INR Features

Our Health care system is riddled with quality problems, with as many as 98,000 hospitalized Americans dying each year from medical errors-a figure that dwarfs those who die from car accidents, breast cancer or AIDs. This astounding estimate from the Institute of Medicine (IOM, 199) was recently affirmed by clinicians on the front lines. Over a third of practicing doctors reported that they experienced an error in their own care or that of a family member, and 18 percent said that such an error had serious consequences for patients including death, disability or sever pain (Blendon et al, 2002).

Blaming nurses and other clinicians for these errors or asking them to just try harder to avoid mistakes, will not fix this pervasive problem. These errors are occurring in the hands of health professionals trying to do their best, but working within faulty systems that do not support them in providing the highest quality patient care. In fact, a number of safety studies estimate that the majority of errors-70 to 90 percent or more-occur from system failures rather than as a result of individual mistakes. (Reason, 1997).

Efforts to fix the nation's severe quality problem must simultaneously occur on a number of levels to be successful, according to leading quality expert Don Berwick, president of the Institute for Healthcare Improvement (IHI). These levels include the clinician-patient; health care team; health care organization; and at the level of the external policy/regulatory environment. The IOM report Keeping Patients Safe largely focuses on ways to enhance quality at the health care organizational level in hospitals, nursing homes, and clinical practices.

The report calls upon nursing leaders to focus their attention on enacting system reforms within these institutions, and specifically to move quickly to transform nursing work environments to enhance patient safety. Nurses are extremely well positioned to improve patient safety because they represent the largest number of workers in our nation's health care system, but more importantly, because of nursing's critical role in providing ongoing surveillance of patients.

Given the goals of nursing surveillance---identification of potential adverse events and early detection of patients, going downhill, followed by interventions to rescue and restore the patient to health-nurses are often described as the front line of patient defense or the sharp end of the health system. Safety studies support the key role of nurses in ensuring patient safety, with one study showing that nurses were responsible for intercepting 86 percent of medication errors made by doctors, pharmacists and other nurses (Leape et al, 1995).

The IOM report, Keeping Patients Safe, provides a vision and a blueprint for ANA/INA in our efforts to transform the nursing work environment to enhance patient safety. Ann Greiner authored Transforming Nursing Work Environments to Enhance Patient Safety and Quality: What CMAs and Nursing Leaders Can Do. The publication of this booklet marks the beginning of a series of documents that the Center for American Nurses developed to support Constituent Member Associations (such as the Iowa Nurses Association) in their efforts to help nurses enhance their professional lives, and to promote positive work-related experiences. The Iowa Nurses Association members affirmed two resolutions during the 2004 convention related to the work environment for nurses. INA is positioned to initiate efforts to partner with other organizations committed to making changes in nursing work environments to improve patient safety and quality.

The external and internal challenges that many health care organizations (HCOs) have experienced over the last two decades-including payment changes as a result of managed care and Medicare policy, numerous mergers and acquisitions, a rapidly expanding knowledge base, among others-have had a significant, and in some cases damaging effect on nursing work and working environments. The IOM report concludes that some of these changes have had profound implications for patient safety.

The changes that have most directly affected nursing work include:

• Patients are sicker and leave institutions quicker-they are more severely ill than in the past, while at the same time hospital length of stays have declined;
• Nursing jobs have been restructured to reduce costs, including substitution of less skilled staff for bedside nurses;
• More frequent turnover of patients, which increases workload for nurses;
• High turnover of nursing staff, which results in employees who are less familiar with work processes;
• Shifts longer than 8 hours in both hospitals and nursing homes, both out of nursing staff desire to increase compensation and have more scheduling flexibility, and as a result of employers mandating overtime;
• More interruptions and paperwork to meet insurance and regulatory requirements, as well as administrative and clinical requirements of health care organizations;
• An expanding array of treatments, interventions and drug therapies that are being introduced at an ever increasing pace.

Keeping Patients Safe identifies four major threats or underlying causes that adversely affect patient safety within hospitals, nursing homes and ambulatory settings that are related to the changes detailed previously. These include issues related to:

1) Work design (what people do) and physical work environments;
2) Workforce capacity or how the workforce is deployed;
3) The safety culture of heath care organizations, e.g. amount of vigilance related to detecting and redressing errors; and
4) Management practices and leadership.

How the Iowa Nurses Association and Nursing leaders Can Respond

There is no one silver bullet recommendation in the IOM report to transform nursing work environments. Instead, the IOM committee argues that this multi-faceted problem of patient safety within health care organizations (HCOs) requires a multi-pronged solution. Most of the report's 18 recommendations focus on health care institutions, but there are also recommendations that target regulatory bodies, federal agencies and other organizations because of the way their policies shape the nursing work environment.

