: one woman who had been an NA at a single facility for more than 20 years said "to me, a CNA [certified nurse assistant] is a high ranking people in a nursing home," while another noted that although she is injured and will never be able to do the full range of work she used to, she has an important educational role: "the younger ones come to me for help."

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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Different facilities have taken innovative approaches to recruiting and retaining NAs. One facility tries to assign NAs to residents on a permanent basis. Another has an NA leadership position that allows for recognition of the knowledge and achievements of senior NAs. Other approaches include tracking NA job satisfaction, offering health benefits to part-time employees, and providing financial assistance in becoming a licensed nurse. In contrast, most of the nursing facilities visited experienced relatively few problems with turnover of RNs and LPNs.

Quality of Patient Care and Quality of Life

Site visit teams heard many anecdotes about how inadequate staffing levels and mixes have threatened or diminished the quality of patient care. Many specific factors considered either to increase or to dilute the quality of care were mentioned and are discussed below. One issue applicable in all settings, however, is the need to meet the cultural and language needs of patients and residents.

Quality of Patient Care and Patient Life in Hospitals

Acute care institutions had quite varied responses to what sounded to the committee like fairly similar concerns about the quality of patient care and the costs of delivering care. The following example provides specific details of how one hospital changed the delivery of nursing services in order to improve the quality of patient care.

One of the committee's teams visited an acute care hospital that had recently restructured the delivery of nursing care. This facility operates in an area with high levels of managed care and has 5-year goals of maintaining and improving quality, decreasing costs, and shifting from inpatient to outpatient programs.

When committee members visited this hospital system, they saw the first test unit in which a new model for patient care had been implemented. Before implementation, 18 months were spent in planning. Job classifications were reduced from 80 or 90 to approximately 8, and service associate (SA) positions were developed. Three-person teams composed of an SA, an RN, and either a CNA or an LPN were formed to deliver care on the test unit. These changes were staff- and budget-neutral; the purpose was to make better use of nursing personnel.

High levels of staff participation and representation were reported in planning for use of the new patient care delivery model. Each test unit had its own implementation team, and techniques such as surveys, shadowing, and focus groups were used for planning purposes. A notable amount of time and money was also budgeted to train the teams. Registered nurses, for example, reported initially needing considerable coaching in delegation and supervision, and SAs needed to learn hospital policies and procedures, as well as ergonomic principles.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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All participants in the 4-week competency-based training module received large amounts of training in team building skills, including conflict resolution.

Some RNs had negative responses to the proposed changes before the new patient care model was implemented. Registered nurse tenures at the 2 campuses in this facility were 7 and 10 years, respectively, and some RNs did resign before implementation of the model. The RNs, LPNs, CNAs, and SAs with whom committee members spoke, however—whether already delivering care in teams or anticipating this change—appeared genuinely enthusiastic about the new model. The consensus, among both nursing and administrative staff, was that the new approach, along with many specific organizational or structural changes, allowed nursing staff to concentrate on patients and provide better-quality care.

Each team with an LPN was typically assigned 7 or 8 patients, while a team with a CNA would be assigned 6 patients; on a 12-hour shift, the total number of patients would go no higher than 10. Members of the care teams almost always work together and plan their shifts together, deciding among themselves whether to work four 12-hour shifts or five 8-hour shifts. They report knowing each others' capabilities well, trusting in and relying on each other, and cooperating to accomplish tasks. The satisfaction and enthusiasm of team members were most impressive, as was their acknowledgment of each individual's part in providing care.

The administrative staff with whom committee members met were cautiously optimistic, while the nursing personnel were extremely enthusiastic. Morale was high, and there appeared to be a pervasive conviction that the quality of patient care had improved. Even though the plan was staff-neutral, nursing staff spoke of feeling as though there were more staff than before implementation of the new model. All levels of team members reported feeling less stress and being more confident about the care delivered, because of the trust and communication among the three members of the team. More patient teaching was reported, and RNs reported feeling secure that in a time of crisis with a patient, other patients would be taken care of and they would be notified if an additional patient needed their attention. In terms of patients' responses to the change, staff related anecdotes of patients returned to the hospital demanding "their" care team and of positive comments from patients who had been on the unit prior to implementation of the new approach and could therefore compare the two models of care delivery. Administrative staff confirmed that patient responses were positive.

