Nursing Shortages and Device Design: A Hidden Connection

Originally Published MDDI October 2004

Design Strategies

Nursing Shortages and Device Design: A Hidden Connection

The U.S. nursing-shortage problem isn't going away. It may be up to the medical device industry to provide solutions.

Erik Swain

Dangerous incidents happen all too often. A patient takes a sudden turn for the worse, and the change isn't detected because the nurse is making rounds elsewhere. The wrong medication is given, or an infusion pump is set up incorrectly because the nurse is tired from an overlong shift. A condition is not addressed properly because the patient has been shifted from one hospital wing to another and the new nurse is unfamiliar with the patient's situation or there is inadequate access to the necessary records.

Many of these kinds of errors and breakdowns can be attributed to the increasing shortage of nurses in the United States. The number of nurses entering the profession is not keeping up with the number retiring or changing professions or the number needed to meet the needs of the nation's aging population. Recent news articles suggest a flood of nursing-school applicants might self-correct the shortage.

However, because of the inevitable burnout that comes with such a stressful job, and because of hospitals' needs to hold the line on labor costs, the nursing shortage isn't likely to be reversed any time soon. It may very well be up to technology to mitigate the effect of the nursing shortage on patient care. It would seem, then, that there is ample opportunity for medical device and medical technology manufacturers to find success with new products that make the nurses' workflow more efficient and less cumbersome. “I think there is a significant amount of money to be made for device companies,” said Eliot Lazar, MD, president and CEO of Elcon Medical (Buffalo, NY). “This can be a new niche. It should be the job of everyone in the industry to rethink this issue.”

However, it appears that only certain kinds of manufacturers are taking nursing use and efficiency issues into account when designing their products. Part of the reason may be that only certain hospitals, and certain sections of other hospitals, consider it a priority to implement technology that helps nurses do their jobs better. The rest, it seems, see it only as potential for added expense.

“It's clear that nurses have less and less time for patients, and that translates into less ability to do basic things that are crucial to patient care,” said Paul Barach, director of the Miami Center for Patient Safety at the University of Miami/Jackson Memorial Hospital. “By reducing the number of nurses, the time allotted to each patient goes down, leading to the number of adverse events going up and the quality of care going down.”

Items like patient-monitoring systems often have nursing-related ergonomics and workflow-efficiency properties factored into their designs. But many other products do not, and some in industry are questioning whether this is a problem.

“In my experience, many devices that come out do not reduce the burden, [but rather] just shift it onto other things,” said Matthew Weinger, director of the San Diego Center for Patient Safety at the San Diego VA Healthcare System. “For example, bar code systems to reduce medication errors tend to take more time, not less, for the nurses” because these systems require multiple scanning steps. To administer a drug, a nurse may have to scan the bottle, the patient's wristband, and her own wristband. This process often takes longer than opening a bottle, giving a patient a pill, and marking it on a chart.

“I don't think enough device companies are doing a very good job in addressing human factors and involving users in the design cycle,” Weinger said.

Barach's explanation: “That's not the way most medical device companies think.” Should they?

The Nature of the Shortage

Many factors are behind the wide-spread nursing shortage. A look at some of the many-faceted statistics helps illustrate the complexity of the problem. Some examples include:

• According to the Health Resources and Services Association (Rockville, MD), 30 states had a shortage of registered nurses in 2000. That number is expected to climb to 44 (plus the District of Columbia) by 2020. The American Hospital Association (Chicago) in 2001 estimated that there were 126,000 nursing vacancies at U.S. hospitals, accounting for 75% of all hospital vacancies. A year before, the Journal of the American Medical Association (JAMA) published an article projecting a shortage of 400,000 nurses by 2020.
• Fewer people are taking the national licensure examination for registered nurses. According to the National Council of State Boards of Nursing, 76,618 sat for it in 2003, compared with 96,438 in 1995.

