The High Price of Health
Where Have All the Nurses Gone?

Final Results of Our Patient Care Survey We all know the changes in our health care system have been substantial and far-reaching.  But what effects are downsizing, restructuring, and the use of unlicensed personnel having on the quality of patient care you deliver and on your work life?  More than 7,000 survey respondents gave us their answers. By Judith Sindul-Rothschild, RN, CS, PhD., Diane Berry, RN, BS, and Ellen Long-Middleton, RN, MN, FNP [Excerpts follow from this survey which was  published in the American Journal of Nursing, November 1996/Vol. 96, No. 11]

Thousands of nurses--7,560, to be exact--completed the AJN Patient Care Survey, which was published in the March 1996 issue of AJN. It's the largest survey of nurses' views on health care and nursing practice ever conducted. Nurses responded from every state and territory in the United States and represented a wide range of positions and specialties. Your participation, and your detailed comments describing conditions in your workplace, have given us the best picture to date of what's happening in the U.S. health care system and in your practice. It's a picture with some commonalties. Nurses across the nation, in every setting and specialty, report that they're taking care of more patients, have been cross-trained to take on more nursing responsibilities, and have substantially less time to provide all aspects of nursing care. But it's also a picture noteworthy for the differences--across regions of the country, settings, specialties, and positions. Other key findings include:

* Almost half of the nurses reported that part-time or temporary RNs have been substituted for full-time RNs, and two out of five reported the substitution of unlicensed assistive personnel for RNs. Significantly higher rates of substitution were reported by nurses in the Pacific region. The greatest cutbacks in RN staffing were reported by nurses in the Northeast and East/North Central regions. These three regions--the Pacific, Northeast, and East/North Central--lead the nation in terms of the percentage of their population that is covered by managed care insurers.

* Over half of the nurses reported less continuity of care and an increase in unexpected readmissions, with significantly higher percentages reported by nurses in the Northeast and Pacific regions. Two-thirds of emergency and psychiatric/mental health nurses also reported increased unexpected readmissions. Most geriatric nurses and two out of five ICU/CCU nurses reported increases in complications secondary to admitting diagnosis.

* Nurses' perceptions of quality in home/community care and subacute care facilities varied widely. Two-thirds of home care nurses stated that the quality of care met their professional standards, compared with only one-third of nurses in subacute care.

* Most psychiatric/mental health, orthopedic, neurology, operating room/PACU, primary care, and emergency nurses reported increases in work-related injuries, with twice as many psychiatric, primary care, and emergency nurses reporting increases in workplace violence.

* Only three-quarters of nurses stated they would remain in nursing, with the fewest in the Pacific region. In Massachusetts--the state hit hardest by recent cutbacks in RNs--the number of nurses stating that they were going to leave the profession has increased fivefold in less than two years. Many nurses said in their written comments that they were going to leave nursing because they couldn't provide patients with adequate nursing care in the current health care environment.

* Nearly two out five nurses said they wouldn't want a family members to receive care at their organization.

How to explain these findings, and what implications they have for the demand for nurses and quality of patient care in the future, is the focus of this article.

'Speed up' phenomenon:  More patients, more responsibilities

The AJN Patient Care Survey deals mainly with three aspects of the health care delivery system--the structure of services provided and the process and outcomes of nursing care. We first asked nurses how the system's infrastructure and the use of nursing personnel have changed in the past year. The answers may seem obvious--after all, who in the health care profession hasn't witnessed remarkable changes? But never before have so many nurses explicitly stated what those changes are.

There were some areas in which nurses' responses were similar across the country--for example, in initiating construction or renovation (66%), establishing/acquiring community-based services (43%), and loss of managed care contracts (14%). And nurses everywhere reported in overwhelming numbers that they're taking care of more patients (66%) and have been cross-trained to take on more responsibilities (59%).

