Better work conditions for nurses urged

Long hours, paperwork, lack of training can lead to errors, committee says

November 05, 2003|By Julie Bell | Julie Bell,SUN STAFF

Nurses are often overworked, undertrained and distracted by paperwork, a situation that contributes to medical errors that cause preventable deaths and injuries, a government advisory panel reported yesterday.

The report from an Institute of Medicine committee, which called for an overhaul of working conditions for nurses, recommended that nursing homes have at least one registered nurse on duty at all times and said staffing levels should increase as the number of patients increases.

The current federal standard is for an R.N. to be there at least eight consecutive hours every day.

The report also pressed state regulators to limit nursing shifts to 12 hours in any 24-hour period and no more than 60 hours in a seven-day stretch. That requirement is in a House bill backed by the American Nurses Association.

"All the health professions contribute to errors occurring, but nursing plays a very special role," committee Chairman Donald M. Steinwachs said, noting that nurses are positioned to catch others' mistakes. "It's the profession by the bedside."

The 18 recommendations came nearly four years after another Institute of Medicine panel focused national attention on patient safety by estimating that medical errors kill up to 98,000 hospital patients a year.

Yesterday's report offered no such revelations, but experts said it's still likely to focus attention on crises in a profession that, when nursing assistants are included, accounts for 54 percent of all health-care workers.

"It provides legitimacy to this whole arena of working conditions being so important" to patient safety, said Linda H. Aiken, director of the University of Pennsylvania Center for Health Outcomes and Policy Research, which has studied the link between patient safety and nurses' workloads, education and overtime hours.

The 327-page report, titled Keeping Patients Safe: Transforming the Work Environment of Nurses, comes amid a shortage that has left Maryland, a state with about 60,000 registered nurses, about 2,000 short, according to the Maryland Nurses Association.

Nationwide, hospitals are filling shifts with temporary workers, hiring foreign nurses and, all too often, asking nurses to work so much overtime that fatigue alone causes them to make mistakes. The conditions have created a vicious cycle, encouraging some registered nurses, many of whom are nearing retirement, to leave the profession, studies have shown.

At the same time, hospital patients are more acutely ill than they once were, and stays have shortened. That means nurses are expected to care for patients "sicker and quicker," the report said.

The committee's staffing recommendations and caps on hours worked might be difficult to achieve when hospitals are hard-pressed to fill shifts, committee members acknowledged.

But Steinwachs, who also is chairman of the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, said the study shows ways in which nursing can be made more efficient.

For example, storing supplies in rooms where work is done would allow nurses to spend less time running from place to place to collect them. Having other workers transfer patients would free nurses for monitoring those who need it.

"If you look at the full set of recommendations, we address areas that would free up nursing time to do critical nursing tasks," Steinwachs said. He noted that "nurses spend 13 to 28 percent of their time in documentation" - time he said probably could be reduced by using improved systems.

The panel also recommended that nurses participate in decision-making at all levels, noting that many hospitals have cut their separate nursing departments and reduced the power of chief nursing officers. "The situation hampers nurses' ability to fix problems in their work environments that threaten patient safety," the report said.

The report noted real-life examples linking nurses' working conditions to patient safety, including an incident in which an inexperienced nurse was assigned to insert a urinary catheter. After running from floor to floor to gather the supplies she needed, including gloves and antiseptics, she fumbled the procedure, leading to an infection in the patient.

A Johns Hopkins University team of patient safety experts has found similar examples through an anonymous incident reporting system it set up for at least 22 intensive care units across the country.

In about 75 percent of cases, nurses were the ones reporting to the system, and in most of those cases they were reporting on their own work, said Dr. Albert Wu, a Johns Hopkins associate professor and a principal co-investigator for the study.

About 10 percent of the cases involved fatigue by health-care workers, and about 10 percent noted heavy workloads as contributing factors to their mistakes.

In one case, a nurse in the 15th hour of her shift said she simply didn't see an order to give a patient antibiotics. In another, a supervisor whose workload became unbearably heavy when a number of nurses were out sick said she programmed twice the desired dose of a blood-pressure medication into an infusion pump.

"Nurses are a vital component, and one that often delivers care," Wu said. "We are basically setting up our best people to fail, and that is something people should get outraged about."

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