• While nursing-school enrollments increased 16.6% from 2002 to 2003, that pace is not enough to meet projected demand. A 2003 article published in Health Affairs concluded that “because the number of young RNs has decreased so dramatically over the past two decades, enrollments of young people in nursing programs would have to increase at least 40% annually to replace those expected to leave the workforce through retirement.”
• According to a study by the Nursing Institute at the University of Illinois College of Nursing (Chicago), the ratio of potential caregivers to the elderly population will decline by 40% between 2010 and 2030.
• A number of studies have documented job burnout and dissatisfaction among nurses. One, published in the October 2002 issue of JAMA, found a correlation between nurses with high levels of dissatisfaction and exhaustion and those who were responsible for more patients than they felt was safe. It concluded that “failure to retain nurses contributes to avoidable patient deaths.”
• According to a 2002 report prepared for the American Hospital Association, one in seven U.S. hospitals has a nursing vacancy rate of more than 20% and the national average is 13%.

The worst shortages appear to be in the standard-care areas of hospitals, said Lazar. “Those used to be the hallmark of hospitals, but now that patients are shuttled out of the hospital quickly, they've become a loss leader for them,” he said. “The OR has been a bit hurt too.”
These statistics indicate that the personnel issue won't go away, so the healthcare community must find ways around it. Data indicate the average age of an OR nurse is more than 50.

“There has to be some process improvements in healthcare delivery,” said Gary Smith, vice president of Battelle Health and Life Sciences (Columbus, OH). “There has to be some process standardization. And, there has to be the technology to support these
improvements.”

Despite a number of obstacles, cost being the most obvious, many hospitals are receptive to technologies that can improve communication, workflow, and information sharing among nurses and other personnel, Smith said. “Some hospitals are even hiring companies to help with industrial processes like six-sigma and failure mode and effects analysis. They used to say that those [processes] were not realistic to use because the hospital environment was too different [from industry settings]. The challenge will be for hospitals to adopt tools and develop processes that improve efficiency but are more sensitive to the patient's experience.”

And that receptiveness is having some effect on how the device industry designs its products, said Carl Mayer, president and CEO of RBC Product Development (Kansas City, KS). “The device industry is thinking about it more, and that's driven by the end customer. In many cases, hospital systems don't feel positive about getting the qualified nurses they need and are looking at opportunities to acquire products that take them to the next level of efficiency.”

Areas for Improvement

Many of today's new devices are complex by necessity. But, Barach argued, when faced with so many technologies that are complex and difficult to use, nurses “lose their ability to ensure that errors do not progress to adverse events.” Therefore, there are a number of devices, technologies, and systems within hospitals that could be improved.

“Some of the technologies that could improve care are continuous, seamless monitoring throughout the hospital and the development of long-life batteries,” said Michael Wiklund, formerly vice president of human factors research and design for the American Institutes for Research (Concord, MA). “If you take a patient with a portable monitor to go get a CT scan, you don't want the nurse to have to worry about the monitor going down. We also need smarter devices and smarter alarm systems, particularly in critical-care units. We need to have them give concrete warnings about specific problems, rather than sounds that are hard to differentiate.”

Even products that have a great effect on patient safety or health outcomes can add to a nurse's workload, said Dawn Tenney, RN, MSN, associate chief nurse at Massachusetts General Hospital (Boston).

“Patient identification systems are touted as a new and great breakthrough, but they've added to the nurse's work,” she said. “They are great from a safety perspective, and we are very excited about that. But what we've found out is that bar code technology takes longer for the nurse to do the work, and that wasn't taken into account when the systems were designed.”

Marie Egan, RN, MSN, technology staff specialist at Mass General, said it is particularly essential that information systems be able to “communicate data to the nurse at bedside, so we don't have to go back to the nursing station. A handheld device that would give the nurse the information she needs when and where she needs it would be ideal.”

While patient data systems have gotten more sophisticated, some hospitals still need to do a better job of integrating and applying all the information. The task has been made more complex by the Health Insurance Portability and Accountability Act. “Everything associated with today's patient can be available in electronic form,” said Wiklund. “It's a question of getting the integration right.”

Weinger is not optimistic about that. “The biggest disappointment is the inability to do electronic medical records right,” he said. “The major problem is the absence of standards. Hospitals spend large amounts of money on a company's system, but then if they want to share the data with another system, it's not compatible. We need to have an information backbone before we can make better progress.”