In conclusion, this new patient care model was instigated by the top levels of the health care system to improve the quality of care delivered. The leadership appears to have successfully created a system and environment in which a reorganization of patient services could take place that improved both the quality of patient care and the morale. Key factors identified by participants in this process were keeping staff aware of planned changes, involving them in decision making aspects of the new model, empowering the care giving staff, and leadership from top levels. The patient care model is still being improved; anxiety about the new

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
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model no doubt remains for some personnel, as do the stresses of transition. Additional facets of the plan have to be improved or clarified, such as ways of increasing communication along some lines (e.g., among teams or between teams and charge nurses). Nevertheless, care giver satisfaction with, and commitment to, the new patient care delivery model appear extremely high, and preliminary indications are that patient satisfaction has also noticeably improved. At the time of the site visit, the entire hospital system was expected to have converted to the new care model by 1 to 2 years after the first unit-level test of the new model began. Pre-implementation evaluations and two evaluations conducted during the implementation process should eventually provide data upon which to base an assessment of the model's success.

The level of involvement of nursing personnel in the shaping and implementation of change seems to account for some of the critical differences in the success of institutional restructuring. Based on insights provided by the site visits, hospitals appear more likely to be successful in restructuring when all or most of the following is true:

  • the top management levels of the institutions provide a strong vision, clear goals, and steady commitment to the reorganization;
  • nursing staff have the time and the opportunity to discuss with management both the goals of restructuring care and the ways in which these might be met;
  • nursing staff have autonomy and accountability in the delivery of care;
  • top management is open to discussion and suggestions and negotiates in good faith; and
  • reorganizations focus on improving the quality of patient care rather than on cost-cutting measures (e.g., are budget- and staff-neutral).

Collaborative change, where successful, resulted in visible confidence among the nursing staff in their ability to deliver quality care, unusually high levels of trust and teamwork, and clearer responsibility for the quality of patient care. In situations where relations between administration and health professionals appeared particularly bad, top-level administrators may have given insufficient value to nursing and not included nursing staff in the strategic plan processes at a decision making level.

Quality of Patient Care and Patient Life in Nursing Facilities

One factor that can positively affect the quality of patient care in long-term care is RN clinical leadership. Physicians have a minimal presence in most nursing homes, and the number of RNs in a facility is extremely low compared to other nursing staff; despite the high levels of acuity in most nursing homes, nationally RNs comprise less than 10 percent of the total nursing staff in long-

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

term-care facilities. Some site visit hosts believed that RNs' administrative and documentation responsibilities reduce the quality of patient care because RNs spend the majority of their time on paperwork rather than with residents. Combined, these factors lead to a deficiency of clinical expertise, minimal direct resident care by RNs or physicians, and lack of RN supervision and clinical leadership for LPNs and NAs. One facility seen by a site visit team used clinical nurse specialists to address these concerns and to implement programs such as a restraint reduction effort.

The extremely high turnover of NAs also exacerbates quality-of-care problems. NAs are the residents' primary care givers. According to some NAs with whom committee members met, LPNs provide little supervision and are unable to deliver adequate clinical support and care. Despite the fact that NAs spend the most time with residents and know them best, they have little or no input into residents' care plans.

Resident comfort is also an element of high-quality care. When one group of residents was asked what they valued, they cited security, medical care and the availability of physicians, and private rooms. (Residents may share a room with as many as three other people.) Other residents wanted more staff and more experienced staff on the night shift. At most of the sites visited by committee members, residents with whom the site visit teams met reported the care to be either good or adequate.

