5
Maximizing Workforce Capability

Monitoring patient health status, performing therapeutic treatments, and integrating patient care to avoid gaps in health care are nursing functions that directly affect patient safety. Accomplishing these activities requires an adequate number of nursing staff with the clinical knowledge and skills needed to carry out these interventions, and with the ability to effectively communicate findings and coordinate care with the interventions of other members of the patient’s health care team. The committee finds strong evidence that nurse staffing levels, the knowledge and skill levels of nursing staff, and the extent to which workers collaborate in sharing their knowledge and skills affect patient outcomes and safety. The committee also finds that staffing levels in hospitals and long-term care facilities are uneven, posing risks to patient safety. Further, the knowledge base for effective clinical care and new health care technologies are advancing rapidly, making it impossible for nurses (and other clinicians) without organizational support to incorporate this information and these technologies into their clinical decision making and practice. Finally, there is evidence of inconsistent interprofessional collaboration among nursing staff and other health care providers.

Health care organizations (HCOs) need to address all three of these barriers to workforce capability and patient safety by taking action to promote safe staffing levels, support nurses’ ongoing knowledge and skill acquisition and clinical decision making at the point of care, and foster interdisciplinary collaboration. The federal government can assist by revising outdated regulations regarding staffing in long-term care facilities and implementing a system for collecting and managing accurate and reliable data on hospital and nursing home staffing.



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Keeping Patients Safe: Transforming the Work Environment of Nurses 5 Maximizing Workforce Capability Monitoring patient health status, performing therapeutic treatments, and integrating patient care to avoid gaps in health care are nursing functions that directly affect patient safety. Accomplishing these activities requires an adequate number of nursing staff with the clinical knowledge and skills needed to carry out these interventions, and with the ability to effectively communicate findings and coordinate care with the interventions of other members of the patient’s health care team. The committee finds strong evidence that nurse staffing levels, the knowledge and skill levels of nursing staff, and the extent to which workers collaborate in sharing their knowledge and skills affect patient outcomes and safety. The committee also finds that staffing levels in hospitals and long-term care facilities are uneven, posing risks to patient safety. Further, the knowledge base for effective clinical care and new health care technologies are advancing rapidly, making it impossible for nurses (and other clinicians) without organizational support to incorporate this information and these technologies into their clinical decision making and practice. Finally, there is evidence of inconsistent interprofessional collaboration among nursing staff and other health care providers. Health care organizations (HCOs) need to address all three of these barriers to workforce capability and patient safety by taking action to promote safe staffing levels, support nurses’ ongoing knowledge and skill acquisition and clinical decision making at the point of care, and foster interdisciplinary collaboration. The federal government can assist by revising outdated regulations regarding staffing in long-term care facilities and implementing a system for collecting and managing accurate and reliable data on hospital and nursing home staffing.

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Keeping Patients Safe: Transforming the Work Environment of Nurses PROMOTING SAFE STAFFING LEVELS I knew it was going to be a busy shift. After all, it was Wednesday—that meant elective surgery admissions from PACU [postanesthesia care unit], direct admissions from the clinic, and anything else the emergency room sent us. Each of us already had five patients apiece, some of them needing a lot of nursing care. There was no secretary available to put charts together and the nurse manager had already said that there was “no nurse in the system” to send to help us. When the ER called to report on my second admission for the shift, I asked if they could please hold the patient until I finished a blood transfusion on one patient and completed the admission on the patient I had gotten from the recovery room. The nurse from the ER told me the patient would be up in five minutes and before I could say another word, she hung up the phone. I called my supervisor and explained that we were overwhelmed with all of the activity on the unit and asked if she could send another nurse to help us get settled or assign the admission to another unit. She told me that she would “look around” but that she had no one she could send right away. I asked her if she could delay the admission for a while until I could stabilize my other patients. She responded that the ER was “backed up” and that I had to take the patient right now or she would have to “write me up.” When the patient came, I had to leave a new mastectomy patient who was crying each time she looked at her surgical dressing and whose PCA [patient-controlled analgesia] pump was alarming. I left her with a promise to get back as soon as I could and went to check the ER admission. The shift ended and I never got back to her except to check her IV fluid totals for the shift. It was only after I got home that I remembered that I had not put the allergy band for seafood and penicillin on the ER admission. I called back to the unit just as the patient was being sent down to the operating room and asked them to put the allergy band on the patient and note on the front of the chart. I could not rest. Every time I closed my eyes I thought about the fact that she could have been prepped using an iodine scrub and/or that they might have given her penicillin as a peri-operative antibiotic. A reaction from either of them could have been fatal. An Adequate Number of Nurses: Essential to Patient Safety The number of nursing staff available to provide in-patient nursing care is linked to patient safety by a substantial and growing number of research studies. Although there have been no experimental controlled studies of interventions that increased or decreased nurse staffing levels and measured the subsequent effect on patients, substantial evidence on the relationship between nurse staffing levels and patient outcomes has been produced by observational studies. This research has been conducted separately for acute care hospital and nursing home care.

