In Good Hands
New IOM report underscores the role of nurses' work environment in protecting patient safety and advises systemic changes to catch—and prevent—errors

By Phil McPeck
January 29, 2004

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.

It's here, too, that the report said, "Other nursing work processes, such as medication administration, are often carried out in ways that are conducive to the commission of errors and without the support of newer technologies that can prevent errors in medication administration." Although charting is not intrinsically dangerous to patients, the report noted that nurses spend as much as 28 percent of their time documenting patient information and care.

• Organizational culture, to encourage reporting of errors, analysis and prevention. The report points to studies that say between 34 percent and 38 percent of medication errors occur in nursing roles, such as administering drugs.

"The committee wishes to underscore that none of these recommendations is 'less important,' " said the report, which was headed by Donald Steinwachs, Ph.D., chairman of the department of health policy and management at the Bloomberg School of Public Health, Johns Hopkins University in Baltimore.

But asked to prioritize the recommendations, two patient safety experts in separate interviews seized on the nursing shortage and especially the need to reduce the RN turnover rate to increase patient safety. Turnover often is a reflection of management, workforce deployment and work design.

"The whole IOM report is a continuing plea to the industry to understand that we do not have safe systems," said Lillee Gelinas, MSN, RN, vice president and chief nursing officer of VHA Inc., an Irving, Texas-based cooperative intent on operational and clinical best practices in its 2,200-plus community hospitals. The organization has network hospitals in every state except Nevada and Utah.

Richard Croteau, MD, was a patient safety expert long before it was a marquee issue and said the IOM committee's report is "a very strong movement in the right direction." For the past eight years, Croteau has been executive director for strategic initiates for the Joint Commission on Accreditation of Healthcare Organizations.

Role of retention

In a sign that Croteau and Gelinas are on target with their emphasis on staffing, the IOM committee called on direct care nurses to help identify causes of turnover and develop ways to retain RNs.

"I would put retention right near the top" in patient safety, Croteau said. "A very common factor in adverse events has to do with incompleteness of the orientation process. The more stable your staff, the less you have to rely on orientation in the first place," whether it is for new hires, RNs floating among units or temporary staff, he said.

In a broad section titled "Maximizing Workforce Capability," the committee recommended that management set aside a percentage of nursing payroll for orientation and education, particularly as new technology is introduced. It also advised an annual, individual educational development plan for each nurse and nurse assistant.

Gelinas, whose network encompasses 246,000 nurses-205,000 of them RNs-called hospitals "recruiting machines."

"They do a great job at recruiting. They do a poor job at retaining and that's where the costs are and that's where the patient safety issues are," she said. "Hospitals with higher turnover have more patient deaths and higher lengths of stay.

"For the most part in health care today, the cultures are cultures of cost-cutting because our reimbursement pressures have been so great. But we have to change … to a culture of retention."

Within her own network and its Tomorrow's Workforce Initiative, Gelinas said it was an eye-opener to discover that turnover of RNs with less than two years' experience was 45 percent to 55 percent. The nursing profession recognizes a figure nowhere near that, she said, which can be blamed on inconsistent reporting standards. Some facilities include retirements and promotions in turnover, but others do not, Gelinas said.

"Use of nurses from external agencies should be avoided," the IOM committee said, as it recommended establishing cross-trained float pools of staff RNs to deal with fluctuations in patient volume on units. It added that preceptors should be assigned to nurses, experienced or otherwise, who are practicing in areas new to them.

The committee also called for updating the 1990 federal nurse-patient ratios, especially for nursing homes where the requirement is only one licensed nurse at all times in a facility, regardless of patient census. At a minimum in nursing homes, the IOM committee backed one RN for every 32 patients, one licensed nurse for every 18 patients and one nurse assistant for every 8.5 patients. No federal standard exists for nurse assistants.

In hospital intensive care units, the report urged one RN for every two patients.

Croteau, however, said staff ratios are the one IOM report provision with which he disagrees. "The Joint Commission does not support the concept of predetermined ratios of caregiver to patients. Staffing is a lot more complex than that," he said.

