Hawai'i's Health in the Balance:
A Report on the State of the Nursing Workforce, October 2004
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IV. Public Health Stakes: Quality and Access

As the shortage of RNs grows, so too will the threat to public health. With a statewide shortage, it follows that employers will find filling vacancies more difficult and some positions may remain vacant for extended periods. In turn, providers may respond by: (1) continuing to provide services with fewer RNs, potentially reducing quality of care and/or (2) delaying or discontinuing services, reducing access to care. While providers may experience the squeeze of a statewide nursing shortage at different points in time and to different degrees, it is certain that all are likely to feel its effect and many will be forced to respond by making decisions that negatively impact the public’s health.

Quality of Care

Registered nurses serve on the frontlines of patient care in hospitals, nursing homes, home health, out-patient settings, and community health programs. Nurses continuously assess patient status, identify downturns in health, communicate changes to other providers, plan and initiate interventions to restore health, and re-assess. A break in this ongoing process of assessment, communication, planning, intervention, and re-assessment can result in adverse events for patients, some life threatening. As a “last line of defense” for patient care, nurses detect not only patient decline, and initiate interventions to “rescue” patients, but also intercept medication errors.⁶⁶ One report finds that nurses are responsible for intercepting over 80 percent of all medication errors.

Research consistently confirms this “last line of defense” image showing that as RN staffing goes down, adverse events go up. Thus, the role of RNs in preventing adverse events is clear. However, what remains ambiguous is how far the RN frontline can be stretched before it begins to break, leaving patients vulnerable. A recent study shows that RNs are 3 times more likely to make significant medical errors when working 12.5 hour or longer shifts. This same study suggests that use of overtime and extended shifts has increased significantly as hospitals try to adapt to the nursing shortage.⁶⁷ Furthermore, research consistently finds a positive relationship between higher nursing staffing levels and quality of care. A recent federal study of acute care hospitals concluded that a higher proportion of RN hours and a greater number of hours of care by RNs are associated with better care. According to the study, low RN staffing is associated with hospital-acquired pneumonia, gastric bleeding, urinary tract infections, and death.⁶⁸ Likewise, RN staffing in nursing homes is directly correlated with better resident outcomes, according to a landmark federal study in 2001. Skin ulcers, urinary tract infection, and electrolyte imbalance were among the quality measures impacted by low staffing. This study established minimum staffing thresholds under which quality of care is compromised. According to the study, RN staffing in 90 percent of nursing homes across the country falls below this minimum threshold.⁶⁹

Access to Care

As vacancies go unfilled for extended periods of time, providers may find that providing services not only jeopardizes quality of care, but that providing care becomes impossible because there are just too few RNs. Nationwide, hospitals are already reporting service delays and closures due to the nursing shortage. According to a 2001 national survey of acute care hospitals, the nursing shortage “substantially” impacts providers’ ability to deliver quality care. Fifty-one percent of providers reported emergency room overcrowding, 26 percent closed the emergency department for four hours a week, 25 percent closed beds, 23 percent restricted admissions, 11 percent increased waiting time for surgery, and 6 percent reduced or eliminated services.⁷⁰ As the shortage worsens, access to service across all health care settings will be threatened.

⁶⁶A. Page, Keeping Patients Safe: Transforming the Work Environment of Nurses (Washington, DC: The National Academies Press, 2003).
⁶⁷A. Rogers, A, W. Hwang, Aiken, L., et al, “The Working Hours of Hospital Staff Nurses and Patient Safety,” Health Affairs 23, no.4 (2004): 202–212.
⁶⁸J. Needleman, Buerhaus, P. I., A. Mattke, et al., Nurse Staffing and Patient Outcomes in Hospitals (Washington, DC: Health Resources and Services Administration, US Department of Health and Human Services; February 2001).
⁶⁹Centers for Medicare and Medicaid, US Department of Health and Human Services, Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II Final Report (Washington, DC: Centers for Medicare and Medicaid, 2001).
⁷⁰American Organization of Nurse Executives, “Acute Care Hospital Survey of RN Vacancy and Turnover Rates in 2000,” 2002, http://www.wha.org/workForce/pdf/aone-surveyrnvacancy.pdf (16 January 2004).