The Influence of NurseMidwife Education on Patient Outcomes - PowerPoint PPT Presentation


Title: The Influence of NurseMidwife Education on Patient Outcomes


1
The Influence of Nurse/Midwife Education on
Patient Outcomes
  • Sean Clarke, RN, PhD, CRNP, FAAN
  • Associate Director, Center for Health Outcomes
    and Policy Research
  • Class of 1965 Reunion Term Associate Professor of
    Nursing
  • University of Pennsylvania
  • Philadelphia, PA, USA

2
Outline
  • History and background
  • Research evidence related to the role of nursing
    education in outcomes
  • Policy implications Why third-level nurse
    education is likely to be beneficial to patients
  • Where next?
  • Conclusion

3
Education
  • Initial formal preparation to begin professional
    practice (prelicensure education)
  • In the U.S. still divided, with about 60 below
    the bachelors degree
  • Post-basic formal education leading to degrees
    and/or certificates
  • Broader rubric of lifelong learning including
    individually-directed learning plans and
    shorter-term organized activities

4
Honors Nursing Graduates, U/Penn, 1927
5
1st Graduating Accelerated BSN Class Villanova
University, 2004
6
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7
3 Countries
8
General Patterns in Evolution of Nursing
Education Across Countries
  • Formalized training in hospitals
  • Debates about service vs. education as focus of
    nurse training programs
  • Concerns about nurse training occurring outside
    of educational institutions
  • Baccalaureate and higher education within and
    outside nursing for nurse leaders
  • Beginning of lobbying to shift the entry
    credential to the baccalaureate level
  • Development of masters and higher education for
    nurse leaders
  • Shift to the baccalaureate as the entry credential

9
The U.S. Story
  • 1872 First formal training program, New England
    Hospital for Women and Children
  • 1903 Beginning of state regulation of nursing
    practice
  • 1909 First bachelors degree program at
    University of Minnesota
  • 1929 Goldmark Report recommends decreasing
    service and increasing educational component, and
    moving towards university education
  • 1920s through 1960s Period of intense growth in
    certificate and degree programs for nurses and
    nurse leaders after initial hospital diploma
    education
  • 1952 Creation of associate degree (AD) programs
    in nursing in community/junior colleges (lower
    tier of higher education hierarchy)
  • 1960s through 1970s Cost factors lead many
    hospitals to close diploma programsAD programs
    take their place
  • 1970s through 1990s Steady growth of doctoral
    programs in nursing, masters degrees
    increasingly required to teach nursing at any
    level
  • 1990s Shift in focus of masters education to
    advanced practice, primarily for nurse
    practitioners

10
Basic Nursing Education of the U.S. Registered
Nurse Population
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
11
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12
NCLEX-RN (National Licensing Examination) Pass
Rates for Newly-Graduated Registered Nurse
Licensure Candidates by Program Type in 2004
(Source NCSBN)
Program Type Number of Graduates NCLEX-RN
Pass Rate Diploma 3,162 88.2 Associ
ate Degree 53,275 85.3 Baccalaureate
Degree 30,648 84.8
13
Initial Educational Preparation of Registered
Nurses, United States, 2004
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
14
Highest Educational Preparation of Registered
Nurses, United States, 2004
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
15
The Canadian Story
  • 1874 First formal training program, Mack
    Training School in St. Catharines, Ontario
  • 1919 First bachelors degree program at
    University of British Columbia
  • 1932 Weir Report recommends decreasing service
    and increasing educational component, and moving
    towards university education
  • 1920s-1960s Period of intense growth in
    certificate and degree programs for nurses and
    nurse leaders after initial hospital diploma
    education
  • 1959 First masters program at University of
    Western Ontario
  • 1960s-1970s Many hospitals to close diploma
    programscommunity college programs awarding
    diplomas take their place
  • 1989 All provincial nursing associations adopt
    motion in favour of baccalaureate entry to
    practice
  • 1990s Birth, followed by steady growth of
    doctoral programs in nursing
  • 2000 Movement is in place to consolidate basic
    nursing education in university-level programs in
    all provinces
  • 2001 All prelicensure students in Ontario
    (largest province) enter bachelors programs,
    bachelors degree required of all new licensees
    in 2005 most other provinces close behind

16
Highest Educational Preparation of Registered
Nurses in Canada, 1989 and 2004
2004
1989
Source Canadian Nurses Association
17
The Irish Story
  • Nightingale era First formal training programs
  • 1917 Beginning of state regulation of nursing
    practice
  • 1940s Discussions regarding university courses
    for nurse leaders begin
  • Nurses, particularly leaders, pursue
    post-diploma education in nursing and other
    fields, sometimes abroad
  • 1980s and beyond Acceleration of discussions
    around preparation and creation of programs at
    undergraduate and postgraduate levels
  • 2001 Government approval for a 4-year
    pre-registration degree as sole entry point to
    practice
  • 2006 First class of university graduates emerges

18
Back to North America
  • Debate for past 40 years not so much about moving
    away from having prelicensure RN education
    programs in service institutions
  • Social forces pushed nursing education out of
    hospitals in 1970s
  • Debates more about which educational institutions
    should be entrusted with this (universities/4-year
    colleges vs. community colleges)
  • criteria for admission, costs, accessibility
  • what the content of the programs should be
  • professional/leadership orientation
  • VERSUS
  • technical orientation

19
The North American Fights Over Nursing Education
Much Heat Not Much Light
  • Intensely political within nursing
  • Clinicians, teachers, administrators, leaders
  • Nursing education is big business in the U.S.
  • Many disciplines (e.g. nutrition/dietetics,
    rehabilitation professions, pharmacy, etc.) all
    moved to postgraduate entry during 1980s and
    1990s in U.S.
  • Physicians and health care administrators
    uninterested except when they believe RN supply
    threatened
  • Data very thin on both sides (quite biased
    research) and never related to much to patient
    care until outcomes research methods started to
    be applied to the question

20
Research Evidence
21
Key Papers Directly Tying Educational Composition
of Hospital Nursing Staff to Patient Outcomes in
Acute Care
  • Aiken et al. (2003), Journal of the American
    Medical Association
  • Estabrooks et al. (2005), Nursing Research
  • Tourangeau et al. (2007), Journal of Advanced
    Nursing

22
Hospital Nurse Staffing and Patient Mortality,
Nurse Burnout, and Job Satisfaction
  • Linda H. Aiken, PhD, RN
  • Sean P. Clarke, PhD, RN
  • Douglas M. Sloane, PhD
  • Julie Sochalski, PhD, RN
  • Jeffrey H. Silber, MD, PhD