Interconnectivity of all medical technology is a significant need, Egan said. “We are anticipating the concept of plug-and-play coming to medical devices,” she said. “Hospitals don't buy the same brand for all their systems. They buy different systems from different companies. But the future does not hold multiple stand-alone devices. Consumer demand will reduce the complexity of our environment. In addition, we should be able to purchase different components of a system from different manufacturers. That's interconnectivity. There is a lot of value in integration. The shrinking healthcare dollar is also causing us to ask what is the added value of each piece of technology—we are now more rigorous in our evaluation of cost-benefit technology to our environment.”

“It seems like the biggest gains are to be had in information technology,” said Joe Juratovac, Battelle's project manager for industrial design. “That's the source of a lot of activity because the systems don't talk to each other very well. Every hospital's information and communication systems are cobbled together, but [no hospital is] about to blow up the whole thing and start over, even if that's probably what some of them need to do. So there's a huge need for improvement out there.”

The OR is not immune to the nursing shortage. There could be opportunities for technologies to reduce or eliminate an OR nurse's more-tedious tasks.

“The OR nurse has to count all the instruments and sponges to make sure none are left in the patient,” said Weinger. “I have seen several different systems that claim to be able to do the same thing electronically. But until a technology that has been documented to be reliable is implemented, clinicians won't trust it and will still ask the nurse to count manually.”

Device companies should not take ease-of-use issues lightly, because devices that are difficult for nurses to use may find themselves on the shelf. “Once it gets a bad name, the tide turns against it in the workplace,” Egan said. “If a physician finds that a particular device interferes with the smooth functioning of the room or surgical team, then [the physician] may simply decide not to use it. For the successful development of any product, the user interface has to be taken into account. Device makers don't necessarily have good contact with device users, the circulating nurses. We will be looking to the vendors that want to work with us.” That, she said, is why Massachusetts General is part of the Center for Innovative Minimally Invasive Therapy consortium, which convenes clinicians, scientists, and engineers to look for ways to overcome barriers to the implementation of new healthcare technologies.

Addressing the Issues

Some sectors of the device industry are at the forefront of improving nursing workflow. “The frontier is more in the software arena than the hardware arena,” said Wiklund. “It's in things like data management and collection of patient information.”

Patient-monitoring systems are frequently cited as technologies that have improved nursing efficiency. One example is a flexible monitoring system from Welch Allyn (Skaneateles Falls, NY). The portable bedside monitors connect to a central station and provide continuous, comprehensive monitoring of patients within the hospital. The implication for nursing workflow, said Jim Welch, chief technology officer, is that patients no longer need to be transferred to a different wing of the hospital unless absolutely necessary. This system cuts down on the time nurses have to spend helping transfer patients. It also reduces the risk of errors from discontinuity that can occur when a new nurse in a new wing takes over a patient's care.

These sorts of efficiencies, Welch said, cut a patient's stay by half a day, which in a 400-bed hospital translates to the equivalent of 33 new beds created and 24 full-time nurses gained.

Wireless transmission of data is also catching on. Many physicians sport convenient PDAs these days, and nurses' use of them is probably not far off. Mayer sees “a huge push in wireless” coming in the next year. “We are seeing a lot of implementation of [IEEE] 802.11 networks in hospitals that are making monitoring systems wireless,” he said.

“We're not there yet, but we will get there,” said Welch. “We need to find ways to get information to the nurses more effectively.”

Similarly, some hospitals are using technologies such as radio-frequency identification (RFID) to improve internal communication and streamline workflow. “Some are beginning to put RFID on drugs, on wheelchairs, on nurses' lapels, even on wall interface units,” Wiklund said. “If done well, that is a great asset. People know where everyone is.”

Process changes have worked well for some hospitals also. “A redesign of a care process or department, focusing on the patient and the nurse, can often improve workflow tremendously,” said Paul Smit, director of strategy and business development for Philips Medical Systems (Andover, MA).

Cost and Other Obstacles
There are impediments to improving these systems, however. The most significant is cost. Hospitals that have spent millions of dollars on capital equipment are not going to be eager to replace it with better versions that improve nursing workflow.

