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Numerous studies have pointed to the
relationship between nurse staffing and
patient safety. Inherent in these is an
ability to obtain and maintain a sufficient
number of staff to provide the care level
necessary to assure a safe climate for
patients. In this time of nursing shortages
many health care provider organizations
are experiencing significant levels of
vacant nursing positions. However there
are others that are able to maintain an
adequate staff. In many instances, this
has been attributed to the organization's
positive work environment attracting and
retaining its nursing staff. Safe patient
care resulting from declines in medical
errors and decreases in adverse outcomes
from care is an important goal of the
health care system. In the face of today's
critical nursing shortages active attention
to the nurse work environment with its
implications for nurse staffing and appropriate
nursing care is an important component
of achieving this goal. As part of NACNEP's
consideration of these issues at its April
2003 meeting, a number of presenters provided
reports on relevant research and demonstration
projects.
Effects of Work Environment
Concerns about the work environment are
uppermost in the minds of nurses as they
discuss their careers. An analysis of
15 study reports on the nursing shortage
to identify common "themes"
found a considerable amount of emphasis
on work environment and nurse satisfaction
data. (See Appendix D and Bleich et al,
2003) Dr. Karen Cox in reporting to NACNEP
on her nurse focus group study of working
conditions for inpatient RNs referenced
nurses' comments about heavy workloads
and chaotic work environments. (See Appendix
E.) She indicated that the nurses, while
commenting on their heavy workloads, expressed
concerns about the safety of their patients.
In an article reporting on a North Carolina
Center for Nursing study, the authors
concluded that the level of nurses' satisfaction
with their jobs and their careers was
greatly affected by "the frequency
with which short staffing interferes with
patient care." (Shaver, 2003)
Within recent years a considerable amount
of research efforts have been centered
on documenting the relationship between
nurse staffing and outcomes of patient
care. Using varying data and methodologies,
the studies generally showed that higher
nurse staffing ratios were related to
lower probabilities of adverse patient
outcomes. The Oregon Health & Science
University Evidence-based Practice Center
under a contract from the Agency for Healthcare
Research and Quality (AHRQ) analyzed 26
such studies for evidence on impacts on
patient safety. (Hickam et al, 2003) The
study concluded that evidence showed that
higher nursing workload is associated
with higher rates of non-fatal adverse
outcomes in both inpatient and nursing
home settings. It further concluded that
higher nursing workload is also associated
with higher incidence of medication errors.
The Institute of Medicine (IOM), at the
request of AHRQ, established a committee
to look at the work environment for nurses
and patient safety. Dr. Ada Sue Hinshaw
provided NACNEP with a review of the scope
and objectives of the then on-going study.
(See Appendix F.) She pointed out that
IOM was asked to look at the key aspects
of the work environment for nurses, including
extended hours and workload, that likely
have an impact on patient safety and to
identify potential improvements that might
result in enhancement of patient safety.
Through the examination of published research,
commissioned "white papers"
and testimony, the study is addressing
such issues as nursing work hours and
fatigue including mandatory overtime,
nursing workload including state regulation
of nurse-to-bed ratios, design of health
care delivery processes including support
systems for decision making, and barriers
to effective communication among care
team members.
The report of this study entitled Keeping
Patients Safe: Transforming the Work Environment
of Nurses, issued in November 2003, has
wide-ranging recommendations touching
on many of the issues discussed at NACNEP's
meeting and covered in this report to
the Secretary of Health and Human Services
and the Congress. The recommendations
ranged from those that were specific to
staffing and the design of the work processes
and environment to those pertaining to
needed research and the development of
substantial databases.
The discussion in the IOM report reinforced
the workload and staffing concerns expressed
at NACNEP's meeting. Specific minimum
licensed nurse staffing ratios for nursing
homes and hospital intensive care units
were among the recommendations included
in the report along with calling for hospitals
and nursing homes to establish nurse staffing
practices based on needs for each patient
care unit per shift and for studies of
nurse staffing ratios. The report also
recognized the effect of fatigue from
lengthy work hours on the possibility
of medical errors by recommending that
nurses be prohibited from working more
than 12 hours in any given 24-hour period
and more than 60 hours per 7-day period.
The report also supported the need for
a work environment involving nurses' direct
participation in the decision-making process
within the health care facility as a means
of determining appropriate nurse staffing
levels and practices. (Page, 2003)
Creating a Positive
Work Environment
Work environment issues have been considered
to have a direct impact on patient safety
as they relate to the ability of health
care providers to recruit and maintain
their particular workforces. Research
carried out in the 1980s on the organizational
structure of hospitals with greater ability
than others to attract and retain nurses
on their staff led to the concept of Magnet
hospitals. These have been summarized
as having highly qualified nursing executives
with participation in the hospital's top
decision-making body and involvement of
nurses in the operation and patient care
decision-making at the unit level. (McClure
et al, 1983) Subsequently, the American
Nurses Credentialling Center (ANCC) established
a "Magnet" program to recognize
hospitals that had similar characteristics
to those of the originally identified
Magnet hospitals. Hospitals apply for
this designation on a voluntary basis.