Yet another issue in the areas of quality of care and quality of life involves the assumptions and expectations of family members. Some care givers pointed out with frustration that a demanding individual or active family member can result in fairly elaborate attention being devoted to one resident, while someone who cannot speak up or has no family nearby—but who requires more care—may be shortchanged on basic care. On the other hand, site visit teams were sometimes informed that scheduled visits by inspectors or family members typically present a reassuring picture but that unannounced visits can be a different matter. If visitors are not expected, care may be limited or inadequate. Yet residents and family members are often afraid to complain for fear—whether realistic or not—of retaliation from care givers. At a meeting with LTC ombudsmen, site visit team members heard some grim stories of neglect, intimidation, abuse, and theft. The stories pointed out the many ways in which both the quality and the quantity of staff in nursing facilities can directly affect the quality of care and quality of life for residents.

Another quality-of-care point that was raised frequently in nursing home visits is that the current survey process and standards can override the clinical judgment of care givers and negatively affect the quality of patient care and quality of life. In at least one example recounted to the site visit team, the problem seems to have been rote enforcement of the OBRA guidelines without permitting the facility to explain the rationale for the restraint or discuss the resident's care plan and without consultation with the resident's family members.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

Finally, a few of the larger, more diversified long-term-care facilities are starting to use outcome measures of quality of care that will be meaningful to managed care entities; these include admissions to the hospital or emergency room, length of stay, and resident and family satisfaction.

Injuries and Stress

In general, discussions during site visits were more about stress than injuries. Information on injuries is equivocal. Some hospitals and nursing homes are maintaining or reducing rates of problems such as back injuries, needlestick incidents, and nosocomial infections. Other facilities expressed concern that injury rates have been reduced through education and training but will soon rise again because of the physical demands of nursing the current resident populations.

Nursing personnel are more subject to injuries than other workers; this is particularly true of NAs who work in nursing homes where many residents must be turned, lifted, or assisted in their toileting. Nevertheless, a noticeable number of facilities and nursing personnel did not seem to be concerned about traditional work-related injuries, probably because they are taking steps to reduce these. Such steps include the use of back supports when lifting, as well as educational programs, and the results seem to indicate that such efforts are often effective in reducing back injury rates.

A possible solution to the physical demands of providing long-term care is the provision of equipment and the use of technology. When NAs at one site were asked to list the equipment they would like to have, their wishes appeared surprisingly modest: hospital beds, bathtubs, shower chairs, bedside commodes, bed linen with rubber backing, and adult diapers were all mentioned as equipment that staff needed but often did not have. At first glance, these technologies might seem relatively unlikely to affect injury rates but the NAs explained that many of them do reduce the physical strain of caring for and lifting residents. Aides were open to the possibility of more technologically sophisticated equipment but were more aware of the basic tools they lacked.

Stress appears to affect nursing staff in a variety of ways. In acute care settings at least, anger, frustration, and confusion about restructuring and cost-cutting measures were often evident. It appeared to committee members that lack of empowerment or participation in the planning and implementation of restructuring, combined with uncertainty about their jobs or new responsibilities, clearly increased the stress level among nurses.

Many licensed nurses in acute care were concerned about the use of ANP, particularly since they are held responsible for the care provided by these unlicensed staff whether or not they are the ANP's supervisors. Committee members also heard reports of mandatory overtime and double shifts being common on weekends. "Floating" from one unit to another and reduced staffing levels be-

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

cause some staff are out on sick leave were frequently mentioned sources of stress, even at institutions with fairly satisfactory staffing levels. Even under good conditions and with sufficient training to establish the familiarity and competence of floating nurses, nursing personnel usually hate floating, often because of strong concerns about the quality of patient care that they can deliver when they are shifted from one location and one type of care to another.

Many of the complaints to LTC ombudsmen about care delivered in nursing facilities concern the inadequacy of staff, particularly at night and on weekends. Other complaints involve patient abuse. Many of those interviewed believed that abuse is most likely when nursing personnel are understaffed or are taking care of unfamiliar residents. Complaints to ombudsmen often result in formal surveys by the state units that handle licensure and certification; the survey process is a mechanism for identifying inadequate care that can result in the issuance of statements of deficiencies against facilities.

