The Problem. In an effort to contain rapidly rising health care costs, many U.S. hospitals have changed the way in which treatment and care are delivered to patients and the way nurses' work is organized and managed. Cost-cutting measures, such as employing fewer and less-experienced nurses, and working them longer hours, may be compromising quality of care, experts believe. How can hospitals address these systemic issues so that nurses can effectively deliver the care that patients deserve?
Grantee background. In Gainesville, Fla., where Linda Aiken grew up, local life centered on the University of Florida, and getting in was her "number one goal." Born in 1943, she was part of an era "when most women who went to college were planning to become either teachers or nurses. In retrospect, that's probably why I didn't think of med school. But it worked out better this way."
At a time when most nurses were still being trained in three-year hospital-sponsored diploma programs, the university offered an ambitious four-year nursing baccalaureate, and Aiken found herself being closely mentored by a group of medical professionals who emphasized the importance of evidence-based practice and careful research. They fostered what Aiken later described as a crop of promising young "troublemakers" intent on remaking the profession.
Her first job after graduating cum laude in 1964 was in the heart surgery unit at Shands University of Florida Hospital. After a year in the trenches, she went back for more training, getting her master's degree as a clinical nurse specialist in heart surgery. In 1967—now married, and the mother of two small children—she moved to the University of Missouri Medical Center, where she spent three more years "nursing the sickest patients in the ICU" and instructing student nurses in their care.
While at Missouri, Aiken began to get an uncomfortably up-close view of the contradictions and limits of hospital culture. No matter how dedicated an individual nurse was, or how many extra hours she was willing to work, it was clear to Aiken that real improvements in patient care would never come without profound institutional changes.
"I realized that there was something broken about the environment," Aiken says. "The environment makes it almost impossible to provide good nursing care—terrible communications, never enough staff. And as soon as you'd dream up a new solution, there'd be a budget cut. It was a constant process of putting band-aids on big problems."
Her experiences in the field pushed Aiken to broaden her understanding of the larger forces at work in the health care system. In 1970, when her husband took a job at the University of Texas at Austin, Aiken pursued a PhD degree in sociology, with a concentration in demography. After graduating in 1974, she landed a postdoctoral research fellowship at the University of Wisconsin at Madison. Her mentor at Madison was David Mechanic, PhD, who had received one of the first grants funded by the Robert Wood Johnson Foundation (RWJF). Since 2000, Mechanic has headed the Foundation's Investigator Awards in Health Policy Research program.
Founded just two years previously, RWJF was looking for new program officers, and Mechanic recommended Aiken, who became an early RWJF staffer—at the time one of only a handful of women and the only one with a background in nursing. It was a challenging career change with a steep institutional learning curve, but once again, Aiken found herself surrounded by mentors. She moved up through the ranks, becoming a vice president of the Foundation in 1981, a post she held until 1987.
Aiken's research training and clinical perspective positioned her to advocate persuasively for major new programs to improve the quality of nursing. In the early 1980s, she helped launch the Clinical Nurse Scholars Program, modeled on RWJF's Clinical Scholars Program for physicians, and the Teaching Nursing Home Program, designed in response to the exposure of widespread abuses in the nursing home industry.
Returning to academic life in 1988, the expertise she gained at RWJF readily translated into an endowed professorship at the University of Pennsylvania where she is the Claire M. Fagin Leadership Professor of Nursing, professor of sociology, and director of the Center for Health Outcomes and Policy Research. "I really got my education in health policy at RWJ," Aiken says.
Research on the culture of hospitals. In 1989, she set up the center to explore organizational effectiveness in health care with the potential to affect patient outcomes. One of the first large studies the center undertook, starting in 1991, was a national study of dedicated AIDS units to test her theories about the impact of hospital culture on nurses and patient care.
Aiken and her research team developed "a survey-based measure of the culture and context of care delivery" that was based on an earlier instrument developed by Marlene Kramer in the 1980s called the Nursing Work Index (NWI). It was designed to measure nurses' satisfaction with various aspects of their work.
In preparation for the national AIDS study, Aiken modified the NWI to create a new research instrument called the Revised Nursing Work Index (NWI-R), which would make it possible to empirically measure and describe the quality of the nursing work environment itself. With NWI-R, nurses rate the culture of their own hospitals and the context within which they deliver care. Survey responses are then aggregated to create a map of hospital work environments. (Over time, subscales of the NWI-R were refined and five of the subscales became known as the Practice Environment Scale, which the National Quality Forum endorsed as a nurse-sensitive measure of hospital quality.
