A 2004 report from the Institute of Medicine (IOM) offered a startling conclusion: “The typical work environment of nurses is characterized by many serious threats to patient safety.” Keeping Patients Safe: Transforming the Work Environment of Nurses went on to offer a series of specific recommendations about how hospitals and other institutions needed to change to reduce the number of health care errors—recommendations that together constituted a fundamental transformation of nurses’ work environment.
Ten years later, how much has changed? And what more needs to be done?
Those questions form the backbone of the latest edition of the Charting Nursing’s Future (CNF) issue brief series from the Robert Wood Johnson Foundation (RWJF).
The IOM report found that hospitals and other health care organizations did a poor job of managing the high-risk nature of the health care enterprise. Accidents were too common, and the management practices in the industry did little to create a culture of safety.
The CNF brief, Ten Years After Keeping Patients Safe: Have Nurses’ Work Environments Been Transformed?, details a series of programs designed by and for nurses that have “spurred the creation of work environments that foster health care quality and patient safety.”
Among them is the RWJF-backed Transforming Care at the Bedside (TCAB) initiative, developed in collaboration with the Institute for Healthcare Improvement. The TCAB effort began shortly before the release of the IOM report, with the aim of empowering frontline nurses to address quality and safety issues on their units, in contrast with more common, top-down improvement efforts. Over several years, the approach was tested and refined, and then in 2007, the American Organization of Nurse Executives (AONE) began to disseminate it more widely. Soon after, AONE expanded its effort, launching the Center for Care Innovation and Transformation, drawing on TCAB principles. The following year, RWJF set the stage for TCAB’s continued growth by integrating the program with Aligning Forces for Quality (AF4Q), the Foundation’s signature effort to improve the quality of health care and reduce disparities in targeted communities.
As reported in CNF, a 2011 study of TCAB’s impact found that the majority of 13 studied medical-surgical units “saw a significant decrease in injury-producing patient falls and 30-day hospital readmission rates.” In addition, “nurse engagement in quality improvement rose, and TCAB innovations spread to other hospital units. TCAB units also reduced staff overtime, translating to an average net financial gain of $625,603 per TCAB unit over three years.”
Teaching Safety in Nursing School
Another RWJF-backed project aimed at improving patient safety focused on nursing schools. Quality and Safety Education for Nurses (QSEN) helped prepare thousands of nursing faculty to integrate quality and safety competencies into nursing school curricula. The program launched in 2005 at the University of North Carolina at Chapel Hill School of Nursing with funding to enhance nursing school curricula, and in 2009 began developing faculty expertise to teach a series of core competencies. QSEN is now hosted by Case Western Reserve University, and offers a wealth of online resources for nursing schools and faculty.
Nurse Staffing: Numbers and Composition
On a different front, policy-makers have also addressed the complex issue of patient safety through nurse staffing, focusing both on nurse-patient ratios and on the composition of the nursing workforce.
To date, California is the first and only state to establish a limit on the number of patients a nurse may be assigned to care for in acute care hospitals (five patients per nurse in general medical-surgical units, and fewer patients on some specialty units). Subsequent research has demonstrated hospital compliance with the mandate, but evidence of improvements in cost, quality, and safety is mixed so far.
Other jurisdictions, including Illinois, Washington state, and Minnesota, have adopted requirements that hospitals pay greater attention to, monitor more closely, or disclose publicly, their staffing policies.
In addition, the IOM’s 2010 Future of Nursing: Leading Change, Advancing Health report gave new impetus to efforts to increase the share of nurses with baccalaureate degrees or higher, and as described in Issue 21 of CNF, various institutions have begun to address that recommendation through hiring requirements, tuition-reimbursement policies, and more.
Disruptive Behavior on the Job
Other programs launched since Keeping Patients Safe have focused on curbing disruptive behavior and professional discourtesy in the workplace, according to the CNF brief. Given the growing importance of teamwork and collaboration, the consequences of such behavior can be, as the brief observes, “monumental when patients’ lives are at stake.” The brief cites a 2010 study of nurses working in critical care and surgical settings that found that “even when safety tools indicated a patient care problem, fewer than one-third of nurses felt comfortable speaking up and were able to get coworkers to listen to their concerns. In addition to undermining a culture of safety, verbal abuse and other forms of unprofessional or disruptive behavior also negatively affect clinicians’ working relationships, the efficient flow of information and communication, and employers’ ability to retain nurses on staff.”
Despite the potential dangers, such behavior is widespread, according to the data. One recent survey of frontline nurses and physicians found that 84 percent of respondents reported personally experiencing disruptive behavior within the past year.
A program now in place at the Vanderbilt University Medical Center in Nashville addresses the problem by training selected staff to promote professionalism, and providing a “pyramid” of escalating interventions to address inappropriate behaviors, ranging from “cup of coffee conversations” in response to first-time incidents, to “awareness intervention,” to guided interventions by authority, and finally, to disciplinary action. Vanderbilt reports that the program has been effective at reducing behaviors that undermine a culture of safety, saving the institution millions of dollars annually, including an 80-percent reduction in malpractice lawsuits.
A nurse-led and –directed initiative at The Johns Hopkins Hospital in Baltimore features a code of conduct and a system for reporting disruptive behaviors. However, surveys of staff have found that they tend not to use formal channels to report disruptive behavior. As Jo Walrath, PhD, RN, co-investigator of the research on the program’s impact sees it, “Clearly, interprofessional education is part of the answer, but we believe that whatever is done to address this problem, it will take multiple interventions, a commitment of hospital leadership, and engagement of the staff at the unit level.”
Nurse leadership on institutional boards is another important element in the discussion about the nursing workplace and its effect on safety. As Lawrence D. Prybil, PhD, LFACHE, of the University of Kentucky, observes, “Many leaders on health system boards lack sufficient clinical knowledge and know little about measuring quality and safety. Given nurses’ expertise in these areas, boards would do well to enlist their leadership.”
Angela Barron McBride, PhD, RN, FAAN, the former dean of Indiana University’s School of Nursing, speaks from experience on this point, as a board member of Indiana University Health (IUH). “Quality and safety are systemic issues that cannot be improved by individual clinicians alone,” she says. “Working with the IUH board, I’ve been able to bring my perspective as a nurse to systems level initiatives that are improving patient care.”
The Way Forward
The CNF brief goes on to cite a series of initiatives by government agencies, professional associations, the public service sector, and credentialing organizations, all designed to advance patient safety and transform nurses’ work environments toward that end.
It concludes with an “emerging blueprint for change” that urges providers, policy-makers, and educators to follow through on:
- monitoring nurse staffing and ensuring that all health care settings are adequately staffed with appropriately educated, licensed, and certified personnel;
- creating institutional cultures that foster professionalism and curb disruptions;
- harnessing nurse leadership at all levels of administration and governance; and
- educating the current and future workforce to work in teams and communicate better across the health professions.
Finally, the brief provides policy-makers, health care organizations, educators, and consumers with a listing of available tools to help in their efforts.