Few of us have control over when we will be admitted to the hospital, but researcher Patti Hamilton notes that a weekend admission puts many patients at risk. Exactly why is a question she and her team at Midwestern State University are examining through a $300,000 grant from the Robert Wood Johnson Foundation’s (RWJF’s) Interdisciplinary Nursing Quality Research (INQRI) Initiative.
Studies show that nearly a quarter of the leading causes of deaths in hospitals happen to patients admitted at night or on weekends. Hamilton, a registered nurse and dean of graduate studies at the Wichita Falls, Texas-based institution, has been surveying dozens of nurses using institutional ethnography to better understand what the hospital work environment is like during “off peak” hours and the effect on patient care. Gretchen Gemeinhardt, Ph.D.., M.B.A., director of the Leadership Institute, has partnered with Hamilton on this effort.
Hamilton recently talked about her research at INQRI’s annual meeting at the Foundation in Princeton, N.J.: “What we’re finding is that many, many small troubles pile up during off-peak shifts. There is rarely one big crisis situation. It’s usually an accumulation of little barriers that keep nurses from doing their jobs as effectively as during peak times,” she says.
Fewer non-nursing staff on the weekends is one reason. The result is that, when nurses clock in, they may not have support staff to answer phones, handle administrative tasks, or retrieve necessary medical supplies. When a unit no longer has support to handle these tasks, nurses have to assume added responsibilities that remove them from direct patient care.
Running out of supplies is a common problem during off-peak shifts. One nurse told Hamilton that she needed tubing for the dialysis machine. Without an aide to track it down, she had to drive herself across town to get the supplies she needed. That meant one less nurse in the intensive care unit to care for patients, leaving more patients—as well as more administrative tasks—for the nurses left behind.
While that is a dramatic example, Hamilton says it is typical of what goes on in hospitals, both in Texas and across the country, on weekends. On a typical shift during off-peak hours, observers can see nurses answering phones, transporting patients, tracking down supplies, and even mopping floors on occasion.
Other activities reduced during off-peak hours include dietary and nutrition support, pharmacy and imaging services, physical therapy, patient teaching, and social services. Nurses tell Hamilton that these reductions in such important services make weekend stays non-productive, preventing them from effectively working to improve patient outcomes.
In addition, Hamilton’s research is showing that during off-peak hours, some nurses may be inexperienced and often without supervision; they have problems communicating with the doctors who sometimes fail to answer pages promptly; they have a harder time working as teams; and are often extremely sleep-deprived, which can lead to errors.
Hamilton and her team will complete their research by August 2010. She hopes the findings will help guide policy-makers as they debate the utility of nurse-patient ratio laws. Texas recently enacted a law that strengthens the role of nurse staffing committees working to ensure that all units in the hospital are fully staffed with nurses. Other states are considering similar legislation.
While these laws are a step in the right direction, Hamilton says staffing committees should be looking at both nurse-patient ratios, as well as whether there is enough ancillary support in the unit to allow nurses to do their jobs.
“There is more to this than how many patients per nurse; it also matters how much responsibility for non-nurse tasks a nurse has to assume,” she says. “At night, when you have five nurses and 10 patients but no clerk or aide, this is not necessarily equivalent to two patients per nurse during the day because at night there are other things that the nurse has to do besides take care of patients. When you have the nurse doing all of the work, you in effect don’t have the ratio the numbers might suggest.”
What has been most surprising to Hamilton in her interviews is how resigned nurses have become to working under these conditions. “There is a general feeling that it’s always been this way and an assumption that no one is going to fix it.” Hamilton hopes her study will change that perception.