More generally, patient acuity levels are up in long-term-care facilities, and staffing levels are insufficient; this situation is compounded by turnover rates that leave staff habitually working shorthanded. Not surprisingly, overall staff stress is high. Specific sources of stress for NAs are lack of time, constant turnover of staff, inadequate time to orient and help new staff, and the addition of unpredictable, poorly prioritized tasks to their responsibilities.

As noted earlier, many facilities and staff in highly urban areas are concerned about the vulnerability of nursing staff to increased stress and injury inflicted by patients. The increase in patient violence toward nurses seems to be more prevalent in settings where a general societal increase in violence and other social ills is evident (e.g., emergency rooms, municipal hospitals, psychiatric units, and nursing home dementia units). The increased violence appears most likely to occur when care is being provided to prisoners, drug abusers, the homeless, and the mentally ill. The level of experience and training of the care provider becomes an issue in these situations. Sometimes the danger is augmented because a less prepared provider is unable to control a situation or does not have the assessment skills to identify such a situation far enough in advance to avoid conflict. A few facilities reported that nonviolent crisis intervention is taught to all emergency room staff.

Reimbursement Issues

Most reimbursement issues raised to committee members were concerned with long-term care. Medicare and Medicaid reimbursement rates are seldom sufficient to cover the actual costs of providing care and can easily be half the average costs. For this reason, private-pay residents are preferred. The rates charged private-pay residents differ widely by facility, region, and resident, but they ranged in just one facility from $27,600 to $59,000 per year. Inadequate

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

reimbursement from Medicaid also makes it difficult for administrators to get physicians into the facilities for routine, required visits to Medicaid patients.

The response of one facility to financial concerns was to set a goal of converting the entire facility into a subacute unit, which yields better (Medicare) reimbursement rates that the current (Medicaid) payments for long-term-care residents. Two facilities, in contrast, were very diversified; they offered many services such as a profitable home health agency or assisted living facility; educational programs, consultations, and workshops; on-site, ongoing NA training; and a day care center. Such facilities may also be seeking more managed care contracts, which some facility administrators consider critical for future financial stability.

Some hosts argued that the current system for reimbursement needs to be improved because it offers no motivation or reward for providing restorative or preventive nursing care. They recommended that the base reimbursement rate be tied to acuity (e.g., activity-of-daily-living factors) and that incentive payments be given for achieving positive outcomes. These outcomes should not necessarily be limited to improvements in health; the avoidance of poor outcomes (e.g., low decubitus, incontinence, or hospitalization rates) should also be considered.

Education

Throughout the site visits, the topic of education—whether initial, continuing, clinical, academic, or managerial—was frequently raised. The majority of those interviewed on site visits felt that the educational preparation of new RNs is insufficient. Assessment skills may be adequate but judgment, experience, knowledge of medications, and leadership and delegation skills are lacking. The need for baccalaureate-prepared RNs was noted by both educators and nursing leaders. Some spoke of the need for nurses in intensive care units to be trained with 6-month internships after graduation. Many mentioned that new graduates need more rehabilitation and geriatrics in their educational program, and some expressed the opinion that 2-year associate degree programs are inadequate to prepare nurses for their roles in the current evolving health care system. Adequate preparation is especially necessary when nurses have to plan the care for patients who require exceptional assessment.

According to some staff nurses in hospitals, one difficulty facing new RN graduates is that they simply have not been prepared for the work. Their schooling is mostly theoretical, and these staff nurses felt that neither associate degree nor bachelor's degree RNs have received the necessary preparation and orientation. Educators, in contrast, point out that changes in the delivery of acute care have exacerbated the difficulty of the transition from school to work because facilities no longer have time to teach new staff, and often those who used to teach them (e.g., staffing coordinators, clinical nurse specialists) have heavy patient loads or have been dismissed.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

The need for clinical leadership for nursing personnel and for educational preparation and training was a topic that recurred several times and across settings. Registered nurses' difficulties in delegation and the importance of being good nurse managers were noted. Some nurses spoke of the role of the RN ''becoming expensive" and the need to maximize these nurses by delegating functions to others such as LPNs and NAs whom RNs would then supervise. It was suggested at more than one site visit that RNs need to be explicitly instructed in delegation, management, and supervision and that these subjects ought to be in the curriculum of the educational program.

