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Nursing is focus of patient safety

One researcher says nurses and staffing ratio play a significant part in the quality of care.

Published February 10, 2004

Linda Aiken, Ph.D, one of the featured speakers at the recent national conference at the University of Florida on "Nursing and the Future of Health Care," says the oft-reported nursing shortage is not so much about numbers of nurses as it is about facilities' unwillingness to hire enough of them. Aiken, a professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, studies patient outcomes at hospitals in the United States, Canada and Europe and what makes a difference in getting people well.

Here are some of her insights:

Q: Do we have a shortage of nurses?

We have more nurses than we've ever had before. But it's easier to blame the shortage of nurses than it is to solve the problems in the health care industry. We have a perceived shortage because hospitals have not budgeted enough positions. The average patient is sicker than they used to be. Shorter lengths of stay create this short cycle of admission and discharge that falls on nurses. Looking at the early '80s to the mid '90s, nationally nurses have declined by 7 percent (based on staffing at every facility). In some states it's been as much as 25 percent.

Q: Isn't it a given that if you have too few nurses you will have lower quality care?

There is now increased interest in trying to improve patient safety (at hospitals). An Institute of Medicine report found that medical errors are prevalent in our health care system and among the five main causes of death in the United States. Most efforts (to reduce errors) have not recognized the important role nurses play - the link between understaffing and problems in care. About two-thirds of nurses say their hospitals don't have sufficient numbers of nurses. Still, we find hospitals, when they get into trouble financially, reducing the number of nurses.

So how do you keep nurses from becoming a line item to be cut?

Our research program has been trying to build an irrefutable data base that links nurse staffing and mortality rate. Journal of the American Medical Association published that for every patient added to the workload of a nurse the mortality following surgical procedures increases 7 percent. There is a 31 percent difference in mortality between hospitals where nurses care for eight patients compared to hospitals where nurses take care of four.

Q: Those patients aren't dying because of nursing mistakes.

No. (Nurses) are the surveillance system. Most errors detected in hospitals are detected by a nurse, about 85 percent. One of the things they bring to care is the ability to assess a patient's condition and to separate important signs...from unimportant signs.

Q: What factors impact that surveillance system?

One of the things is how many nurses there are. The second thing is the education of nurses at the bedside. (Level of) education is a factor in good outcomes for patients. Some hospitals have no nurses with a baccalaureate degree and some have over 75 percent. Every 10 percent increase in (that type of degree) results in a 5 percent decrease in mortality. We think that it has to do with clinical judgment, the ability to distinguish....something that is potentially dangerous. The second thing is that....they have to be able to mobilize the resources of the hospital, to have good relations with physicians.

Q: What are other factors impacting nursing care?

Impossible jobs lead to burnout and high turnover. They are spending an inordinate amount of time on things that don't require the expertise of nurses: maintaining a clean environment, delivering and clearing food trays, transporting patients around the hospital. These things could be done by other people...or systems. Hospitals are extremely slow in adopting these technologies. They still use labor where other industries long ago realized they don't need labor (and have switched to computerization).

Q: What can a patient do?

Patients should demand they have a nurse and that their family knows how to get hold of the nurse. The nurse is responsible for their care and an advocate for them. There's an accreditation for nursing excellence for hospitals. It's a peer review process called Magnet Recognition Program. ...It requires 14 standards of nursing excellence, from adequate staffing to nurses' qualifications. Consumers need to ask many more questions about their hospitals. Consumers can influence doctors to become more informed about nurses (to also make them) advocates.

Q: What do you see for the future?

Renewed attention on patient safety is going to bring nursing into the center of the discussion. We're on the verge of trying to fix some of these issues. California has passed mandated nurse staffing ratios in its hospitals. A number of other states are considering this. (Florida lawmakers considered a version in 2002 and 2003 but took no action.) If initiative (by hospitals) is not forthcoming, then policymakers are going to step in.

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