Chapter 3: The Moral Climate of Health Care

Section 6. Readings

The story below indicates a form of institutional malpractice.

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The New York Times,  February 18, 2002

9 of 10 Nursing Homes Lack Adequate Staff, Study Finds


Anna M. Spinella of Tampa, Fla., has become an advocate for legislation protecting nursing home residents. She said she had friends and relatives at Florida nursing homes that were "dreadfully short-staffed."

WASHINGTON, Feb. 17 More than 90 percent of the nation's nursing homes have too few workers to take proper care of patients, a new federal study has found.

But the Bush administration, citing the costs involved, says it has no plans to set minimum staffing levels for nursing homes, hoping instead that the problem will be resolved through market forces and more efficient use of existing nurses and nurse's aides.

The report, ordered by Congress and prepared by the Department of Health and Human Services, concludes that "it is not currently feasible" for the federal government to require that homes achieve a minimum ratio of nursing staff to patients, as many experts have recommended, largely because of cost. It would take $7.6 billion a year, an 8 percent increase over current spending, to reach adequate staffing levels, the report says.

Instead of imposing new rules, the Bush administration said, it wants to publish data on the number of workers at each nursing home, in the hope that "nurse staffing levels may simply increase due to the market demand created by an informed public."

Also, the administration said, it will encourage nursing homes to adopt better management techniques, so nurse's aides can achieve "high productivity."

The report, which will be sent to Congress in a few weeks, found "strong and compelling" evidence that nursing homes with a low ratio of nursing personnel to patients were more likely to provide substandard care.

Patients in these homes were more likely to experience bedsores, malnutrition, weight loss, dehydration, pneumonia and serious blood- borne infections, the report said.

Its conclusions about the prevalence of staffing problems were borne out in interviews around the country with relatives of nursing home residents.

Anna M. Spinella, 67, of Tampa, Fla., said she had friends and relatives at nursing homes that were "dreadfully short-staffed."

As a result, said Mrs. Spinella, an advocate for legislation protecting nursing home residents "a lot of people are left in bed, wet, and labeled as incontinent and bedbound when, in fact, they are continent, but the nursing home does not have enough staff to transfer them from bed to the bathroom."

State inspection reports confirm that concern, saying that patients at a Tampa nursing home were found in "wet, unchanged beds."

Phyllis A. Moga, 50, said she visited her mother three times a week for three years at a nursing home in suburban Detroit.

"Food was put in front of the residents, but there was not enough staff to help them eat," Ms. Moga said. "Many patients have dementia or are stroke victims, so they don't have the ability to feed themselves, or even to know they should be eating."

On two occasions, Ms. Moga said, "I caught a woman who was climbing out of bed and was trapped in the bedrail, screaming for help, but there was no staff nearby to help her."

In most nursing homes, the report said, a patient needs an average of 4.1 hours of care each day 2.8 hours from nurse's aides and 1.3 hours from registered nurses or licensed practical nurses.

Dr. John F. Schnelle, a co-author of the report, said the recommendations would require homes to have one nurse's aide for every five or six residents from 7 a.m. to 11 p.m. Currently, he said, it is common for nursing homes to have 1 aide for every 8 to 14 residents.

"In 2000, over 91 percent of nursing homes had nurse aide staffing levels that fell below the thresholds identified as minimally necessary to provide the needed care," the report said.

In addition, it said, "over 40 percent of all nursing homes would need to increase nurse aide staffing by 50 percent or more to reach the minimum threshold associated with their resident population."

Curtis R. Montgomery, 44, a certified nursing assistant in Monterey, Calif., said patients were more likely to fall and injure themselves in homes that were short of staff members.

"There's nobody to walk with the patients from the dining room to the bedroom, and they fall when they try to do it on their own," Mr. Montgomery said in an interview.

Sephia A. Nava, 43, a certified nursing assistant in Manteca, Calif., said: "Patients are supposed to be turned every two hours, and they're supposed to get showers twice a week, but when one nurse's aide is responsible for 15 patients, how can you do that? It's almost impossible."

