FOR IMMEDIATE RELEASE/January 18, 1996 CONTACT: Joan Meehan [202/651-7020] IOM Study on Nurse Staffing Falls Short Says ANAExpresses Disappointment Over Scope of RecommendationsWASHINGTON, DC - - Today's release of a report by the Institute of Medicine (IOM) on nurse staffing is "a step in the right direction, yet many of its recommendations fall short because they lack a sense of urgency in addressing critical issues that affect the quality of care that consumers receive," said a spokesman for the American Nurses Association (ANA). Over the past few years, ANA has been tracking and calling public attention to reduced registered nurse (RN) staffing in hospitals and other settings and its impact on patient safety and quality of care, and has continued to advocate for safe staffing levels in long-term care facilities. It provided written and oral testimony and other documentation to the IOM's Committee on the Adequacy of Nurse Staffing, which authored the report. "The report is a positive step in focusing policy makers' attention on the issue of nurse staffing, quality care, and the safety of both patients and nurses," said David Keepnews, JD, MPH, RN, director of policy for ANA. "The recommendations it makes are generally good, although we are disappointed, that on the whole, they do not go far enough," he said. "The problem of reduced RN staffing in hospitals and other facilities is a clear and present danger to all health care consumers," said Keepnews. "Despite some of its positive contributions, the report's main flaw is that it fails to grasp the immediacy of this problem." According to the report, the IOM committee was "shocked by the lack of current data relating to the status of hospital quality care on a national basis," and called for a national research agenda on hospital quality, as well as the linkages between staffing and quality. "The committee is convinced that investigation of hospital quality of care warrants increasing and immediate attention." This conclusion should be viewed as "an admonition to a health care industry that has moved full steam ahead with restructuring, reorganization and downsizing plans without any reliable data on the effect of these changes on patient care," said Keepnews. "It should also stand as a warning to health care consumers that hospitals are making fundamental changes in how care is delivered and organized, with little information about how those changes impact safety or quality." Because of this lack of data, the committee concluded that it could not draw any conclusions or inferences about the levels of quality of care across the nation's hospitals today. "ANA agrees that data is critically needed," said Keepnews. "But a lack of scientific data does not mean that a problem does not exist in hospital care. Mountains of anecdotal evidence, much of it gathered by ANA and state nurses associations, reveals a real and growing problem in patient care as a result of inadequate staffing and a lowered proportion of RNs in nursing staff mix. This is consistent with many studies demonstrating that when there are more nurses, there will be lower mortality rates, shorter lengths of stay, lower costs, and fewer complications." Still, ANA saluted the committee's call for stepped-up research, and pointed out that ANA has taken important initial steps with its development of the Nursing Report Card for Acute Care Settings, which identifies seven indicators, such as skin integrity (bedsores), infection rates and patient injuries, that link quality and safe care with nursing staff levels and mix. Efforts are currently underway to gather much-needed data using this tool. The committee "commended" ANA for its important work on this report card effort. "We strongly agree with the call for more research, and appreciate the committee's recognition of our efforts," said Keepnews. "But we don't think that anyone can afford to wait until all the data are in before addressing a real and growing problem in America's hospitals." ANA has called for public accountability of hospitals and other institutions for nurse staffing levels and mix, including public disclosure of staffing and outcome data to consumers, insurers and federal and state agencies. ANA has alerted consumers about hospitals' increased reliance on unlicensed personnel to provide a growing range of patient care services. The committee noted a lack of uniformity in training and testing of these personnel. The report called for hospitals to "have documented evidence that ancillary personnel are competent and that such personnel are tested and certified by an appropriate entity for this competence." Keepnews commented on this recommendation: "We share the committee's concerns about lack of training and competence, but we also have to ask, competence to do what?' Unlike the nursing home sector, where nursing assistants' responsibilities are generally agreed upon, one of the big problems in hospitals is the rapid expansion of unlicensed persons' responsibilities, often including functions that they cannot perform safely and reliably." In addition, Keepnews expressed concern over entrusting hospitals with the responsibility to attest to the training and competency of nursing assistants. In the nursing home area, the committee was more specific in its recommendations on staffing, calling for a requirement for a 24-hour presence of registered nurse coverage. Currently, nursing homes need to have an RN present eight hours a day. The committee also recommended adjustments in Medicare and Medicaid payment levels to cover the additional cost of such a staffing requirement. Keepnews said that ANA "strongly supports" this proposal. "The phenomenon of nursing homes without nurses' must become a thing of the past. The changing needs of nursing home residents, including increased acuity and increased needs for rehabilitative and therapeutic care, demand it." The committee also called for increased use of gerontological clinical nurse specialists and nurse practitioners in nursing homes, recognizing their growing importance in providing and assuring quality services for nursing home residents. In the area of work-related injury, the committee calls for increased training and use of technology, such as needle-less medication delivery systems. Some institutions have balked at these steps because of cost concerns. Keepnews noted that the committee found no linkage between staffing levels and workplace injuries. "There is data to suggest such a linkage," he said, citing a pioneering study by the Minnesota Nurses Association. "We are disappointed that the committee did not offer recommendations relating to the need for adequate staffing to help prevent workplace injury," he said, "or, at the very least, outline the need to expand research initiatives such as the Minnesota nurses' important work." The committee called for increased use of advanced practice nurses in acute care settings to provide both direct patient care and clinical leadership. It also called for involving nursing personnel in planning and implementing restructuring and reorganization moves, echoing ANA's call that "nurses must be at the table" when such decisions are made. "On the whole, the IOM committee has focused careful and thoughtful attention on some of the key issues in quality and safety in hospitals and nursing homes," said Keepnews. "It has made some good recommendations, and some that are a first step. It has identified the need for more research on quality and on staffing in hospitals. Significantly, it notes the need for the health care industry to be accountable for the quality of the services they provide. It has made some concrete and important recommendations for nursing home staffing. "Our members, however, regard the ongoing problems in patient care, particularly in acute care hospitals, as a matter of urgency. By all means, let's forge ahead with collecting and interpreting data--but we--and our patients--can't simply afford to sit and wait until that process has been completed."
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