In 2003, the Institute for Healthcare Improvement and the Robert Wood Johnson Foundation launched Transforming Care at the Bedside (TCAB), a nationwide, nurse-focused effort to improve health care delivery. TCAB recognized that nurses often hold the key to making hospital care more effective, patient-centered and efficient. David Harrington, RN, BSN, CMSRN, has been a nurse at Providence St. Vincent Medical Center since 2006 and a TCAB leader there for two years. Erin Hochstein, RN, BSN, PCCN has been a staff nurse at Providence since 2010 and a TCAB leader for two years. This is part of a series of posts for National Nurses Week, highlighting how nurses are driving quality and innovation in patient care.

As nurses, we are with our patients and their families during some of the most pivotal moments in their lives, which is a true honor. Yet, with the ever-increasing demands of health care, the responsibilities of nurses have become greater, pulling us away from the bedside. To curb this trend we were given the opportunity, at Providence St. Vincent Medical Center, to adopt Transforming Care at the Bedside (TCAB), a program that gives bedside staff the chance to streamline care and improve patient outcomes.

By allowing us direct input on our workflow, we have the opportunity to develop rapid tests of change that we implement over the course of one shift.  This adjustment in practice empowers frontline nurses to be catalysts of change for patient care, permitting us creative liberty in finding solutions to practice and system issues we face on a daily basis.

The Providence St. Vincent TCAB team began its journey in 2010 by visiting Prairie Lakes Hospital in Watertown, South Dakota, one of the original TCAB pilot sites, as part of an innovation grant provided by Providence Health & Services. Nurse representatives from three medical-surgical units along with hospital leaders were introduced to TCAB in action. As newly appointed TCAB leaders, we returned from the trip feeling motivated, inspired, and ready for change.

Four in 10 physicians say their typical patient load “exceeds safe levels” at least once a month, causing the quality of care they provide to suffer, according to a study by researchers at Johns Hopkins University, published online in the Journal of the American Medical Association (JAMA). More than one-third of physicians (36%) reported their workloads exceeded safe levels at least weekly.

In the survey of more than 500 self-identified hospitalists in an online physician community, respondents said their workloads had caused patient care to suffer. Respondents reported that inadequate time with a patient had caused them to order potentially unnecessary tests or procedures, and that their workloads had “likely contributed” to a host of poor patient outcomes, including morbidity and mortality.

Among the other problems physicians attributed to excessive workloads: inability to fully discuss treatment options; delayed admissions and discharge; increased readmissions; worsened patient satisfaction; and worsened overall quality of care.

Read the study abstract.
Read more about the results in Medpage Today [free subscription required].

Long working hours that cause fatigue, sleepiness, burnout and depression are a threat to the personal safety of medical residents, according to a Mayo Clinic study published this month. Working conditions associated with these characteristics are linked to motor vehicle crashes and near crashes, and may contribute to exposure to blood and body fluids on the job.

In the survey of 340 internal medicine residents in training at the Mayo Clinic, 168 respondents (56%) reported a motor vehicle incident during their training. Of those incidents, 34 were motor vehicle crashes, and 130 were near misses. Sixty residents reported falling asleep while driving, and 53 reported falling asleep while stopped in traffic. Residents attribute these incidents to diminished quality of life, exhaustion and depression, and fatigue and sleepiness, the study finds.

Residents also reported exposure to blood and body fluid during their training, some of which was attributed to fatigue. The researchers call the rates “reassuringly low,” but caution that “it is not possible to definitively rule out associations of distress with [blood and body fluid] exposure.”

“These findings indicate that resident distress is related not only to patient safety and quality of care but to residents’ personal safety as well,” the study says. “In addition to ongoing efforts to limit physician fatigue and sleepiness, interventions to promote well-being and reduce distress among physicians are needed to improve both patient and resident safety.”

Read the study.

Twelve-hour nursing shifts cause higher levels of burnout and negatively affect patient care, according to a study published this month in Health Affairs.

Researchers from the University of Pennsylvania found that more than 80 percent of nurses working shifts of eight or more hours were satisfied with the scheduling practices at their hospitals, but “the percentages of nurses reporting burnout and an intention to leave the job increased incrementally as shift length increased.” Nurses who worked shifts longer than 8-9 hours were up to 2.5 times more likely to have burnout and job dissatisfaction.

Long nursing shifts also have consequences for patients. In hospitals with high proportions of nurses working long shifts, patients perceived worse care, both overall and in nursing-specific factors. Patients in these hospitals reported that nurses didn’t communicate well or respond quickly, and said their pain was not well controlled. For many patient outcomes, dissatisfaction increased as the proportion of nurses working longer shifts increased, the study says.

The researchers hypothesize that nurses may underestimate the impact of working long shifts because long shifts mean working fewer days a week, which may be appealing.

Accrediting bodies should consider policies for nurses—like those already in place for medical residents—limiting the number of hours they can work a week, the research team suggests, and boards of nursing and nursing management should monitor nurses’ hours and overtime, and promote a workplace culture that facilitates manageable work hours.

What do you think? Are long shifts good for nurses or patients? Is there a way to help nurses keep flexible schedules without compromising their job satisfaction and patient care? Register below to leave a comment.

