Appendix F

Progress Report: IOM Committee on Work Environment for Nurse and Patient Safety

Ada Sue Hinshaw, Ph.D., R.N., F.A.A.N.
Vice Chair,
Institute of Medicine
Committee on Work Environment for Nurses And Patient Safety

The Institute of Medicine (IOM) constituted a study committee to examine the "Work Environment for Nurses and Patient Safety" under the sponsorship of the Agency for Healthcare Research and Quality (AHRQ). This study addresses a major component of the national shortage of nurses; i.e., the retention of nurses within major hospitals and long term care facilities as it relates to patient safety. In the past, the IOM addressed the supply issues involved with the shortage of nurses as is traditional in the field. This address is to provide an in-progress report for the National Advisory Council on Nurse Education and Practice.

The charge for the IOM committee study from the AHRQ was to identify:

• key aspects of the work environment for nurses, including extended hours and workload, that likely have an impact on patient safety, and
• potential improvements in healthcare working conditions that would likely result in enhancements in patient safety.

The study was directed to include examination of acute care, long term care, home care and community care environments. The topics that needed to be addressed were:

• nursing workload including state regulation of nurse-to-patient ratios,
• nursing work hours and fatigue, including mandatory overtime issues,
• he design of healthcare delivery processes (not intended to include ergonomics) and systems, including support systems for decision making, and
• barriers to effective communication among care team members.

In essence, the study recommendations were to address possible steps for enhancing patient safety through improved working conditions of nurses.

This Work Environment for Nurses and Patient Safety committee study is part of a series of IOM studies focusing on the quality of healthcare and patient safety. The initial study outlined the errors and adverse events that occur in healthcare; i.e., To Err is Human: Building a Safer Health System (IOM, March 2000). A major second report; Crossing the Quality Chasm: A New Health Care System for the 21st Century (IOM, 2001), identified a number of health system issues and a series of recommendations to redesign the healthcare system to make the system "patient-centered" with a higher quality of care. A third report focused on developing a higher quality of healthcare and patient safety through interdisciplinary health professional education; i.e., Health Professions Education: A Bridge to Quality (IOM, 2003). The work environment study for nurses and patient safety reinforces the importance and centrality of nurses to high quality healthcare and the safety of patients.

The three important features of the charge to the study committee; work environment, nurses and patient safety framed the selection of member expertise for the committee; experts on safety-sensitive industries, patient safety, healthcare delivery, nursing, medicine, interdisciplinary healthcare, informatics, acute care, chronic care, health professions education, organizational behavior, operations management and human factors engineering. The committee membership was strongly interdisciplinary reflecting the scholarship of a number of major fields; e.g., nursing, health services research, organizational psychology, high reliability organizations, informatics, organizational design, nursing administration, hospital administration and nursing facility researchers.

Two major types of recommendations will be provided in the final report; substantive/content and further research recommendations. This report, similar to earlier quality of care patient safety reports will take a "systems" approach to dealing the work environment of nurses as it influences patient safety. Thus, the report will address recommendations to multiple stakeholders who are responsible for providing high quality of care and keeping patients safe. The audience for the recommendations will include, but is not limited to: federal/ state policy makers, healthcare organizational leaders, health professionals, healthcare payors and others.

The recommendations from the IOM study committee will be based on published research from numerous disciplines, white papers commissioned from experts and testimony from multiple stakeholders. Examples of the research examined include:

• High reliability organizations where the risk of errors/adverse events is high but the accident rate is low,
• Organizational psychology with concepts such as "stranger on site" helping to understand the effect of temporary nurses in agencies,
• Design of work environment; e.g., the influence of centralized vs. decentralized structures on decision making of nurses with patients or residents,
• Magnet hospitals as examples of strong, positive work environments with reportedly higher retention of nurses and lower adverse events occurring,
• Safety-sensitive industries and the models and strategies for increasing safety,
• Areas of high risk for errors in nursing at the individual practice and system levels,
• National Centers for Patient Safety in the Veterans¹ Administration hospitals and the Wellspring program in long term care facilities as models for lowering errors/ adverse events,
• Nurse staffing, case mix and adverse events includes numerous studies substantiating a strong relationship between higher nurse staffing levels and positive patient outcomes, and
• Economic costs of nurse turnover in hospitals and nursing facilities.

A number of white papers were commissioned by experts in the research fields cited above. These include, for example:

• "Nurse and nurse-aid workforce profiles, trends and projections" by Julie Sochalski PhD, RN, FAAN
• Evidence-based design of nursing workspace in hospitals" by Ann L Hendrich MS, RN
• The work of nurses and nurses aides"
• In Acute Care Settings by Barbara Mark PhD, RN, FAAN
• In Long Term Facilities by Barbara Bowers PhD, RN, FAAN
• In Home, Community and Public Health Nursing by Karen Martin MSN, RN, FAAN
• Work groups and patient safety by Gail Ingersoll EdD, RN, FAAN, FNAP and Madeline Schmitt PhD, RN, FAAN, FNAP
• Work hour regulation in safety sensitive industries by Ann Rogers, PhD, RN, FAAN

These white papers contributed major concepts and issues to the committee's consideration of the work environment of nurses and how it influences patient safety. The papers also touched on the issue of nurse safety in various work environments but the committee did not include that information since the charge for the study focused only on patients.

In addition, testimony was heard from a number of different stakeholders such major nursing organizations including, for example, the American Academy of Nursing (AAN), the American Association of Colleges of Nursing (AACN), the American Nurses' Association (ANA) and the American Organization of Nurse Executives (AONE). Other major stakeholders provides information such as the American Healthcare Association, the American Association for Homes for the Aged, the SCIU, the American Hospital Association, the United American Nurses, the Joint Commission on Accreditation of Healthcare Organizations, and the Veteran's Administration. Synthesizing the information from published research, the White Papers, and the testimonies, it became apparent that the study committee would be able to address only hospitals and long term nursing facilities in the recommendations. The research base for home care and for community care on nursing work environment and client safety was not available which posed a major area for future research opportunities.

The timeframe for the study committee's completion of the report was projected to be in mid-fall of 2003.

UPDATE: Following this "in-progress" report to the National Advisory Council on Nurse Education and Practice, the IOM study report; entitled, Keeping Patients Safe: Transforming the Work Environment of Nurses was released on November 4, 2003. The IOM chose to showcase the report to the public and the multiple stakeholders. The report provides 18 recommendations on redesigning and enhancing the work environment of nurses and shows the strong relationship among the nurses work environment, the characteristics needed for a positive environment and the relationship to high quality care and patient safety. Ten of the recommendations focus on healthcare organizations and the system changes that need to be instituted. A copy of the Executive Summary for the report is attached to this submission. The prepublication copy of the report can be accessed at (http://www.iom.edu/CMS/3809/4671/16173.aspx). The report will be available in published form in January of 2004.