 2004 AJN Table of Contents
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Issues Update
American Journal of Nursing -
February, 2004 - Volume 104, Issue 02
Want Safer Patient Care?
An IOM report confirms the ANA’s belief that the answer lies in better working conditions for nurses.
Long hours. Understaffing. A work culture that fuels mistrust.
These are just some of the work-related factors that undermine nursing and,
in turn, patient safety, according to a new report issued by the
Institute of Medicine (IOM),
an independent organization that advises the federal
government on health policy issues.
Released in November 2003, Keeping Patients Safe: Transforming the Work Environment of
Nurses, serves as yet another building
block in the ANA’s case for improving working conditions for nurses.
“The ANA has long contended that improved
patient safety and quality of care cannot be achieved without investing in
and valuing nursing,” said ANA president Barbara Blakeney, MS,
APRN,BC, ANP. “This study provides even more evidence that urgent
action is needed to improve nurses’ working conditions, and that by
doing so, patients will be protected from preventable errors.”
Nurses who served on the IOM committee say the report
is all about the need for action—immediate and wide ranging.
“This report is not meant to sit on a
shelf,” said Marilyn Chow, DNSc, RN, FAAN, a member of the IOM
Committee on the Work Environment for Nurses and Patient Safety.
“It’s a call for action. We are asking health care organization
administrators to read the report, take it to heart and implement its
recommendations to keep patients safe and keep nurses at the
bedside.”
Fellow committee member Gwen Johnson, MA, RNC,
concurred.
“This report not only looks at the pivotal role
nurses play in patient safety, but it also provides solutions that will
create a culture of safety,” Johnson said. “Although health
care administrators won’t agree with all the recommendations, they
cannot take a piecemeal approach to patient safety. They must work toward
implementing all the recommendations.”
A closer look
Comprising 18 health care experts, including seven
nurses, the IOM committee began meeting in September 2002. Members
reviewed research and heard testimony from nurses and professionals in
other fields about work-related problems, such as the effects of fatigue on
job performance.
Blakeney, for example, asked the committee to ensure
that nurses have professional autonomy and decision-making authority
regarding patient care at all levels within a health care facility. She
also wanted the committee to be an advocate of mandatory collection and
public reporting of standardized data specific to nursing care. And she
testified that resources must be allocated to develop systems that provide
safe and appropriate nurse staffing levels.
In its final form, the IOM report addresses most of
the ANA’s concerns, as well as many others.
In terms of staffing, the committee included a
recommendation that hospitals and long-term care facilities implement
staffing practices that identify the level of nurse staffing needed for
each shift on every unit. Any staffing practices, for example, should
provide nurses with an ability to handle the expected changes in patient
census, such as discharges and scheduled procedures, as well as unpredicted
changes, such as emergent care. To allow for this flexibility in staffing
levels, the committee suggested that health care organizations use
cross-trained, in-house, float pool staff and avoid using nurses from
outside agencies.
Committee members also emphasized that direct-care
nursing staff must help develop and evaluate unit staffing systems. Nursing
staff should have the power to regulate work flow on their units and
develop criteria for closing their units to admissions and transfers when
they believe patient safety will be compromised because of staffing
shortfalls.
The committee called for federal regulators to
increase required RN staffing and nurse assistant numbers in long-term care
facilities, and they asked that health care facilities assess the impact on
patient care when ICU staffing levels drop below one nurse to two patients.
Members also addressed the need for more research on safe staffing
levels in labor and delivery and other units.
Although Johnson is proud of the report as a whole,
the staff nurse and District of Columbia Nurses Association member is
particularly pleased with the recommendations that address staffing.
“Staffing principles are so important to
establishing a culture of safety,” Johnson said. “When you are
looking at implementing a sound acuity system, you can’t just look at
a magic number at the beginning of a shift. You need to look at work flow,
from transfers to admissions.”
Another major recommendation in the IOM report
addresses overtime.
“The IOM is really driven by
evidence,” said Chow, an ANA–California member and vice
president of Patient Care Services, California Division of Kaiser
Permanente. Therefore, one of the papers the panel commissioned was on
fatigue, particularly because nurses are working so many hours. Chow said
the panel was extremely interested in seeing solid research on the
relationship between fatigue and error, as well as how other industries
have dealt with worker fatigue.
Based on those findings and other testimony, the
committee recommended that state regulators ban nursing staff from working
more than 12 hours in a 24-hour period and 60 hours in seven days. The
panel also called for schools of nursing, state boards of nursing, and
health care organizations to educate nurses on how fatigue threatens
patient safety.
Another key aspect of the report addresses the need
for health care organizations to create a culture of safety, which includes
numerous across-the-board strategies—from ensuring strong nursing
leadership to direct-care–nurse input into work redesign to a systems
approach when addressing medical errors.
Johnson and other nurses maintained that restructured
and redesigned patient care systems in the 1990s led to deep cuts in
nursing staff and created a culture of mistrust among RNs.
“When we talk about creating a culture of
safety, we are saying that patient safety needs to be as important as
productivity and finances,” Johnson said.
Nurses on the committee pointed to the success of
creating positive work cultures in health care facilities that have been
designated by the American Nurses Credentialing Center as Magnet
facilities. The report cited Magnet facilities’ proven ability to
recruit and retain experienced nurses and, in turn, safeguard patients.
Judy Sheridan-Gonzalez, RN, an ED staff nurse and New
York State Nurses Association member and local bargaining unit chairperson,
noted that the report’s call for ongoing education for RNs and a
solid orientation for new nurses—areas that, in her view, have been
seriously neglected—also must not be overlooked when health care
facilities begin to address work culture.
The work continues
Now that the report is released, IOM committee member
and ANA–California member Charlene Harrington, PhD, RN, FAAN,
hopes that professional associations, such as the ANA, federal agencies,
and accrediting organizations will push for legislation and standards that
will enforce the recommendations. Harrington, an expert in long-term
care, particularly wants to see staffing levels improved in long-term care
facilities.
The ANA intends to work with the Agency for Healthcare
Research and Quality, which commissioned the report, to ensure that the IOM
panel’s recommendations are implemented and that nurses have a strong
voice in that process. Furthermore, the ANA is promoting the use of
its Principles for Nurse Staffing
as a mechanism for health care facilities to fulfill
the IOM’s recommendations on safe staffing levels. And the ANA is
promoting the use of its quality indicators as a way for health care
facilities to collect meaningful data on nursing care and its effect on the
quality of patient care.
The ANA will continue its efforts to improve
nurses’ working conditions and patient safety. Among them is lobbying
for federal bills that prohibit mandatory overtime and ensure safe staffing
levels, and requesting state boards of nursing to adopt the ANA’s
position on patient abandonment when looking at overtime issues.
For more information on
the ANA’s position statements and advocacy efforts, go to
www.nursingworld.org. For more
information on the IOM report, go to www.iom.edu and click on “Reports.”
Susan Trossman is the senior reporter for the American Nurse, published by the ANA.
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