Indeed, device companies aren't going to invest in developing better systems if the market doesn't seem to be interested in them. “Part of the problem is the fundamentals of the way healthcare is paid for,” Barach said. “Device companies can't use a simple business model to project the success of a system because payment to hospitals is so unreliable and haphazard, which can make hospitals wary of investing in a costly and unproven technology.”

Mayer agreed. “It takes a certain amount of forecasting on a device company's part,” he said. “Determining the extent of the benefit and what would be the incremental sales associated with it can be a pretty subjective area. You're not going to risk spending $2 billion to develop or improve a product if it might lead to incremental sales of only $800 million. Also, customers asking about it is one thing, but really wanting it is something else.”

Old-fashioned budget conflicts account for some of the problem, too. “Continuing costs in other areas are taking money away from any implementation of nursing-efficiency technologies,” said Welch. “If a hospital can fund either a new MRI or nursing efficiency, nursing efficiency falls to the back of the line. In a lot of cases the ROI has yet to be demonstrated, so the best way to do it may be with pilot money.”

FDA, the Centers for Medicare & Medicaid Services (CMS), and state regulators represent obstacles too, said Barach, because “the connection between the nursing shortage and technology is not really on their radar screen. It would be nice if they worked with device companies to improve healthcare delivery by offering incentives to hospitals to reduce the burden on hospital personnel.”

And even when device companies are seeking input from hospital personnel on how best to design a product, nursing issues aren't always taken into account. “When our technology task force evaluates a new product, on our checklist of what's important, the nurses' experience isn't necessarily at the top,” Tenney said. “Even clinicians aren't thinking about making the nurses' work easier. But at the same time, we are probably guilty of not raising the flag. We may not be pushing as hard as we should to get our views heard.”

Lazar agreed that hospital administrators don't make nurses' concerns as much of a priority as they should. “They are occupied with ‘front-line' issues, and nurses' issues often don't rise to the top,” he said. “There needs to be a more vocal presence about them, and the administrators are the ones who should be driving it. But nurses' issues are not nearly as sexy as surgical and infrastructure issues.”

Shifting Responsibilities

One way to address the nursing shortage involves shifting certain responsibilities to other personnel, or even to patients themselves. Technology is playing a role in making that shift.

The advent of point-of-care testing was a major boost to nursing efficiency, Wiklund said. “Rather than having the tests done in a hospital lab and having to have a runner get the information to the nurses, the same results can now be handled by a point-of-care test at the bedside, so nurses are able to get answers more quickly.”

In addition, he said, “One way to relieve the burden is to enable patients to take devices home with them. Many patients are being asked to leave the hospital earlier, often to reduce costs. One opportunity may be to make devices so intuitive to use that nurses can learn them easily and teach patients how to use them effectively so they can take them home. This includes infusion pumps, heart monitors, automatic
external defibrillators, and dialysis equipment.”

Weinger agreed. “Getting the patient into the loop is a big priority,” he said. “If patients could take more responsibility for their own healthcare, and the information about their own healthcare, that would ease the burden. The hospital would have to provide appropriate levels of support, so there are opportunities for computer-based support systems. There is at least one company trying to develop an interface for patients to monitor their own medical records.”

Technology can also assist nurses in learning the more-complex new devices. “Not all nurses get the opportunity to do in-service training because they may not have time,” Wiklund said. “On-line training may be a solution. As it gets better, it may become malpractice not to take the time to get trained on products as complex as multichannel infusion pumps.”

Even with training and patient participation, nurses still have a lot to juggle, which at some hospitals is leading to a further division of labor. “There is no way to be able to manage all this technology plus deliver patient care,” Tenney said. “We need a computer expert alongside. Over the next few years, a new role in healthcare will be created and this technology person will partner with the nurse. That will allow the nurse to keep the patients satisfied while others juggle the technology, which includes patient records, supply-chain management, and tracking of personnel and equipment.”

A New Frontier

If nursing-shortage issues are understood and technological solutions for them embraced, hospitals could look very different in five years.

But to do so, changes to the device design process are critical. “There are two areas of technological development that would most mitigate the nursing shortage,” said Smit. “One is improving the working environment of the nurse by innovating the patient environment through use of ambient experience technology. The other is patient- and nurse-centric design processes.”

Is the industry up to the challenge? Only time will tell.

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