AACN JOINS INSTITUTE OF MEDICINE
IN URGING MORE
DATA ON NURSE STAFFING
Institute Calls for Higher
Numbers of Advanced Practice Nurses
for Hospitals,
Nursing Home Care
WASHINGTON, D.C., January 23, 1996
-- The American Association of Colleges of Nursing (AACN)
endorses an Institute of Medicine (IOM) call for more systematic
research and data on how changes in hospital nurse staffing
affect the quality of patient care, and shares the Institute's
strong concern that hospitals are engaging in broadscale
restructuring and changes in staffing patterns without adequate
monitoring or evaluation of their impact on patient outcomes.
"Hospital redesign in this nation
is occurring in sweeping and historic proportions, yet the
new staffing patterns being created from these actions are
being made with virtually no research or data to guide it,"
says AACN President Rachel Z. Booth, PhD, RN, in response
to a report by an IOM committee on the adequacy of nurse
staffing in hospitals and nursing homes.
"The Institute's findings confirm
AACN's concerns that decisions to reduce hospital nurse
staffing are often based less on appropriate, safe, and
effective use of personnel and more on short-term, short-sighted
solutions to cut costs."
At the request of Congress, the IOM committee
studied relationships among staffing levels, the mix of
different types of nursing personnel, and the quality of
patient care in hospitals and nursing homes, as well as
the incidence of work-related injuries and stress among
nursing staff. While noting the view of several researchers
that the nation's total of 2.2 million RNs is sufficient
to meet national needs at least for the near future, the
committee's report found that the educational mix of RNs
"may not be adequate to meet either current or future
demands of a rapidly changing health care system."
Workforce adequacy must be defined both in terms of numbers
of RNs and the mix of their knowledge and skills, the IOM
panel concluded.
In particular, AACN commends the IOM panel
for urging that increasing numbers of registered nurses
with advanced practice skills be utilized in outpatient
and inpatient settings to meet the demand for RNs with management,
leadership, and supervisory abilities. As the panel noted,
advanced RNs such as clinical nurse specialists not only
provide high-quality and cost-effective care especially
for patients with complicated or serious clinical conditions,
but are well-skilled for the sophisticated levels of practice
required in today's hospitals, where working on multi-disciplinary
teams and delivering a continuum of care across settings
rather than a "single event" of hospitalization
are increasingly becoming the norm.
As does the IOM committee, AACN also recognizes
the need for hospital leaders to involve "at the outset"
nursing personnel who are directly affected by redesign
and staffing pattern changes. Growing reports of RN layoffs
indicate that hospitals are replacing registered nurses
with lesser-skilled, lower-paid aides and unlicensed assistive
personnel. Anecdotal information from nurses in many hospitals
indicates that basic procedures such as dispensing medication,
inserting catheters, changing surgical dressings, monitoring
blood sugar levels, and maintaining patients' charts at
times are being performed by assistants with only a few
weeks or less of training.
AACN agrees that more systematic data on
such practices and on reassignments of existing nursing
staff are vitally needed to understand the scope of the
problem and its impact on the quality of patient care. In
particular, AACN commends the panel for recognizing the
"harmful and demoralizing effects" these changes
can and have caused nursing staff and for urging that such
effects be "mitigated if not forestalled altogether"
by the hospital industry's active involvement of nursing
personnel at the earliest stages of redesign efforts.
"We echo the report's concern
over the shortfall of objective research on the relationships
among restructuring, staffing, and quality, and urge the
development of a research agenda by the National Institute
of Nursing Research and other relevant federal agencies
and private organizations that sheds additional light on
how staffing levels and mix, the processes of patient care,
and patient outcomes are related," Dr. Booth says.
This is especially critical, the IOM committee notes, given
the practice of some hospitals to implement restructuring
without regard for other approaches that could produce "better
patient outcomes with "fewer, more appropriately trained
and used staff."
Moreover, "while we agree with the
IOM that hospitals must require documented evidence of the
competency of assistive personnel and for that competency
to be tested and certified by an appropriate entity, this
does not go far enough to provide nursing with sufficient
autonomy over its own practice," Dr. Booth says. "Actual
decisions to hire unlicensed assistive personnel and other
aides, and deciding what duties can be safely delegated
to them, must be performed by registered nurses in order
to assure the health, safety, and welfare of patients."
"The aim of employing assistive
personnel is to enable the registered nurse to focus on
the patient," Dr. Booth explains. "Nursing is
ultimately accountable for the quality of care it provides.
As such, RNs not only should supervise all nursing personnel,
but also define the appropriate educational preparation
for all individuals delivering nursing care."
Indeed, this supervision must be carried
over into nursing homes, as well, where the intensive level
of nursing assistants' direct care responsibilities and
the minimal training for resident care required of them
make professional oversight and close supervision by registered
nurses critical, particularly given the increased acuity
of today's residents, the IOM report urges.
"Based on the empirical evidence
amassed, the committee concludes that a strong relationship
between RN-to-resident staffing in nursing facilities and
various dimensions of quality, especially resident outcomes,
has been established," the committee reported.
AACN strongly supports the committee's call
for 24-hour presence by RNs in nursing homes to enhance
the current 8-hour requirement. "Indeed, we find it
surprising -- to say the least -- that this recommendation
has been tagged 'controversial' by many observers,"
Dr. Booth says. "Round-the-clock staffing by registered
nurses in a nursing home should be as
controversial as 24-hour physician presence in a hospital
emergency room. Anything less is substandard care that compromises
the welfare and safety of patients."
AACN also commends the IOM committee's urging
that nursing home care be enhanced through increased presence
of gerontological nurse specialists and nurse practitioners,
enriched training of nurse assistants (who comprise 70 to
90 percent of nursing home staff), and strengthened leadership
in nursing homes through higher educational requirements
for these facilities' directors of nursing, most of whom
the committee notes "are not academically prepared
for their positions."
These changes are especially vital, the
committee explains, as nursing homes not only take on increasingly
dominant roles in long-term care, but are utilized more
as sub-acute care facilities to provide transitional treatment
as patients are discharged faster from hospital stays.
The American Association of Colleges
of Nursing is the national voice for university and four-year-college
education programs in nursing. Representing more than 580
member schools of nursing at public and private institutions
nationwide, AACN's educational, research, governmental advocacy,
data collection, publications, and other programs work to
establish quality standards for bachelor's- and graduate-degree
nursing education, assist deans and directors to implement
those standards, influence the nursing profession to improve
health care, and promote public support of baccalaureate
and graduate nursing education, research, and practice.
###
CONTACT: Robert Rosseter
(202) 463-6930, x231
rrosseter@aacn.nche.edu