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Keeping Patients Safe: Transforming the Work Environment of Nurses Acute Care Hospitals Because of the substantial changes that have occurred in the environment of acute care hospitals (see Chapter 1), studies based on older data are not the most useful for understanding staffing effects. Rather, the strongest evidence comes from studies published in the last 15 years (Aiken et al., 1999, 2002; Amaravadi et al., 2000; Blegen and Vaughn, 1998; Blegen et al., 1998; Bolton et al., 2001; Bond et al., 1999; Dimick et al., 2001; Flood and Diers, 1988; Hartz et al., 1989; Hunt and Hagen, 1998; Kovner and Gergen, 1998; Kovner et al., 2002; Lichtig et al., 1999; Needleman et al., 2002; Pronovost et al., 2001; Shortell et al., 1994). All of these are cross-sectional studies that explored correlations between measures of nurse staffing levels and rates of adverse occurrences. They examined in-hospital deaths and nonfatal adverse outcomes, including various types of nosocomial infections, decubitus ulcers, and falls. A variety of acute care hospital settings were examined, including intensive care units (ICUs), general medical–surgical units, and various specialty units. In some studies, process errors were measured, including medication errors. The amount of nursing service (staffing level) in a given unit or hospital typically is expressed administratively as nursing hours per patient per day (hppd). It is also expressed as a nurse-to-patient ratio, or the average number of patients for each nurse; for example, 1:4 or 1:6 represents one nurse for every four or six patients, respectively. Higher levels of hppd indicate higher nurse-to-patient ratios.1 An important methodological issue in studies of hospital staffing is the unit of analysis. Sometimes staffing-level data are obtained for individual nursing units within hospitals; at other times, staffing data are aggregated across the entire hospital. Measures of outcomes similarly are aggregated across individual patients to the unit or hospital level to produce an incidence rate of adverse events. A problem with hospital-level aggregation is that heterogeneous nursing units, such as pediatric units, labor and delivery units, adult medical and surgical units, and ICUs, are combined. As a result, data on hospital-wide staffing levels may not well represent the staffing levels experienced by patients in a given nursing unit or of interest to poten- 1   Discussions of nurse-to-patient ratios can often be confusing. A nurse-to-patient ratio is expressed as a numerical relation; e.g., one nurse for each six patients is a nurse-to-patient ratio of 1:6. Because this figure often resembles a fraction (e.g., 1/6), a “higher” nurse-to-patient ratio is one in which the ratio of nurses to patients, expressed as a fraction, comes closest to the whole number 1. That is, a 1:2 ratio (one nurse for every two patients) is a higher nurse-to-patient ratio than one nurse for every six patients (1:6). In this chapter, we attempt to avoid this confusion by using the expressions “more nurses” or “fewer nurses” per patient.