On the topic of NA training, several CNAs who had worked as uncertified NAs while attending certification classes believed that this combination of learning and experience prepared them better than only attending classes would have. They also pointed out that it might be an efficient way to "weed out" those student NAs who would not continue working in long-term care once they experienced the day-to-day work. The disadvantage is that this double load of work and learning can be tiring. They also identified a need for additional training and, most particularly, additional supervision of newly certified NAs after they have started working; this is the time when new CNAs need explicit guidance and reinforcement in translating their training into clinical care.

Concluding Remarks About Site Visits

The site visits were a vital part of the IOM committee's information gathering efforts. They provided committee members with opportunities to learn about a variety of staffing issues in acute and long-term care and to ground their discussions and deliberations in an appreciation of the complex ways such issues play out in the actual delivery of bedside care. Furthermore, the site visit teams benefited from the opinions, expertise, and experiences of a number of individuals and organizations in the areas of health care delivery and policy; nursing care and nursing administration; hospital and nursing home administration; labor relations; state-level regulation and oversight of nursing facilities; nursing education; resident advocacy; business concerns; and health care policy.

Despite the fact that committee members often had quite different experiences on site visits, analysis of all this information enabled them to reach several overarching conclusions:

  • Issues such as increased patient acuity, difficulties in recruiting and retaining NAs, and the effects of reimbursement systems and rates on the ways in which care is delivered are increasingly crucial factors influencing the quality of care and the safety of the workplace.
  • Hospitals are restructuring the delivery of health care in many diverse ways, and gathering and using data on these changes are difficult challenges for hospitals, nursing personnel, consumers, payers, and other concerned groups.
Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×
  • The links between reimbursement and patient acuity levels or case-mix could be strengthened.
  • In both nursing homes and hospitals, flexibility in staffing arrangements and in nursing personnel's approaches to work can result in improved morale and quality of care.
  • High-level leadership and direction within a facility are critical for maintaining and improving the quality of patient care.

The committee is grateful to the individuals and organizations that hosted its visits. In addition to the information conveyed in person, many sites and individuals provided information before and after the visits. It is impossible to document the myriad forms of assistance that were provided, but the committee wishes to express here its recognition of the expenditure of time and energy on the part of all those who helped committee members.

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

EXHIBIT 1.1 Request by the Committee on the Adequacy of Nurse Staffing for written testimony.

INSTITUTE OF MEDICINE

2101 Constitution Avenue, Washington, D.C. 20418

Division of Health Care Services TEL (202) 334-1321

Committee on the Adequacy of Nurse Staffing FAX (202) 334-2031

The Adequacy of Nurse Staffing:

Stress, Injury, and Quality of Care

Request For Testimony

The following is an open invitation to prepare written testimony for submission to the Institute of Medicine (IOM) Committee on the Adequacy of Nurse Staffing, with the opportunity for oral presentation before the committee at a later date. Any organization or individual may submit testimony to the committee, but written statements are to be received no later than September 26, 1994. Please read further for more details.

Background

The Congress of the United States, following 1993 hearings on the current state of staffing of nursing personnel in hospitals and nursing homes, directed the Secretary of the Department of Health and Human Services to request a study from the Institute of Medicine, National Academy of Sciences, to determine whether and to what extent there is a need for an increase in the number of nurses in hospitals and nursing homes in order to promote the quality of patient care and reduce the incidence among nurses of work-related injuries and stress. For the purposes of this legislative mandate "nurses" includes registered nurses, licensed practical and vocational nurses, and nursing assistants and aides. The Congress has requested a formal report at the conclusion of this study.