October 23/30, 2002. Journal of the
American Medical Association, 288,
1987-1993 Funding Source National Institute of
Nursing Research, National Institutes of Health
23
Patient Selection Criteria
  • between the ages of 20 and 85
  • hospitalized between April 1, 1998 to November
    30, 1999
  • underwent general surgical, orthopedic, or
    vascular procedures
  • hospitalized in an institution that could be
    linked to survey and administrative datasets as
    an individual agency

24
Surgical Proceduresin the 232,342 Patients
Vascular
Digestive Tract
Orthopedic
Hepatobiliary
Skin/Breast
Endocrine/Metabolic
25
Comorbidities in PA Surgical Patients (in s)

26
Patient Characteristics PA Surgical Analyses
  • 43.7 of the patients were male
  • Mean age of the patients 59.3 ? 16.9 years
  • 27.3 of these patients were admitted on an
    emergency basis

27
Number of Beds 168 PA Hospitals
28
168 PA Hospitals Hospitals with Open Heart
and/or Major Organ Transplant Capacity
29
168 PA Hospitals Teaching Status(Graduate
Medical Education)
30
168 PA Hospitals Average Patient Load Carried By
Nurses on Last Shift Worked
31
Outcomes in the 232,342Surgical Patients
  • 4,535 (2.0) died within 30 days of admission
  • 53,813 (23.2 ) were observed to experience a
    major complication
  • the death rate among complicated patients
    (failure to rescue rate) was 8.4

32
Effect of Nurse Staffingon Mortality
  • For every one patient-per-nurse increase in
    nursing workload in Pennsylvania hospitals 14
    increase in risk of death within 30 days for an
    individual patient
  • After controlling for 136 hospital and patient
    variables 7 increase in risk of death

33
Education Levels of Hospital Nurses and Patient
Mortality
  • Aiken, Clarke, Cheung, Sloane, Silber
    (September 24, 2003, Journal of the American
    Medical Association)
  • The proportion of hospital staff RNs holding
    baccalaureate or higher degrees as their highest
    (not initial) credential ranged from 0 to 77
    across the hospitals.

34
Excess Surgical Deaths (Observed-Expected) per
1000 Cases Across PA Hospitals With Differing
Proportions of BSN/MSN-Educated Nurses
More deaths than expected
Fewer deaths than expected
Proportion of Nurses with BSNs/MSNs
35
Odds Ratios for Patient Mortality (Fully-Adjusted
Model)
  • Nurse education
  • (10 increase in BSN)
  • Nurse workload/staffing
  • (1 pt per nurse increase)
  • Nurse experience
  • (per 1 year increase)
  • Board-certified surgeon
  • .95 (.91-.99) p.008
  • 1.06 (1.01-1.10) p.02
  • 1.00 (.98-1.02) p.86
  • .85 (.73-.99) p.03

36
Patient deaths after surgery were lowest in
hospitals where nurses cared for fewer patients
on average and had higher levels of education
Patient-to-nurse ratios
Estimated deaths per 1000 patients
Bachelors-prepared nurses
37
Impact of Hospital Characteristics on 30-Day
Medical Mortality (N18,142), Alberta,
CanadaEstabrooks et al. (2005), Nursing
Research, Final Model
38
Tourangeau et al., J Adv Nurs 2007 57(1) 32-44.
  • 46,993 patients with 4 medical conditions (AMI,
    CVA, pneumonia, sepsis) in 75 Ontario (Canada)
    hospitals in 2003
  • Significant associations seen between risk
    adjusted 30-day mortality and
  • Hours per patient day
  • Registered Nurses
  • baccalaureate-educated nurses
  • Perceptions of staffing adequacy and support from
    managers

39
The Bottom Line
  • Early research suggests that patient mortality is
    lower in hospitals where higher proportions of
    front-line staff nurses hold undergraduate and
    higher degrees
  • In studies where patient and hospital
    characteristics are measured and analyzed
  • In studies where other organizational and
    physician-related factors are observed to have
    effects

40
Caveats
  • Correlational results at present
  • Other factors may be involved in the association
  • Proportion of BSN nurses may be partially a proxy
    for hospital/community characteristics
  • Mortality is the best studied objective outcome
    of care to date (!)
  • Currently lack empirical evidence that actual
    nurse practice differs at a clinically
    significant level across levels of education and
    across patient populations
  • This is coming

41
What else is missingFuture avenues for research
  • Outcomes for patients/clients in setting other
    than acute care
  • Positive outcomes of acute care
  • Outcomes that tend not to be observed when the
    educational composition is lower

42
Caveats/Other Factors to Be Disentangled
  • Role of jobs/academic preparation before
    professional nursing education
  • Variable quality of students and of educational
    programs at all levels
  • Role of non-nursing academic preparation
  • Role of vision of practice established by nurse
    leaders and resources for enacting professional
    approach
  • Role of (the right types of) clinical experience

43
How Does Education Make a Difference? Thoughts
for Policymaking and Future Research
44
How Does Academic Preparation Improve Quality of
Care Outcomes in General?
  • Broader base of knowledge
  • Courses and practice often can build on a more
    rigorous science and humanities preprofessional
    foundation
  • Depth of coverage in courses possible when
    broader aims than technical proficiency targeted
  • Benefits of being educated where knowledge is
    being created
  • Learning to learn
  • Greater flexibility in mastering new bodies of
    knowledge, new techniques
  • Ability to see longer-term, bigger-picture
    aspects of care

45
Attitudinal/Affective Benefits of a
Professionally Oriented Education
  • A humanism in practice built on a deeper
    understanding of the profession, its history and
    its scientific basis
  • Values
  • Reflective practice
  • Education (formal and informal)
  • Community of care/working environments
  • Importance of leadership
  • Sense of self as a knowledge worker/self-confidenc
    e

46
U.S. Institute of Medicine Report Crossing the
Quality Chasm
  • Six aims in health care systems reform
  • Safety avoid injuries
  • Effectiveness evidence-based
  • Patient-centeredness patient values guide
    decisions
  • Timeliness reduce waiting and delay
  • Efficiency avoid waste
  • Equity care doesnt vary by gender, ethnicity,
    etc,

47
Potential Impacts of Educationon Safety and
Quality
  • Willingness to question other clinicians
    (colleagues, clinicians from other disciplines),
    managers
  • Effective communication
  • Effective leadership
  • Longer-term, bigger-picture view that enables
    patients interests to be first priority
  • Getting beyond task completion

48
Potential Impacts of Educational Programs in
Other Aspects of Quality
  • Timely, cost-effective
  • Diagnosing problems in systems and acting as
    change agents
  • Communication, leadership
  • Effective
  • Evidence-based practice (specifics and general
    methods)
  • Culturally-sensitive, culturally-appropriate,
    patient-centered
  • Humanism, philosophy of practice formal content