The study highlights difficult choices that will increasingly confront an aging society. The population age 85 and older, the group most likely to need long-term care, is expected to double, to 8.9 million, by 2030.

Congress ordered the study in a 1990 law. The Clinton administration issued preliminary findings in July 2000. The Bush administration is expected to send Congress the final report and recommendations within a month.

To reach the recommended staffing levels, the report said, nursing homes would have to hire 77,000 to 137,000 registered nurses, 22,000 to 27,000 licensed practical nurses and 181,000 to 310,000 nurse's aides. This would increase overall demand for registered nurses by 5 percent to 9 percent, while the demand for nurse's aides would rise 13 percent to 21 percent. Nursing home executives said they would have difficulty finding the additional workers.

The figures reflect the number of additional nursing employees needed to care for Medicaid patients, who account for about two-thirds of nursing home residents, and Medicare patients, who typically have shorter stays.

Nurse's aides provide 90 percent of the front-line care in nursing homes. They help patients with eating, dressing and going to the bathroom, provide regular exercise for many patients and reposition those who are immobile.

Medicaid and Medicare, the insurance programs for low-income people, the elderly and the disabled, help pay for three-fourths of nursing home residents. So they would incur additional costs if nursing homes hired more nurses and nurse's aides.

Nursing homes are lobbying Congress to increase the payments they receive under Medicare and Medicaid, or at least to block cuts in Medicare scheduled to take effect on Oct. 1. Several members of Congress said they would vote for higher payments, on the condition that nursing homes used some of the extra money to hire additional nurse's aides.

Nursing home executives and consumer advocates agree that there is a severe shortage of nursing personnel, but disagree on the solution.

Consumer groups support minimum labor requirements. Donna R. Lenhoff, executive director of the National Citizens' Coalition for Nursing Home Reform, said: "The government admits that increasing staff to the levels recommended in the report would improve quality, but then asserts that no action can be taken until there's further analysis of the tradeoff between cost and quality improvement. That's a very weak response."

Ms. Lenhoff said that if nursing homes had more employees they could save money and lives by preventing many problems that require patients to be hospitalized.

Suzanne M. Weiss, senior vice president of the American Association of Homes and Services for the Aging, said, "We oppose minimum staffing ratios" because they do not take account of the fact that some patients are sicker and more disabled than others.

One chapter of the report, written by experts in geriatric medicine, calls explicitly for "some minimum staffing ratio to protect nursing home residents."

But the Bush administration said, "We do not think there is currently sufficient information upon which to base a federal requirement for all certified nursing homes," and "any requirement would have to be balanced against cost."

Nursing homes are licensed by the states and must meet federal standards to participate in Medicaid or Medicare. About 95 percent of the nation's 17,000 nursing homes participate in those programs.

The report said the shortage of nursing personnel was "likely to become worse," in part because of low pay, meager fringe benefits and difficult working conditions at many nursing homes. Accordingly, it said, if the federal government or the states set new standards, they must be "phased in over a multiyear period to give providers an opportunity to recruit and train the required additional staff."

If the recommendations are carried out, the report said, the new demand for nursing personnel would probably lead to an increase in wages. Hospitals and home care agencies, as well as nursing homes, would have to pay the higher rates.

For registered nurses, the report said, wages would probably increase 2.5 percent to 7 percent, or 50 cents to $1.40 an hour, given the average wage of $20 an hour for registered nurses. Likewise, it said, the increased demand for nurse's aides would force employers to raise their pay by 10 percent to 22 percent, or 86 cents to $1.89 an hour, since they earn an average of $8.60 an hour.


Study: More RNs, Healthier Patients

By Roni Rabin             STAFF WRITER

May 30, 2002

One of the most comprehensive studies of nursing care ever done in the United States has found that staffing with registered nurses has a direct and positive impact on care, but did not find an association between the staffing and patient mortality rates.

