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1 Study Activities
Pages 241-276

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From page 241...
... The first activity was the committee's wide-ranging request for written and oral testimony, and the second was a series of four site visits by small subgroups of the committee. WRITTEN AND ORAL TESTIMONY SUBMITTED TO TlIE COMMITTEE Many IOM studies use requests for testimony to elicit a broader expression of views on the main topics of the project than would otherwise be available from committee members, published literature, and site visits.
From page 242...
... Written and oral testimony received equal weight in the committee's deliberations. The written testimony ensured input from all interested parties, and the information, references, referrals, and suggestions provided in the statements were of considerable benefit to the study.
From page 243...
... American Association of Colleges of Nursing American Association of Homes and Services for the Aging American Association of Occupational Health Nurses American Federation of State, County and Municipal Employees American Health Care Association American Nephrology Nurses' Association American Nurses Association American Organization of Nurse Executives American Psychiatric Nurses Association American Public Health Association American Radiological Nurses Association American Society for Parenteral and Enteral Nutrition Association of Child and Adolescent Psychiatric Nurses, Inc. Association of Operating Room Nurses Association of Rehabilitation Nurses Baptist Hospital of East Tennessee Belew, John Bureau of Aging and In-Home Services California Advocates for Nursing Home Reform California Association of Hospitals and Health Systems California Nurses Association Career Nurse Assistants' Programs Catlett, Carter Williams Commonwealth of Pennsylvania, Department of Aging Connecticut Nurses Association Danbury Hospital Professional Nurses Association Davenport, Jennie Davis, Feather Ann East Tennessee Human Resource Agency Emergency Nurses Association Federation for Accessible Nursing Education and Licensure Federation of Nurses and Health Professionals Florida Nurses Association Gerontological Nursing Consulting Services Graves, Ruby Hannigan, Hank Harvard Medical School, Center for National Health Program Studies Harvard School of Public Health HBO & Company Healthcare Association of New York State DC DC DC DC DC DC DC CA CA CA CA DC CA DC CA DC DC CA CA DC DC continued on next page
From page 244...
... National Association of Hispanic Nurses National Association of Neonatal Nurses National Citizens' Coalition for Nursing Home Reform DC National Committee to Preserve Social Security and Medicare DC National Council of State Boards of Nursing, Inc. DC National League for Nursing DC New York City Substate Long Term Care Ombudsman Program New York State Nurses Association Nurses Organization of Veterans Affairs Nursing Home Advisory and Research Council, Inc.
From page 245...
... The following section presents an overview of the concerns and issues raised in the testimony submitted to the committee. The testimony is divided into four categories: hospitals, nursing homes, nursing education, and individual comments (e.g., from academics, self-employed geriatric nurse practitioners, a nursing journal)
From page 246...
... In addition to concerns about the quality and safety of patient care, the unions expressed concern about the safety and quality of the workplace. Many nursing personnel stated that their work environment is unsafe for employees as well as for patients.
From page 247...
... Some testifiers also expressed concern that hospitals are altering the threshold on their acuity systems as a means of justifying lower staffing levels. Both the state nurse organizations and the unions were concerned about licensed nurses' professional, legal, and ethical responsibility and liability for
From page 248...
... Many state nursing organizations and unions have responded by encouraging their members to use "assignment despite protest" forms to document their concerns; this is not, however, considered a solution to the concerns about patient safety and quality of patient care. Furthermore, according to one union, some hospitals are pushing for "reinterpretation or revisions in state nurse practice acts so as to allow unlicensed personnel to perform significant nursing duties, while leaving ultimate responsibility and legal liability in nurse hands." Most of the testimony noted the current challenges of delivering nursing care: higher levels of patient acuity; an aging population; shorter lengths of stay in which to deliver care and teach patients self-care; the use of ANP in place of RNs; and sometimes the loss of support services.
From page 249...
... the "taidequacy of nurse staffing in hospitals and nursing homes needs to be determined in the context of the future, restructured health care delivery system not in the context of today's needs"; (2) "tnJurse and other staffing needs are and will continue to be unique to each health care delivery organization and the community it serves.
From page 250...