49
Advantages of Addressing Prelicensure Education
  • Where Irish nursing has succeeded and U.S.
    nursing has and will not

50
The U.S. Story (Continued)
  • Mobility has been a big attraction for entry to
    nursing historically
  • BUT, upgrading to 4-year preparation after entry
    to practice is expensive for the student and
    society (particularly in a higher education in
    the US where public-private mix renders costs
    very high)
  • Motivation for upgrading waxes and wanes
    depending on job market (wage incentives for
    upgrading now waning)
  • Front-line clinicians in short supply (any RN
    qualifications more or less guarantee employment)
  • Front-line management and education considered
    hard work for little benefit (both training and
    the work itself)
  • Advanced practice clinical positions quite
    saturated

51
Percentage of US RNs Who Upgrade Their Education,
by Age
Biviano et al., HRSA, 2004
52
Declining Proportions of US Hospital Nurses in
Higher Education and Getting Employer Tuition
Assistance (NSSRN, 1984-2000)
53
Problems Posed By Stagnant Growth in Numbers of
Nurses With Bachelors and Higher Preparation
  • Many institutions, especially tertiary ones,
    would like 60 or more of their nurses to hold
    university degrees to deal with clinical and
    leadership challenges on the front lines
  • Not possible with current mix
  • Pipeline for leadership roles and for teaching in
    jeopardy
  • Nursing education capacity limited by teacher
    shortage
  • MSN required to teach in the US in any type of
    program

54
Where the U.S. may be going
  • BSN bachelors/university-level in 10
  • All current license holders grandfathered
    (allowed to retain credential)no new
    requirements
  • As of a certain date, allowing graduates of all
    types of programs to register initially but by
    year 10, must hold a university degree to renews
  • Proposal working its way through in New York
    State and is under discussion in a number of
    other states
  • Can colleges/universities keep up?

55
Arguments of Increased Formal Education for
Nurses--Summary
  • Implications for quality of care of a broader
    base, more depth in knowledge base, greater
    adaptability
  • Environments for caresystems thinking, greater
    understanding of contexts of care and of quality
    of care
  • Followership and stewardship
  • Sowing the seeds for a new generation of clinical
    leaders, managers/executors, researchers,
    educators who will shape environments and steer
    practice

56
Ongoing Challenges for Managers and Leaders
57
  • Managing work environments
  • Work environments The common link between nurse
    retention and optimal quality of care
  • Challenges of influx of individuals with academic
    instruction Reality shock and its remedies

58
Work Environments and Well-Educated Staff Nurse
Chicken and Egg?
Higher quality of patient care, superior
environments
Better patient and staff outcomes
Better educated staff
Recruitment and retention
How do we lead highly-educated clinicians to
maximize their contributions to patient care over
a career?
59
What Leads Some Institutions to Differentially
Attract and Retain Educated Nurses?
  • Salary
  • Differentials that recognize educational
    preparation
  • Benefits
  • Including tuition reimbursement
  • Working conditions
  • Stimulation
  • Challenging patient care
  • Like-minded colleagues
  • Autonomy
  • Opportunities for advancement

60
Reality Shock Work Environments and the New
Clinician
  • The Role of Nursing Leadership

61
Kramer, M. (1974). Reality shock Why nurses
leave nursing. St. Louis Mosby.
  • Reality shock stems from the realization that the
    way the graduate was taught to do things in
    school is not necessarily the way things are
    actually done on the job
  • Originally developed to describe difficulties in
    socialization experienced by nurses in the US
    educated in the university model

62
Where the conflict can arise Academia vs.
practice
  • comprehensive vs. episodic/specialized health
    care
  • quality vs. quantity of work
  • unclear expectations/testing by coworkers
  • bureaucratic/part-task orientation vs.
    professional orientation to nursing practice

63
Bureaucratic Orientation
  • Workers have specialized roles/tasks
  • Extensive rules
  • Overall orientation to rational, efficient
    implementation of goals
  • Hierarchical authority structure
  • Depersonalization of worker-client contacts

64
Part-Task Orientation
  • Relatively few skills needed, mostly learned on
    the job
  • Evaluation through completion of tasks
  • Hierarchical control and authority structure
  • Rules and regulations serve as external standards
  • Control and coordination removed from workers
  • A layer of the organization to maintain the
    structure

65
Professional (Whole-Task) Orientation
  • Specialized competence with an intellectual
    foundation (total knowledge and skills) for
    global approach to work
  • Extensive authority, influence, responsibility in
    exercising special competence
  • Commitment
  • Peer control/authority

66
Reality Shock Conceptualized
Professional values
Bureaucratic values
ROLE CONFLICT ROLE DEPRIVATION
67
Reality ShockFour Phases
  • Honeymoon Phase
  • Shock (Rejection) Phase
  • Recovery Phase
  • Resolution Phase

68
Kramers Four Typologies of Nurses Dealing with
the Conflict
69
Counteracting Reality Shock
  • Sociological immunization anticipatory
    guidance and other types of educational
    interventions
  • Careful and thoughtful orientation of new
    graduates
  • Improve the odds that students will become
    bicultural
  • Training in change theory
  • Reform nursing education
  • Nursing leadership on the front lines through the
    executive level that visibly promotes the
    professional model

70
Challenges in Practice
  • Respecting experience and length of
    serviceturbulence and uncertainty produced by
    change
  • Particularly when a lot of other change is going
    on
  • Generational considerations (not just educational
    difference)
  • Fostering mutual respect among staff with
    different backgrounds

71
What issues/questions are arising in your
institutions and settings?
72
What Aspects of Education Need To Be Modified to
Ensure/Protect/Advance Quality of Care?
  • Basic clinical preparation
  • Postgraduate/advanced clinical education
  • Preparation of managers and leaders
  • Lifelong learning for all
  • Areas for research
  • Modes of delivery
  • Use of technologies
  • Evaluation of outcomes for nurses and their
    clients(!)