The study of discharge data from more than 6 million patients in eleven different states, written by Jack Needleman of the Harvard School of Public Health and Peter Buerhaus of Vanderbilt University's School of Nursing, is being published in today's New England Journal of Medicine.

The publication comes as suburban hospitals in the greater New York area struggle with a deepening nursing shortage, with Long Island hospitals reporting vacancy rates creeping up from 8.5 percent in 2000 to 9.5 percent last year, according to a survey by the Greater New York Hospital Association.

Vacancy rates in New York City hospitals vary widely, and actually decreased somewhat in Manhattan, Brooklyn and Queens last year, according to the survey, which found vacancy rates as low as 3.9 percent in Queens, 5.6 percent in Manhattan and 6 percent in Brooklyn - and as high as 14.1 percent in the Bronx.

Kenneth Raske, president of the Greater New York Hospital Association, a trade association, said the findings of the massive nurse staffing study were not surprising.

"It's intuitively logical: the higher the staffing ratio, the better off the patient care," Raske said, emphasizing that hospitals with vacancies fill gaps through mandatory overtime and per-diem hiring. "I think anybody in the business has known this since hospital administration school."

The study, the first to analyze three different levels of nursing care including RNs, licensed practical nurses and aides, found that medical patients in hospitals where registered nurses represented a smaller proportion of nursing hours suffered higher rates of urinary tract infections, pneumonia, shock and cardiac arrest and upper gastrointestinal bleeding.

They were likely to stay in the hospital longer, and they were more likely to die from a serious complication such as sepsis, which is a toxic condition resulting from the spread of bacteria, which may be prevented if identified early on and treated by nurses and medical personnel. Despite the association between nurse staffing and deaths in this latter category, which is termed a "failure to rescue," the research found no evidence of an association between nurse staffing and overall patient mortality rates.

But, the researchers found, patients cared for in hospitals with high registered nurse staffing had lengths of stay 3 percent to 5 percent shorter and complication rates 2 percent to 9 percent lower than in hospitals with low RN staffing.

And several of the complications - including pneumonia, shock and cardiac arrest and upper gastrointestinal bleeding - are associated with an increased risk of death; they also may prolong a hospital stay and increase patient costs and discomfort.

"What I think is really happening is that in units where there is not a lot of staff, they are not seeing patients frequently enough to pick up on complications after surgery," said Peter Buerhaus, co-project director for the study and senior associate dean of research at Vanderbilt's School of Nursing. "RNs are the ones that have the education and the experience to pick up on these subtle changes in patients, and head them off before things get really bad.

"Where aides or LPNs may come in to feed the patient and help the patient to the bathroom or change a dressing, they're not really educated to see the whole patient. ... What we found is that RN staffing is key."

Maureen White, the chief nurse executive for the North Shore LIJ Health System, which has won two national Magnet Awards for its nursing staff, agreed.

"The RN is trained to be the eyes and ears, not just for the physician, but for the patient, and to be the patient's advocate," she said. "A tremendous responsibility is placed on them."

The study, which reviewed data from 799 hospitals in 11 states including California and New York, was funded by the U.S. Department of Health and Human Services, the Health Care Financing Administration, the NIH's National Institute of Nursing Research and other agencies.

Copyright 2002, Newsday, Inc.


Shortage of Nurses Hurts Patient Care

Shortage of Nurses Hurts Patient Care, Study Finds


In hospitals with low numbers of registered nurses, patients are more likely to suffer complications like urinary infections and pneumonia, to stay in the hospital longer and to die from treatable conditions like shock or gastrointestinal bleeding, researchers report today.

"I estimate that hundreds or, perhaps, thousands of deaths each year are due to low staffing," said Dr. Jack Needleman, an economist at the Harvard School of Public Health and the lead author of a study on staffing published today in The New England Journal of Medicine.

The nation has a serious nursing shortage, with 126,000 jobs unfilled, 12 percent of capacity, says the American Hospital Association. The shortage is a result of hospital mergers, layoffs and heavy workloads. Many hospital nurses shifted to other work. The average salary, $46,000 a year, has not increased much in a decade. Even though hospitals are trying to hire again, nurses are no longer available.

