When Care Becomes A Burden: Diminishing Access to Adequate Nursing


Many patients, their families and friends, physicians, and nurses have complained in recent years about a decline in the quality and availability of nursing services in hospitals. More than a few experienced observers of American hospitals interpret these complaints as evidence of a shift in responsibility for care from professional nurses to less-skilled workers, families, friends, and patients themselves. Others, however, consider the complaints to be exaggerated, viewing them as expressions of the anger of nurses and physicians about the restructuring of hospitals and health systems in response to pressure on prices from managed care companies.

The extent and causes of the problem are obscured by the absence of quantitative evidence about them. In 1997, Claire Fagin, former dean of nursing and acting president of the University of Pennsylvania, and other experts on nursing asked the Fund to convene meetings to discuss whether the perception of the declining quality and availability of nursing care could be documented more precisely. The purpose of documenting the problem would be to suggest remedies for it.

As a result of these meetings and subsequent conversations, the Fund commissioned a journalist who writes frequently about health care to conduct interviews about changes in the adequacy of nursing care with staff nurses, nursing executives, physicians, and chief executive officers at four hospitals. These persons told the journalist many anecdotes about harm or prospective harm to patients from inadequate nurse staffing. But she was unable either to document these stories or to persuade other witnesses to corroborate them.

Fagin and staff of the Fund worked to understand why so many people complained about a problem that was so difficult to document. To assist in explaining this situation, the Fund commissioned Barbara Norrish and Thomas Rundall, of the School of Public Health of the University of California at Berkeley, to write a paper reviewing the extensive empirical literature about the impact of various restructuring projects on nursing care. Their paper, “Hospital Restructuring and the Work of Registered Nurses,” is scheduled for publication in the Milbank Quarterly, volume 79.1, in March 2001.

Simultaneously, Fagin wrote this report in order to describe perceptions of the problem and plausible explanations for it. The Fund then convened a series of conference calls with nurses prominent in hospital management, education, and research; two former nurses who are elected officials; and a senior executive of a state health care association to discuss the implications of her report for policy. Staff of the Fund summarized their recommendations in the final section of this report. Although crafting the recommendations required the expertise of persons knowledgeable in nursing and politics, implementing them will require a broad coalition of persons within and outside the health sector.

The Acknowledgments that follow list the many people who participated in this project. We thank them for their efforts to clarify and seek remedies for a difficult and important problem.

Samuel L. Milbank

Daniel M. Fox