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Nursing shortages up hospital risks.

Nursing Shortages Up Hospital Risks

Nursing vacancy rates in hospitals and health care organizations throughout the country have hit double digits in 1986 standing at 13.6 percent. According to a survey of the American Organization of Nurse Executives just one year earlier, vacancy rates were only 6.3 percent. What has caused such a dramatic increase from 1980, when 25 percent of all hospitals were reporting no nursing vacancies?

In managing nursing shortages, hospitals argue that new and different factors have contributed to the current situation. Legal theories examine hospital liability through the acts or omissions of its nursing staff.

Factors that have been historically cited as being behind the high nursing vacancy rates are low wages, poor working conditions and a poor public image. Historically, nursing shortages have been cyclical in nature, and the pattern of reaction by the hospital industry has been to wait until a shortage reaches crisis proportions. Interventions have often not begun until shortages have disrupted patient care, burned out nursing staffs, frustrated nursing directors and resulted in cutthroat competition.

In today's health care environment, however, the stakes are higher. The impact of a nursing shortage in the current competitive health care industry could seriously disrupt the quality of patient care and the ability for hospitals to meet health service commitments. Undoubtedly, the risk of hospital liabilities increases when nursing vacancies are at current levels. There are steps that risk managers can take to minimize risks created by today's shortages. Hospitals have previously taken steps to reduce the impact of nursing shortages on hospital operations. Among these are increasing wages (shortages were relieved in 1980-81 when wages increased 13.5 percent); increasing the use of overtime hours; using float pools, nurse registries and crosstraining existing staff; using innovative staffing plans and patient classification systems; using supplemental nursing services/agency services; downsizing health services and closing beds.

These steps have temporarily eased nursing shortages, but few long-term remedies have been taken to improve working conditions for nurses. The fact that nursing in today's fast-paced hospitals is physically grueling, emotionally draining and intellectually taxing has led many nurses to leave the hospital setting or to drop out of the nursing employment market.

The principal reasons cited for the current vacancy rate is that there are simply more career options available to women today. Why should a person go into nursing when he or she can make more money and have better working conditions in business? Another factor contributing to the high vacancy rates in hospitals is that nurses are choosing to work in alternative health care settings such as ambulatory and home care, where improved working conditions and better wages are offered. This latter factor has led to a redistribution of the current supply of nurses away from acute care hospitals to out-patient and home care settings.

The task ahead for hospitals in providing a quality nursing staff will depend on how well hospitals develop, implement and maintain programs of recruitment and retention. At the same time, the nursing profession must deal with the changing clinical and managerial trends in health care. From a clinical perspective, some of the changes already affecting the nursing profession are the movement from general medical/surgical nursing to specialty care nursing, managing an aging patient population, meeting nursing needs in ambulatory and primary care settings, maintaining high quality standards in a more controlled health care environment and teaching families the basic principles of self-care. From a management perspective, nursing must adapt to more decentralized organizations, staffing efficiency requirements, the expanded role of the nursing administrator in planning, marketing and new business development and help management make health care service delivery more economical.

Thus, the changing and expanded role of the nursing profession has exposed the nursing staff and the hospital to increased liabilities. Lawsuits against hospitals and health care professionals have increased with a better-in-formed public that is taking a more active role in health care choices and a more liberal interpretation by the courts of the concept of negligence. Many malpractice incidents occur not because of the injury, but when patients and their families are angry, due to some unnecessary discourtesy or personal indignity that was visited on them by a physician, nurse or other health care professional.

When nursing shortages threaten the quality of patient care, hospitals are exposed to a greater risk of legal action and malpractice liability. Under current legal theory, the hospital, as the employer of a nurse, is responsible for any and all acts that occur within the employee's scope of employment. In cases in which the hospital experiences high nursing shortages, the law looks to two legal theories, corporate liability and respondeat superior, for proving hospital liability. Under corporate liability, the hospital may be held liable for its own acts or omissions. Under the theory of respondeat superior (defined as let the master respond), the employer may be held liable for the negligent acts of its employee which may occur while the employee carries out orders or otherwise serves the employer's interests.

