The Evidence Base for Influencing Nursing Workforce Policy

1
The Evidence Base for Influencing Nursing
Workforce Policy

• Linda H. Aiken, PhD, RN
• Center for Health Outcomes Research
• University of Pennsylvania
• laiken_at_nursing.upenn.edu
• www.nursing.upenn.edu/chopr

L. Aiken, Univ. of Pennsylvania
2
Five Years After IOM Medical Errors Report Are
Patients Safer?Source Kaiser Family
Foundation, July 2004

• 40 Americans believe quality of health care has
  gotten worse over past 5 years only 17 think
  it is better.
• Half are worried about medical care safety.
• One-third reported personal or family experience
  with medical errors.
• dissatisfied with quality of health care
• 55 in 2004
• 44 in 2000

3
Views of the Public on Causes of Medical Errors
Blendon and colleagues, NEJM 3471935-6, 2002

• Public Top causes of medical error
• Understaffing of nurses in hospitals
• MDs not having enough time with patients
• Overwork, stress, fatigue health
  professionals
• Communications failures within team

4
Patients views on what would have the biggest
impact on hospital care quality
More nurse staffing
More doctors
Better facilities and accommodations
Better admissions procedures
Source Hudson Healthcare Survey, September 2004
5
Views of MDs on Top Causes of Medical
ErrorsBlendon and colleagues, NEJM 3471935-6,
2002

• Understaffing of nurses in hospitals
• Overwork, stress, fatigue of health
  professionals

6
What MDs Think Would Improve Quality Altman,
Clancy, Blendon, 2004

• Practicing MDs see just 2 approaches as very
  effective in reducing medical errors
• requiring hospitals to develop systems to avoid
  errors 55
• increasing number of hospital nurses 51
• high volume referrals 40
• intensivists 34
• computerized ordering systems 23
• computerized medical records 19

7
Hospital Nurses Reports Aiken et al., Health
Affairs, 2001

• Too few nurses for care quality 66
• Lack of CEO response to problems 71
• Not confident patients can care for themselves
  at discharge 66
• RNs suffering high burnout 43
• Intend to leave within year 23

8
Issues of Greatest Concern to Hospital CEOs (Top
3 Rankings)
Source ACHE, 2004
9
In the past 5 years the number of licensed nurse
hours per inpatient day adjusted for acuity has
declined.
10
Link between Nurse Staffing, Organizational
Culture, and Patient Outcomes

• Good surveillance keeps bad things from
  happening.
• Nurses are the surveillance system for early
  detection and intervention for adverse
  occurrences and the institutional advocate for
  patient-centeredness.
• Surveillance and patient-centeredness is
  influenced by nurse staffing adequacy..
• Once a problem is identified, organizational
  culture determines the success of the patient
  rescue.

11
Patient to Nurse Ratios Important in Nurse
RetentionAiken et al. JAMA 2002

• Higher burnout and greater job dissatisfaction--pr
  ecursors of turnover-- are strongly related to
  patient-to-nurse ratios.
• An increase of 1 patient per nurse increases the
  probability of
• high levels of burnout by 23
• job dissatisfaction by 15

12
Nurse Burnout and Patient SatisfactionVahey,
Aiken, et al., Medical Care, 2004

• The higher proportion of nurses scoring in high
  burnout range, the higher patient
  dissatisfaction.
• The same organizational features associated with
  high RN burnout are also associated with patient
  dissatisfaction.
• Investments in better RN staffing are associated
  with higher nurse retention and patient
  satisfaction, both outcomes that positively
  influence hospitals financial position.