73
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74
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75
Next Steps in Research and Evaluation
  • Currently, no tools/datasets for examining
    individual nurses practice and outcomes in
    relation to education/experience that permit
    direct comparisons/evaluations of educational
    models
  • Major challenge to be addressed

76
The Challenges of Nursingin the Academy
  • Challenges of educating clinicians
  • for meeting healthcare needs of very complex
    societies in changing healthcare systems
  • equipping them for lifelong learning
  • Adding more is decreasingly an
    optionfundamental reworking is necessary (at
    least in North America)
  • Scholarly imperativefiguring out personnel mix
    in Schools of Nursing and designing manageable
    jobs to allow top-flight student experiences and
    permit nurse academics to meet the institutional
    expectations

77
ConclusionPutting It Together and Making It
About Patients
78
Scenario
  • September, 2000 17-year-old patient with
    neurological complications of sickle-cell
    disease, undergoes gallbladder surgery at
    internationally-renowned pediatric hospital with
    10-week-old preop bloodwork
  • returns to general surgical floor from recovery
    room, initially under the care of an RN trained
    in a well-regarded BSN program with one year of
    experience (who has been assigned 5 patients)
  • preponderance of nurses working on floor had less
    than three years experience, and there was an
    exodus of experienced nurses from the ward
    since October, 1999

79
Scenario (Contd)
  • 2 hour delay in transfer from recovery room.
    320 p.m. 45 minutes after admission to floor,
    HR and RR elevated, BP 80/40
  • Testimony of RN at coroners inquest "I did not
    realize how serious her blood pressure was. I did
    realize her blood pressure was low and it was not
    normal."
  • RN continues to record worsening VS (not BP) at
    prescribed intervals, patient develops cold hands
    and feet

80
Scenario (Contd)
  • 6 p.m.--Electronic monitor begins sounding
    nurses disregard it, believing readings to be in
    error
  • Around 6 p.m.--Surgeon visits patient, standing
    in doorway, chatting with patients mother, and
    then leaving without physically examining the
    teen, reading a vital-signs chart close by, or
    reviewing the read-outs on her heart and breath
    monitors
  • 750 p.m.--Nurses respond to respiratory rate
    alarm
  • 800 p.m.--Patient goes into cardiac arrest and
    dies
  • Cause of death six hours after admission
    Postoperative hemorrhage

81
Unhelpful (and erroneous) explanations
  • A focus on individual practitioners, their
    qualifications, and what they did or didnt do at
    specific moments
  • Shame and blame
  • The second victim
  • Treating symptoms
  • A focus on specific procedures and regulations
    heeded or not heeded alone

82
What elements might explain what
happened?Possible Root Causes 1
  • Staffing levels relative to patient needs
  • Staff mix (levels of experience)implications for
    recruitment and retention
  • Opportunities for senior clinical staff to assist
    less experienced nurses
  • Staff development issues
  • NURSE HUMAN RESOURCES IN A BROAD SENSE (not
    staffing numbers alone)

83
What other elements might explain what
happened?Possible Root Causes 2
  • Maintaining high level of suspicion for rare, but
    potentially fatal complications in a busy,
    intense environment
  • Team functioning--overlapping functions,
    cross-checking, building in redundancies to build
    in safety
  • Climate, culture and resources to remain
    patient-focused in context of heavy demands
  • SAFETY CLIMATE, INTER- AND INTRAPROFESSIONAL
    COMMUNICATION

84
Another Case, This OneFrom the U.K. in 1998
  • 54-year-old woman undergoes hysterectomy
  • Registered nurse patient ratio on postsurgical
    floor 301
  • Patient experiences severe internal bleeding when
    arterial ligature slips and detection is delayed
    heart attack and brain death
  • 2 d postoperatively, life support discontinued
  • See Nursing Standard, September 6 2006, p. 16

85
Successful Rescues When Complications Arise
  • Surveillance
  • Interpreting cues
  • Taking appropriate immediate actions
  • Bringing the right personnel to the bedside
  • Instituting appropriate definitive corrective
    treatment in time

Clarke Aiken, 2003
86
Surveillance in Practice
Intervention
Yes
Assessment Patient condition and potential
for complications (frequency and risk)
Plan Assessment parameters and frequency
of assessments
Implementation Surveillance and interpretation of
cues
Abnormalities Correction needed?
No
Regular review With passage of time Change of
settings Handover, etc.
87
Abnormal assessment findings needing correction
Establish immediate priorities
No
Immediate actions
Reestablish surveillance with new data
Inform other clinicians
Problem resolved?
Yes
Collaborative actions
Intervention Phase
88
Package of Work Environment Issues Associated
With Rescue
  • Basic staff competencies
  • Experience issuesopportunities for oversight of
    less experienced nurses care
  • Culture of clinical practice style
  • Staffing levels
  • Unit physical layout
  • Policies/procedures for adjusting staffing
  • Culture of interprofessional interactions
  • Resources for rescue (equipment/personnel)
  • Dealing with the rare/unusual or off-service
    care

89
Recent Patient Safety Events in North
America--Importance of Systems Thinking
  • Labor and delivery unitMadison, Wisconsin
  • A 16-year-old dies in labor when a bag with
    epidural anesthetic is connected to her IV line
    instead of the prescribed antibiotic experienced
    nursefatigue implicated in the event
  • Neonatal ICUIndianapolis
  • 3 infants die from heparin overdoses
  • Adult dose vials of heparin mistakenly delivered
    to the unit by a pharmacy technician
  • Emergency DepartmentWaukegan, Illinois
  • 47 year old woman with 10/10 Chest pain, nausea
    made to wait 15 minutes to be triaged and 2 hours
    in the waiting room before being seen died an
    hour later
  • Quebec, Canada
  • Report on 12 deaths from respiratory depression
    following the use of narcotic analgesics in
    otherwise healthy adults under 50 over a 10-year
    period coroner directly attributed 8 to failure
    of nurses to adequately monitor patientsHigh
    profile news stories

90
Another Case, This OneFrom the U.K. in 1998
  • 54-year-old woman undergoes hysterectomy
  • Registered nurse patient ratio on postsurgical
    floor 301
  • Patient experiences severe internal bleeding when
    arterial ligature slips and detection is delayed
    heart attack and brain death
  • 2 d postoperatively, life support discontinued
  • See Nursing Standard, September 6 2006, p. 16

91
In the end
  • Education is a critical piece of the puzzle
  • as are adequate staffing levels
  • as is a positive work environment
  • Front-line workers cover non-nursing tasks
  • Clinical resource nurses/specialists
  • Collegial relations with physicians and other
    workers and professionals
  • Support of front-line nurses by
    managers/administrators
  • Profile of nursing in the institution/facility
  • Orientation, lifelong learning
  • Quality measurement and improvement
  • All are needed to get optimal patient outcomes
    and to retain staff

92
  • Without good and careful nursing many must
    suffer greatly, and probably perish, that might
    have been restored to health and comfort, and
    become useful to themselves, their families, and
    the public, for many years after.
    Benjamin Franklin (1751)

93
sclarke_at_nursing.upenn.eduhttp//www.nursing.upen
n.edu/chopr
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The Influence of NurseMidwife Education on Patient Outcomes