... Nursing Homes-Related Testimony Resident Advocacy Groups and Long-term-Care Ombudsmen Testimony from nursing home resident advocacy groups, family members, and long-term-care (LTC) ombudsmen exhibited great concern about poor-quality care and inadequate staffing.3 This testimony is useful because these insights are often not available directly from residents.
From page 251...
... Nursing Personnel Unions and Union Members Union concerns about nursing homes are somewhat different from those about hospitals. Structural changes and managed care do not pose immediate issues in nursing facilities; consequently, union testimony tended to focus more on concerns in acute care than in long-term care.
From page 252...
... To summarize, the unions appear to believe that "while adequate staffing levels in themselves do not guarantee good care, consistently good care is not possible in their absence." Professional Nursing Organizations Formed Around Clinical Specialties or Careers Although there were 17 testifiers from professional nursing organizations for the hospital testimony, only 1 such organization focused on nursing home care. The Career Nurse Assistants' Programs "promotes recognition, education and peer support development for experienced nurse assistants in long term care settings." The Career Nurse Assistants' Programs (CNAP)
From page 253...
... On the first topic, the associations noted the numerous regulations and expectations confronting nursing facilities and the low reimbursement rates that make meeting those tasks so difficult. They also noted the increase in resident acuity levels, the challenges of providing subacute care, and how the levels of nursing skills and the documentation required have grown with the increase in acuity and regulation.
From page 254...
... The California Association of Health Facilities urged that any changes to the workforce in nursing facilities take into consideration growth projections, educational opportunities, and actual workplace dynamics. Testimony from the American Health Care Association stated that the number of nursing staff in nursing homes is adequate.
From page 255...
... To make this possible, the facility brings in replacement staff. Ogden concluded by noting that at present, when acuity cannot really be used to set staffing levels, he and his facility feel the need for regulations that require some kind of minimum staffing levels of resident assistants or nurse assistants.
From page 256...
... In its testimony, AACN explicitly considered the bachelor's degree in nursing "the critical first step to a professional nursing career" and supported it as "the minimum educational requirement for professional nursing practice." The AACN also offered an agenda for nursing education in the twentyfirst century, noting that schools of nursing must redefine the role and rewards of nursing scholarship to include nursing practice in an expanding array of settings, as well as nursing theory. The movement from delivering services in acute care settings to delivering them in outpatient and home-based settings also implies a need to retrain and redeploy health care professionals in the future.
From page 257...
... are organizations charged with the regulation of nursing practice. State boards of nursing are created by statute to administer the licenses of RNs and LPNs in accordance with a state's nurse practice act, and complaints against licensed nursing personnel would be filed with state boards.
From page 258...
... One presented information on a state-level strategic plan for summarizing data about the current nurse supply and predicting the future need for RNs in California. Another argued strongly that current staffing levels for direct care are insufficient while staffing levels for administrative tasks are excessive.
From page 259...
... A principal objective of these visits was to increase the committee's understanding of the issues of nurse staffing levels and skill mixes, quality of patient care, and nurses' work-related stress and injuries. The visits were an opportunity for committee members to benefit from the experiences and opinions of those directly involved in the questions posed by the study's mandate.
From page 260...
... A "typical" site visit would include (1) 2 /-hour visits to 2 hospitals and 2 nursing homes and (2)
From page 261...
... The staff at some facilities pointed out, first, that many or most of their residents have been in the facility for a while and are "aging in place," and, second, that they are getting more short-term rehabilitative patients discharged from the hospital and more patients classified as "subacute." This means that nursing homes are now receiving people with such care needs as in-house kidney dialysis, tracheotomy care, and intravenous pain management; 10 or 15 years ago, these patients would have remained in an acute care setting. Alternative models for delivering long-term care, such as increased placement of the elderly in community-based care settings, are extensively used in some areas.
From page 262...
... Site visit teams also heard concerns from several different groups of hospital nursing staff about the fact that some hospitals have "backtracked" from an acuity-based system to a census-based system for determining staffing levels. In urban areas, RN positions are infrequently vacant because of a number of changes in recent years, not the least of which are various cost containment and efficiency models that have resulted in the downsizing and restructuring of hospitals and comparatively high RN salaries in acute care settings.
From page 263...
