 | The 131st Annual Meeting (November 15-19, 2003) of APHA |
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| The 131st Annual Meeting (November 15-19, 2003) of APHA |
Lynn Unruh, PhD, RN, Health Services Administration Program, University of Central Florida, HPA-2, Rm 210L, Orlando, FL 32816-2200, (407) 823-4237, lunruh@mail.ucf.edu
Nurse understaffing has received significant press lately due to 1990s downsizing and the current nursing shortage. Surveys of nurses report that workloads are unmanageable, and that patient care quality is suffering (Shindul-Rothschild, Berry & Long-Middleton, 1996; Aiken, Clarke, Sloan, et al., 2001). Several new studies point to an inverse relationship between staffing levels or mix on the one hand, and patient outcomes on the other (Aiken, Clarke, Sloane, et al., 2002; Kovner, Jones, Zhan, et al., 2002; Needleman, Buerhaus, Mattke, et al., 2002; Unruh, 2003). Yet until recently, understaffing has not been addressed as a safety issue. For example, Institute of Medicine (IOM) reports on patient safety suggest many system changes to improve safety without mentioning adequate staffing (IOM, 2000, 2001).
The first statement regarding understaffing and safety came from a 2002 Joint Commission on the Accreditation of Health Care Organizations (JCAHO) report, Health Care at the Crossroads. JCAHO revealed that staffing was a factor in 24% of sentinel events, and recommended that institutions set staffing levels based on nurse competency, skill mix, patient mix, and patient acuity. Aside from this report, the relationship of understaffing to medical error remains unexplored.
We examine nurse understaffing as a significant source of medical error. First, we develop a framework for the role of understaffing in medical error, drawing upon human factors and systems analyses. Understaffing is identified as a latent cause of medical error. Understaffing causes work overload, which creates conditions for skill-, rule- and knowledge-based errors. We discuss how understaffing impacts patient safety through a structure-process-outcomes framework. We also consider that institutional staffing decisions are not the most distal latent error in the system. Reimbursement mechanisms that place financial pressures on institutions, and the lack of supply of appropriate nursing staff, may stand behind staffing decisions.
We review research that supports the understaffing-medical error connection. Studies find that lower RN/patient ratios, licensed nurse levels, RN/nurse or licensed nurse/nurse are associated with higher institutional rates of complications, falls, failure to rescue, medication errors, mortality, nosocomial infections, patient/family complaints, and skin breakdown.
The paper concludes with policy and research suggestions. We call for a reexamination of public and private payment systems that may not adequately reimburse institutions for their costs of hiring the proper numbers of appropriately skilled nurses. We discuss the current nursing shortage and measures to overcome it. Finally, we suggest various ways to improve staffing at the institutional level.
Learning Objectives:
Keywords: Safety, Quality Improvement
Presenting author's disclosure statement:
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.