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Title: The Influence of NurseMidwife Education on Patient Outcomes


1
The Influence of Nurse/Midwife Education on
Patient Outcomes
  • Sean Clarke, RN, PhD, CRNP, FAAN
  • Associate Director, Center for Health Outcomes
    and Policy Research
  • Class of 1965 Reunion Term Associate Professor of
    Nursing
  • University of Pennsylvania
  • Philadelphia, PA, USA

2
Outline
  • History and background
  • Research evidence related to the role of nursing
    education in outcomes
  • Policy implications Why third-level nurse
    education is likely to be beneficial to patients
  • Where next?
  • Conclusion

3
Education
  • Initial formal preparation to begin professional
    practice (prelicensure education)
  • In the U.S. still divided, with about 60 below
    the bachelors degree
  • Post-basic formal education leading to degrees
    and/or certificates
  • Broader rubric of lifelong learning including
    individually-directed learning plans and
    shorter-term organized activities

4
Honors Nursing Graduates, U/Penn, 1927
5
1st Graduating Accelerated BSN Class Villanova
University, 2004
6
(No Transcript)
7
3 Countries
8
General Patterns in Evolution of Nursing
Education Across Countries
  • Formalized training in hospitals
  • Debates about service vs. education as focus of
    nurse training programs
  • Concerns about nurse training occurring outside
    of educational institutions
  • Baccalaureate and higher education within and
    outside nursing for nurse leaders
  • Beginning of lobbying to shift the entry
    credential to the baccalaureate level
  • Development of masters and higher education for
    nurse leaders
  • Shift to the baccalaureate as the entry credential

9
The U.S. Story
  • 1872 First formal training program, New England
    Hospital for Women and Children
  • 1903 Beginning of state regulation of nursing
    practice
  • 1909 First bachelors degree program at
    University of Minnesota
  • 1929 Goldmark Report recommends decreasing
    service and increasing educational component, and
    moving towards university education
  • 1920s through 1960s Period of intense growth in
    certificate and degree programs for nurses and
    nurse leaders after initial hospital diploma
    education
  • 1952 Creation of associate degree (AD) programs
    in nursing in community/junior colleges (lower
    tier of higher education hierarchy)
  • 1960s through 1970s Cost factors lead many
    hospitals to close diploma programsAD programs
    take their place
  • 1970s through 1990s Steady growth of doctoral
    programs in nursing, masters degrees
    increasingly required to teach nursing at any
    level
  • 1990s Shift in focus of masters education to
    advanced practice, primarily for nurse
    practitioners

10
Basic Nursing Education of the U.S. Registered
Nurse Population
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
11
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12
NCLEX-RN (National Licensing Examination) Pass
Rates for Newly-Graduated Registered Nurse
Licensure Candidates by Program Type in 2004
(Source NCSBN)
Program Type Number of Graduates NCLEX-RN
Pass Rate Diploma 3,162 88.2 Associ
ate Degree 53,275 85.3 Baccalaureate
Degree 30,648 84.8
13
Initial Educational Preparation of Registered
Nurses, United States, 2004
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
14
Highest Educational Preparation of Registered
Nurses, United States, 2004
Source National Sample Survey of Registered
Nurses, March 2004, HRSA
15
The Canadian Story
  • 1874 First formal training program, Mack
    Training School in St. Catharines, Ontario
  • 1919 First bachelors degree program at
    University of British Columbia
  • 1932 Weir Report recommends decreasing service
    and increasing educational component, and moving
    towards university education
  • 1920s-1960s Period of intense growth in
    certificate and degree programs for nurses and
    nurse leaders after initial hospital diploma
    education
  • 1959 First masters program at University of
    Western Ontario
  • 1960s-1970s Many hospitals to close diploma
    programscommunity college programs awarding
    diplomas take their place
  • 1989 All provincial nursing associations adopt
    motion in favour of baccalaureate entry to
    practice
  • 1990s Birth, followed by steady growth of
    doctoral programs in nursing
  • 2000 Movement is in place to consolidate basic
    nursing education in university-level programs in
    all provinces
  • 2001 All prelicensure students in Ontario
    (largest province) enter bachelors programs,
    bachelors degree required of all new licensees
    in 2005 most other provinces close behind

16
Highest Educational Preparation of Registered
Nurses in Canada, 1989 and 2004
2004
1989
Source Canadian Nurses Association
17
The Irish Story
  • Nightingale era First formal training programs
  • 1917 Beginning of state regulation of nursing
    practice
  • 1940s Discussions regarding university courses
    for nurse leaders begin
  • Nurses, particularly leaders, pursue
    post-diploma education in nursing and other
    fields, sometimes abroad
  • 1980s and beyond Acceleration of discussions
    around preparation and creation of programs at
    undergraduate and postgraduate levels
  • 2001 Government approval for a 4-year
    pre-registration degree as sole entry point to
    practice
  • 2006 First class of university graduates emerges

18
Back to North America
  • Debate for past 40 years not so much about moving
    away from having prelicensure RN education
    programs in service institutions
  • Social forces pushed nursing education out of
    hospitals in 1970s
  • Debates more about which educational institutions
    should be entrusted with this (universities/4-year
    colleges vs. community colleges)
  • criteria for admission, costs, accessibility
  • what the content of the programs should be
  • professional/leadership orientation
  • VERSUS
  • technical orientation

19
The North American Fights Over Nursing Education
Much Heat Not Much Light
  • Intensely political within nursing
  • Clinicians, teachers, administrators, leaders
  • Nursing education is big business in the U.S.
  • Many disciplines (e.g. nutrition/dietetics,
    rehabilitation professions, pharmacy, etc.) all
    moved to postgraduate entry during 1980s and
    1990s in U.S.
  • Physicians and health care administrators
    uninterested except when they believe RN supply
    threatened
  • Data very thin on both sides (quite biased
    research) and never related to much to patient
    care until outcomes research methods started to
    be applied to the question

20
Research Evidence
21
Key Papers Directly Tying Educational Composition
of Hospital Nursing Staff to Patient Outcomes in
Acute Care
  • Aiken et al. (2003), Journal of the American
    Medical Association
  • Estabrooks et al. (2005), Nursing Research
  • Tourangeau et al. (2007), Journal of Advanced
    Nursing

22
Hospital Nurse Staffing and Patient Mortality,
Nurse Burnout, and Job Satisfaction
  • Linda H. Aiken, PhD, RN
  • Sean P. Clarke, PhD, RN
  • Douglas M. Sloane, PhD
  • Julie Sochalski, PhD, RN
  • Jeffrey H. Silber, MD, PhD