As of October 15, 2003, 88 facilities
have applied for and received such designation.
(ANCC, 2003)
An important aspect of the Magnet hospitals
is the quality of their nurse leadership.
The climate established by the nurse leaders
plays an important role in nurse satisfaction.
For example, Dr. Cox in her presentation
to NACNEP pointed out that nurse managers
could make a significant difference in
how nurses perceive their jobs. Nurses
were concerned about nurse managers being
responsible for multiple units rather
than being able to focus on the patient
care needs within a unit and, also, about
the manager's ability to influence administrative
decisions. In an article summarizing a
review of the literature on factors related
to staff retention, Dr. Nancy Wells and
her colleagues indicated that the development
of autonomy and group cohesion and the
reduction of job stress were key aspects
of job satisfaction eading to retention
of nurses. They stressed the importance
of the management role in the work environment.
(Wells, 2002)
Dr. Valda V. Upenieks who carried out
a comparative study of nurses employed
in Magnet and non-Magnet hospitals points
to the importance of the nurse leadership
role to clinical nurses and the effect
of nursing leadership in Magnet hospitals.
(Upenieks, 2002) She summarized her findings
with respect to nurse satisfaction as
indicating that "Magnet hospital
nurses with resources, support, information,
and the opportunity to use their expertise
were more satisfied than nurses in non-Magnet
hospitals." (Upenieks, 2003) She
points out that these results supported
previous studies.
Another aspect of the Magnet hospital
is that the facility's climate is one
in which the staff can function within
a collaborative working relationship.
In an article focusing on the attributes
in the work place that contribute to nurse
satisfaction, Dr. Kathi Kendall Sengin
stated "Studies have found that relationships
with co-workers and supervisors, team
work, as well as collaboration with physicians
in decision-making about patient care
are important correlates of job satisfaction."
(Sengin, 2003) While the provision of
the climate for collaborative practices
in the work setting is crucial, the conditions
under which such practices will be successful
must first be established in the disparate
health care occupations' educational experiences.
The recognition of the need for such
experiences and their impact on patient
safety was the crux of NACNEP's joint
interest with COGME in interdisciplinary
health professions education. The councils
held a joint meeting in 2000 on interdisciplinary
education, which resulted in the support
of five interdisciplinary education projects,
centered on patient safety. These projects
began their final years of support in
the Fall of 2003. Through participation
on the committee established to guide
IOM's national invitational summit of
June 2002 and attendance at the summit,
the councils furthered their interdisciplinary
activities. At the summit discussion centered
on developing proposed strategies and
actions for addressing five competency
areas: provide patient-centered care,
work in interdisciplinary teams, employ
evidence-based practice, apply quality
improvement, and utilize informatics.
As pointed out in Health Professions Education:
A Bridge to Quality, the document summarizing
the outcomes from the summit and the committee's
deliberations, the cross-cutting changes
in clinical education and related training
environments that are needed to ensure
the implementation of the core competencies
requires leaders across the professions
to work together. The report concludes
with a call for biennial summits of health
care leaders responsible for education
to further efforts of reform-minded leaders.
Effects on Patient
Care
Positive work environments, as represented
by the work settings in Magnet hospitals,
have an impact on the outcomes of patient
care. Magnet hospitals generally have
higher nurse-to-patient ratios than non-Magnet
hospitals. Dr. Linda Aiken indicated that
in a study contrasting the mortality rates
in Magnet and non-Magnet hospitals the
rates were lower in the Magnet hospitals.
She states that "Higher nurse-to-patient
ratios in magnet hospitals were the major
factor explaining their lower mortality
rates." In this paper providing an
examination of research on Magnet hospitals,
Dr. Aiken concludes, "The evidence
base in support of superior outcomes for
magnet hospitals is extensive. Magnet
hospitals have been shown to achieve substantially
more favorable outcomes for patients when
compared to non-magnet hospitals."
Positive Patient Care
Environment
These data all lead to the conclusion
that quality health care with positive
patient outcomes can best be achieved
with well-staffed nursing services. The
expectation of obtaining and sustaining
the necessary staff in the current nursing
climate is greatly enhanced by an organizational
structure that provides effective leadership
in an atmosphere of shared responsibility
and the ability of nursing at all levels
to affect patient care decisions.
