Nurses’ Work Environments: What a Difference a Decade Makes, or Does It?

By Debra Wood, RN, contributor

April 4, 2014 - The Institute of Medicine called for transforming the nursing work environment to keep patients safe in 2004. Just how much better is the workplace today? According to a recent report from the Robert Wood Johnson Foundation, gains have been made but more work is needed.

Patricia Starck: Improvements still needed in nurses’ work environments.
Patricia L. Starck, PhD, RN, FAAN, said healthcare leaders need to continue working on improving all aspects of the nurse environment.

“We have made definite progress, but we are not at perfection,” agreed Patricia L. Starck, PhD, RN, FAAN, dean of the school of nursing and senior vice president for interprofessional education at The University of Texas Health Science Center at Houston (UTHealth).

The Institute of Medicine’s (IOM’s) 2004 report, Keeping Patients Safe: Transforming the Work Environment of Nurses, described the typical environment as one “characterized by many serious threats to patient safety.” It called for fundamental changes in how the workforce is deployed, in work processes designed, and in the leadership structure and culture.

“Ten years ago, there was a lot of interest and people came together,” said Maryjoan D. Ladden, PhD, RN, FAAN, senior program officer for the Robert Wood Johnson Foundation (RWJF). “We wanted to take a look and see what the progress has been and raise the important issue of care within acute-care institutions and others.”

Maryjoan Ladden: Use report to improve nurses’ work environments.
Maryjoan D. Ladden, PhD, RN, FAAN, hopes people will use the new report to make further improvements in the nurse work environment.

Adverse events still cause patients harm. A 2010 report from the U.S. Department of Health and Human Services found that 27 percent of Medicare beneficiaries were harmed during their hospital stay. A review by physicians deemed 44 percent clearly or likely preventable.

“This is an enormous issue for all of us,” Ladden said. “I think we were surprised that some things had happened but discouraged there were some issues that needed to be addressed.”

Steps toward further improvements

Ladden and colleagues came up with three strategies professionals in the practice and academic settings could work on now to improve the nurse work environment:

1. Ensure adequate staffing

The RWJF report found institutional and state policy makers have actively pursued adequate nurse staffing, despite knowing how many patients per nurse is ideal. They acknowledged the controversy surrounding adequate staffing persists.

“We believe staffing is one issue and a very important issue, because the more time nurses can spend with patients, understanding the needs and communicating, we will all be better served,” Ladden said. “When you have a lot of patients because of poor staffing, there isn’t time to do that.”

California adopted nurse-to-patient ratios, but the authors suggested it is not a panacea for improving quality and safety.

“There is some data but not overwhelming data that [ratios] are the best solution,” Ladden said.

Other states have directed hospitals to publicly disclose staffing plans or establish committees to oversee staffing.

The RWJF authors did indicate a deeper understanding of the need to increase nurses’ education level.

Sheila Burke and RWJF report encourage more nurse education.
Sheila Burke, RN, MSN, MBA, DNP(c), encourages nurses to get more education to prepare for future opportunities.

“The higher educated the nurses are, the better the patient outcomes,” said Sheila Burke, RN, MSN, MBA, DNP(c), dean of Kaplan University School of Nursing. “There’s a national movement to focus on competencies and make sure education results in people who are competent practitioners.”

Additionally, she said evidence is finding better outcomes when nurses have balance in their lives. Limiting hours, challenging policies on mandatory overtime and looking at different staffing arrangements can help prevent nurses from leaving the workforce, and reducing turnover decreases some of the safety issues.

2. Curb unprofessional behavior

Another strategy is curbing unprofessional and disruptive behavior. Nurses often will not speak up even if they detect a patient care problem. Additionally, verbal abuse undermines a culture of safety, clinicians’ relationships, the flow of communication and the ability to retain nurses.

“Physicians, nurses, therapists, pharmacists and non-healthcare staff all have to work as a team,” Burke said. “There’s a huge emphasis on interdisciplinary communication, because they have demonstrated when communication between the team members is not good, safety risk goes up.”

UTHealth emphasizes interprofessional communication and collaboration. Better coordination results in cost savings as well, Starck said.

“We’re trying to get didactic and clinical experience in teams while they are still students,” Starck said.

Factors in the nurse environment, such as the pressure from high patient counts and a high number of admissions, transfers or discharges, often contribute to disruptive behavior, according to a study discussed in the RWJF report. The problem occurs between nurses and not only with professionals in other disciplines.

“We all deal with stress and constant interruptions and life and death pressures differently,” Ladden said. “We have to acknowledge there is stress but find ways to deal with it.”

3. Harness nurse leadership

The third recommended strategy is developing and harnessing nurse leadership. The RWJF authors cite an association between nursing leadership and higher patient satisfaction and fewer adverse events, including patient mortality, medication errors and hospital-acquired infections. Only 6 percent of voting members on hospital boards are nurses, according to the American Hospital Association.

“Decisions are made by people at very high levels, like boards, CEOs and the C-suite, without getting the input of those on the front lines of care,” Ladden said. “When you don’t have nurses on boards, you don’t get the perspectives of those on the front lines.”

Increasing the number of nurses serving on boards is a 2014 focus area for the RWJF-supported Campaign for Action, which is implementing recommendations from a different IOM report, The Future of Nursing: Leading Change, Advancing Health.

“As hospitals are merging and care more intense, it’s more important than ever to have someone who knows the system,” Starck said.

UTHealth has incorporated more leadership content into its nursing programs. And hospitals at the Texas Medical Center are collaborating on a nursing leadership institute for nurses working at the various facilities.

“Nurses are seeing increased opportunities to have a role in leadership decisions at higher levels,” said Burke, adding that influencing policy does not mean strictly politics, but influencing policy that sets patient care outcomes.

The blueprint for change

The RWJF report ends with a blueprint for change that centers on these strategies and includes resources to help providers, policy makers and educators follow through with the recommendations to:
• Monitor nurse staffing and ensure that all health care settings are adequately staffed with appropriately educated, licensed and certified personnel
• Create institutional cultures that foster professionalism and curb disruptions
• Harness nurse leadership at all levels of administration and governance
• Educate the current and future workforce to work in teams and communicate better across the health professions.

“We are not done,” Ladden said. “There are policy, education and practice organizational issues that have to be addressed. In order to make real improvement for our patients, families and providers, we cannot have the report sit on the shelf. We have to look at was has been implemented and develop clear strategies for moving forward.”

The RWJF report:
Ten Years After Keeping Patients Safe: Have Nurses’ Work Environments Been Transformed?

Related articles and resources:
2013 Survey of Registered Nurses
Nurse Understaffing and Burnout Linked to More Hospital Infections
Creating a Great Nurse Work Environment to Improve the Bottom Line

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