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The push for what now is being termed "evidence-based
practice" began in the clinical areas of nursing
and has moved into how care is delivered. The groundbreaking
research by Knaus, Draper, Wagner and Zimmerman in 1986
that showed a correlation between collaboration among
nurses and physicians in the ICU and the lower incidence
of patient morbidity and mortality started the movement
to identify organizational issues that make a difference
in patient care outcomes.
Consider: In 1992, Baggs et al. studied the association
between interdisciplinary collaboration and patient
outcomes in an MICU. After controlling for severity,
the risk of negative outcomes (readmission or death)
was reduced from 16 percent when the nurse reported
no collaboration in the decision-making about patient
transfers out of the MICU, to 5 percent when there was
full collaboration.
In 1994, Aiken, Smith and Lake compared Medicare mortality
between 39 Magnet hospitals and 195 control hospitals.
When the data were adjusted for differences in predicted
mortality, the mortality rate in the Magnet hospitals
was 4.6 percent lower than in the control hospitals.
Also, in 1994, Shortell et al. studied 17,440 patients
from 42 ICUs and found that caregiver interaction was
significantly associated with lower risk-adjusted length
of stay, higher technical quality of care and greater
ability to meet family members' needs.
In 1999, Aiken et al. studied organization and outcomes
in inpatient AIDS care by looking at hospitals with
dedicated AIDS units, hospitals with scattered-bed AIDS
care and Magnet hospitals. The 30-day mortality was
60 percent lower in Magnet hospitals and 39 percent
lower in dedicated AIDS units. There also was a strong
association between organizational control of care by
bedside nurses and patient satisfaction.
Two studies by the American Nurses Association in 1997
and 2000 show that increased RN hours of care and increased
RN staffing mix both result in lower infection rates.
The Department of Health and Human Services' study on
nurse staffing and patient outcomes (released in February
2001 and highlighted in the May 30 issue of the New
England Journal of Medicine) showed strong and consistent
relationships between both level and mix of RN staffing
and negative patient outcomes such as UTIs, upper GI
bleeding, pneumonia, length of stay, shock and failure
to rescue.
Most recently, the results of a study by Clarke et
al. reported in the June issue of the American Journal
of Infection Control show that the likelihood of needlestick
injuries and near-misses to nurses are increased 50
percent to 200 percent in hospitals with poor organizational
climates and high workloads.
The evidence continues to mount. Studies consistently
show that three key elements are associated with improved
patient outcomes: staffing adequacy, support of nursing
care by hospital administration, and collaboration between
nurses and physicians.
Nurses have been building this evidence base for the
last 10 years, but only recently has increased attention
been paid to the results. One reason is the spotlight
on nurses as we become a scarce resource. The other
is the growing awareness that negative patient outcomes,
in addition to being bad for patients, also are bad
for health care facilities. Money and other resources
needed elsewhere must be diverted to fixing the problems
and often fighting or settling lawsuits; reputations
become tarnished when patient outcomes do not meet the
expectations of patients, insurers and providers.
Health care executives, patients and their significant
others, insurers and many other groups need to understand
the value of registered nurses. Our task is to make
sure that this evidence gets into their hands and is
translated into terms that each group understands.
Discuss this and other topics with your colleagues
at www.nurseweek.com/rnvillage.
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