Comparative Views of the Impact of the Nursing Shortage on Quality

of Hospital Care

AcademyHealth

Health Workforce Interest Group

June 2, 2007

Peter I. Buerhaus

Disclosure

Funded by:

• Johnson & Johnson Campaign for Nursing’s Future

Data come from …

• Project to Evaluate the Johnson & Johnson Campaign for Nursing’s Future

• Project Personnel:– Peter Buerhaus (PI) and Robert Dittus

Vanderbilt University Medical Center– Karen Donelan (Co-PI) and Cate DesRoches

Massachusetts General Hospital

National Random Sample Surveys Public opinion of nursing profession (2001) Web-based survey of teens (2003) Parents and teenagers (2003) Nursing students (2003) Physicians (2004) Nurses (2002, 2004 & 2006) co-funded by

Nursing Spectrum (Beth Ulrich, Co-PI) Hospital chief executive officers (2005) Hospital chief nursing officers (2005) Public opinion of nursing profession

(Completed mid-April, 2007)

National Survey of Physicians• Mailed survey to 840 primary care and specialty

physicians reporting more than 20 hours per week in patient care activities

• Conducted January 6 through March 5, 2004

• 500 completed surveys, response rate 55%

• First survey of physicians on nursing shortage

National Surveys of Registered Nurses

• Surveys:– Random national samples– Mail and web based – Conducted by Harris Interactive, Inc.

• 2002 survey: Data from 4004 RNs, response rate 55%

→2004 survey: Data from 1783 RNs, response rate 53% (co-PI B. Ulrich)

• 2006 survey: Data from 1392 RNs, response rate 52% (co-PI B. Ulrich)

• Provides national follow-up survey of nurses

National Survey of CEOs and CNOs

• Conducted from December 2004 - February 2005

• Telephone interviews and mailed questionnaire

• 222 of 443 contacted completed surveys from CNOs, 50% response rate

• 142 of 404 contacted completed surveys from CEOs, 31% response rate

Themes Across Surveys

• Causes, effects, and hospitals’ responses to the nursing shortage

• Work environment– Physical and mental safety– Professional practice– Working relationships

• Quality of care• RN job and career satisfaction

Observations of RNs, Physicians, Hospital CEOs,

and Hospital CNOs

See: Buerhaus, Donelan, Ulrich, DesRoches, Dittus. Impact of the Nurse Shortage on Hospital Patient Care:Comparative Perspectives. Health Affairs, 26(3); 2007: 853-862.

Percent Observing Nursing Shortage in Hospitals

RNs

2004

MDs

2004

CNOs

2005

CEOs

2005

Serious or somewhat serious shortage of nurses

82% 81% 74% 68%

Impact of Nursing Shortage on Care Processes

In the past year, have you observed any of the following as a result of nursing shortage?

Observed…RNs

2004

MDs

2004

CNOs

2005

CEOs

2005

Increase in time it takes for nurses to respond to pages or calls

89% 67%* 84% 76%*

Increase in patients’ complaints about nursing care

87 74* 58* 55*

Increase in staff communication problems

88 71* 72* 69*

Increase in workload for physicians

53 55 29* 30*

Impact of Shortage on Hospital Capacity

In the past year, have you observed any of the following as a result of nursing shortage?

ObservedRNs

2004

MDs

2004

CNOs

2005

CEOs

2005

Increased reduction in the number of available beds

81% 64%* 60%* 56%*

Increase wait time for discharge

72 50* 60* 61*

Increased patient wait time for surgery or tests

75 45* 47* 48*

Increase in discontinued or closed patient care programs

42 49 20* 20*

Impact of Shortage on Nurses

How much of a problem do you think the shortage of nurses has been

for…“Major problem”

RNs

2004

MDs

2004

CNOs

2005

CEOs

2005

Quality of patient care provided by nurses

78% 61%* 64%* 54%*

Time to collaborate with other team members

55 33* 56 50

Ability of nurses to maintain patient safety

69 21* 62 38*

How much of a problem do you think the shortage of nurses has been

for…“Major problem”

RNs

2004

MDs

2004

CNOs

2005

CEOs

2005

Early detection of patient complications by nurses

65% 44%* 60 47*

Nurses’ time for patients 91 78* 66* 59*

Quality of nurses’ work life 82 59* 76 62*

Impact of Shortage on Institute of Medicine’s Six

Aims for Improving the Quality of the HealthCare

Systems

IOM Report: Crossing the Quality Chasm, 2003

See: Buerhaus, Donelan, DesRoches, Ulrich, Norman, Dittus. Impact of the Nurse Shortage on Hospital Patient Care: Comparative Perspectives. Health Affairs, 26(3); 2007: 853-862.

