Keeping Patients Safe Transforming the Work Environment of Nurses (2004) / Chapter Skim
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1 Nursing: Inseparably Linked to Patient Safety
1 Nursing: Inseparably Linked to Patient Safety
Pages 23-52
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From page 23... ...
Some of these changes have resulted, for example, in greater numbers of more acutely ill and technologydependent patients being assigned to individual nurses; changes in how licensed and unlicensed nursing staff are deployed; and a growing number of competing demands on nurses' time, such as increased paperwork and documentation requirements. Many individuals and organizations have expressed concern that these and other changes have adversely affected nurses' ability to provide safe patient care (Aiken et al., 2001a; Service Employees International Union, 2001; Shindul-Rothschild et al., 1996)
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From page 24... ...
We then present evidence of the key role played by nurses in patient care and safety, and briefly describe some of the characteristics of the current health care delivery system that shape the work and work environment of nurses, particularly in in-patient facilities. Evidence is then presented showing that nurses are not immune to the problems that plague health care delivery in the United States -- problems that foster the occurrence of errors in which all health care providers, not just nurses, are involved.
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From page 25... ...
come to a better understanding of the likely hundreds of thousands of health care errors and adverse events that occur in the United States every year in which nurses, physicians, pharmacists, dentists, nurse aides, and assistants -- in fact, all health care providers -- are involved. First, To Err Is Human presented the vocabulary necessary to begin to better understand the problem: • Errors are failures of planned actions to be completed as intended, or the use of wrong plans to achieve what is intended.
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From page 26... ...
Indeed, To Err Is Human presents evidence that these numbers are likely underestimates of the numbers of people injured by errors in health care. These numbers also do not include persons injured as a result of medical errors in nursing homes, home health care, and other health care settings.
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From page 27... ...
. No one receiving health care -- young or old; severely or slightly ill; patients in hospitals, in nursing homes, or in their doctors' offices; wealthy, middle class, poor, or near poor; those receiving health insurance through Medicare, Medicaid, or private health insurance -- is immune to health care errors and adverse events.
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From page 28... ...
. To Err Is Human endorses the systems approach to understanding and reducing errors and notes that failures in large systems, such as hospitals or their various patient care units, nursing homes, or ambulatory practice sites, are most often due to unanticipated events or factors occurring within multiple parts of the system.
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From page 29... ...
In contrast, latent conditions are factors in the production process or system that are not under the direct control of front-line workers. These factors include poor design of work or equipment, inadequate training, gaps in supervision, insufficient supply of equipment to perform work, undetected manufacturing defects or faulty maintenance, inadequate personnel deployment, and poorly structured operations.
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From page 30... ...
Because the nurse did not come forward, none of these latent conditions were recognized as threats to patient safety, and the potential remained that future patients admitted to this unit would face a similar risk to their safety. Indeed, latent conditions such as these are present in all organizations and have been identified as posing the greatest risk to safety in complex or high-technology systems because of their capacity to result in multiple types of active failures.
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From page 31... ...
refers to unlicensed health care personnel who supplement the work of licensed nurses by performing routine patient care activities under the supervision of an RN or LPN/LVN. A variety of titles are used for these unlicensed nursing personnel, including nurse assistants, nurse aides, home health aides, personal care aides, ancillary nursing personnel, unlicensed nursing personnel, unlicensed assistive personnel (UAPs)
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From page 32... ...
In nursing homes, the majority of patient care is provided by NAs, under the supervision of a licensed nurse. Efforts to detect and remedy error-producing defects in health care systems will be severely constrained without the assistance of the eyes, ears, cognitive powers, and interventions of over half the health care workforce.
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From page 34... ...
. Although the type and frequency of patient assessment and monitoring activities carried out by licensed nurses vary by the setting of care, the clinical condition, and other characteristics of the patient, such activities are performed by nurses for each patient in every setting in which health care is delivered ambulatory primary care sites, hospitals, schools, workplace health sites, home health agencies, and nursing homes.
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From page 35... ...
Because licensed nurses and NAs work at the "sharp end" of health care delivery, they are key instruments for carrying out such vigilance in health care. The goal of this nursing surveillance or vigilance function is the early detection of a downturn in a patient's health status or the advent of an adverse event, and the initiation of activities to "rescue" the patient and restore health.
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From page 36... ...
Coordination and Integration of Care and Services from Multiple Providers In addition to providing surveillance of patients, therapeutic nursing interventions, and treatments to carry out medical orders, licensed nurses serve as the integrator or coordinator of patient care. These integrating activities include implementing physician treatment orders and explaining them to the patient; planning for patients' discharge from hospitals or other health care facilities to enable continued care in the home, school, or nursing home; providing health care treatment in the home or other setting of care; and educating the patient and family about the patient's disease, course of therapy, medications, self-care activities, and other areas of concern to the patient.
