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What's clear from the IOM report is that changing nurses' work environment and putting patient safety first is not for the faint of heart. Band-Aids won't do.

Nurses, who more than any single group are responsible for patient safety, have a new care plan in mind. It's a multipoint document written in their own hand through the Institute of Medicine to change the nursing work environment and focus on patient safety.

Reaction since its unveiling in November has been unequivocally positive, from the RNs instrumental in creating "Keeping Patients Safe: Transforming the Work Environment of Nurses," to the chief nursing officer of a large health network, a patient safety guru and others.

"We now have the research from the 1990s, which shows without a doubt that inadequate staffing, and that often is a problem of a poor work environment, does in fact affect patient safety," said Ada Sue Hinshaw, Ph.D., RN, dean of the University of Michigan School of Nursing and vice chair of the IOM committee.

What's clear from the report is that changing nurses' work environment and putting patient safety first is not for the faint of heart. Band-Aids won't do.

The IOM estimates that as many as 98,000 hospital patients die each year, not from injury or disease, but rather as a result of their care. Untold numbers survive adverse events, such as medication errors, with serious health effects: long-term disability and severe pain.

Such a toll doesn't rest solely on nurses' shoulders, but they and their assistants account for 54 percent of all health care providers.

"When people are hospitalized, in a nursing home, having a baby or learning to manage a chronic condition in their own homes-at some of their most vulnerable moments-nurses are the health care providers they are most likely to encounter, spend the greatest amount of time with and … depend on for their recovery," the IOM said.

It's against this backdrop that the Agency for Healthcare Research and Quality, a part of the U.S. Department of Health and Human Services, asked the independent IOM to look at nurses' work environment and how it must change to better protect patients.

The institute marshaled a committee of 18, eight of whom were RNs.

The panel concluded that hospital restructuring and redesign initiatives during about 20 years have "damaged trust between nursing staff and management … infrequently have involved nurses in decision-making pertaining to the redesign of their work, and have not employed practices that encourage the uptake and dissemination of knowledge throughout the organization."

System overhaul

The report calls for systemic changes in:

• Leadership and management, to strike a balance between cost-effective care and patient safety, "emphasizing safety to the same extent as productivity and financial goals." It's incumbent on leadership to foster trust between nurses and management, create the culture of a "learning organization" and involve workers in decision-making and work flow.
• Workforce deployment, to update decade-old staff-patient ratios in long-term care facilities, hospital intensive care units and elsewhere. California has taken the lead with its first-in-the-nation minimums for RN staffing across the breadth of hospitals, not just in trauma, coronary and other specialty units. Under workforce deployment, the committee stressed a commitment to orientation, mentoring, precepting and other education, among other things.
• Work design, to limit nurses' hours to 12 per shift in any 24-hour period and 60 per week. The committee looked at fatigue and remedies in the transportation industries and the military.
  

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