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Keeping Patients Safe: Transforming the Work Environment of Nurses tial patients. These data can also sometimes cloud the findings of research (Seago, 2001). This issue is less significant in nursing homes, where heterogeneous nursing units are much less likely to exist, the resident population is more homogeneous, and variation in patients can be addressed for research studies as needed through case-mix adjustment. A number of studies of the effect of nurse staffing levels on patient outcomes have attempted to use patient mortality as an outcome measure. However, patient mortality is a problematic nurse-staffing outcome for several reasons. First, patient death is not common; its low frequency makes detecting statistically significant differences difficult (Hartz et al., 1989). Second, while some patients die as a result of injuries related to health care, others die as a result of overwhelming disease. While some studies evaluating the quality of hospital care have used methods to assess the reasons for in-hospital deaths (Brennan et al., 1991; Thomas et al., 2000), studies of nurse staffing that have used patient mortality as an outcome measure have lacked methods for attributing the cause of death to preventable or non-preventable causes. Thus, it is not surprising that these studies do not agree on whether lower nurse-to-patient ratios (i.e., fewer nurses per patient) are associated with higher patient mortality (measured as either in-hospital mortality or death within 30 days of admission). The strongest evidence supporting such a mortality relationship was derived from a study of patients with AIDS (Aiken et al., 1999). This study was conducted in 20 hospitals, aggregated data at the nursing unit level, and had good case-mix controls. Other diagnosis-specific studies have not been able to demonstrate a relationship between nurse staffing levels and patient mortality. Studies in which patients were not selected by diagnosis also have yielded inconsistent findings about the effect of staffing levels on mortality. Two nationwide studies that aggregated data at the hospital level (Aiken et al., 2002; Bond et al., 1999) found that lower nurse-to-patient ratios were associated with higher patient mortality. This association was not found, however, in other studies examining multiple ICUs (Amaravadi et al., 2000; Shortell et al., 1994) and hospital-level staffing ratios (Hunt and Hagen, 1998; Needleman et al., 2002). Nonfatal adverse events, such as nosocomial infections and decubitus ulcers, are thought to have a more plausible direct relationship to the availability of hospital nursing staff. A consistent finding across multiple recent studies is that lower nurse-to-patient staffing ratios are associated with higher rates of nonfatal adverse events, including nosocomial infections, pressure ulcers, and cardiac and respiratory failure (Aiken et al., 2002; Cho et al., 2003; Kovner et al., 2002; Needleman et al., 2002). Similarly, a review of evidence pertaining to acute care hospital staffing published in the health professions literature from 1990 to 2001 revealed that of 16 hospital-based studies of the relationship between levels of nursing staff and pa-

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Keeping Patients Safe: Transforming the Work Environment of Nurses tient outcomes,2 11 found a positive effect on patient outcomes from higher levels of nurse staffing. The 5 studies that did not detect such an association tended to be older, and/or used smaller samples or less sophisticated methods for controlling for confounding variables. This evidence review concludes that “there is strong evidence that leaner nurse staffing is associated with increased length of stay, nosocomial infection (urinary tract infection, postoperative infection, and pneumonia), and pressure ulcers.” It concludes further that “these studies had various types and acuities of patients and, taken together, provide substantial evidence that richer nurse staffing is associated with better patient outcomes” (Seago, 2001:430). Nursing Homes The relationship between nurse staffing levels and patient outcomes in nursing homes has also been shown in numerous studies (Gustafson et al., 1990; Kayser-Jones et al., 1989; Nyman, 1988). Higher levels of registered nurse (RN) hours per patient have been significantly associated with patient survival, improved functional status, and discharge from the nursing home (Linn et al., 1977). Higher staff levels and lower turnover among RNs also have been found to be related to functional improvement in residents (Spector and Takada, 1991). Increased RN hours have been associated with improved mortality and the probability of discharge (Braun, 1991); with fewer pressure ulcers, catheterized residents, and urinary tract infections; and with lower rates of antibiotic use (Cherry, 1991). Higher staffing also has been related to fewer pressure sores (but more use of physical restraints) (Aaronson et al., 1994). In addition, higher RN levels, adjusted for case mix, have been shown to be associated with lower mortality rates. An economic analysis using 1987 data from the National Medical Expenditure Survey found that an increase of 0.5 full-time equivalent (FTE) RNs per 100 residents (an approximately 10 percent increase in average RN staffing at that time) would have reduced the probability of dying by about 1 percent. Although this percentage may appear small, the researchers point out that it translates to an estimated 3,000 fewer deaths annually for nursing home residents. Moreover, a higher level of licensed practical nurse/licensed vocational nurse (LPN/LVN) staffing was found to be related to improved functional status as measured by activities of daily living (ADL) dependency (Cohen and Spector, 1996). Inadequate nurse staffing has been shown to be associated 2   The review included observational studies that used controls to protect against threats to validity—e.g., case control, cohort, and pre- and post-design studies and studies using data from large public databases. Observational studies without controls were excluded.