Read the study abstract.

Around the country, print, broadcast and online media outlets are covering the groundbreaking work of Robert Wood Johnson Foundation (RWJF) leaders, scholars, fellows and grantees. Some recent examples:

Zachary Goldberger, MD, an RWJF Clinical Scholar, spoke to the New York Times about a study he led that examined the ideal amount of time to continue cardiopulmonary resuscitation (CPR) on patients in cardiac arrest. “The study found that patients have a better chance of surviving in hospitals that persist with CPR for just nine minutes longer, on average, than hospitals where efforts are halted earlier,” the story reports.  First published in The Lancet, the study is one of the first to link the duration of CPR efforts with survival rates.  It is expected to prompt hospitals to reconsider their protocols.

RWJF Health & Society Scholar Jason Houle, PhD, continues to receive media coverage for his study that finds students from middle-income families leave school with an average of $6,000 more in student loan debt than their lower-income peers. The students were also more likely to have more student loan debt than their higher-income peers. Among the outlets to report on the findings: United Press International, Bloomberg Business Week, the Atlanta Journal-Constitution, and the Wisconsin State Journal.

A study supported by the RWJF Interdisciplinary Nursing Quality Research Initiative (INQRI) finds that “when nurses take steps to intervene in the medication process, they are more likely to catch would-be errors before they reach the patient,” Fierce Healthcare reports. The findings also indicate that a supportive practice environment is associated with a higher quality of nursing care. Read more about the study.

Robert Wood Johnson Foundation Interdisciplinary Nursing Quality Research Initiative (INQRI) grantee Susan Letvak, PhD, RN, recently spoke to the New York Times about her research on nurses with musculoskeletal pain and depression.

The study results were published in the February issue of the American Journal of Nursing.  Letvak and her team found that nurses experience depressive symptoms at a rate twice as high—18 percent—as the general public. The researchers specifically addressed depression in nurses and focused on treatment options in, “Depression in Hospital-Employed Nurses,” published in the May/June issue of the journal Clinical Nurse Specialist.

“The only way to ensure the best quality for our patients is to have an expert staff of qualified nurses who are healthy enough to offer that kind of care,” Letvak told the New York Times. “We can’t ignore nurses’ health anymore.”

To learn more about INQRI, visit www.inqri.org or follow @INQRIProgram on Twitter.

More physicians are working less than full time, seeking part-time or flexible schedules instead, according to a survey released earlier this month. The 2011 Physician Retention Survey, conducted by physician search firm Cejka Search and the American Medical Group Association, found that 22 percent of male physicians and 44 percent of female physicians worked less than full time in 2011.

Physicians from two particular age groups are driving this trend, according to American Medical News. Men nearing retirement age and women at the beginning or middle of their careers—presumably when they are raising children—are most likely to work part time or to insist on a flexible work schedule.

Nurses are also taking advantage of flexible work schedules, NurseZone.com reports, and more employers are offering programs and policies to improve employees’ work-life balance. Hospitals are offering on-site fitness centers, child care, incentive programs for employees to eat healthier meals and smoking cessation programs, the story reports, to help staff members live healthier and more balanced lives while they are at work.

“You can’t give of yourself [as an employee] if you are not whole,” Karen Drenkard, PhD, RN, an alumna of the RWJF Executive Nurse Fellows program and executive director of the American Nurses Credentialing Center (ANCC), told NurseZone.com. ANCC’s Magnet Recognition program and Pathway to Excellence program encourage flexible staffing models, healthy work environments and work-life balance for nurses. ANCC’s participating organizations “are very deliberate and very thoughtful about making sure their nurses are whole,” she added.

What do you think? Is flexible scheduling important for health care professionals? Are there other ways organizations can help their employees manage their work-life balance? Register below to leave a comment.

Carol S. Brewer, PhD, RN, FAAN, a professor at the University of Buffalo School of Nursing, leads the Robert Wood Johnson Foundation (RWJF)-supported RN Work Project with Christine T. Kovner, PhD, RN, FAAN. The 10-year, longitudinal study is the only one of its kind to study the careers of new nurses. Most recently, the RN Work Project released a study on the recession’s impact on new nurses.

Human Capital Blog: Your most recently-published study looked at registered nurses in the recession. Can you review the most important findings?

Carol Brewer: What we found was fairly interesting and fits with some of the other studies and data we’ve collected on new graduates in the recession. We found that the nurses’ intent to stay at their current job and their organizational commitment was higher than before the recession. We also found some indicators that the work environment was a little better. The nurses report that their relationship with physicians was better, and they had a lighter workload and fewer organizational constraints.

We can interpret this in a few different ways. One is that there has actually been a change for the better in the work environment, and stress and workload are going down a little bit. But we also found that nurses perceived fewer job opportunities, so they may feel like they can’t leave their jobs because there aren’t many other opportunities. They could be making their perceptions fit their reality, which would cause them to rate their environment higher than if they knew they had options and could afford to be pickier.

More likely, these nurses are just biding their time. We found that, despite perceiving fewer opportunities, the nurses were more likely to be searching for a job. Even though the perception is that things seem to be little better with their current employer, they’re still looking for other jobs.