Nurses: Leaders in Improving Patient Care

    • June 24, 2010

The Problem. Experience and research alike teach us that hospital nurses need to spend as much time as possible with their patients.

Florence Nightingale may have been the first to describe what could be seen in "the experienced eye of a careful observing nurse, the daily, I had almost said hourly, changes which take place in patients." Such changes, she wrote in her 1860 Notes on Nursing, did not "come under the cognizance of the periodical medical visitor," and yet provided "a class of data from which to judge" appropriate treatment.

Almost 150 years later, in 2007, the U.S. Agency for Healthcare Research and Quality said the same thing, couched in the language of research: "Studies show that the more time nurses devote to patient care, the better the patient outcomes."

Unfortunately, the health care system today imposes barriers on a nurse's ability to devote adequate attention to patient care. According to a 2008 article ("A 36-Hospital Time and Motion Study: How Do Medical-Surgical Nurses Spend Their Time?") published in the Permanente Journal, "increased nurse workload and the growing nursing workforce shortage reduce the amount of nursing time available for patient care activities."

Programee Background. Linda Burnes Bolton, DrPH, MPH, MSN, BSN, has dedicated much of her professional life to changing that.

After a childhood spent in and out of hospitals, where she was treated for asthma, she understands better than most that nurses are healers. Nurses not only helped her handle asthma, they also influenced her worldview: "The individuals who touched my life the most were the nurses," she said. "They told me asthma would not impair me. They gave me hope and encouragement."

Burnes Bolton's dedication to nursing as a profession began at the bedside and advanced into national leadership. In 1968, while studying for her bachelor's degree in nursing, she also accepted her first nursing job, as an aide at Mesa Community Hospital in Mesa, Ariz.

By 1971, Burnes Bolton was a staff nurse at Cedars-Sinai Medical Center in Los Angeles, where she has spent the past 40 years in positions of increasing responsibility. She is currently the medical center's director of nursing research and development, and since 1996 has also served as vice president and chief nursing officer of Cedars-Sinai Health System & Research Institute.

Along the way, Burnes Bolton added educational credentials to her accomplishments, earning two master's degrees—in nursing and in public health—as well as a doctoral degree in public health, all from the University of California at Los Angeles (UCLA) School of Public Health.

Convinced that nurses could be both caring professionals and effective agents of change, Burnes Bolton has been a vocal advocate on their behalf, serving as president of the American Academy of Nursing and chair of the Academy's Workforce Commission. She is also a member of the national advisory council for the Joint Commission on Accreditation of Healthcare Organizations and vice chair of the Robert Wood Johnson Foundation (RWJF) Future of Nursing Initiative at the Institute of Medicine.

Nursing Technology: Problem or Solution? That unique combination of front-line, managerial and policy knowledge convinced Bolton that nurses would have to lead the effort to transform hospital nursing care and return nurses to their patients.

Fortunately, she has been joined in that conviction by other dedicated nursing professionals, including Marilyn Chow, DNSc, RN, FAAN, vice president of patient care services at Kaiser Permanente. According to Chow, "When the Institute of Medicine released its report To Err is Human in 2000, we began to understand that as nursing professionals, we had to do more than get more people into the nursing field."

At first, technology seemed to offer the greatest opportunity to overcome some of the obstacles that prevented nurses from spending quality time with patients. It did not prove quite that simple. "We came to realize that technology, which we thought was a great answer, was often a burden because no one had been involving nurses—the people who used the technology," says Burnes Bolton.

One example is 'smart pumps,' which are designed to automatically pump medication into a patient and give nurses timely feedback on dosage and patient response. The problem was that the pump database didn't distinguish among physiologies, such as whether the patient was a child or adult. As a result, says Burnes Bolton, "nurses had to compensate for the shortcoming, which took even more time."

Chow adds, "Nurses had to nurse the technology as opposed to nursing the patient. We created an oxymoron environment in which nurses had to focus away from patients because of the technology that was supposed to help them spend more time with patients."

Nurses Take the Lead. Such wrong turns highlighted the importance of putting nurses at the front and center of any effort to influence the environment in which they worked. With support from their professional associations, their own institutions and RWJF, Burnes Bolton, Chow and other nurse researchers and leaders began thinking about strategies to reconnect nurses and patients.

Burnes Bolton assumed leadership roles in two particularly significant RWJF initiatives:

  • Transforming Care at the Bedside, a national program that tested and spread hospital nursing strategies to improve the work environment and quality of care. Burnes Bolton chaired the national advisory committee for the program, which ran from 2003 through 2008.
  • The Technology Drill Down project, in which nurses at 25 acute care hospitals participated in a structured process for identifying technological solutions to nurse workflow problems. Burnes Bolton directed this project, which ran from 2004 through 2009. See Program Results Report for details.

Emerging results from a separate RWJF-funded "Time and Motion Study" informed Burnes Bolton's work on both projects. In this study, researchers at 36 hospitals used electronic monitoring devices to track the movements of 767 nurses and assess how they spent their time. They found that direct patient care activities accounted for less than one-fifth of nursing activities. See Program Results Report for details about the study.

A visible "mover and shaker" of nurse-led initiatives, Burnes Bolton is nothing if not passionate about her work. "This is really about making the nation a better place," she says. "It is about human caring in its most personal aspect—giving of oneself.

"My everyday job is vice president at Cedars Sinai. My career, or my work, is different: It is how I use my knowledge, skills and abilities to help...and how I translate what nursing does to other disciplines, creating environments that care and that touch people."

RWJF Perspective. RWJF has invested more than $150 million in nursing projects that address shortages and other issues related to the nursing profession. In 2002, RWJF designated nursing as one of its priority areas in its Building Human Capital portfolio. "We wanted to create a range of initiatives that would address the diverse challenges facing the field of nursing," said Susan Hassmiller, RWJF program officer.

"Linda's work helped us both shape our nursing strategy and execute it. We consider her leadership and involvement in three significant projects—Transforming Care at the Bedside, the Technology Drill Downs and the Time and Motion Study—as important contributions to our insights and learnings."

The admiration runs in both directions. RWJF provided "a systematic, organized approach that we built upon," says Burnes Bolton. Chow agreed, calling RWJF a "steady, honorable steward. They funded efforts like the Time and Motion Study and Technology Drill Downs to help us understand the problems. Then, they funded Transforming Care at the Bedside to help us fix the problems we identified. They had a cohesive strategy that made our work more effective."

Burnes Bolton notes that RWJF also created programs that advanced the careers of individual nurses, launching many into positions of leadership in research, policy and academic settings. "The RWJF Executive Nurse Fellows national program has helped the careers of a lot of nurses. The Partners Investing in Nursing's Future program involved nurses and brought in other foundations as well."

RWJF's current support for nursing focuses on improving the quality of patient care, building a strong capable health care workforce and furthering the evidence base that links to nursing quality of care.