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Keeping Patients Safe: Transforming the Work Environment of Nurses with malnutrition, starvation, and dehydration in nursing home residents (Kayser-Jones, 1996, 1997; Kayser-Jones and Schell, 1997; Kayser-Jones et al., 1999). Licensed nursing hours (but not unlicensed hours) have been found to be significantly related to improved functional ability, increased probability of discharge to home, and reduced mortality in the first year after admission (Bliesmer et al., 1998). And higher total nurse staffing hours, particularly higher RN hours, were shown to be associated with fewer facility deficiencies in a study of all U.S. nursing homes (Harrington et al., 2000b). Other studies have found that gerontological nurse specialists and geriatric nurse practitioners also contribute to improved quality outcomes in nursing homes (Buchanan et al., 1990; Kane et al., 1988; Mezey and Lynaugh, 1989). These and other studies are reviewed in two Institute of Medicine (IOM) reports (IOM, 1996, 2001b) that confirm the important relationship between staffing and quality. The 1996 IOM report Nursing Staff in Hospitals and Nursing Homes: Is It Adequate, found that “the preponderance of evidence from a number of studies using different types of quality measures has shown a positive relationship between nursing staff levels and quality of nursing home care.” Based on this evidence, “a relationship between RN-to-resident staffing and quality of care in nursing facilities has been established” (IOM, 1996:153). Subsequent, additional strong evidence of the effect of nurse staffing on nursing home resident outcomes is provided by a congressionally mandated study on the Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes carried out under the auspices of the U.S. Department of Health and Humans Services’ (DHHS) Centers for Medicare and Medicaid Services (CMS) between 1998 and 2002. This study was conducted in two phases, with a Phase I report being provided in July 2000 (CMS, 2000) and a Phase II report in December 2001 (CMS, 2001). The Phase I study involved the development of methodologies and a preliminary assessment of relationships between patient (resident) outcomes and staffing levels using 1996 and 1997 data from three states and over 3,000 facilities. The Phase I report provides a discussion of relevant policy issues, including trends in payment and staffing levels in nursing homes; a discussion of how current federal regulatory staffing requirements are implemented; stakeholder perspectives; a literature review; and an analysis of different staffing data sources. The report also includes two other approaches to determining staffing needs: a time-motion study and use of operations research models. The Phase II report provides further analysis of staffing–outcome associations using 1999 data from almost 9,000 facilities in 10 states. This report includes a refinement of the previous operations research estimates, studies of nursing staff turnover and retention, case studies of the relationship between care outcomes and nurse staffing issues beyond staffing levels,

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Keeping Patients Safe: Transforming the Work Environment of Nurses an assessment of training and education for certified nurse assistants (CNAs), discussion of the adequacy of the nursing workforce to meet higher minimum nurse staffing standards, the development of improved nurse staffing data collection approaches, and an examination of payment options for improving nurse staffing. In combination, these reports provide a comprehensive assessment of staffing-related issues in long-term care and the policy context for addressing these issues. However, the core of this research was empirical work that demonstrated consistent associations between staffing levels and quality of care. The Phase II empirical study included two separate samples of nursing home residents and facilities (CMS, 2001). The first was a Medicare admission sample designed to evaluate the relationship between staffing and outcomes of postacute nursing home care—care for those residents with acute conditions who are admitted to skilled nursing facilities (SNFs) generally for a relatively short stay. This short-stay sample included all SNF nursing homes from the 10 study states and used claims data linked to data from the federal government’s nursing home minimum data set (MDS), which contains information on each resident’s diagnoses, physical functioning, and other health conditions, as well as demographic and additional health status information.3 Outcome measures for this sample related to patient safety were rehospitalizations within 30 days of admission for potentially avoidable causes, including congestive heart failure, electrolyte imbalance, respiratory infection, urinary tract infection (UTI), and sepsis. These resident-level measures were aggregated to the facility level to obtain a nursing home rate4 for each outcome measure. The second sample, of long-stay residents, was used to examine the relationship between staffing and care outcomes for nursing home residents. This sample included all residents with two MDS assessments 90 days apart. Outcome measures relevant to patient safety included incidents of pressure ulcers, skin trauma, and weight loss, which were then aggregated to the nursing home level. These outcome measures were selected because they were likely to be affected by nurse staffing, had sufficient incidence for stable estimates, had a measurable set of risk adjustors that could be used to control for differences in risk, and were based on accurate secondary data elements. A much larger set of measures was evaluated initially. Data sources for hospital-transfer outcome measures were hospital claims, whereas long-stay outcome measures utilized MDS data. Risk factors were obtained from both 3   Further information on the MDS is available at the CMS website: http://cms.hhs.gov/medicaid/mds20/man-form.asp [accessed September 26, 2003]. 4   Facilities with fewer than 25 admissions were excluded.

