Nurse environment still seen as at-risk
Some progress made since IOM report
Five years ago, the Institute of Medicine (IOM) warned that patient safety relies on a safe nursing work environment, including adequate staffing, limiting shifts to no more than 12 hours, and a better organizational climate.
Today, although strides have been made, the risks identified by the IOM remain, according to an IOM panel member and nurse advocates.
"In general, [hospital administrators] are beginning to recognize that creating an attractive, sustainable environment is important," says panel member Edward O'Neil, PhD, professor of medicine and nursing at the University of California-San Francisco, where he is director of the Center for the Health Professions. Yet if the nursing shortage begins to ease with a rise in enrollment in nursing schools, hospitals may become less committed to making necessary changes, he cautions.
The IOM panel was primarily concerned about creating a "culture of safety" for patient safety, with good communication among health professionals, nonhierarchal decision-making, and blame-free reporting of near-misses as well as errors.
"[T]he typical work environment of nurses is characterized by many serious threats to patient safety. These threats are found in all four of the basic components of all organizations organizational management practices, work force deployment practices, work design, and organizational culture," the panel said in the report, Keeping Patients Safe: Transforming the Work Environment of Nurses.
Inadequate staffing, fatigued nurses and other organizational problems also affect worker safety, says Linda Aiken, PhD, FAAN, FRCN, RN, professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia.
"We have growing scientific evidence about what the hazards are for errors that affect both staff and patients, but we haven't seen a dramatic change in the safety of the practice environment," she says. "There's no evidence that the work environment of nurses has been transformed in the majority of hospitals.
"One of our recent studies shows that despite the whole series of Institute of Medicine reports on patient safety, the burnout levels among nurses are just as great as they were before 1999 when the [first] IOM reports came out," she says.
Meanwhile, failure to protect nurses from injury worsens the problems, says Bill Borwegen, MPH, director of health and safety for the Service Employees International Union (SEIU) in Washing-ton, DC. He notes that an estimated 12% of nurses leave the profession each year because of back injuries roughly the same number needed to fill the nursing shortage.
"We could solve the nursing shortage tomorrow if we retained the skilled nurses we already have in the workplace rather than crippling them," he says. "We have a solution to the problem and it's being ignored.
"The lack of a safety culture in health care is really at the root of all of this. I'd like say we're making improvements, but it's hard to measure," Borwegen says.
Magnet hospitals show better outcomes
Here's one positive sign of change: Some 288 hospitals have attained "magnet" status that requires them to meet standards that call for staffing models that ensure adequate experienced nurses, policies that encourage communication and nurse involvement in decision making and leadership.
About an equal number of hospitals are currently working toward magnet status, says Cyndy Hagstrom, RN, MSN, BC, outcomes analyst with the Magnet Recognition Program of the American Nurses Credentialing Center in Silver Spring, MD. The ANCC is a subsidiary of the American Nurses Association.
"That's about a tenth of the acute care hospitals in the United States," including those that are in the application process, says Hagstrom. She notes that many other hospitals seek to achieve the same goals but don't apply for magnet status.
The explosion of interest in magnet status shows that hospitals are interested in engaging their nurses and involving them in improvements, says Bobbi Kimball, RN, MBA, a health care management consultant who previously worked as a chief nursing officer and co-authored a Robert Wood Johnson report on the nursing shortage.
"The magnet nursing model promotes a professional work environment," she says. "Hospitals and hospital systems have figured out [that nursing] is a valuable asset and they need to protect it."
In studies comparing the original magnet with nonmagnet hospitals, Aiken found lower patient mortality in the magnet facilities even after adjusting for staffing.1 In other studies, she found the magnet qualities led to less burnout among nurses, greater patient satisfaction, and even fewer needlesticks.
"There's a lot of evidence that this blueprint that these hospitals are trying to implement actually creates a safer environment," she says. Hospitals also face increasing regulatory pressure to provide minimum staffing. California was the first to set specific nurse-patient ratios, but 10 other states including Illinois, Washington, and Oregon have laws or regulations that address nurse staffing. While having adequate staff is critical, ratios will not solve the problems outline by the IOM, says O'Neil. The system of care using a team approach and creating a culture of safety is more important than a number, he says.
Nurses worry about health and safety
The nurses themselves do not necessarily believe that their work environment has improved. In a 2007 American Nurses Association survey of 1,039 nurses, about 90% of the respondents said health and safety concerns would be a determinant in their decision about whether or not to stay in the profession.
"Nurses are still concerned about the conditions of their workplace," says Nancy Hughes, RN, MS, director of the ANA's Center for Occupational and Environmental Health in Silver Spring, MD.
For example, 58% of nurses said they did not feel they had an opportunity to influence the selection of sharps safety devices. The U.S. Occupational Safety and Health Administration requires hospitals to include frontline health care workers in evaluation and selection of devices.
Nurses also are worried about patient handling and violence, Hughes says. "We have a long way to go to make [the workplace] safe," she says.
Quoting ANA president Rebecca Patton, Hughes says, "We don't have a shortage of nurses. We have a shortage of places nurses want to work."
(Editor's note: The IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses, is available at www.iom.edu/?id=19376.)
Reference
1. Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care 1994; 32:771-787.
Five years ago, the Institute of Medicine (IOM) warned that patient safety relies on a safe nursing work environment, including adequate staffing, limiting shifts to no more than 12 hours, and a better organizational climate.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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