2003-11-04 -- Institute of Medicine Report Cites Danger in Long Nurses' Hours


Health Administrators bemoan the lack of nurses now, but it is really
a problem of their own making.

In 1995, the Pew Health Professions Commission at UCSF, one of the
most influential medical think tanks in the US, issued a report
advocating closing 60% of the beds in the nation, half the hospitals,
and 20% of the medical schools in the nation. It predicted "surpluses"
of 100,000 doctors and 200,000 nurses by the year 2000. (NY Times
11-17-95) The San Francisco-based Pew Commission includes former
government officials, medical educators including UCSF, public health
professionals and insurance company executives. The commission report
was headed by Richard Lamm, former governor of Colorado, who became
notorious for speeches in 1984 declaring that old people had the DUTY
to die and free up scarce national resources. (SF Chronicle, 3-29-84,
NY Times, 11-17-95, and SF Examiner, 11-17-95)

In addition, the health industry made a conscious and concerted attack
on having trained, experienced, and skilled caregivers in managed care
institutions.  In May 1995, a symposium, "Health Careers Education and
Health Care Industry Partnership" was convened. It was sponsored by
the California Department of Education, the Office of Statewide Health
Planning and Development (OSHPD), Chancellor's Office of California
Community Colleges, and Health Care Industry Council. The
"Assumptions" section of the handout stated:

"A drastically reduced workforce will not compromise quality of care
...  Health care practitioners are educated beyond the need for
serving patients effectively.... The health care workforce has
overspecialized ... The multi-skilled worker will improve health care
by serving the patient more effectively  ...Licensure is a barrier to
cost-effective quality health care ... Technology will eventually
replace health care workers"


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New York Times, November 5, 2003

Report Cites Danger in Long Nurses' Hours

By ROBERT PEAR

WASHINGTON, Nov. 4 - Many hospitals and nursing homes are endangering
patients by allowing or requiring nurses to work more than 12 hours a
day, the National Academy of Sciences said on Tuesday.

Such long hours cause fatigue, reduce productivity and increase the
risk that the nurses will make mistakes that harm patients, the
academy said in a new report commissioned by the federal government.

Donald M. Steinwachs, chairman of the health policy department at
Johns Hopkins University, said fatigue was a "major cause of mistakes
and errors" in hospitals and nursing homes. Mr. Steinwachs was
chairman of the panel of 18 experts who conducted the study.

The report said many nurses and nursing assistants worked more than 12
consecutive hours, with some working double shifts of 16 hours.

To reduce "error-producing fatigue," the report said, state officials
should prohibit nurses from working more than 12 hours in any 24-hour
period or more than 60 hours a week.

In one study for the government, 27 percent of nurses at hospitals and
nursing homes reported that they worked more than 13 consecutive hours
at least once a week.

The report, from the academy's Institute of Medicine, said, "Long work
hours pose one of the most serious threats to patient safety, because
fatigue slows reaction time, decreases energy, diminishes attention to
detail, and otherwise contributes to errors."

Many hospitals and nursing homes have too few nurses to take proper
care of patients, the panel said.

Intensive care units at hospitals should have one licensed nurse on
duty for every two patients, the report said. Nursing homes, it said,
should have one registered nurse for every 32 patients and one nursing
assistant for every 8.5 patients.

The Bush administration said last year that it had no plans to set
minimum staffing levels for nursing homes, in part because such
requirements would generate billions of dollars in additional costs
for Medicaid, Medicare and nursing homes.

But the National Academy of Sciences said the administration should do
what it declined to do last year: set "minimum standards for
registered and licensed nurse staffing in nursing homes."

The academy found overwhelming evidence that as levels of nurse
staffing rose the quality of care improved, because nurses had more
time to monitor patients and can more readily detect changes in their
conditions.

"Studies show that increased infections, bleeding and cardiac and
respiratory failure are associated with inadequate numbers of nurses,"
the report said. "Nurses also defend against medical errors. For
example, a study in two hospitals found that nurses intercepted 86
percent of medication errors before they reached patients."

Senator Charles E. Grassley, an Iowa Republican who has been
investigating nursing homes since 1997, said he saw no need for the
government to specify the proper number of nurses.

"If we mandate minimum staffing levels, the nursing home industry will
want more money," Senator Grassley said. "It seems nursing homes
already receive plenty of money to do the job" - more than $58 billion
a year from Medicare and Medicaid. Senator Grassley recently secured a
promise from the industry to use $4 billion in Medicare money to
improve services to patients in the next decade.

Dr. Andrew M. Kramer, a panel member who is a professor of medicine at
the University of Colorado, said nursing assistants "work double
shifts on a fairly regular basis" at some nursing homes.

The academy said the nation's 2.8 million licensed nurses and 2.3
million nursing assistants accounted for 54 percent of health care
workers. Thus, said Dr. Harvey V. Fineberg, president of the Institute
of Medicine, "It is nurses who deliver most of the care we receive."

But Dr. William C. Rupp, a member of the panel who is president of a
Mayo Health System hospital in Mankato, Minn., said, "Virtually every
other industry in the country pays more attention to fatigue than we
do."

Pamela Thompson, chief executive of the American Organization of Nurse
Executives, a subsidiary of the American Hospital Association, said it
was "an accepted practice" for nurses to work 12-hour shifts.

Alan E. DeFend, vice president of the American Health Care
Association, which represents nursing homes, said: "The shortage of
nursing assistants has reached crisis proportions. Sometimes there's
just no alternative to overtime."

The panel did not distinguish between voluntary and mandatory
overtime.

Ada Sue Hinshaw, a panel member who is dean of the School of Nursing
at the University of Michigan, said: "The fatigue effects are the
same. Medical errors start climbing after 12 hours of work."

To reduce such errors, the panel said, nurses should be more involved
in the day-to-day management of hospitals and nursing homes.