11.04.2003

Institute of Medicine Study Links RN Staffing to Patient Safety Calls for Major Changes in Nurse Staffing and Work Environment To Protect Patients

Report Underscores Concerns of Massachusetts Nurses Who are Pushing for Legislation to Regulate RN Staffing Levels

CANTON, Mass.—Adding to mounting evidence that inadequate RN staffing in hospitals threatens patient safety, a report from the Institute of Medicine of the National Academies released today said, "The environment of nurses, the largest segment of the nation's health care work force, needs to be substantially transformed to better protect patients from health care errors."

The report calls for changes in how nurse staffing levels are established and for mandatory limits on nurses' work hours as part of a comprehensive plan to reduce problems that threaten patients. In a statement, the blue ribbon panel said, "Despite the growing body of evidence that better nurse staff levels result in safer patient care, nurses in some health care facilities may be overburdened. For instance, some hospital nurses may be assigned up to 12 patients per shift."

"There is a clear relationship between staffing levels and patient safety," said Donald M. Steinwachs of Johns Hopkins's Bloomberg School of Public Health and chair of the Institute of Medicine committee.

"This is what MNA long has been arguing," said Karen Higgins, president of the Massachusetts Nurses Association, which is promoting safe RN staffing legislation (H.1282) that would address many of the problems identified in the report. "I couldn't have put it more clearly myself. Fatigue and overwork, brought on by understaffing, are causing errors in patient care."

Higgins points to a number of other reports and surveys released in the last few months, including a Department of Public Health report detailing a 76% increase in patient injuries, complaints and medication errors in Massachusetts hospitals. A recent survey of nurses in Massachusetts conducted by Opinion Dynamics Corporation found that a vast majority of nurses in Massachusetts attributed a rise in medical errors, complications and even patient deaths to the regular practice of nurses being assigned to many patients to care for. A survey released this week of the general public found that more than 60% attributed a deterioration in the quality of patient care to understaffing of registered nurses in hospitals.

The Institute of Medicine report calls upon the hospital industry to increase staffing levels to accommodate changes in patient volume on a given shift, it asks leaders of hospitals to grant front-line nurses the power and ability to stop admissions to units that are understaffed, and it calls upon nursing leaders to involve direct care nursing staff in identifying the causes of nursing staff turnover and in developing methods to improve nursing staff retention. It also recommends nurse-to-patient ratios be established in nursing homes, and for one RN for every two patients in hospital intensive care units.

Unfortunately, the hospital industry has consistently refused to implement any of the changes recommended in the report, and consistently implements staffing practices that place the health and safety
of patients in jeopardy. As the National Academy panel said, "The solutions would seem obvious, but they aren't being made because the culture of healthcare institutions is blocking changes." In fact, a portion of the report is devoted to the widespread mistrust front-line nurses have for administrators within the health care system, and the report identifies past practices of the industry as an underlying cause of the problems we now face.

According to the report, "Along with changes in staff levels and hours, hospital restructuring initiatives begun in the mid-1980s led to substantial changes in how nurses work. As hospitals tried to respond to the financial pressures resulting from modifications to public and private insurance payment systems, their efforts altered the ways in which nurses are organized to provide care and, in many cases, undermined trust between nurses and management."

Higgins said the findings point to the urgent need for the Massachusetts Legislature to pass safe RN staffing legislation (House 1282). The bill accomplishes the goals set forth by the IOM report and it does it right away. "We can't afford to wait for the health industry to do what it should have been doing for the last 15 years. Without regulations guaranteeing patients the care they deserve, they will never get it. And people will most certainly die as a result."

"Our primary concern about the National Academy report is that it does not go far enough in proposing specific actions," said Julie Pinkham, MNA's executive director. "Self regulation by the hospital industry over RN staffing has been a total failure and as a result, patients in our hospital are being harmed on a daily basis. We need this legislation to ensure that patients receive the care they deserve and to prevent further unnecessary harm."

Pinkham noted that the panel recommended a minimum nurse-patient ratio of one nurse for every two patients in Intensive Care Units (ICU). But, she warned, "it was already proven in California – where ICU staffing levels have been regulated for three decades – that a piecemeal approach cannot work. California adopted comprehensive RN-to-patient ratios for all hospital units, similar to those in the Massachusetts legislation, precisely because hospitals tried to evade the regulations by shifting patients who should have been in ICUs to other units.

H.1282, which aims to mandate minimum RN-to-patient ratios in all acute care hospitals in Massachusetts, was developed in response to studies by the New England Journal of Medicine, The Journal of the American Medical Association, JCAHO, and other prestigious researchers revealing that the more patients a registered nurse cares for, the higher the risk of injury, illness and mortality to those patients. The bill calls for the creation of a standardized patient classification system to adjust nurse staffing on a daily basis to provide the flexibility called for in the IOM report. It also would prohibit the use of forced overtime beyond the 12-hour limit set forth in the IOM report. It also calls for maintaining support systems for nurses to allow them to work to their optimum level as recommended in the IOM report.

The safe staffing bill was filed by Rep. Christine Canavan, RN (D-Brockton) and the MNA. It is co-sponsored by 101 out of 200 members of the Legislature, including 14 of the 17 members of the Joint Committee on Health Care.

In addition to legislative support, the bill has garnered strong support from 64 health care and consumer advocacy groups that have joined forces with Bay State RNs to form the Coalition to Protect Massachusetts Patients, which will push for the urgently needed measure to safeguard hospital patients. Information about the Coalition and the safe staffing legislation can be found at www.protectmasspatients.org.