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Keeping Patients Safe: Transforming the Work Environment of Nurses data sets. Staffing data were obtained from Medicaid cost reports for the 10 states, which were found to have a higher correlation with payroll data than the Medicaid On-line Survey and Certification Report (OSCAR) data that are provided to state survey agencies and the federal government by facilities. Analysis involved the generation of resident-level risk models for each outcome, which were then used to estimate resident-level risk scores, calculate a facility average risk score, and assess the association between staffing levels and rate of adverse events, adjusting for the facility average risk score. Facilities in the worst 10th percentile were considered to have an inappropriately high level of untoward events, which generally reflected a rate that was three or more times the mean rate for the outcome (e.g. overall UTI hospitalization mean = 0.03; 10th percentile mean = 0.09). Consistently, associations were found between different staffing levels and whether facilities were in the worst 10th percentile. These significant associations persisted until a staffing threshold was reached, above which there was no further detectable benefit from additional staffing. These findings occurred for all three types of nursing staff separately (nursing assistant [NA], licensed [LPN/LVN and RN combined], and RN). The thresholds occurred at staffing levels that exceeded the current levels of 75–90 percent of facilities, depending on the type of staff and the measure. Thus, most facilities fell considerably below the staffing thresholds. These thresholds were between 2.4 and 2.8 hours per resident day for NAs, between 1.1 and 1.3 hours per resident day for licensed staff, and between 0.55 and 0.75 hours per resident day for RNs. However, incremental improvements in quality occurred at all levels until these staffing thresholds were reached. This study also found (based on an analysis of 631 facilities in California for which information on staff turnover and retention was available) a strong relationship between staff retention and outcomes related to patient safety. For example, improved annual retention of nursing staff up to a threshold of about 51 percent (i.e., half the staff stay for a full year) was associated with a substantially higher likelihood (odds ratio 3.66) that a nursing home would not be in the worst 10 percent of facilities. However, retention of less than 51 percent was associated with a high risk of adverse events, such as hospitalizations for UTIs and pressure ulcers. Explanations for the Causal Relationship Between Staffing Levels and Patient Outcomes Several studies have attempted to explain the relationship between higher levels of nurse staffing and improved patient outcomes. The results of these studies support the position that as the numbers of nursing staff increase, the staff are proportionately able to provide increasing amounts of