Gelinas is of the same mind: "I do not believe in ratios," she said. "In a consensus of the nursing profession, nurse-patient ratios are not adequate to detail staffing. The two parameters as measures are nursing hours per patient day and skill mix, but not ratios."

The IOM committee also called for publicly accessible state and federal report cards on facilities, with information to include "standardized, case-mix-adjusted information on the average hours per patient day of RN, licensed and nurse assistant care."

"The point is this," Gelinas said: "Hospitals that are well-run, that have low turnover rates and healthier bottom lines, from the nurses' standpoint, are safer hospitals. I'm perplexed at why we don't accept the amount of evidence that's there."

The IOM summed up the evidence this way: "Over the last two decades … changes have been focused largely on increasing efficiency and have been undertaken in ways that have damaged trust between nursing staff and management … so that the intended results have not been achieved."

Speaking up

In a variety of ways, the report said, nurses have been hushed. Yet they are in a perfect position to determine staffing needs as well as to identify inefficiencies and practices that may contribute to medication and other errors. The committee said nurses rarely have, but should have, the authority to halt admissions or transfers to units when patient loads threaten to tax staff and test the limits of patient safety.

The IOM wants to reinvigorate nurse managers, whose numbers have fallen as financial pressures in health care have risen. It's not uncommon for a manager to oversee multiple units, a situation the report said "hampers nurses' ability to fix problems in their work environments that threaten patient safety."

A step up from nurse managers, the IOM said chief nursing officers should be on par with other administrators and that nursing must be part of the equation in executive decisions. It's then incumbent on leadership to create a culture of support for nurses, the report said.

The essence of patient safety lives in that culture.

Take medication errors, for instance. The IOM noted that nurses intercept 86 percent of medication errors. But with the right steps, that number can be better and there can be fewer errors to catch.

One step is limiting nurses' hours. "The work hours of a minority of nurses, in particular, are identified as a serious threat to the safety of patients," the report committee said. It recommended that states prohibit nurses from "patient care in any combination of scheduled shifts, mandatory overtime or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per seven-day period."

The trucking and airline industries have long recognized fatigue as a threat to safety and have widely accepted limits on work hours, said Hedy Cohen, RN, vice president of the independent Institute for Safe Medication Practices [www.ismp.org] in Huntingdon Valley, Pa.

Among other things, the institute publishes newsletters on medication errors, including one that is free of charge to RNs. The effect of fatigue on nurses is analogous to having one or two alcoholic drinks, Cohen said: "Your thought process and your coordination are decreased."

The IOM agreed: "The effects of fatigue include slowed reaction time, lapses of attention to detail, errors of omission, compromised problem-solving, reduced motivation and decreased energy for successful completion of required tasks."

Another step is for nurse managers with adequate resources to work with direct care nurses in areas where errors commonly occur: monitoring patients, transfers and patient hand-offs, complex processes and tasks that take nurses away from care. Locating and obtaining supplies, looking for personnel, doing redundant or unnecessary documentation and compensating for poor communication systems all detract from nurses' primary work and contribute to errors.

Cohen said technology offers relatively expensive safeguards, which she called a piece of the puzzle-not a panacea. For instance, bar code systems identify nurse, patient and medication and send up a red flag when they don't match.

The Institute for Safe Medication Practices concentrates on quick dissemination of information-warning of new, look-alike drugs-and practical processes that cost little more than a commitment to improve oral and written communication and to change habits, such as storing similarly packaged drugs together.

The institute also seeks to make nursing and administering medication more than a task. That goes back to training and the importance of a stable staff.

The key to reporting, Croteau said, is nursing leaders who are committed to improvement rather than "a bad apple, punitive kind of approach." He said it's crucial to reward people rather than punish them for reporting. It's equally important to recognize that the nurse who makes an error is a victim, not a perpetrator, he said.

"There are damn few people who go into work in the morning intending to do harm. They get trapped by faulty systems and that's what we need to understand."

Contact Phil McPeck at getpjm@aol.com