Providing Testimony

To respond to this request, the IOM has established a committee of 15 experts representing a wide range of expertise (the committee roster is attached). As part of the committee's activities, written testimony is being solicited from organizations and groups representing all points of view on the subject, with the opportunity for oral presentation before the committee and to respond to the committee's

Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×

questions. Two invitational sessions, each one-half-day long, will be convened — one in Washington, D.C., and the other in Irvine, California. The committee will make every effort to accommodate as many oral presentations as possible within the very limited time available for each session. Those organizations and individuals asked to present oral statements will be grouped in panels, asked to confine their remarks to about 5-7 minutes summarizing their written testimonies, and requested to be prepared to respond to committee members' questions. These sessions will be open to the public for observation. Reporters interested in attending the oral presentation sessions should contact the Office of News and Public Information at 202-334-2138, or through Internet at NEWS@NAS.EDU.

These hearings are an opportunity for the committee members to obtain firsthand an extensive range of opinion on the matters under consideration. Written and oral statements will be summarized by staff for the committee after they are completed. The topics to be addressed in the written testimony are provided in the following Guide to Preparing Testimony.

Guide to Preparing Testimony

First, as background, briefly describe your organization and its activities; existing brochures or publications are acceptable. Then, to the extent possible, please address at least the topics listed below. Your written statement may be as long as you choose and you may confine your remarks to only hospitals or only nursing homes, if you prefer. Please note that, in accordance with the legislative mandate for this study, the term "nurses" is used to cover registered nurses, licensed practical and vocational nurses, and nursing assistants and aides. All testimony should include a one-page executive summary and a cover letter identifying the name, affiliation, address, and telephone number of the contact person.

  1. Your experiences with and conclusions about the current status of nurse staffing and its adequacy (both for numbers and skill mix), effects on the quality of patient care, and effects on nurses' work-related well-being.
  2. The gaps in knowledge and documented evidence in the areas that the committee is studying, and priority areas and concerns.
  3. The measures that are or should be used to assess the impact of nurse staffing levels and skill mix on the quality of nursing care and patient well-being.
  4. The measures that are or should be used to assess the impact of nurse staffing levels and skill mix on nurses' work-related well-being (including stress and injuries).
Suggested Citation:"1 Study Activities." Institute of Medicine. 1996. Nursing Staff in Hospitals and Nursing Homes: Is It Adequate?. Washington, DC: The National Academies Press. doi: 10.17226/5151.
×
  1. Beyond anecdotes, what data are available to support the committee's analysis? What resources and mechanisms exist to confirm and strengthen anecdotal information? Can you provide any of these resources or data?
  2. The appropriateness and adequacy of current nursing undergraduate, graduate, and in-service education and training in addressing the changing delivery and organization of health care.
  3. What data or information are available relating to the institutional cost-benefits, quality of patient care, and nurses' work-related well-being associated with restructuring of the delivery of nursing care utilizing different skill mixes? What information is available about patients' satisfaction with different skill mixes in nursing care?
  4. Keeping in mind the current national environment for cost containment, please note any suggestions you have for the committee.

Please note that all written statements are to be received no later than September 26, 1994. Feel free to distribute this announcement to others who may wish to submit written testimony. Questions regarding the written statements may be directed to Gooloo S. Wunderlich, Ph.D., Study Director, at Institute of Medicine, 2101 Constitution Avenue, NW, Washington, DC 20418.

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Hospitals and nursing homes are responding to changes in the health care system by modifying staffing levels and the mix of nursing personnel. But do these changes endanger the quality of patient care? Do nursing staff suffer increased rates of injury, illness, or stress because of changing workplace demands? These questions are addressed in Nursing Staff in Hospitals and Nursing Homes, a thorough and authoritative look at today's health care system that also takes a long-term view of staffing needs for nursing as the nation moves into the next century. The committee draws fundamental conclusions about the evolving role of nurses in hospitals and nursing homes and presents recommendations about staffing decisions, nursing training, measurement of quality, reimbursement, and other areas. The volume also discusses work-related injuries, violence toward and abuse of nursing staffs, and stress among nursing personnel--and examines whether these problems are related to staffing levels. Included is a readable overview of the underlying trends in health care that have given rise to urgent questions about nurse staffing: population changes, budget pressures, and the introduction of new technologies. Nursing Staff in Hospitals and Nursing Homes provides a straightforward examination of complex and sensitive issues surround the role and value of nursing on our health care system.

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