... Others believed that the overall quality of patient care is being maintained, but at a high personal and professional cost to nursing staff that cannot be sustained indefinitely. Staking Issues in Nursing Facilities Three staffing issues for nursing facilities are notable: turnover and retention rates for NAs; adequacy of staffing levels, particularly in light of increasing patient acuity; and reimbursement levels for care.
From page 264...
... In general, what site visit teams seemed to hear was that delivering care was much more difficult because of the increase in patient acuity and other factors, including the higher concentrations of extremely ill residents in nursing homes resulting from new care options such as board and care, home health, and hospital subacute units. Nevertheless, many NAs were doing what they could to deliver, despite static staffing levels and rising needs, at least a basic level of care.
From page 265...
... In contrast, most of the nursing facilities visited experienced relatively few problems with turnover of RNs and LPNs. Quality of Patient Care and Quality of Life Site visit teams heard many anecdotes about how inadequate staffing levels and mixes have threatened or diminished the quality of patient care.
From page 266...
... The satisfaction and enthusiasm of team members were most impressive, as was their acknowledgment of each individual's part in providing care. The administrative staff with whom committee members met were cautiously optimistic, while the nursing personnel were extremely enthusiastic.
From page 267...
... Physicians have a minimal presence in most nursing homes, and the number of RNs in a facility is extremely low compared to other nursing staff; despite the high levels of acuity in most nursing homes, nationally RNs comprise less than 10 percent of the total nursing staff in long
From page 268...
... At a meeting with LTC ombudsmen, site visit team members heard some grim stories of neglect, intimidation, abuse, and theft. The stories pointed out the many ways in which both the quality and the quantity of staff in nursing facilities can directly affect the quality of care and quality of life for residents.
From page 269...
... Other facilities expressed concern that injury rates have been reduced through education and training but will soon rise again because of the physical demands of nursing the current resident populations. Nursing personnel are more subject to injuries than other workers; this is particularly true of NAs who work in nursing homes where many residents must be turned, lifted, or assisted in their toileting.
From page 270...
... More generally, patient acuity levels are up in long-term-care facilities, and staffing levels are insufficient; this situation is compounded by turnover rates that leave staff habitually working shorthanded. Not surprisingly, overall staff stress is high.
From page 271...
... Educators, in contrast, point out that changes in the delivery of acute care have exacerbated the difficulty of the transition from school to work because facilities no longer have time to teach new staff, and often those who used to teach them (e.g., staffing coordinators, clinical nurse specialists) have heavy patient loads or have been dismissed.
From page 272...
... Furthermore, the site visit teams benefited from the opinions, expertise, and experiences of a number of individuals and organizations in the areas of health care delivery and policy; nursing care and nursing administration; hospital and nursing home administration; labor relations; state-level regulation and oversight of nursing facilities; nursing education; resident advocacy; business concerns; and health care policy. Despite the fact that committee members often had quite different experiences on site visits, analysis of all this information enabled them to reach several overarching conclusions: · Issues such as increased patient acuity, difficulties in recruiting and retaining NAs, and the effects of reimbursement systems and rates on the ways in which care is delivered are increasingly crucial factors influencing the quality of care and the safety of the workplace.
From page 273...
... STUDY ACTIVITIES 273 · The links between reimbursement and patient acuity levels or case-mix could be strengthened. · In both nursing homes and hospitals, flexibility in staffing arrangements and in nursing personnel' s approaches to work can result in improved morale and quality of care.
From page 274...
... Background The Congress of the United States, following 1993 hearings on the current state of staffing of nursing personnel in hospitals and nursing homes, directed the Secretary of the Department of Health and Human Services to request a study from the Institute of Medicine, National Academy of Sciences, to determine whether and to what extent there is a need for an increase in the number of nurses in hospitals and nursing homes in order to promote the quality of patient care and reduce the incidence among nurses of work-related injuries and stress. For the purposes of this legislative mandate "nurses" includes registered nurses, licensed practical and vocational nurses, and nursing assistants and aides.
From page 275...
... 3. The measures that are or should be used to assess the impact of nurse staffing levels and skill mix on the quality of nursing care and patient well-being.
From page 276...
... 7. What data or information are available relating to the institutional cost benefits, quality of patient care, and nurses' work-related well-being associated with restructuring of the delivery of nursing care utilizing different skill mixes?


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