The new study, paid mostly by the government, is one of the largest to look at care in relation to staffing. The findings were based on a computer analysis of the discharge records of more than six million patients at 799 hospitals in 11 states in 1997. Five million had medical problems. One million had surgery.

The research sought to find out whether there was a correlation between how patients fared and the levels of registered nurses and two other types of workers with less training, licensed practical nurses and aides.

Registered nurses receive several years of training and usually hold associate's or bachelor's degrees. Practical nurses usually have high school diplomas and a year of training. Aides have less training.

The researchers found that for certain aspects of care just nurses made a difference. In hospitals with higher nurse staffing, stays were 3 to 5 percent shorter, and complication rates 2 to 9 percent lower than in hospitals with lower staffing. No relation was found between patients' well-being or length of stay and the levels of aides or practical nurses.

Registered nurses, Dr. Needleman said, are "the eyes and ears of the hospital" for judging whether a patient is recovering normally.

"If something is going wrong," he said, "they can catch the signs early, before the problem gets worse."

But problems cannot be spotted early, he added, if nurses do not have time to observe their patients.

The president of the American Nurses Association, Mary E. Foley, said, "We're very pleased that another large set of research data has validated what the American Nurses Association has been saying since the mid-90's, that there is a direct effect on the outcome of patient care when you have enough nurses."

As an example, Ms. Foley said, pneumonia and blood clots in hospitalized patients often result from immobility, and nurses help prevent such complications by turning and repositioning bedridden patients, encouraging them to exercise and cough and helping others to get up and walk around. Even if nurses themselves do not do those things for patients, they have the training and experience to know when such help is needed and to ensure it is provided.

A senior vice president for policy at the American Hospital Association, Carmela Coyle, said: "The study suggests that registered nurses are key and critical to insuring good patient care. This is something that hospitals and patients have known for some time."

Ms. Coyle said she feared that the study would lead some people to assume that health care problems could be solved by laws that require specific staffing ratios, a move that hospital trade groups have long resisted. She called such a reaction overly simplistic.

"What you really need to look at," Ms. Coyle said, "is much more than the number of nurses and the number of patients. How many of the nurses have 20 years of experience or more, and how many are right out of school? What technology is there to support them? How sick are the patients?"

Dr. Needleman said his group made its study because the government sought to fill a large research gap on the connection between nurse staffing and quality of care. In the early 1990's, nurses testified to Congress that patients in some hospitals were endangered by managed-care companies that were trying to save money by replacing registered nurses with less skilled and lower paid workers. Congress asked the Institute of Medicine to study the issue. In a report in 1996, the institute said there was not enough data to draw conclusions and called on the government to finance studies.

Dr. Needleman's is one of those. It measured staffing two ways, by the proportion of nursing hours provided by each type of worker and by the number of hours a day the types of workers devoted to each patient.

For registered nurses, the average number of hours a day per patient worked out to eight. The hours included not only time spent at the bedside, but also time spent preparing medication, writing chart reports and consulting colleagues or family members.

The averages include intensive care units, with one nurse for every one or two patients around the clock.

"There were some hospitals, that if I were going to them as a patient, I would be very concerned," Dr. Needleman said. "The hospitals at the very low end of our sample had as little as two hours, and some at the high end had 16 hours."

When the study compared the hospitals in the top quarter with those in the bottom quarter on the proportion of nursing time from registered nurses, it found that the medical patients, as opposed to surgical patients, in the bottom quarter had stays 3.5 percent longer, 9 percent more urinary infections, 5.1 percent more gastrointestinal bleeding, 6.4 percent more pneumonia and 9.4 percent more shock or cardiac arrest.

In addition, the death rate was 2.5 percent higher for "failure to rescue," meaning that the patients died from conditions that might have been reversed if they had been treated in time. Those conditions include pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis or a blood clot.

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Copyright Philip A. Pecorino 2002. All Rights reserved.

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