How severe is the nurse shortage?
By Donald E. L. Johnson
Health Care Strategic Management, June. 2003, Vol. 21, No. 1
Copyright 2003 by The Business Word Inc.
The hospital nursing shortage, while real, may not be as serious as many nurses, physicians and health care executives believe, according to two reports on medical errors that were published last month.
Although the reports published in the Dec. 12 issue of The New England Journal of Medicine (NEJM) and the January 2003 issue of Consumer Reports focused on how the public and physicians have experienced medical errors in hospitals, both gave a lot of attention to the nurse staffing issue and how staffing affects the quality of care.
Reports on consumers dont’ agree Consumer Reports said that of its 21,144 readers (out of about 3 million) who returned questionnaires, 52% of non surgical patients, 64% of surgical patients and 66% of obstetric patients strongly agreed that “staffing seemed adequate to meet their needs.”
These results aren’t exactly confirmed by the more scientific telephone survey of 1,207 adults by the Harvard School of Public Health for the Henry J. Kaiser Family Foundation (www.kff.org), which was reported in the NEJM. That survey found that the public thinks more nurses are needed.
A very important cause of preventable medical errors in hospitals, according to 65% of those responding, was “not enough nurses in hospitals.” And 69% feel that “increasing the number of hospital nurses” would be “very effective” in reducing preventable medical errors, according to the Harvard study.
Which study do you believe? Which study is more statistically significant and credible? The Consumer Reports study is based on a huge sample of 21,144 relatively well educated and affluent readers who were self-selected participants for various reasons, including dissatisfaction and satisfaction with recent encounters with hospitals. The Harvard study reported in the NEJM was based on telephone interviews conducted in English and Spanish with a “nationally representative sample of 1,207 adults 18 years and older.”
Another wrinkle. The Harvard School of Public Health also surveyed 831 physicians by mail and online. This study had a margin of sampling error of +/- 3.5 percentage points, compared with +/- 2.6 percentage points for Harvard’s consumer survey. Like Consumer Reports’ survey, Harvard’s study of physicians involved more self-selected participants.
Public, physicians disagree The headline news is that while consumers and the public responding to the Kaiser-Harvard study had about the same experiences with medical errors, their analyses and solutions were quite different.
Only 53% of physicians believe there are not enough nurses in hospitals. And only 51% of responding physicians believe that increasing the number of hospital nurses would reduce medical errors.
Consumers, of course, base their observations and opinions on their personal, mostly brief hospital stays or on those of relatives. Physicians also were asked about their personal hospital stays and those of their families. But their opinions were strongly influenced by their professional experiences.
Physicians have their own agendas. Some are very concerned about nursing shortages in their hospitals, and others are, like consumers, are more worried about how soaring health insurance premiums will make it harder for them to get paid and for their patients to afford health insurance.
In the Harvard study, 72% of the public said preventable errors were caused by “doctors not having enough time with patients,” but only 37% of the doctors agreed. And 70% of the public blamed “overwork, stress, or fatigue of health professionals,” compared with 50% of physicians. Similarly, 67% of the public blamed “health professionals not working together or not communicating as a team,” compared with 39% of physicians.
78% highly satisfied with hospital stays If Consumer Reports rated its cover story, “How safe is your hospital?” it would give itself a “less reliable” score, or a 10 for super sensationalism.
For 78% of respondents to its survey “were highly satisfied with their stay.” And, the magazine reported, “overall, readers rated their hospital experiences higher than our survey respondents have rated service in banks, restaurants, or hotel chains.”
And as noted in an editorial in the Dec. 12 issue of NEJM, many physicians and consumers believe the whole issue of medical errors in hospitals has been overstated.
Indeed, the Kaiser-Harvard studies found that both consumers and physicians consider medical errors less of a problem than the Leapfrog Group and the Institute of Medicine would have the public believe. This is even though 42% of the public and 35% of physicians “said they have been personally involved in a situation where a preventable medical error was made in their own medical care or that of a family member.”
Harvard study reports more medical errors In the Consumer Reports study, “12% of the respondents said they were aware of a medication error, misdiagnosis, or similar problem during their stay. For 5% of all respondents, such problems led to serious health complications.” The magazine noted that “from 3% to 4% of hospital patients experience some kind of ‘adverse event’ caused by medical error or mismanagement,” according to major studies. Notice the wide and unexplainable divergence with the experiences of consumers and physicians with medical reported in the Harvard study.
Equally interesting is that Harvard found that, for the most part, the public and physicians attribute medical errors to health professionals more than to the institution involved. “Among those who have had experiences with medical errors,” 81% of the public and 70% of the physicians responding said “a lot” of the responsibility rests with the doctor involved. This compared with “a lot” for nurses (25% public and physicians); “a lot” for the institution involved (43% public and 22% physicians); and “a lot” for other health professional (26% public and 15% physicians).
See www.kff.org for a downloadable version of the Kaiser-Harvard study and the NEJM report and commentary on the study in that Journal’s Dec. 12, 2002 issue (pp. 1933 and 1965).