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Patricia Underwood, of nurses association, on the U.S. nursing shortage


(CNN) -- Almost one year ago, the Institute of Medicine released a report showing that up to 98,000 patients die in hospitals every year due to medical errors. This week, a major newspaper reported that nursing mistakes alone are responsible for thousands of injuries and deaths.

Patricia Underwood is First Vice President of the American Nurses Association.

Chat Moderator: Welcome Patricia Underwood.

Patricia Underwood: I would just like to say hello -- I am really pleased on behalf of the American Nurses Association to have this opportunity to discuss issues that are vital to nurses and the safety of people everywhere.

Chat Moderator: How would you describe the state of the work environment for nurses these days?


Chat Moderator: The work environment for nurses these days can be characterized as challenging. Many times rewarding. But more often I think one of the critical issues is that over the last 10 years hospitals have tried to influence their bottom-line by reducing registered nurse staff. At the same time that patients are more ill and have need of more critical judgments made by professional registered nurses.

Question from undoneRN: How has the CNA dealt with understaffing?

Patricia Underwood: I can't speak for the CNA, but they -- like the rest of nursing -- have been very concerned about adequate staff. One of the things that CNA has done is to propose minimum staffing ratios for various types of patient units. The American Nurses Association has chosen not to set specific ratios because often times when minimums are set they become maximums. A second problem is that when you set a ratio, people think they have addressed the problem by having the number of nurses suggested. To provide safe quality care for patients we need to consider more than just numbers. The American Nurses Association has put forward some principles for nurse staffing. These include looking at the types of patients that are on the unit... needs in terms of how sick they are, special needs in terms of their age. Needs in terms of communication patterns for example, looking at the geography of the unit, looking at communication on the unit, looking at the preparation of the registered nurse staff that is available and looking at how the unit is run in general. And using some of these issues to make decisions on a day-to-day basis about the staff that is needed. California has a law that's going to require minimum ratios by the year 2002. Some ratios have been proposed. One ratio for example, is having one nurse to three patients in labor and delivery. I myself am an OB Nurse. A one-to-three ratio might be appropriate if the patients are at different phases of labor. But if you have 2 patients delivering at the same time, a one-to-three ratio is not safe. This is just an example of how we can think about ratios but ratios should not been seen as the answer to staffing problems.

Question from Doug: Patricia, I work for a state prison, and I also work for a group home for developmentally disabled adults part-time and they, management, has us staff administer medication to the residents to save on nursing expenses. Do you see alot of agencies going that way?

Patricia Underwood: I don't know nationally what the percentage is right now in terms of state prisons and group homes. We do see a concern and trend within public schools where schools have had principals and secretaries give medication to avoid having to have a nurse come in to do that. Both the School Nurses Association and the American Nurses Association have been attempting to bring our concerns about this issue to the public. One of the problems in the schools, which is not the prison or the group home, is that the people giving the medications are not knowledgeable to detect differences in the patient that would necessitate a change in the medication. I think we have to be very cautious not to preclude the possibility of, as is happening with sometimes disabled individuals who have personal care attendants, but the issue overall for all of these settings is if the recipients are not able to exert personal judgment about their own medication then they need to have some avenue for a professional assistance.

Question from Haley-CNN: Have hospitals been placing more emphasis on skill than on the number of nurses per shift?

Patricia Underwood: Not that I know of.

Question from LJNoel-CNN: What advice would you give those thinking about a nursing career?

Patricia Underwood: Actually I think this is a wonderful time to enter nursing despite the fact that for this week we have been so focused on some of the problems. The advantage of focusing on some of the problems is that it gives us an opportunity to begin to develop comprehensive and lasting solutions. Nurses today have so many different opportunities and ways to make a difference in people's health. Nursing today requires the highest abilities of critical thinking and knowledge. Nursing today still continues to require the compassion to put that scientific knowledge together and to work with individuals to help them make a difference in their health. So I would encourage anyone who is thinking of entering nursing today to really take advantage. We are heading for the largest shortage of nurses that this country has ever seen. It will be a shortage not just of nurses at the bedside as we have seen in the past, it is a shortage of nurses with advanced expertise at the bedside and nursing faculty and nurses with the highest level of education.

Question from hi: Is this nursing shortage a worldwide problem?

Patricia Underwood: I don't know the data from other countries right now. There are many countries that have never had what we would consider a (full) compliment of nurses. Therefore they have always experienced a shortage. I do not think that there are countries that have an oversupply but beyond that, I do not have the data at the moment. People could probably get access to some of that by contacting the American Nurses Association.

Question from maleRN: Thanks, Ms. Underwood I work both hospital ICU and on-call at a nursing home due to my love for the elderly. Medication errors are common in this setting, particularly due to nursing staff shortages as a reult of the Balanced Budget Admendment that cut Medicare funding. Is the ANA taking any steps in the legislature to help address this issue that so fundamentally affects our vunerable adults?

Patricia Underwood: Two things are happening in the legislature. One of the things that we have tried to do is to pass the Patient Safety Act. (It) does not address directly medications but does address some of the safety issues in terms of staffing. Because for the most part when you talk about the medication errors they are often a result not of individual mistakes as much as systems that make it difficult for the nurse to give the quality of care that he or she believes in. Some times medication errors are the result of nurses being too tired to exercise the critical judgment that is needed. Policies mandating overtime contribute to safety issues. The American Nurses Association House of Delegates in June took the position that we are going all out to fight the practice of mandatory over-time.

Throughout our state nurses associations various initiatives are going forward to oppose this practice. You can't expect that a 47-year-old nurse can work 16-hour shifts several days in a row without it compromising the safety of the care that that nurse wants to provide.

This week a bill was introduced in the U.S. House of Representatives, HR5179, titled Registered Nurses and Patients Protection Act. This bill would limit the number of hours licensed health care workers, including registered nurses, are forced to work. Under this bill no RN would be required to work beyond 8 hours in any work day or 80 hours in any 14 day period. We hope that some of these actions will be successful in addressing the concerns that you have raised so that all of us as nurses can have the opportunity to give the kind of care to which we are committed.

Question from LJNoel-CNN: What kinds of people make the best nurses, in your opinion?

Patricia Underwood: First of all, in talking about people who make the best nurses I think it is important to say that we want nurses who represent the diversity of our population. We want nurses who are very bright because nursing demands as I mentioned before knowledge and critical judgment. We also want nurses who are caring so that they can put the knowledge and critical judgment to work in a way that respects the needs and diversity of people who come to them for help and care. The people who make the best nurses are also people who are articulate, who are committed, who are willing to make a stand on difficult issues, because nursing today requires that nurses stand with their patients to try to address the problems of the health care delivery system to make it be a better system for all of us.

Chat Moderator: Do you have any final thoughts for our audience today?

Patricia Underwood: There has been much public attention drawn this week to the issue of errors in health care, and nurses everywhere are committed to working with people to give the highest quality care possible. We need people everywhere to work with us to demand that they have the access to registered nurses when they come to the hospitals or when they need care to manage a chronic illness. We need people to partner with us to make sure that health care for the nation is accessible, safe, quality as well as affordable.

Chat Moderator: Thank you for joining us today, Patricia Underwood.

Patricia Underwood: Thank you to everyone who has participated and feel free to direct anymore questions to the American Nurses Association, the association for all nurses.

Patricia Underwood joined the chat via telephone from Michigan. provided a typist for her. The above is an edited transcript of the chat, which took place on Friday, September 15, 2000.

Nursing mistakes cause thousands of deaths, probe finds
September 10, 2000

American Nurses Association

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