Nurses' responses also suggest that efforts to increase productivity through "speed ups"--expecting fewer workers to work harder and do more--aren't confined simply to nurses at the bedside. Nurses at all levels are feeling the effects of downsizing, with almost half (45%) reporting cuts in nurse mangers and almost two out of five (38%) reporting losing a nurse at the executive level without replacement. Prospects for nurses in advanced practice may not be as optimistic as once predicted, with only 12% of respondents stating there are more positions for APNs.

While we found these and other commonalties, in other areas we found dissimilarities in nurses' reports by region, setting, and specialty. This may explain why it's been difficult to reconcile the apparent contradictions between what nurses are saying anecdotally and national data in the aggregate on nursing manpower trends. Overall, more than half (56%) of the respondents reported that their health care organization has closed beds or units within the past year. Although two-thirds of nurses in the Northeast and Mid- Atlantic regions reported such cutbacks, only two out of five nurses in the Mountain and West/South Central regions reported them. Even as the health care system downsizes, almost an equal number (51%) of nurses across the country reported their health care organization is adding services. There were wide variations, however, between the West Coast and the South. In the Pacific region, only 43% of the respondents reported their organization is adding services, compared with 57% of nurses in the South Atlantic region and 56% of nurses in the East/South Central and West/South Central regions.

Responses match data sources

How do we know that nurses' responses to the AJN Patient Care Survey is an accurate portrayal of what's happening in our health care system as a whole, in our nursing practice, and to our patients? By comparing the responses with information from national databases, we can judge how closely nurses' perceptions match other sources.

The most relevant and recent secondary data sources are from the American Hospital Association's "Annual Survey of Hospitals" and the foolproof validation methods. Some critics might claim that these "hard" data, especially those gathered by the AHA, are potentially more biased and fraught with problems of manipulation than what's gleaned by simply asking nurses to report what they see. Also, the most recent data available were collected in 1994, and with the volatility of the health care system there's the risk that changes reported by nurses today won't be reflected in data sources dating back two years. But even with these limitations, they're the best secondary sources of information available, so we've used them to compare the reports of nurses in the AJN survey.

On the whole, findings in the AJN survey show a striking similarity to trends identified by these sources. According to the 1996 AHA Hospital Stats, which is the published report of the "Annual Survey of Hospitals," declines in the number of hospital beds varied from region to region, with the greatest losses occurring along the coasts and in the East/North Central region. The primary factor driving down hospital utilization is managed care, and downsizing has occurred most intensely in regions where a higher percentage of the population is covered by managed care insurers--specifically, the coasts and the East/North Central region.

While the AHA anticipates that declines in the number of U.S. hospitals will level off in the 1990s, it's unlikely that any regions of the country will be immune from hospital downsizing and restructuring. Hospital bed or unit closures are likely to intensify in regions with a combination of low managed care infiltration and high percentage of hospital downsizing and restructuring. Hospital bed or unit closures are likely to intensify in regions with a combinations of low managed care infiltration and a high percentage of hospital beds per population--specifically, the Mid-Atlantic, West/North Central, and East/South Central regions. One mitigating factor may be the consolidation of health care services through mergers. In the AJN survey, nurses in the West/North Central region reported significantly more (55%) of mergers than nurses elsewhere.

Less time to provide nursing care

While many of the structural changes we've described were undertaken to integrate the process of health care, respondents to the AJN Patient Care Survey suggest that just the opposite is occurring. A surprising 55% of nurses across the U.S. reported that there's less continuity of care, and an overwhelming number of nurses reported having less time to provide all aspects of nursing care. For example, most RNs reported less time to teach patients and their families (73%) comfort and talk to patients (74%), provide basic nursing care (69%), document care (66%), and consult with other members of the health care team (57%).

The substantial reduction in the time nurses have to care for patients is probably due to a combination of factors, including cuts in the overall number of RNs, more patients assigned to each RN, shortened length of stay, and rising acuity. After 10 years of steady, incremental declines in length of stay, the AHA found in 1994 that length of stay in community hospitals had fallen a dramatic 4.3%. Consistent with this trend, 66% of the participants in the AJN survey reported declines in length of stay and 77% reported increases in patient acuity.

