investigative series. Regrettably, however, your articles place the blame squarely on nurses and fail to recognize that medical errors are a symptom of a much larger problem. The patient errors you described are indeed tragic, yet they are largely unavoidable in a health care system downsized, restructured, and reorganized to the point where patients are increasingly a t risk.

Nurses are an important part of the solution-not the problem. It is indisputable that patient outcomes are better in hospitals with higher staffing levels and higher ratios of registered nurses in the staffing mix. Nurses are fiercely committed to quality health care for their patients, yet they are often powerless to pro- vide the kind of care patients deserve. Although nurs- es, like other health care providers, d o make mistakes, they are the patient’s greatest advocates in the health care system fraught with problems. Nurses are the first point of contact and the last line of defense for most patients. They connect members of the health care team and often provide a vital link between the patient and his or her family.

The majority of patient errors result from unsafe sys- tems, not incompetence. Inadequate and inappropriate staffing, insufficient training in new technologies, clini- cal research, and practice have created situations where a nursing workforce may be ill equipped to provide the quality of care patients need. We are just beginning to feel the effects of a nursing shortage of devastating pro- portions, which may place nurses and patients at even greater risk. Measures, such as mandatory overtime, merely exacerbate the problem with nurses exhausted on their feet and unable to think clearly or make good clinical decisions.

The supply of registered nurses i s rapidly declining and there i s no relief in sight. Nursing school enroll- ments are down and careers in nursing don’t hold the appeal they once did for young people today. In fact, many nurses are leaving the profession for job opportu- nities in technology-related fields where employers d o offer the training, support, and resources necessary for personnel to succeed.

As an organization comprised of 22,000 health care professionals, the Association of Women’s Health, Obstetric and Neonatal Nurses is committed to excel- lence in nursing practice and quality health care for women and newborns. We are deeply committed to pro- viding nurses with the educational programs, tools, and resources to keep them abreast of the latest clinical advances and assist them in providing excellent care. In addition, we are working with health care systems to develop strategies to protect patients from preventable errors. Through tools like the AWHONN Perinatal Risk Assessment Survey, we can help hospitals in identifying factors that place units, staff, and patients at higher risk of medical error. With the help of tools such as this, effective and efficient solutions can be implemented to ensure patient safety.

sion or organization. Partnerships with health care providers, institutions, legislators, policymakers, and third-party payers must be created to address this emer- gency now. Please join us in placing the health care

However, the problem is larger than any one profes-

emergency at the top of our national agenda, an agenda that places patient safety first and provides well-sup- ported, trained, and resourced registered nurses to d o what they do bes t -care for patients. Through responsi- ble reporting, the Chicago Tribune and other media can help mobilize a nationwide effort to resolve our nation’s health care emergency.

Please provide your readers with a comprehensive discussion of the growing nursing shortage and how it may affect patient care in a follow-up article. We would be pleased to work with you to develop such an article.

Gail G . Kincuide Executive Director, AWHONN

Washington, DC

Flawed Care Delivery System A Response from ANA ‘W he public has a right to expect quality care when . - entering a health care facility-and certainly not to

endure injury, o r worse, as a result. Since the Institute of Medicine ( IOM) released its December 1999 report: To Err is Human: Building a Safer Health System, which attributed approximately 100,000 hospital deaths annu- ally due to medical error, the public has become increas- ingly concerned about their safety when hospitalized. Rightfully so. That concern may be increased on the heels of the recent three-part series on nurse “mistakes” written by Michael Berens, September 10-12.

Despite the sensational headlines and a skewed, exclusive focus on nurses, the articles brought attention to many of the system failures that individual nurses and the American Nurses Association (ANA) have been calling attention to for years. An important point here is that the majority of medical errors d o not result from individual recklessness, but from flaws in the organiza- tion and delivery of health care.

1 would like to reassure the public that nurses are dedicated professionals who put the health and well- being of their patients first. The ANA is committed to safe, quality care and has worked tirelessly to promote a range of initiatives to support this priority. Most recent- ly ANA provided testimony at the National Summit on Medical Errors and Patient Safety Research sponsored by the Agency for Healthcare Research and Quality. The testimony referenced the critical need for research on patient safety as it relates to staffing levels, skill mix, and continuous work hours. This is the same message that ANA has been resonating for years in testimony and comments to the Clinton Administration, the Senate, and the House of Representatives.

