Path of change

Despite all the answers in "Keeping Patients Safe: Transforming the Work Environment of Nurses," one question remains: Will nursing organizations and health care as an industry bring the report to life?

Four of eight RNs who served on the 18-member Institute of Medicine committee that wrote the November report said in interviews they would like to see the panel's recommendations heeded, with a dual benefit.

The report is targeted to patient safety. "But it also solves and addresses our nursing shortage issues. The link between the nursing shortage and patient safety is definitely there. The solutions are the same," said Marilyn Chow, DNSc, RN, FAAN, Kaiser Permanente vice president of patient care.

"I would suggest that each health care organization carefully look at these recommendations and then assess … in terms of their ability to address and implement those recommendations," Chow said.

For the first time, the report presents data from the 1990s that link patient safety and staffing issues, said Ada Sue Hinshaw, Ph.D., RN, vice chair of the committee and dean of the University of Michigan School of Nursing.

The breadth of the panel, from a diverse group of RNs to physicians and experts in organizational psychology and safety-conscious industries such as trucking and aviation, lends credibility to the report. "It helps to control bias and … not look like a vested report from nursing itself," Hinshaw said.

Howard University women's health nurse Gwendylon Johnson, MA, RN, said she was impressed with the committee's inclusiveness and its emphasis on decision-making and direct care nursing. She pointed to the panel's call to empower nurses in patient flow "to control admissions and transfers so that staffing and patient care are pretty much in balance."

"I'm very hopeful," Johnson said. "I think organizations from the boardroom down to nursing direct care have a strong stake in making sure that the recommendations are implemented. It's important to note that it can't be done piecemeal. Everyone in the organization has a role."

Hinshaw, too, said she would like to see hospitals, long-term care facilities and nursing organizations digest the report, disseminate the findings and put them into practice, both voluntarily and by pushing legislation. The committee did not call for legislation, but Hinshaw said it's an idea she's heard since the report was issued to an audience that included executives from every major nursing organization. "There's going to need to be help from legislative processes to provide incentives. I would assume that's going to happen," she said.

If nursing organizations lobby to enact the report with the force of law, it could be as influential in patient safety as a 1986 report was when it became the basis of the federal Nursing Home Reform Act of 1987, said Charlene Harrington, RN, professor of sociology and nursing at the University of California, San Francisco, who specializes in long-term care issues.

"The problem is that the hospitals and nursing homes don't have any incentive" for costly patient safety measures such as adopting minimum staffing standards and limiting work hours to reduce fatigue-related errors, Harrington said. "The national nursing organizations need to try to build a coalition with other groups to try to get some legislation to adopt some of these things."

The Nursing Home Reform Act wouldn't have happened without such advocacy, she said.

"Nurses often want to have everything done on a voluntary basis, but at some point we have to realize that doesn't always work. If we really want to change the environment, some of these things have to be put into requirements," Harrington said.

Given the anti-regulatory climate in Washington, requirements probably will have to come through state legislatures or accrediting bodies, such as the Joint Commission on Accreditation of Healthcare Organizations, she said.

But whatever the path of change, Hinshaw said there has long been talk in patient-safety circles that "you need to change the work environment. But what about that? How do you get hold of that? Now, there's a whole report to tell them how to do it."

- Phil McPeck