Institute of Medicine

Six Aims for Improving Quality of HealthCare System

• Patient-centered

• Effective

• Safe

• Timely

• Efficient

• Equitable

Shortage frequently or often impacting….

Patient-Centered Care

73

61

43 41

0

10

20

30

40

50

60

70

80

Hospital RNs Physicians CNOs CEOs

Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions

Effective Care

73

58

34

27

0

10

20

30

40

50

60

70

80

Hospital RNs Physicians CNOs CEOs

Effective: Providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit

Safety of Care

63

36

25

17

0

10

20

30

40

50

60

70

Hospital RNs Physicians CNOs CEOs

Safe: Avoiding injuries to patients from the care that is intended to help them

Timeliness of Care

81

72

4944

0

10

20

30

40

50

60

70

80

90

Hospital RNs Physicians CNOs CEOs

Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care

Efficiency of Care

71

55 55

47

0

10

20

30

40

50

60

70

80

Hospital RNs Physicians CNOs CEOs

Efficient: Avoiding waste, including waste of equipment, supplies, ideas, and energy

Equity of Care

61

38

26

18

0

10

20

30

40

50

60

70

Hospital RNs Physicians CNOs CEOs

Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status

Expectations of Where Nursing Shortage Will Lead

Expect Shortage Will Lead to …

RNs

2004

MDs

2004CNOs 2005

CEOs

2005

Higher pay for nurses 48% 78% 86% 94%

The need to have other staff perform some nursing patient care activities

83 92 81 87

Nurses leaving for non-nursing jobs 91 84 83 79

More respect for nurses 21 44 36 59

Improvements in workplace environment 25 34 74 75

Lower quality care for patients 90 83 71 69

Increased stress on nurses 96 86 97 98

3. Wee bit about the Changing Composition of the RN workforce

Older and More Foreign-Born

Recent Total RN Employment Growth in US by Age

RN Age

Year 21-34 35-49 50-64

2002 - 21,170 43,152 63,911

2003 87,131 - 32,271 65,839

2004 - 45,034 21,294 23,212

2005 - 31,277 - 87,284 91,312

2006 46,172 16,970 12,888

2002-2006 35,822 - 40,139 257,161

Source: Buerhaus, Auerbach, Staiger. Recent trends in the registered nurse labor market in the US: Short-run swings ontop of long-term trends. Nursing Economic$, 25(2); 2007: 59-67.

RN FTEs by age group for selected years

-

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

2005 (obs) 2012 2020

<30

30s

40s

50s

60+

43.5 yrs, avg. 44.7 yrs 44.7 yrs

Source: Auerbach, Buerhaus, Staiger “Better Late than Never: Implications of Later Entry into the Profession for the FutureSupply of Nurses” Health Affairs, January/February 2007

Growth in Foreign-born RNs

Percent FTE Foreign-Born RNs, 1994-2006

5%

7%

9%

11%

13%

15%

17%

19%

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Year

Source: Buerhaus, Auerbach, Staiger. Recent trends in the registered nurse labor market in the US: Short-run swings on top of long-term trends. Nursing Economic$, 25(2); 2007: 59-67.

Recent Total RN Employment Growth By US and Foreign-Born Status

Year U.S. Foreign-Born

2002 44,045 41,849

2003 94,503 24,190

2004 - 9,824 9,275

2005 - 5,897 -21,353

2006 36,616 39,075

2002-2006 159,443 93,036

Source: Buerhaus, Auerbach, Staiger. Recent trends in the registered nurse labor market in the US: Short-run swings on top of long-term trends. Nursing Economic$, 25(2); 2007: 59-67.

4. Conclusions

• Across the four groups, considerable majorities report shortage harming nearly all of 20 indicators of hospital capacity, care processes, nurses’ ability to provide care, and six IOM aims

• Most hold pessimistic views of where the shortage will lead

Conclusions

• Several areas where clinicians and executives are not on the same page:– Majorities of RNs and CNO: early detection, safety,

quality of work environment; MDs and CEOS don’t agree

– Clear majorities of RNs reported six IOM aims affected, physicians were somewhat less likely to agree, executives substantially less likely to agree

Recommendations aimed at promoting problem recognition

• Build teamwork• Focus on safety

– Early detection of complications

• Stronger interdisciplinary curriculum on quality and safety

• Recognize that, in the future, teams will be composed of much older and more foreign-born RNs