Basic to the achievement of a good working
environment is creating an environment
that recognizes the needs of today's diverse
staff and patient population. A critical
aspect of serving the patient population
is recognizing the disparities in the
availability and delivery of care and
actively taking steps to mitigate them.
A recent study by IOM, carried out at
the request of Congress, indicates that
racial and ethnic minorities experience
lower quality and more limited health
services than others within the country's
population. The study identifies the many
factors that lead to such differences
in health care delivery and recommends
a variety of approaches to alleviate the
problems. Among these it considers the
role of providers through calling for
increased awareness of health care providers
of the disparities in care, enhanced patient-provider
communication and the integration of cross-cultural
education into the training of health
professionals. (Smedley et al, 2002)
Organizations need to take a conscious
approach to accomplishing these goals
with leadership in the active forefront.
Dr. Rose Rivers, the Vice President for
Nursing and Patient Services at SHANDS
HealthCare at the University of Florida,
in her paper presented by Dr. Linda Burnes
Bolton at NACNEP's meeting, indicated
that to achieve its mission to provide
excellent patient care, improve community
health and create an environment supportive
of education and research the institution
had to be able "to serve in a very
diverse environment from the perspective
of staff and patients." In support
of this goal the Diversity Awareness Program
was established involving the total staff
at all levels in training with the Vice
President for Nursing leading the Diversity
Steering Committee. (See Appendix G.)
Doreen Frusti and her colleagues at the
Mayo Clinic, in an article discussing
their organization's approach to ensuring
a "culturally competent organization",
state that "the fiscal health of
hospitals depends not only on an adequate
supply of nurses but also on a nursing
workforce that reflects the racial and
ethnic diversity of the population for
whom it cares." The goals of the
strategic plan to assist in building a
diverse workforce developed and implemented
by the nursing administrators in the organization
related to active and visible leadership
support, minority recruitment, diversity
competence among employees, and a work
environment supportive of employee success.
(Frusti et al, 2003)
As pointed out in this article, creating
an appropriate environment for good patient
care involves both active approaches to
assuring that the staff work environment
takes into account cultural competency
and that the staff reflects the population
diversity. The need to attract individuals
from diverse backgrounds into nursing
is also critical to the assurance of an
adequate supply of nurses in these times
of nursing shortages. The largest expansion
of the country's population, particularly
among the youngest age groups, is coming
from those with minority backgrounds.
Yet a significant gap exists between the
proportion of individuals with minority
backgrounds in the population as a whole
and in nursing.
Dr. Bolton in her talk to the Council
on improving the nursing practice environment
indicated the importance of both employer
organizations and schools of nursing creating
and implementing new models designed to
attract, prepare and retain individuals
from diverse backgrounds into nursing
practice. (See Appendix H.) Dr. Nilda
Peragallo in her presentation to NACNEP
pointed to the need for specific directed
efforts toward promoting nursing as a
career choice in the Hispanic population.
She pointed out that Hispanic nursing
students constitute a very low proportion
of all nursing students in the face of
the fact that the fastest growing minority
group in the country is Hispanics. Dr.
Peragallo stressed the need for programs
that both seek to recruit Hispanics into
nursing schools and those that actively
work to retain them. Barriers to retention
include possible inadequate secondary
education, inability to pay tuition, feelings
of isolation, lack of faculty contact/support,
and perceived discrimination. (See Appendix
I.)
Dr. Janet S. Rami, the Dean of the Southern
University School of Nursing, in her paper
presented at the meeting by Dr. Constance
Hendricks from the school's faculty, demonstrated
the achievements of the university's efforts
to enroll and graduate a predominantly
African American student body. Her strategies
for successful retention and graduation
of minority students included eliminating
barriers to admissions by using multiple
variables for admission; focus on graduation
and entry into practice rather than retention
alone, and ensuring that standards for
minority students be consistent with those
of majority students. She stressed that
faculty commitment; attitudes toward minority
students, and knowledge were key to success.
(See Appendix J.)
Thus creating an adequate nursing workforce
to achieve a quality, safe, patient care
is dependent on actions on the part of
both the schools, which prepare the nurses
for practice and the organizations in
which they practice. Schools need to reach
out and develop programs that provide
for the needs of students from a variety
of backgrounds. They need to set the stage
for a practice environment where decision-making
and patient care are shared responsibilities
among the disparate health care practitioners
and the care needs of all patients are
taken into account. Employing organizations
need to ensure that they provide the leadership
and environment where the staff can participate
in the joint decision-making and practice
necessary to provide quality, safe, patient
care to patients from all segments of
our society. The congressional action
in the passage of the NRA was an important
part of accomplishing these objectives.
The models developed by the projects supported
under the NRA programs should provide
the stimulus for the changes in the educational
and practice environment to achieve an
adequate nurse workforce for quality patient
care.
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