October 23/30, 2002. Journal of the
American Medical Association, 288,
1987-1993 Funding Source National Institute of
Nursing Research, National Institutes of Health
23
Patient Selection Criteria
  • between the ages of 20 and 85
  • hospitalized between April 1, 1998 to November
    30, 1999
  • underwent general surgical, orthopedic, or
    vascular procedures
  • hospitalized in an institution that could be
    linked to survey and administrative datasets as
    an individual agency

24
Surgical Proceduresin the 232,342 Patients
Vascular
Digestive Tract
Orthopedic
Hepatobiliary
Skin/Breast
Endocrine/Metabolic
25
Comorbidities in PA Surgical Patients (in s)

26
Patient Characteristics PA Surgical Analyses
  • 43.7 of the patients were male
  • Mean age of the patients 59.3 ? 16.9 years
  • 27.3 of these patients were admitted on an
    emergency basis

27
Number of Beds 168 PA Hospitals
28
168 PA Hospitals Hospitals with Open Heart
and/or Major Organ Transplant Capacity
29
168 PA Hospitals Teaching Status(Graduate
Medical Education)
30
168 PA Hospitals Average Patient Load Carried By
Nurses on Last Shift Worked
31
Outcomes in the 232,342Surgical Patients
  • 4,535 (2.0) died within 30 days of admission
  • 53,813 (23.2 ) were observed to experience a
    major complication
  • the death rate among complicated patients
    (failure to rescue rate) was 8.4

32
Effect of Nurse Staffingon Mortality
  • For every one patient-per-nurse increase in
    nursing workload in Pennsylvania hospitals 14
    increase in risk of death within 30 days for an
    individual patient
  • After controlling for 136 hospital and patient
    variables 7 increase in risk of death

33
Education Levels of Hospital Nurses and Patient
Mortality
  • Aiken, Clarke, Cheung, Sloane, Silber
    (September 24, 2003, Journal of the American
    Medical Association)
  • The proportion of hospital staff RNs holding
    baccalaureate or higher degrees as their highest
    (not initial) credential ranged from 0 to 77
    across the hospitals.

34
Excess Surgical Deaths (Observed-Expected) per
1000 Cases Across PA Hospitals With Differing
Proportions of BSN/MSN-Educated Nurses
More deaths than expected
Fewer deaths than expected
Proportion of Nurses with BSNs/MSNs
35
Odds Ratios for Patient Mortality (Fully-Adjusted
Model)
  • Nurse education
  • (10 increase in BSN)
  • Nurse workload/staffing
  • (1 pt per nurse increase)
  • Nurse experience
  • (per 1 year increase)
  • Board-certified surgeon
  • .95 (.91-.99) p.008
  • 1.06 (1.01-1.10) p.02
  • 1.00 (.98-1.02) p.86
  • .85 (.73-.99) p.03

36
Patient deaths after surgery were lowest in
hospitals where nurses cared for fewer patients
on average and had higher levels of education
Patient-to-nurse ratios
Estimated deaths per 1000 patients
Bachelors-prepared nurses
37
Impact of Hospital Characteristics on 30-Day
Medical Mortality (N18,142), Alberta,
CanadaEstabrooks et al. (2005), Nursing
Research, Final Model
38
Tourangeau et al., J Adv Nurs 2007 57(1) 32-44.
  • 46,993 patients with 4 medical conditions (AMI,
    CVA, pneumonia, sepsis) in 75 Ontario (Canada)
    hospitals in 2003
  • Significant associations seen between risk
    adjusted 30-day mortality and
  • Hours per patient day
  • Registered Nurses
  • baccalaureate-educated nurses
  • Perceptions of staffing adequacy and support from
    managers

39
The Bottom Line
  • Early research suggests that patient mortality is
    lower in hospitals where higher proportions of
    front-line staff nurses hold undergraduate and
    higher degrees
  • In studies where patient and hospital
    characteristics are measured and analyzed
  • In studies where other organizational and
    physician-related factors are observed to have
    effects

40
Caveats
  • Correlational results at present
  • Other factors may be involved in the association
  • Proportion of BSN nurses may be partially a proxy
    for hospital/community characteristics
  • Mortality is the best studied objective outcome
    of care to date (!)
  • Currently lack empirical evidence that actual
    nurse practice differs at a clinically
    significant level across levels of education and
    across patient populations
  • This is coming

41
What else is missingFuture avenues for research
  • Outcomes for patients/clients in setting other
    than acute care
  • Positive outcomes of acute care
  • Outcomes that tend not to be observed when the
    educational composition is lower

42
Caveats/Other Factors to Be Disentangled
  • Role of jobs/academic preparation before
    professional nursing education
  • Variable quality of students and of educational
    programs at all levels
  • Role of non-nursing academic preparation
  • Role of vision of practice established by nurse
    leaders and resources for enacting professional
    approach
  • Role of (the right types of) clinical experience

43
How Does Education Make a Difference? Thoughts
for Policymaking and Future Research
44
How Does Academic Preparation Improve Quality of
Care Outcomes in General?
  • Broader base of knowledge
  • Courses and practice often can build on a more
    rigorous science and humanities preprofessional
    foundation
  • Depth of coverage in courses possible when
    broader aims than technical proficiency targeted
  • Benefits of being educated where knowledge is
    being created
  • Learning to learn
  • Greater flexibility in mastering new bodies of
    knowledge, new techniques
  • Ability to see longer-term, bigger-picture
    aspects of care

45
Attitudinal/Affective Benefits of a
Professionally Oriented Education
  • A humanism in practice built on a deeper
    understanding of the profession, its history and
    its scientific basis
  • Values
  • Reflective practice
  • Education (formal and informal)
  • Community of care/working environments
  • Importance of leadership
  • Sense of self as a knowledge worker/self-confidenc
    e

46
U.S. Institute of Medicine Report Crossing the
Quality Chasm
  • Six aims in health care systems reform
  • Safety avoid injuries
  • Effectiveness evidence-based
  • Patient-centeredness patient values guide
    decisions
  • Timeliness reduce waiting and delay
  • Efficiency avoid waste
  • Equity care doesnt vary by gender, ethnicity,
    etc,

47
Potential Impacts of Educationon Safety and
Quality
  • Willingness to question other clinicians
    (colleagues, clinicians from other disciplines),
    managers
  • Effective communication
  • Effective leadership
  • Longer-term, bigger-picture view that enables
    patients interests to be first priority
  • Getting beyond task completion

48
Potential Impacts of Educational Programs in
Other Aspects of Quality
  • Timely, cost-effective
  • Diagnosing problems in systems and acting as
    change agents
  • Communication, leadership
  • Effective
  • Evidence-based practice (specifics and general
    methods)
  • Culturally-sensitive, culturally-appropriate,
    patient-centered
  • Humanism, philosophy of practice formal content