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From page 37... ...
(Thomas, 1983:66-67) PATIENT SAFETY RISK FACTORS IN NURSES' WORK AND WORK ENVIRONMENTS Because nurses carry out the responsibilities described above, they potentially are well positioned to observe and influence how the health care system functions across all aspects of patient care, and thereby to detect and address threats to patient safety.
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From page 38... ...
As a consequence, over the last few years, nursing homes have developed specialized units to care for patients who need more extensive care, such as those with dementia, rehabilitation needs, ventilator dependency, or brain injury. Approximately 12.6 percent of all nursing homes in 1996 had units devoted to the specialized care of 6A hospital's CMI represents the average diagnosis-related group (DRG)
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From page 39... ...
While there is no precise way to measure trends in the numbers of nursing home patients having more complex medical needs necessitating intervention from a licensed nurse as opposed to ADL support from an NA changes can be inferred from the proportion of residents whose care is covered by Medicare, because Medicare coverage of nursing home care is limited to payment for rehabilitation care and skilled nursing services. Between 1987 and 1996, the percentage of nursing home patients whose care was paid for by Medicare increased from 3 to 9 percent, and the proportion of nursing homes certified to receive Medicare reimbursement increased from 28 to 73 percent, indicating that the number of nursing homes planning to take in residents with more acute illness or more complex needs increased substantially (Rhoades and Krauss, 2001~.
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From page 40... ...
The outcomes of these redesign initiatives are not clear (Walston et al., 2000~. Formal measurements of the results of these multifaceted restructuring, reengineering, and redesign initiatives have been few, and findings have been contradictory with respect to the consequences for nurses' work and work environment, including nursing staff satisfaction, control over work environment, concern over changes in responsibilities, and work group relationships.
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From page 41... ...
A recent and detailed analysis of nurse staffing levels at the aggregate level across facilities and at 8For example, commonly used data sources do not always distinguish between nursing staff in outpatient and inpatient care units or between nurses in administrative positions providing no direct patient care and nurses providing bedside patient care, or collect data on NAs.
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From page 42... ...
High Staff Turnover High rates of turnover characterize the nursing staff of both hospitals and nursing homes. Such high turnover can have adverse consequences for patient safety.
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From page 43... ...
Turnover rates among nursing staff in nursing homes are even greater. A national survey conducted by the American Health Care Association (AHCA)
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From page 44... ...
report Crossing the Quality Chasm cites the growing complexity of science and technology, resulting from the tremendous advances made in clinical knowledge, drugs, medical devices, and technologies for use in patient care, as one of the four main attributes of the U.S. health system affecting health care quality.
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From page 45... ...
In addition to the heavier patient care loads borne by nursing staff, evidence cited above indicates that large proportions of nurses spend time performing activities that can disrupt their primary patient care responsibilities, such as delivering and retrieving food trays; performing housekeeping duties; transporting patients; and ordering, coordinating, or performing ancillary services, such as delivery of medical equipment or supplies, blood products, or laboratory specimens (Aiken et al., 2001a; Prescott et al., 1991; Upenieks, 19981. It is clear that interruptions and interference occur frequently in nursing care from these and other nursing unit activities (Bowers et al., 2001; O'Shea, 1999; Wakefield et al., 1998; Walters, 19921.
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From page 46... ...
Home care nurses are estimated to spend a much greater proportion of their time in documenting care. According to some estimates, home health nurses spend approximately twice as much time in documenting patient care as do hospital nurses, in part because of more prescriptive federal regulatory requirements (Trossman, 20011.
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From page 47... ...
The IDAHO database is relatively small and subject to underreporting. Nevertheless, for 19 percent of the total errors reported to the database from 1995 to 2002, nurse staffing levels are cited as one of the four major causal factors for reported serious errors/adverse events, such as patient falls, medication and transfusion errors, delays in treatment, and operative and postoperative complications.
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From page 48... ...
We also describe further how this report relates to To Err Is Human and Crossing the Quality Chasm. Chapter 3 describes the characteristics of the nursing workforce and its work that are important factors in reshaping nursing work environments.
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From page 49... ...
2002. Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II Final Report: U.S.
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From page 50... ...
2002. Nurse staffing and post surgical adverse events: An analysis of administrative data from a sample of U.S.
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From page 51... ...
2001. Nurse staffing, models of care delivery, and interventions.
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From page 52... ...
Final results of our patient care survey. American Journal of Nursing 96 11 :25-39.
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