Outcomes of the research. One of the most important outcomes of the NWI-R study was Aiken's realization that "we needed a different research strategy that did not involve recruiting hospitals." In the center's next big study, funded by the NIH Institute for Nursing Research and launched in 1996, "we used the same survey instrument but instead of recruiting hospitals, we surveyed 50 percent of all nurses licensed to practice in Pennsylvania and asked them to provide the names of their employing hospitals."
With this innovation, they were able to "create a unique database on all 210 hospitals in Pennsylvania without having to recruit any hospitals directly," adding to the information nurses provided about these hospitals by linking their nurse survey data with patient discharge outcomes reported to a state agency.
Over the last decade, Aiken and other researchers have made rich use of this mother lode of data to pinpoint crucial interactions between nurses and their patients and other medical staff—from monitoring vital signs and managing pain to ensuring that precautions against infection are scrupulously followed. They have been able to map out the consequences of understaffing, budget cutting, extended shifts and nurse burnout. Study after study, says Aiken, "shows that the greatest single major change a hospital could make [to ensure quality care] would be to improve the nursing environment."
Role of Aiken's Investigator Award. In 1998, Aiken received an award from the RWJF Investigator Awards in Health Policy Research program. Her project focused on how aspects of human resource allocation and hospital organization might be modified or shaped to yield better outcomes given financial constraints.
Aiken credits the Investigator Award with helping her to move her "program of research to the next levels of national and international impact." In the course of her project, she learned how to translate research findings for general and policy audiences, and to "craft a more succinct message than is generally the case in scientific writing—and the impact of our publications increased significantly as a result." The grant also helped make it possible over time to greatly expand the scope of the center's research efforts.
Findings. Among the findings made possible by Aiken's work cross-referencing data from nurses with patient outcomes:
- "Patients cared for on units that nurses characterized as having adequate staff, good administrative support for nursing care, and good relations between doctors and nurses were more than twice as likely as other patients to report high satisfaction with their care, and their nurses reported significantly lower burnout." Vahey DC et al. "Nurse Burnout and Patient Satisfaction." Medical Care, 42(2, supplement): 2004.
- "The likelihood of making an error increased with longer work hours and was three times higher when nurses worked shifts lasting 12.5 hours or more." Rogers AE. et al. "The Working Hours of Hospital Staff Nurses and Patient Safety." Health Affairs, 23(4): 2004.
- "In hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates [death following the occurrence of an adverse event during hospitalization]." Aiken L et al. "Educational Levels of Hospital Nurses and Surgical Patient Mortality," Journal of the American Medical Association, 290(12): 2003.
- The odds of dying following common surgical procedures are reduced by 19 percent in environments that nurses rate better for nursing practice. Aiken L et al. "Effects of Hospital Care Environment on Patient Mortality and Nurse Outcomes, Journal of Nursing Administration, 38(5): 2008.
Moving forward. Aiken believes the accumulation of research has changed the nature of the debate about nursing shortages and their consequences, and about the outcomes of hospital restructuring.
As evidence she points to the Institute of Medicine's study of the nurse practice environment and patient safety presented in Keeping Patients Safe: Transforming the Work Environment of Nurses (2004).
Aiken and her team are now extending their research on nursing and quality of hospital care to 12 countries in Europe, as well as to other regions of the world, to gain fresh insight into the interplay of nurses and the quality of care and to help frame the next set of research questions.
"Most countries spend less and get better results than we do," Aiken says. "How do they deploy their workforce to achieve these better outcomes at lower cost?" One answer is they don't shorten hospital stays.
"The U.S. keeps trying to reduce costs by reducing the length of a hospital stay. Remember in the old days, how you came in the day before surgery to be prepped? Now everything is concentrated in one high intensity day." She notes that this requires a higher ratio of nurses to patients. "There's a 1 to 5 nurse-to-patient ratio in the U.S.; in the U.K., nurses take care of 10 patients." Shortening patient stays is a false economy, says Aiken, because "to keep care safe, we have to have more and more nurses."
Yet another issue that threatens to undermine the quality of American nursing is one close to Aiken's heart—the shortage of senior nurses qualified to teach the next generation. Not only is this bad for patients in hospital, she says, but "unless the majority of nurses get baccalaureates, and a significant number go on and get masters, there won't be sufficient faculty to meet the demand for skilled nurses in the future."
My main challenge," Aiken says, "is to get people to understand that all medical issues"—from quality of care, to broad-based health reform—"involve nursing."
RWJF Perspective. "One of the important criteria for selecting investigators is the likelihood that their work will inform health policy," says Lori Melichar, PhD, RWJF director.
"Equally important to being selected is the promise of the investigator's proposal to rejuvenate the field of health policy research by asking innovative questions, applying innovative frameworks and using innovative methods."