Human beings are fallible, but the major contribution to errors is not the human factor but rather workplace practices, procedures, techniques and devices that are overly complex, unreliable, or unsafe in some other way. The IOM report focuses particular attention on addressing the following work design issues, including long work hours that cause fatigue and can lead to quality problems; nursing processes, such as medication administration and handwashing, with multiple features that can contribute to errors; and inefficient processes, including documentation, that keeps nurses away from performing patient surveillance.

Nursing staffing levels, the competency of nurses, and the extent to which health professionals and other workers collaborate all affect patient safety and quality. The IOM report focuses particular attention on: nurse staffing that is uneven and in some cases too low, posing risks to patient safety; insufficient organizational support for nurses to incorporate new knowledge and technologies into their practices, which furthers the gap between what we know to be good care and the care actually delivered; and inconsistencies within and across HCOs in terms of interprofessional collaboration.

Improving patient safety requires more than well-designed work processes, adequate staff levels, and staff who are well prepared to provide evidence-based care in an ever changing and increasingly complex system. Organizations must also be highly vigilant with respect to identifying potential errors, and prepared to analyze and redress them when they do occur-dedicating the staff, resources, and training to make this vigilance a reality. While such "cultures of safety" do exist in some safety-conscious industries and in some health care organizations, the culture of most HCOs is often based on an unspoken belief that clinical perfection is an attainable goal, and that errors are due to individual carelessness, incompetency, poor decisions, or worse. The broader regulatory and malpractice environment reinforces this dominant culture by emphasizing individual rather than system errors. To counter theses pervasive norms, the IOM report recommends specific ways that HCOs can create and sustain a culture of safety, proposes some reforms for the National Council of Sate Boards of Nursing, and recommends that Congress provide HCOs with peer review protection as it relates to patient safety and quality improvement (QI) activities.

Leadership and management are key to the changes required to create a nursing work environment that enhances patient safety, including comprehensive policies and practices to transform the ways nurses work and their physical workspace, ways to enhance the capacity of the nursing workforce, and approaches to instilling a culture of safety that permeates all aspects of an organization. However, recent changes with in and outside of HCOs may have diminished both nursing leadership and the ranks of nursing managers in important ways. First, nursing executives have taken on the responsibility for a wider range of staff and services within HCOs, e.g., radiology departments, outpatient services, emergency departments (Gelinas and Manthey, 1977) resulting in some cases to less direct representation of nurses and their issues at both institutional and policy levels. Furthermore, the ranks of nursing managers have been thinned as part of redesign efforts, and nursing managers have been asked to manage multiple units and staff outside of nursing, resulting in less direct management support and clinical leadership for staff nurses (Sovie and Jawad, 2001).

Health care organizations are faced with challenges on multiple fronts, including workforce shortages, competition from specialty hospitals, rising malpractice insurance rates, increasing requirements for quality reporting, among other challenges. Consequently, some leaders may not put transforming the nursing work environment on their top list of priorities. The Iowa Nurses Association can make it clear why such a decision would be a mistake. In fact, efforts to enhance patient safety and quality by focusing on the nursing work environment may actually help HCOs respond to many of these challenges by improving staff satisfaction and retention, furthering an organization's competitive position, and potentially even reducing malpractice claims.

Finally, the members of the Iowa Nurses Association resolved to partner with others who are committed to enhancing patient safety-including other professional associations such as the Iowa Organization of Nurse Executives, the Iowa Board of Nursing, the education and research community at the state and local levels, and perhaps the state department of health to advance the report's vision for a transformed nursing work environment.

Few documents offer such a comprehensive blueprint to simultaneously improve patient care and enhance the satisfaction of nurses with their work and professional calling. The Center for American Nurses is committed to supporting INA as we work to make this blueprint a reality. It is certainly an effort worthy of pursuit.

References

1. IOM.2000.To Err is Human: Building a Safer Health System. Washington DC: National Academy Press.
2. Blendon R., et al. 2002. Views of practicing physicians and the public on medical errors. The New England Jounal of Medicine,347(24):1933-1940.
3. Reason. 1997. Managing Risk of Organizational Accidents. Burlington, VT:Ashgate Publishing Complany.
4. Leape L. et al. 1995. Systems analysis of adverse drug events. Journal of the American Medical Association. 274(1):35-43.
5. Gelinas L, Manthey M. 1997. The impact of organizational ediesign on nurse executive leadership. Journal of Nursing Administration. 27 (10):35-42.
6. Sovie M. Jawad A. 2001. hospital restructuring and its impact on outcomes. Journal of Nursing Administration. 31(12):588-600.
7. Greiner A.2004. Transforming Nursing Work Environments to Enhance Patient Safety and Quality: What CMAs and Nursing Leaders Can Do.Washington DC: Center for American Nurses.

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