13
Nurse Staffing and Mortality Following Common
Surgical Procedures Aiken et al. JAMA 2002

• 7 increase in mortality for every patient added
  to the average hospital-wide nurse workload
• 7 increase in failure-to-rescue patients with
  complications

14
For every 100 surgical patients who die in
hospitals with 4 to 1 patient to nurse ratios,
the number that would die in hospitals with
higher ratios would be be(linear relationship)
15
Nurse Staffing and Patient Outcomes Research
Literature

• Majority HSR on correlates of variation in
  hospital mortality have shown a significant
  relationship of nurse staffing to mortality
• National Halothane Study, Moses Mosteller,
  JAMA,1968 (National data US)
• Shortell Hughes NEJM, 1988 (Medicare US)
• Hartz et al., NEJM 1989 (Medicare US)
• Al-Haider Wan, HSR 1991
• Silber et al. Medical Care 1992, Anesthesiology
  2000

16
Recent Research on Link between Nurse Staffing
and Outcomes

• Aiken et al., JAMA 2002 and 2003mortality
• Needleman et al., NEJM 2002mortality/morbidity/LO
  S
• Uhruh, Med Care, 2003morbidity
• Cho et al., Nurs Res, 2003 mortality/morbidity/ad
  verse events
• Kovner et al., HSR, 2002 morbidity
• Blegen et al., Nurs Res,1998 morbidity
• Czaplinski Diers, Med Care, 1998

17
RN Work Hours and ErrorsSource Rogers, Aiken
et al. Health Affairs July 2004

• No regulations governing nurses work hours.
• About half of staff nurses are scheduled
  routinely to work 12 hour shifts.
• 85 of staff nurses routinely work longer than
  scheduled hours.
• Nurses error rates increase significantly during
  overtime, after 12 hours, and over 60 hrs/wk.
• A substantial portion of the hospital nurse
  workforce is at increased risk of errors because
  of fatigue.
• Safety is a system property thus better
  solutions are required to reduce fatigue and
  related errors.

18
Variation in Nurses Education and its
ConsequencesAiken et al., JAMA 2003

• The proportion of hospital staff nurses with BSNs
  in PA hospitals varied from 0 - 77
• Each 10 increase in proportion of nurses with
  BSNs was associated with a 5 decline in
  mortality following common surgical procedures.
• Each 10 increase in BSN was associated with 5
  decline in failure to rescue

19
As workloads in hospitals increase, so does
mortality ...
But as nurse education increases, mortality
decreases
Deaths per 1000 patients with complications
Staffing (Patients per nurse)
Education ( of nurses with degrees)
Adjusting for patient and hospital
characteristics
L. Aiken, Univ. of Pennsylvania
20
Mortality Rates in Hospitals with Differing
Workloads and Percentages of BSNs
21
Evidence suggests that a smaller, more highly
educated nurse workforce could achieve comparable
outcomes to a larger less well educated workforce.
22
Features of Nurse Practice Environments
Associated with Excellent Outcomes

• Staffing Adequacy Enough nurses and support
  staff to provide care of high quality
• Administrative support for nursing Top
  management responds to problems in patient care
  identified by staff nurses
• Good doctor-nurse relations assumption of
  clinical competence in interactions between every
  doctor and every nurse
• Career support for nurses

23
of Nurses Moderately/Very Satisfied with
Present Job by High and Low Hospital
Organizational Quality and Staffing
24
of Nurses Reporting Patient Falls Occur
Occasionally/Frequently by Hospital
Organizational Quality and Staffing Levels
Note Results for PA, ON, and BC
25
Despite evidence that nurse practice environment
is critical to patient safety, quality of care,
and nurse retention, we do not have many
hospitals that have achieved an excellent nurse
practice environment.
26
Percent of Hospitals In Which Majority (51)
Staff Nurses Agree ...

• Staffing is adequate to provide care of high
  quality 10
• Hospital administration supports nursing practice
  9
• Nurses and physicians have good relations 73

27
Crossing the Quality Chasm

• Evidence abounds that nursing is a pillar for
  building and maintaining safe, patient-centered,
  and affordable healthcare.
• If nursing is weak, safety cannot be guaranteed.
• Keeping patients safe requires fundamental
  changes in organization and design of work,
  improved nurse staffing levels, a better educated
  nurse workforce, and a collegial and
  participatory culture in health care settings.