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Keeping Patients Safe: Transforming the Work Environment of Nurses necessary care. Once necessary care is provided, one would expect to see no additional improvement in health outcomes from greater numbers of staff. This point is supported by the above-referenced CMS study of nursing home staffing, which identified a threshold level of nurse staffing above which no further improvements in patient outcomes were detected (CMS, 2001). An HCO’s staffing level is traditionally considered a structural measure of quality that can affect the processes and outcomes of care (Donabedian, 1980; IOM, 1996). In nursing homes, the processes of care include a range of nursing activities, such as assistance with ADLs and monitoring of health status; therapeutic services, such as dressing changes and administration of medications; and other nursing activities, such as the management of incontinence. The outcomes of care can be measured as weight loss, pressure ulcers, incontinence, or other markers of physical decline (Zimmerman et al., l995). In long-term care, higher staff levels and lower RN turnover have been shown to be related to better care processes, such as lower urinary catheter use, better skin care, and better resident participation rates (Spector and Takada, 1991). Inadequate nurse staffing is correlated with inadequate feeding assistance and poor oral health (Kayser-Jones, 1996, 1997; Kayser-Jones and Schell, 1997; Kayser-Jones et al., 1999). NAs with inadequate time to provide care have been documented to cut corners in order to manage their workloads (Bowers and Becker, 1992). Schnelle et al. (2002) conducted a blinded study to determine whether there were differences in the quality of care processes among 34 randomly selected California long-term care facilities with different staffing levels. Three groups of homes were identified in the sample. Group 1 (nine homes at the 0 to 25th percentile of staffing levels) reported 2.7 mean total (RNs, LVNs, and NAs) direct-care hours per resident/day (hprd). Group 2 (six homes in the 75th to 90th percentile) reported 3.4 hprd; and Group 3 (six homes in the 91st to 100th percentile) reported 4.9 hprd. During a 3-day on-site visit, research staff used standardized protocols for direct observation, resident assessment, resident interview, and medical record review to assess 16 care processes delivered by NAs and 11 care processes delivered by licensed nurses. NAs in Group 3 homes reported significantly lower resident care loads across the day and evening shifts in 2001–2002 (7.6 residents per NA) compared with NAs in all of the remaining homes. Group 3 homes also performed significantly better on 12 of 16 care processes implemented by NAs compared with all other remaining homes combined. Residents in the Group 3, or highest-staffed, homes were significantly more likely to be out of bed and engaged in activities during the day and to receive more feeding assistance and incontinence care. The researchers concluded that there is a relationship between nursing home reports of total staffing, NA reports of resident care load, and the quality of implementa-

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Keeping Patients Safe: Transforming the Work Environment of Nurses tion of care processes. Comparing these findings with those of studies of eight separate quality indicators (weight loss, bedfast, physical restraints, pressure ulcers, incontinence, loss of physical activity, pain, and depression), the researchers concluded that staffing levels are a better predictor of high-quality care processes than the eight quality indicators (Schnelle et al., 2002). For acute hospital care, the relationship between licensed nurse staffing levels and patient outcomes also has been attributed in part to the surveillance function of nursing described in Chapters 1 and 3. As the staffing level rises, so does the availability of nurses to spend more time in surveillance (monitoring) of patients for changes in their condition, which in turn enables quicker detection of changes in health status and more prompt rescue activities by the health care team. When this does not happen, “failure to rescue” is said to occur. The concept of failure to rescue has been tested and validated as an indicator of the quality of acute hospital care for surgical patients (Silber et al., 1992). When higher levels of nurse staffing are present in hospitals, failure to rescue is reduced (Aiken et al., 2002; Needleman et al., 2002). Other attempts to understand how overall staffing affects patient safety in acute care hospitals have examined ratios of RNs to nonlicensed nursing personnel. Two studies found that higher ratios of RNs to unlicensed nurses are associated with lower rates of both medication errors and decubiti (Blegen et al., 1998) and with lower mortality rates (Hartz et al., 1989). However, one study that did not include case-mix adjustment found no association between the ratio of RNs to unlicensed nurses and nonfatal complications (Bolton et al., 2001). Variation in Hospital and Nursing Home Staffing Levels Acute Care Hospital Staffing There is no national database on hospital nurse staffing levels that (1) reports staffing levels by type of patient care unit; (2) distinguishes direct-care nursing staff from nursing staff in administrative, managerial, educational, or other non–direct patient care positions; or (3) distinguishes inpatient nurses from those delivering outpatient care in hospitals. However, a few studies and state hospital data sets show that staffing levels vary considerably from hospital to hospital and across inpatient units within hospitals. Variation in hospital staffing is illustrated by 1998–2000 data from the California Nursing Outcomes Coalition (CalNOC), which maintains a statewide database of nurse staffing levels submitted directly by California hospitals (see also Chapter 3). Although these data constitute a convenience

