Comparative Views of the Impact of the Nursing Shortage on Quality of Hospital Care

1. 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

2. Disclosure Funded by: • Johnson & Johnson Campaign for Nursing’s Future

3. 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

4. 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)

5. 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

6. 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

7. 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

8. 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 Themes Across Surveys

9. 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.

10. Percent Observing Nursing Shortage in Hospitals

11. Impact of Nursing Shortage on Care Processes

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

13. Impact of Shortage on Hospital Capacity

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

15. Impact of Shortage on Nurses

16. How much of a problem do you think the shortage of nurses has been for…“Major problem”

17. How much of a problem do you think the shortage of nurses has been for…“Major problem”

18. Impact of Shortage on Institute of Medicine’s Six Aims for Improving the Quality of the HealthCare SystemsIOM 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.

19. Patient-centered Effective Safe Timely Efficient Equitable Institute of MedicineSix Aims for Improving Quality of HealthCare System

20. Shortage frequently or often impacting….

21. Patient-Centered Care 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

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

23. Safety of Care Safe:Avoiding injuries to patients from the care that is intended to help them

24. Timeliness of Care Timely: Reducing waits and sometimes harmful delays for both those who receive and those who give care

25. Efficiency of Care Efficient:Avoiding waste, including waste of equipment, supplies, ideas, and energy

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

27. Expectations of Where Nursing Shortage Will Lead

28. Expect Shortage Will Lead to …

29. 3. Wee bit about the Changing Composition of the RN workforceOlder and More Foreign-Born

30. Recent Total RN Employment Growth in US by Age 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.

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

32. Growth in Foreign-born RNs

33. 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.

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

35. 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

36. 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

37. 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