49
Advantages of Addressing Prelicensure Education
  • Where Irish nursing has succeeded and U.S.
    nursing has and will not

50
The U.S. Story (Continued)
  • Mobility has been a big attraction for entry to
    nursing historically
  • BUT, upgrading to 4-year preparation after entry
    to practice is expensive for the student and
    society (particularly in a higher education in
    the US where public-private mix renders costs
    very high)
  • Motivation for upgrading waxes and wanes
    depending on job market (wage incentives for
    upgrading now waning)
  • Front-line clinicians in short supply (any RN
    qualifications more or less guarantee employment)
  • Front-line management and education considered
    hard work for little benefit (both training and
    the work itself)
  • Advanced practice clinical positions quite
    saturated

51
Percentage of US RNs Who Upgrade Their Education,
by Age
Biviano et al., HRSA, 2004
52
Declining Proportions of US Hospital Nurses in
Higher Education and Getting Employer Tuition
Assistance (NSSRN, 1984-2000)
53
Problems Posed By Stagnant Growth in Numbers of
Nurses With Bachelors and Higher Preparation
  • Many institutions, especially tertiary ones,
    would like 60 or more of their nurses to hold
    university degrees to deal with clinical and
    leadership challenges on the front lines
  • Not possible with current mix
  • Pipeline for leadership roles and for teaching in
    jeopardy
  • Nursing education capacity limited by teacher
    shortage
  • MSN required to teach in the US in any type of
    program

54
Where the U.S. may be going
  • BSN bachelors/university-level in 10
  • All current license holders grandfathered
    (allowed to retain credential)no new
    requirements
  • As of a certain date, allowing graduates of all
    types of programs to register initially but by
    year 10, must hold a university degree to renews
  • Proposal working its way through in New York
    State and is under discussion in a number of
    other states
  • Can colleges/universities keep up?

55
Arguments of Increased Formal Education for
Nurses--Summary
  • Implications for quality of care of a broader
    base, more depth in knowledge base, greater
    adaptability
  • Environments for caresystems thinking, greater
    understanding of contexts of care and of quality
    of care
  • Followership and stewardship
  • Sowing the seeds for a new generation of clinical
    leaders, managers/executors, researchers,
    educators who will shape environments and steer
    practice

56
Ongoing Challenges for Managers and Leaders
57
  • Managing work environments
  • Work environments The common link between nurse
    retention and optimal quality of care
  • Challenges of influx of individuals with academic
    instruction Reality shock and its remedies

58
Work Environments and Well-Educated Staff Nurse
Chicken and Egg?
Higher quality of patient care, superior
environments
Better patient and staff outcomes
Better educated staff
Recruitment and retention
How do we lead highly-educated clinicians to
maximize their contributions to patient care over
a career?
59
What Leads Some Institutions to Differentially
Attract and Retain Educated Nurses?
  • Salary
  • Differentials that recognize educational
    preparation
  • Benefits
  • Including tuition reimbursement
  • Working conditions
  • Stimulation
  • Challenging patient care
  • Like-minded colleagues
  • Autonomy
  • Opportunities for advancement

60
Reality Shock Work Environments and the New
Clinician
  • The Role of Nursing Leadership

61
Kramer, M. (1974). Reality shock Why nurses
leave nursing. St. Louis Mosby.
  • Reality shock stems from the realization that the
    way the graduate was taught to do things in
    school is not necessarily the way things are
    actually done on the job
  • Originally developed to describe difficulties in
    socialization experienced by nurses in the US
    educated in the university model

62
Where the conflict can arise Academia vs.
practice
  • comprehensive vs. episodic/specialized health
    care
  • quality vs. quantity of work
  • unclear expectations/testing by coworkers
  • bureaucratic/part-task orientation vs.
    professional orientation to nursing practice

63
Bureaucratic Orientation
  • Workers have specialized roles/tasks
  • Extensive rules
  • Overall orientation to rational, efficient
    implementation of goals
  • Hierarchical authority structure
  • Depersonalization of worker-client contacts

64
Part-Task Orientation
  • Relatively few skills needed, mostly learned on
    the job
  • Evaluation through completion of tasks
  • Hierarchical control and authority structure
  • Rules and regulations serve as external standards
  • Control and coordination removed from workers
  • A layer of the organization to maintain the
    structure

65
Professional (Whole-Task) Orientation
  • Specialized competence with an intellectual
    foundation (total knowledge and skills) for
    global approach to work
  • Extensive authority, influence, responsibility in
    exercising special competence
  • Commitment
  • Peer control/authority

66
Reality Shock Conceptualized
Professional values
Bureaucratic values
ROLE CONFLICT ROLE DEPRIVATION
67
Reality ShockFour Phases
  • Honeymoon Phase
  • Shock (Rejection) Phase
  • Recovery Phase
  • Resolution Phase

68
Kramers Four Typologies of Nurses Dealing with
the Conflict
69
Counteracting Reality Shock
  • Sociological immunization anticipatory
    guidance and other types of educational
    interventions
  • Careful and thoughtful orientation of new
    graduates
  • Improve the odds that students will become
    bicultural
  • Training in change theory
  • Reform nursing education
  • Nursing leadership on the front lines through the
    executive level that visibly promotes the
    professional model

70
Challenges in Practice
  • Respecting experience and length of
    serviceturbulence and uncertainty produced by
    change
  • Particularly when a lot of other change is going
    on
  • Generational considerations (not just educational
    difference)
  • Fostering mutual respect among staff with
    different backgrounds

71
What issues/questions are arising in your
institutions and settings?
72
What Aspects of Education Need To Be Modified to
Ensure/Protect/Advance Quality of Care?
  • Basic clinical preparation
  • Postgraduate/advanced clinical education
  • Preparation of managers and leaders
  • Lifelong learning for all
  • Areas for research
  • Modes of delivery
  • Use of technologies
  • Evaluation of outcomes for nurses and their
    clients(!)