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Keeping Patients Safe: Transforming the Work Environment of Nurses sample of 52 California hospitals voluntarily contributing staffing data to the initiative, the data are useful because they are collected at the level of the nursing unit (as opposed to the aggregate hospital level), use common data definitions and reporting, and have ongoing verification to ensure accuracy. Data reported on the 330 critical care, medical–surgical, and step-down units across nine calendar quarters in these hospitals revealed averages and ranges of RN-to-patient staffing ratios across these facilities: ICUs—a range of one RN for every 0.5–5.3 patients (average = one RN for every 1.6 patients) Step-down units—a range of one RN for every 1.5–11.6 patients (average = one RN for every 4.2 patients) Medical–surgical units—a range of one RN for every 2.7–13.8 patients (average = one RN for every 5.9 patients) These findings did not vary over the nine quarters or by the size of the hospital (Donaldson et al., 2001). As discussed in Chapter 3, data from a fiscal year 2002 national convenience sample survey of hospitals on staffing, scheduling, and workforce management of nursing department employees show similar variation. The 135 hospitals responding varied in nurse staffing levels even with the shift and type of patient care unit being held constant. Although the average RN-to-patient ratio in medical–surgical units on the day shift was 1:6, the range was from 1:3 to 1:12. Twenty-three percent of hospitals reported that nurses in their medical–surgical units on the day shift were each responsible for caring for between 7 and 12 patients. On the night shift, 7 patients on average were assigned to each nurse, but 34 percent of hospitals reported between 8 and 12 patients assigned to each nurse. For critical care units, the average number of patients assigned to each nurse was 2 for both the day and the night shifts, but 7.4 percent of hospitals reported having nurses care for 3 or 4 ICU patients during the day shift, and 11 percent reported nurses caring for 3 or 4 ICU patients during the night shift (Cavouras and Suby, 2003). A 1999 survey (Aiken et al., 2002) of a 50 percent random sample of Pennsylvania hospital RNs working in all hospital units who held staff positions involving direct patient care similarly reported variable nurse-to-patient ratios (see Table 5-1). Unfortunately, studies that distinguish type of nursing unit or separate direct-care nurses from nurses in administrative positions are rare. Most studies measuring nurse staffing levels collect staffing data aggregated across all hospital units, such as ICUs, general medical–surgical units, emergency rooms, and labor and delivery units (Aiken et al., 1999, 2002; Bolton et al., 2001; Bond et al., 1999; Cho et al., 2003; Flood and Diers, 1988; Kovner

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Keeping Patients Safe: Transforming the Work Environment of Nurses ences are identified as a key component of effective caregiver interactions (Shortell et al., 1994). Inconsistent Collaboration Between Nursing Staff and Other Health Care Providers While the literature on interdisciplinary teams has focused on a broad array of disciplines involved in health care delivery, the literature concerning collaboration has focused primarily on nurse–physician interactions (Ingersoll and Schmitt, 2003). The limited existing evidence indicates that most nurses experience positive relationships with their physician colleagues. However, the extent to which a “positive relationship” is indicative of collaboration is unknown. There are also indications that positive relationships with physicians are not experienced by all nurses. There are numerous anecdotal and historical reports of poor nurse–physician relationships, including reports of generally poor communication (Greenfield, 1999; Schmitt, 2001), hierarchical communication patterns (Disch et al., 2001), unilateral decision making by physicians (Schmitt, 2001), and verbal abuse of nurses by physicians (Manderino and Berkey, 1997; Rosenstein, 2002). These problems are sometimes attributed to differences in power, sex, class, economics, and education (McMahan and Hoffman, 1994). However, interpretation of these reports is impeded by the absence of any representative survey of practicing nurses across health care delivery settings regarding the levels of collaboration they experience with physicians and other health care providers. Studies that have attempted to measure nurse–physician interactions are often convenience samples without controls for sampling bias. Further, surveys that have attempted to measure the incidence of verbal abuse of nurses have not used physicians as the unit of analysis, so it is not known whether abusive behavior characterizes a small minority of physicians or is more widely practiced. In two representative samples of nurses, large majorities reported “good” working relationships with physicians. In 2002–2003, a random sample survey of nurses licensed to work in Illinois and North Carolina13 was conducted as part of a longitudinal study of nurses’ worklife and health funded by the National Institute for Occupational Safety and Health (NIOSH) of the U.S. Centers for Disease Control and Prevention (CDC). Of the 674 RN respondents to this survey who were currently employed as full-time hospital or nursing home general-duty staff, 82.4 percent agreed or agreed strongly with the statement, “In my job, doctors and nurses have 13   These states were selected because they have large ethnic diversity in their RN populations and because they renew RN licenses annually, providing up-to-date mailing lists.