Such a significant one-year drop in hospital length of stay occurred only once before, when DRGs were introduced in the mid-1980s. The latest plunge is also most likely due to changes in health care financing--specifically, the nationwide move toward managed care. A 1995 report from Congressional Budget Office found that while HMOs increased the use of outpatient services by 3% over traditional fee- for-service plans, on average HMOs used 34% less inpatient care. The CBO report emphasized that at least half of the reduction in medical costs achieved by HMOs came from cutting length of hospital stay for childbirth.

Profits before patients

The ratcheting down of length of stay has triggered an outcry from the public and providers that profits are superseding the needs of patients. In free-market economies, one of the central roles of government is to balance the interests of business, and workers, and consumers. As the corporatization of health care has escalated, so too have the number of state and federal regulations designed to rein in the actions of managed care organizations and safeguard the public. For example, President Clinton has signed into law a bill eventually passed by Congress guaranteeing coverage for two-day stay after childbirth.

It's conceivable that the legislative reforms sweeping the country could stabilize hospital length of stay. The findings in the AJN Patient Care Survey suggest that the need for regulatory safeguards is greatest for consumers in the Northeast and Pacific regions. Nurses in these regions reported significantly higher levels (68% and 60%, respectively) of unexpected readmissions. While in some instances the Northeast has led the nation in enacting legislative reforms designed to empower patients and improve access to care, the Pacific region has notable lagged behind the rest of the country. However, two health care referendums mandating a variety of regulatory protections were put on the California ballot for public vote this month.

Newborns and their mothers have been the focus of regulations mandating hospital length of stay, and the lowest rates of readmission reported in the AJN survey (39%) were by obstetrics/gynecology nurses (n=478). We can't infer from this finding that state regulations have been an effective deterrent to the premature discharge of mothers and babies. However, we were interested in whether there might be other vulnerable populations who could benefit from such reforms.

Unexpected readmissions:  Highest in emergency and psychiatric nursing

When we examined the incidence of unexpected readmissions by specialty, increases were concentrated in two specialty areas. Sixty- eight percent of emergency nurses (n=396) and 63% of psychiatric/mental health nurses (n=476) reported increases in unexpected readmissions, compared with 55% of nurses in all other specialties. Samuel and colleagues reported this past spring that among psychiatric patients, younger patients had the highest rates of hospital readmission. These findings are consistent with a 1995 study investigating the impact of managed care on psychiatric treatment reported in Health Affairs , which found that psychiatric readmission rates were highest for children and adolescents. While younger patients may be at greatest risk for psychiatric readmissions, Safran and colleagues reported in a large retrospective study of 5,000 emergency readmissions that patients who were at greatest risk were older and had longer hospitalizations and higher hospital charges. More recently, Fransworth and colleagues found that 50% of elderly patients discharged from the emergency department deteriorated at home due to lack of community support, and 5.6% required rehospitalization.

Whether mandating length of hospital stay for postpartum women has any demonstrable clinical benefit continues to be hotly debated. But there may be other populations at risk for premature discharge--specifically, children and young adults seeking psychiatric treatment and the elderly. From a public perspective, of all our citizens, those at either end of the age spectrum are sometimes the least capable of advocating for themselves and the most in need of regulatory protections. With every well-intentioned regulation enacted by government, of course, there's a clever consultant who manages to find a loophole. So it's entirely possible that as more regulations proscribe the conditions under which hospital care will be provided, patients will be shifted to other settings. Even before the rash of mandates on hospital length of stay, managed care providers were transferring more patients to sub acute and intermediate care facilities because of the perceived cost savings.

To read the entire nurses survey, please visit the American Journal of Nursing which is publised by Lippincott-Raven Publishers.


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