Yesterday I wrote a diary about two of the articles on improving American hospitals in
Newsweek magazine -
Innovative Hospitals: Face Mistakes; Feed Real Food. Today I want to focus on the other story that really caught my eye, about improving conditions for nurses and how it saved money and improved patient outcomes.
To me, it is a no-brainer that nurses are a crtical element in good hospital care - perhaps THE most critical element. They are the ones who spend most of the time with a patient, and they are the ones who will notice (or not) if a patient begins to decline. Still, having numbers and data is a big help to convincing skeptics.
So here it is: Improving working conditions for nurses saves money and saves lives.
Here's an article from USA Today in 2001 on
working conditions for nurses:
The nurses are out on the picket line because the hospitals have cut staff, often forcing nurses to work double shifts caring for severely ill patients, says Susan Bianchi-Sand, director of the United American Nurses (UAN), which represents the nurses in Youngstown and Minneapolis. The same dangerous working conditions drove the Brockton nurses to strike, says David Schildmeier at the Canton-based Massachusetts Nurses Association.
Some experts warn that the strikes represent a larger problem, one that affects hospitals nationwide.
Linda Aiken, a researcher at the University of Pennsylvania, says many hospital nurses in the USA are burned out because they're working longer hours, and with less help.
"You have tired nurses working in critical situations," says Linda Warino, a striking Youngstown nurse. She says Forum Health hospitals often requires nurses to work four to eight hours on top of a normal shift, bringing them up to a total of 16 hours straight. "I think it lays the groundwork for errors," she says.
These risks aren't just anecdotal: consider this paper in JAMA from 2002:
Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Satisfaction by Aiken et al. as discussed in this commentary from JournalWatch:
Eighty percent of hospitals had patient-to-nurse ratios from 5:1 to 7:1. Most patients and nurses came from high-tech hospitals (as defined by open-heart surgery capability); 23% of surveyed patient records showed major complications, and 2% of patients died within 30 days after admission. Forty-three percent of nurses had high burnout scores and low job-satisfaction scores. There were significant associations between patient-to-nurse ratio and both likelihood of burnout and risk for surgical mortality; each increase of 1 patient in the staffing ratio increased likelihood of nurse burnout by 23% and risk for patient mortality by 7%. The authors calculated that an increase (worsening) in patient-to-nurse ratios from 4:1 to 8:1 would result in 5 excess deaths per 1000 patients.
Another study on nurse staffing talks about poor satisfaction for nurses and that lack of nursing staff is a factor in hospital acquired infections and other adverse outcomes.
In hospitals with high RN staffing, medical patients had lower rates of five adverse patient outcomes (UTIs, pneumonia, shock, upper gastrointestinal bleeding, and longer hospital stay) than patients in hospitals with low RN staffing.C
* Major surgery patients in hospitals with high RN staffing had lower rates of two patient outcomes (UTIs and failure to rescue).
* Higher rates of RN staffing were associated with a 3- to 12-percent reduction in adverse outcomes, depending on the outcome.
* Higher staffing at all levels of nursing was associated with a 2- to 25-percent reduction in adverse outcomes, depending on the outcome.
It doesn't have to be this way. And to prove it, the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement have been giving grants to give hospitals a chance to try the experiment of improving conditions for better nursing.
Newsweek's article focuses on the University of Pittsburg Medical Center, where they've made several changes to improve the environment for nursing,
Even on a hectic day, things seem to be under control. There's a sense of energy rather than panic. "I truly love coming to work," says medical-cardiology nurse Cynthia Hostetler, 51.
It is a sad state of affairs that that is a newsworthy or remarkable quote from a nurse.
The true shame is that hospital nursing doesn't need to be in a state of crisis. As UPMC Shadyside shows, it's possible to get things right. And no person takes greater credit for that success than Tami Merryman, UPMC's vice president for (get this) quality improvement and innovation. A nurse herself, Merryman knows the convoluted procedures that typically bog nurses down. So nine years ago, when she became chief nursing officer at Shadyside, she started experimenting with solutions.
Early on, she zeroed in on the time nurses spend running to central supply cabinets. "In a year, nurses on the average unit walk the circumfrence of the globe," she says. So she suggested keeping basics like gauze and bedpans in patients' rooms. This simple fix saved nurses on a single ward more than 700 trips a week.
To hear Merryman tell it, these reforms were common sense. Still, they were so forward-thinking that, in 2003, Shadyside became one of just three hospitals selected to participate in a new program called Transforming Care at the Bedside (TCAB), a joint initiative of the Robert Wood Johnson Foundation and the Institute for Healthcare Improvement. The mission: to boost nurse retention by improving teamwork and eliminating inefficiencies, such as unnecssary paperwork, that divert nurses from direct patient care.
Theyve also instituted rapid response teams that a family can summon if they are concerned about their loved one and the regular nurse isn't available. This helps the family, prevents needless delays, and also helps the nurses, giving them a safety net if they have several urgent issues at once.
Making people happier is lovely and all, but we know how much policymakers love to watch the financials. So is there a financial impact from these changes? Is coddling nurses sending costs through the roof?
At all 10, nurse satisfaction is way up, overtime is down and turnover of RNs has plummetted from an average of 15 percent a year in 2003 to 4 percent today. Equally important, the average amount of time nurses spend in direct patient care has risen from 40 percent of their shift to 52 percent, leading to fewer patient falls, fewer bedsores, and fewer failures to rescue patients from life-threatening complicaions.
Nurses are really the key to good hospital care, and I hope this article means we'll see better conditions for good nursing. Every time I hear that there is a nursing shortage, and thus that we need to import nurses or train nurses, I wonder why our society believes in the free market everywhere except in labor shortages. Training more nurses won't get us anywhere if they leave the field in just a few years. There is a reservoir of already trained, experienced nurses who felt they had to leave the field because they couldn't stand the working conditions. Let's entice them back with a chance to do good work in settings that appreciate them and truly let them care for their patients to the best of their training. It's important for all of us to turn this around.