Over the years, hospitals have slowly and systemi- cally eroded nursing care in the name of cost-cutting. In the early ’ ~ O S , many providers of health care ser- vices reduced their R N staffs under the premise of saving money. Nurses with years of experience were being replaced by lesser-trained, lower-paid unlicensed assistive personnel (UAPs). UAPs are not equipped

12 A W H O N N L i f e l i n e s Volume 4, Issue 6

with the academic knowledge of RNs o r their ability to assess and evaluate patients. In many cases, con- sumers who thought they were receiving professional nursing care were not.

by the use of excessive overtime to f i l l gaps in staffing, and is the number one concern of nurses today. Nurses already face great stress and challenges on the job-they must care for greater numbers of patients who are more acutely il l than even a few years ago. Research has shown that adequate nurse staffing is critical to the delivery of quality patient care because it allows time for appropriate nursing assessment of patients and their needs. Studies show that hospitalized patients have fewer complications in hospitals with high staffing levels and higher ratios of RNs in the staffing mix. Contrary to what Berens reported, specific nurse-to-patient ratios have not been identified by the ANA. However, in its “Principles for Nurse Staffing,” ANA outlines a range of considerations, related to patients, nursing staff, and the facility itself, for the determination of appropriate R N staffing. Staffing should be such that the quality of patient care is maintained, the quality of organizational outcomes are met and the quality of nurses’ work life is acceptable.

As referenced, many hospitals are requiring RNs to work mandatory overtime as a method of dealing with inadequate staffing. Nurses have been threatened with loss of jobs due to patient abandonment upon refusal. This staffing practice is unsafe. Patients need nurses who are well-rested and alert in order to execute the complex thinking, decision-making, and technical skills that are necessary to deliver quality care. In addition, provisions should be put in place that both prohibit mandatory overtime and require specific rest intervals before nurses return to work. In June, ANA’s House of Delegates passed a motion in opposition of mandatory overtime. Furthermore, several bargaining units affiliat- ed with ANA’s labor arm, the United American Nurse (UAN), have gone on strike over mandatory overtime and inappropriate staffing in the last year.

ANA and its nurse members continue to be at the forefront of the movement for state and federal whistle- blower and patient safety legislation. This type of legis- lation lifts the veil of secrecy that keeps hospital staffing

Inappropriate and insufficient staffing is compounded

1 - 8 0 0 - 4 - C A N C E R

practices and patient outcomes a mystery; gives con- sumers access to information they need to make informed decisions; and protects nurses who speak out on behalf of safe patient care. Furthermore, ANA is pushing the federal government to impose quality “report cards” so hospitals and other health care sys- tems will be required by law to report to the public about R N staffing, patient outcomes, infection rates, length of stay, readmissions, malpractice and other safe- ty and quality issues. Despite comments in the articles from officials of the American Hospital Association acknowledging that patients face risks due to inade- quate staffing and insufficient training, AHA and other health care organizations continue to oppose whistle- blower legislation and legislation that would make information regarding nurse staffing and patient out- comes available to the public.

To further assist in providing safe, quality care, ANA supports the recommendations posed in the IOM report which include developing a National Center for Patient Safety; establishing a nationwide mandatory state-based error reporting system; implementing non- punitive systems that don’t blame individuals; develop- ing performance standards for health care organiza- tions; and implementing proven medication safety sys- tems and practices.

Reducing the occurrences of medical errors must be a collaborative effort between doctors, nurses, administra- tors and all health care workers. Hospitals depend on interdisciplinary teams of professionals and auxiliary workers, all of whom have defined areas of expertise and responsibility. Provision of safe care demands that there be adequate numbers of each of these health care team members and that their deployment be appropriate to their training. Any initiative to reduce medical errors that does not look at a full range of related causes such as insufficient staffing, mandatory overtime and inade- quate training of all health care workers is fundamental- ly flawed and would not succeed in reaching ANA’s goal of providing safe, high quality health care services for all Americans.

Patricia Underwood, PhD, RN First Vice-President, American Nurses Association

Washington, DC

Thanks to research, we now know much more about breast cancer and how to treat it. Today, most women with breast cancer who are diagnosed and treated early continue to lead active and vibrant lives. For current information on breast cancer, call the National Cancer Institute’s Cancer Information Service at 14004CANCER.

December 2000/January 2001 A W H O N N L i f e l i n e s 13