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Keeping Patients Safe: Transforming the Work Environment of Nurses good working relationships.”14 Likewise, in a survey of 50 percent of RNs living in Pennsylvania, 83.4 percent of nurses working in hospitals reported that “physicians and nurses have good working relationships” (Aiken et al., 2001). Positive and collaborative relationships between nurses and physicians are also characteristically found in magnet hospitals (Kramer and Schmalenberg, 2002). The use of agency staff, high turnover rates among nursing staff (Disch et al., 2001), and short rotation periods for medical residents (Baggs and Schmitt, 1997) also threaten collaborative relationships. Building collaborative relationships takes time, and these phenomena have been cited as making it difficult to form the sustained relationships that are essential for the development of trust and a precursor to collaboration. Heavy workloads are also cited as interfering with the formation of collaborative relationships. When staff are overwhelmed with caregiving responsibilities, they may not take the time to collaborate. Yet while unilateral decision making is easier in the short run, collaborative relationships are viewed as saving time in the long run (Baggs and Schmitt, 1997; Disch et al., 2001). Building and Nurturing Collaboration There is some evidence that collaboration can be facilitated by supportive organizational structures and processes including the following: Leadership modeling of collaborative behaviors—This approach can help other medical staff improve their relationships with nursing staff (Disch et al., 2001). Commitment of resources to build nurse expertise—The strong evidence cited above that individual clinical competency is an essential precursor to collaborative practice is further reinforcement for recommendation 5.5 regarding the actions HCOs should take to support nursing staff in their ongoing acquisition and maintenance of knowledge and skills. Design of work and workspace to facilitate collaboration—Collaboration is facilitated by providing workspaces that encourage physical proximity among those performing the work and by ensuring that staff have the time to participate in collaborative activities, such as conducting interdisciplinary patient rounds (Baggs and Schmitt, 1997). Hospital unit design and staffing approaches should reflect attention to whether they will promote or discourage interdisciplinary collaboration. This observation further sup- 14   Unpublished data from Alison Trinkoff, Ph.D., University of Maryland at Baltimore, NIOSH grant R01OH3702 (personal communication, April 9, 2003).

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Keeping Patients Safe: Transforming the Work Environment of Nurses ports the staffing recommendations made earlier in this chapter. A discussion of workspace design is presented in Chapter 6. Interdisciplinary practice mechanisms—There is some evidence that using structured interdisciplinary forums, such as interdisciplinary rounds, can be effective in improving patient care (Curley et al., 1998). Regularly scheduled interdisciplinary meetings also can be held at the patient care unit level. During these meetings, nursing, medical, pharmacy, and other clinical providers can work together to address issues pertaining to the running of the unit and patient care. Small work groups can be formed to address specific concerns and report back to the larger group (Disch et al., 2001). Interdisciplinary practice can also be facilitated by patient record and documentation practices that promote interdisciplinary information sharing, such as the use of interdisciplinary clinical pathways (Lange et al., 1998). Training—Training and development may be needed in collaborative practice behaviors, such as effective communication and conflict resolution (Disch et al., 2001). Human resource policies—Human resource policies that identify verbal abuse and other hostile behaviors as unacceptable, along with procedures for addressing such behaviors, may be helpful (Manderino and Berkey, 1997). Some have suggested identifying interpersonal components of organizational practice expectations for clinicians. Such components might include, for example, expectations that all health care providers involved in clinical services within the organization cooperate and communicate with other providers while displaying regard for their dignity; refrain from foul language, shouting, and rudeness; and use conflict management skills in handling disagreements (Pfifferling, 1999). Performance evaluation also can include measures of the extent to which health care providers are viewed as collaborators by those in other disciplines. HCOs can act on this information to build and nurture collaboration across health care providers. Many strategies to this end have already been addressed in the committee’s recommendations pertaining to evidence-based management, staffing, and the acquisition of new knowledge and skills by nursing staff. In addition, the committee makes the following recommendation: Recommendation 5-6. HCOs should take action to support interdisciplinary collaboration by adopting such interdisciplinary practice mechanisms as interdisciplinary rounds, and by providing ongoing formal education and training in interdisciplinary collaboration for all health care providers on a regularly scheduled, continuous basis (e.g., monthly, quarterly, or semiannually).

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