73
(No Transcript)
74
(No Transcript)
75
Next Steps in Research and Evaluation
  • Currently, no tools/datasets for examining
    individual nurses practice and outcomes in
    relation to education/experience that permit
    direct comparisons/evaluations of educational
    models
  • Major challenge to be addressed

76
The Challenges of Nursingin the Academy
  • Challenges of educating clinicians
  • for meeting healthcare needs of very complex
    societies in changing healthcare systems
  • equipping them for lifelong learning
  • Adding more is decreasingly an
    optionfundamental reworking is necessary (at
    least in North America)
  • Scholarly imperativefiguring out personnel mix
    in Schools of Nursing and designing manageable
    jobs to allow top-flight student experiences and
    permit nurse academics to meet the institutional
    expectations

77
ConclusionPutting It Together and Making It
About Patients
78
Scenario
  • September, 2000 17-year-old patient with
    neurological complications of sickle-cell
    disease, undergoes gallbladder surgery at
    internationally-renowned pediatric hospital with
    10-week-old preop bloodwork
  • returns to general surgical floor from recovery
    room, initially under the care of an RN trained
    in a well-regarded BSN program with one year of
    experience (who has been assigned 5 patients)
  • preponderance of nurses working on floor had less
    than three years experience, and there was an
    exodus of experienced nurses from the ward
    since October, 1999

79
Scenario (Contd)
  • 2 hour delay in transfer from recovery room.
    320 p.m. 45 minutes after admission to floor,
    HR and RR elevated, BP 80/40
  • Testimony of RN at coroners inquest "I did not
    realize how serious her blood pressure was. I did
    realize her blood pressure was low and it was not
    normal."
  • RN continues to record worsening VS (not BP) at
    prescribed intervals, patient develops cold hands
    and feet

80
Scenario (Contd)
  • 6 p.m.--Electronic monitor begins sounding
    nurses disregard it, believing readings to be in
    error
  • Around 6 p.m.--Surgeon visits patient, standing
    in doorway, chatting with patients mother, and
    then leaving without physically examining the
    teen, reading a vital-signs chart close by, or
    reviewing the read-outs on her heart and breath
    monitors
  • 750 p.m.--Nurses respond to respiratory rate
    alarm
  • 800 p.m.--Patient goes into cardiac arrest and
    dies
  • Cause of death six hours after admission
    Postoperative hemorrhage

81
Unhelpful (and erroneous) explanations
  • A focus on individual practitioners, their
    qualifications, and what they did or didnt do at
    specific moments
  • Shame and blame
  • The second victim
  • Treating symptoms
  • A focus on specific procedures and regulations
    heeded or not heeded alone

82
What elements might explain what
happened?Possible Root Causes 1
  • Staffing levels relative to patient needs
  • Staff mix (levels of experience)implications for
    recruitment and retention
  • Opportunities for senior clinical staff to assist
    less experienced nurses
  • Staff development issues
  • NURSE HUMAN RESOURCES IN A BROAD SENSE (not
    staffing numbers alone)

83
What other elements might explain what
happened?Possible Root Causes 2
  • Maintaining high level of suspicion for rare, but
    potentially fatal complications in a busy,
    intense environment
  • Team functioning--overlapping functions,
    cross-checking, building in redundancies to build
    in safety
  • Climate, culture and resources to remain
    patient-focused in context of heavy demands
  • SAFETY CLIMATE, INTER- AND INTRAPROFESSIONAL
    COMMUNICATION

84
Another Case, This OneFrom the U.K. in 1998
  • 54-year-old woman undergoes hysterectomy
  • Registered nurse patient ratio on postsurgical
    floor 301
  • Patient experiences severe internal bleeding when
    arterial ligature slips and detection is delayed
    heart attack and brain death
  • 2 d postoperatively, life support discontinued
  • See Nursing Standard, September 6 2006, p. 16

85
Successful Rescues When Complications Arise
  • Surveillance
  • Interpreting cues
  • Taking appropriate immediate actions
  • Bringing the right personnel to the bedside
  • Instituting appropriate definitive corrective
    treatment in time

Clarke Aiken, 2003
86
Surveillance in Practice
Intervention
Yes
Assessment Patient condition and potential
for complications (frequency and risk)
Plan Assessment parameters and frequency
of assessments
Implementation Surveillance and interpretation of
cues
Abnormalities Correction needed?
No
Regular review With passage of time Change of
settings Handover, etc.
87
Abnormal assessment findings needing correction
Establish immediate priorities
No
Immediate actions
Reestablish surveillance with new data
Inform other clinicians
Problem resolved?
Yes
Collaborative actions
Intervention Phase
88
Package of Work Environment Issues Associated
With Rescue
  • Basic staff competencies
  • Experience issuesopportunities for oversight of
    less experienced nurses care
  • Culture of clinical practice style
  • Staffing levels
  • Unit physical layout
  • Policies/procedures for adjusting staffing
  • Culture of interprofessional interactions
  • Resources for rescue (equipment/personnel)
  • Dealing with the rare/unusual or off-service
    care

89
Recent Patient Safety Events in North
America--Importance of Systems Thinking
  • Labor and delivery unitMadison, Wisconsin
  • A 16-year-old dies in labor when a bag with
    epidural anesthetic is connected to her IV line
    instead of the prescribed antibiotic experienced
    nursefatigue implicated in the event
  • Neonatal ICUIndianapolis
  • 3 infants die from heparin overdoses
  • Adult dose vials of heparin mistakenly delivered
    to the unit by a pharmacy technician
  • Emergency DepartmentWaukegan, Illinois
  • 47 year old woman with 10/10 Chest pain, nausea
    made to wait 15 minutes to be triaged and 2 hours
    in the waiting room before being seen died an
    hour later
  • Quebec, Canada
  • Report on 12 deaths from respiratory depression
    following the use of narcotic analgesics in
    otherwise healthy adults under 50 over a 10-year
    period coroner directly attributed 8 to failure
    of nurses to adequately monitor patientsHigh
    profile news stories

90
Another Case, This OneFrom the U.K. in 1998
  • 54-year-old woman undergoes hysterectomy
  • Registered nurse patient ratio on postsurgical
    floor 301
  • Patient experiences severe internal bleeding when
    arterial ligature slips and detection is delayed
    heart attack and brain death
  • 2 d postoperatively, life support discontinued
  • See Nursing Standard, September 6 2006, p. 16

91
In the end
  • Education is a critical piece of the puzzle
  • as are adequate staffing levels
  • as is a positive work environment
  • Front-line workers cover non-nursing tasks
  • Clinical resource nurses/specialists
  • Collegial relations with physicians and other
    workers and professionals
  • Support of front-line nurses by
    managers/administrators
  • Profile of nursing in the institution/facility
  • Orientation, lifelong learning
  • Quality measurement and improvement
  • All are needed to get optimal patient outcomes
    and to retain staff

92
  • Without good and careful nursing many must
    suffer greatly, and probably perish, that might
    have been restored to health and comfort, and
    become useful to themselves, their families, and
    the public, for many years after.
    Benjamin Franklin (1751)

93
sclarke_at_nursing.upenn.eduhttp//www.nursing.upen
n.edu/chopr
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