Our legal system recognizes that multiple individuals often contribute to patient injury, and therefore, malpractice liability is extended not only to the hospital and doctor but increasingly also to the nurse and other ancillary health care professionals. In general, malpractice is defined as the failure of one rendering professional services to exercise that degree of skill and learning applied by the average prudent reputable member of the profession.

In evaluating whether the nurse was negligent in the provision of professional services, the law will look to see if the nurse practiced in accordance with the standard of care of a reasonably prudent nurse practicing under the same or similar circumstances. The nurse, like the hospital, has a duty to exercise ordinary or reasonable care to see that no harm comes to the patient. This duty is defined by professional and statutory standards established by professional organizations such as the American Nurses' Association and the Joint Commission on the Accreditation of Healthcare Facilities. In the case of the nurse, statutory standards are governed by a state's nurse practice act, through which nursing licensure is regulated by the state's board of nursing. In cases in which the nurse fails to meet either professional or statutory standards, the law will hold the nurse and hospital liable for negligent nursing actions or omissions. Standards of nursing practice are driven by regulations, self-evaluation, physicians, hospital protocols, laws and patient expectations.

Health care manpower projections for the remainder of the 20th century indicate that from 10 percent to 15 percent of nursing positions will shift from the hospital's acute care environment to ambulatory and home care settings, according to the Journal of Professional Nursing. The number of full-time positions in hospitals will decline, while part-time opportunities will increase. Hospitals are expected to continue to reward efficiency, favor high technology over people and encourage alternatives less costly than intensive therapies. Registered nurses with baccalaureate degrees will continue to be in greater demand, since they will have the flexibility of shifting from clinical to administrative responsibilities. Also, greater employment opportunities for licensed practical nurses, which have declined in hospitals, will increase in nursing homes and home health entities.

Hospital risk managers should not loose sight of the importance of maintaining high standards for quality patient care even under a competitive health care environment with pressures for efficiency controls and cost containment. Nursing shortages can present a greater risk to hospital liability if compromises in patient care occur when staffing is limited and restrictions in service delivery are made.

Typically, four major areas of concern pose some of the greatest risks of liability for the hospital from its nursing staff. These include errors in the administration of medications, the lack of communication and failure to respond to the patient's condition, failure to act that could lead to patient injury and failure to treat with a responsible level of care.

With a greater emphasis on a hospital's systematic integration of risk management and quality assurance activities, hospitals should look at their early warning detection systems of potential patient problems to see if these indicators have the sensitivity to pick up the additional risks that are more likely to occur during periods of nursing shortages. The screening process should also include an evaluation of the current risk, a plan for corrective action and continuous monitoring and follow-up to determine if the action plan has had the desired result.

Projections fail to show encouraging signs of relief for current nursing shortages. Attractive career options for young people, ambulatory and home care opportunities, tough working conditions in hospitals and the limited supply of nurses will continue to create increased risks for hospitals. Competitive pressures to contain costs and promote efficiencies in service delivery may lead managers to relax adherence to high-quality control standards.

Hospital risk managers need to review existing policies and procedures, performance evaluation systems and early warning detection systems to determine sensitivity to increased risk of liability under conditions of nursing shortages. It is only through dedication to upkeeping a quality staff and continuous monitoring of the delivery of high quality patient care that hospitals will be able to minimize their risks of increased liability during conditions of nursing staff shortages.

Stuart I. Freedman is the national coordinator for health care for M&M Protection Consultants in Pittsburgh, PA.
COPYRIGHT 1989 Risk Management Society Publishing, Inc.
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Title Annotation:includes related information
Author:Freedman, Stuart I.
Publication:Risk Management
Date:Jul 1, 1989
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