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CBC
(Tony Doucette):
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Windsor
Regional Hospital is going to lay off 166 staff members, about 120 of those will
be registered nurses. Hospital CEO David Musyj says 80 of those RN positions
will be replaced by cheaper registered practical nurses or RPNs. Musyj blames a
$20 million budget shortfall because of decreased funding from the provincial
government. In making the announcement last week, Musyj also said, and I'm
quoting, quality outcomes are not diminished. Ann Tourangeau takes issue with
that. She is an associate professor in the Faculty of Nursing at the University
of Toronto. She has done two large studies that looked at the mix of nursing
staffs at seventy-five Ontario hospitals, and she looked at the impact on
patient mortality. Ann Tourangeau is on the telephone. Good
morning.
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ANN
TOURANGEAU (University of Toronto):
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Good
morning Tony, how are you today?
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CBC:
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I'm
well, thank you so much. What did your studies find?
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TOURANGEAU:
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Well,
we found that overall, that the larger the proportion of registered nurses
within the staff mix in acute care hospitals where patients are generally
extremely ill, the lower are mortality rates. And we are very confident that
mortality rates are certainly one of the most sensitive measures of quality of
care in hospitals, and we know that some hospitals are better than others at
preventing unnecessary deaths within these hospitals.
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CBC:
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Why
the increase in patient mortality?
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TOURANGEAU:
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Because
nurses really, our registered nurses are the surveillance system within a
hospital. They are the people who are there twenty-four hours a day, seven days
a week, observing patients, providing care to those patients, assessing them,
contacting the rest of the health care team when they notice or observe that a
patient is becoming ill with a complication or with their primary disease, and
there are not as many other people in the health care circle of care of patients
that can do that like registered nurses can. They're the ones who identify that
particular issue quickly, gather around the health care team to intervene, and
allay that complication so people don't die unnecessarily.
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CBC:
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In
the hospitals you looked at, how great was the increase in patient
mortality?
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TOURANGEAU:
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Well,
for example, we found in our latest study that a ten percent increase in the
proportion of registered nurses in a hospital's nursing staff mix was associated
with six fewer deaths for every thousand patients discharged from that hospital.
But even further, we looked at the preparation of the registered nurses, and now
increasingly, since 2005, nurses in this province, registered nurses, have to
have a baccalaureate degree to practice nursing, but not everybody does yet.
Additionally, a ten percent increase in the proportion of baccalaureate educated
registered nurses was associated with an additional nine fewer deaths per a
thousand discharged patients.
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CBC:
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Baccalaureate
educated nurses being those who get the four year bachelor of nursing
degree.
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TOURANGEAU:
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Yes.
Yeah.
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CBC:
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How
can you draw a direct link between patient deaths and the nurses a hospital
employees?
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TOURANGEAU:
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Well,
what we do in our studies is we, well, we know for sure that most of the reasons
people die within hospital or associated with their hospital care is related to
their own health condition. So as a health services researcher, I'm less
interested in their health condition, I'm more interested in the structure and
processes of care. So I have to do things to adjust for or control for patients'
own characteristics. So we adjust for or control for patients' own health
conditions, and their characteristics. And we look, so that allows us to look at
the structures and processes of health care. And when we look across these
seventy-five hospitals, we see that there's a wide range of risk adjusted,
already adjusted for patients' own health conditions, mortality rates. Some
hospitals are much better than others across Ontario, that have lower mortality
rates. I don't know about you, but I'd like to be at the hospital with the lower
mortality rate. And so we look at the direct relationship, and the impact that
staffing and those kinds of things have on mortality rates. We look at all kinds
of different things. We also look at physician qualifications, et cetera. But
consistently, it's the registered nurse staff mix that comes up as being the
predictor of mortality.
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CBC:
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You
say the mix of RNs and RPNs is much more important in a hospital today than it
was twenty or twenty-five years ago. What do you mean by that?
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TOURANGEAU:
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Well,
what I mean by that is that the patients in hospitals are quite different than
they were ten years ago, fifteen years ago, twenty years ago, twenty-five years
ago. Patients are much more ill. They're there for a much shorter period of
time. They come in very ill. And they leave quite ill as well. And so it's only
those very sick people that are usually admitted to hospital, and those are the
kinds of patients that really need the clinical knowledge, the clinical judgment
of registered nurses taking care of them. That doesn't mean there's not room for
everybody in the health care system. There's more than enough room. But when
patients are unstable and unpredictable, the person that you want caring for
them is a baccalaureate prepared registered nurse.
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CBC:
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The
CEO at Windsor Regional Hospital claims that the number of all RN hospitals has
diminished drastically in Ontario, in other words hospitals staffed entirely by
registered nurses. Is that something you've seen?
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TOURANGEAU:
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I
can't say that I've been watching the statistics from year to year go up about
the proportion of registered nurses in caring for patients in hospitals. But I
would say that there's certainly quite a pull to do that because the outcome
that is most visible to hospitals, and hospital executives, and they're really
only doing their very best, they're trying to stay afloat, and do good things
for patients, do good things for the communities. The most important thing that
they have to take care of is budget. And when you have a budget that doesn't
allow for... That you have to find things in to reduce, well, the most obvious
thing is your employee budget, and the nurses take a huge part of the budget.
The place to look for cuts is, of course, in your nursing pool.
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CBC:
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Is
there such a thing as a good mix of registered nurses and registered practical
nurses?
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TOURANGEAU:
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Well,
it depends on the setting. So if Windsor Regional has not so sick patients, and
has units where patients are predictable and stable, that's the kind of unit
where you could have a lower mix of registered nurses. But in general, that's
not what's in acute care hospitals now. Acute care hospitals, if you want the
best outcomes for your patients, the best quality outcomes, including mortality,
the evidence across Canada, the United States, Europe, is very clear--it's a
registered nurse, baccalaureate prepared registered nurse, you know, highest
proportion, even a hundred percent, that you can arrive at the best outcomes for
your patients.
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CBC:
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To
the best of your knowledge, are any Ontario hospitals solely staffed by
registered nurses?
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TOURANGEAU:
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I
believe there are some. And there are certainly many units within hospitals that
are staffed entirely by registered nurses, and that's in recognition of the high
intensity, acute needs of those patients. And remember, there are units in
hospitals that may not need all registered nurse staff because they may not have
highly unpredictable, unstable patients. There might be areas in those hospitals
where patients are less... Are more predictable, more stable. And there can be a
lower proportion of registered nurses in those areas.
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CBC:
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So
deployment is a critical issue.
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TOURANGEAU:
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Absolutely.
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CBC:
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It's
good to talk to you. Thank you very much.
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TOURANGEAU:
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Thank
you very much. Bye Tony.
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CBC:
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Bye-bye.
That is Ann Tourangeau, an associate professor in the Bloomberg Faculty of
Nursing at the University of Toronto.
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