Greater Investments in Nurses are Key to Preventing Patient Harm

By Kelly M. Pyrek

One of the drivers of healthcare reform, a landmark study by the National Academy of Medicine (NAM) issued nearly 20 years ago, highlighted the prevalence of medical errors and called for a national commitment to reduce patient harm. Despite substantial investment by government and private institutions to increase patient safety, progress has been slow and uneven, experts say. 

One of those experts is Linda Aiken, PhD, RN, director of the Center for Health Outcomes and Policy Research at Penn State, who, along with colleagues from the Center for Health Outcomes and Policy Research (CHOPR) of the University of Pennsylvania School of Nursing, say that progress in improving nurse working environments and improving nurse staffing is lacking. She also emphasizes that this finding can impact the performance of nurses functioning as infection preventionists (IPs).

"An IP will not likely have successful outcomes in an institution where nurse staffing is inadequate and where clinical work environments are chaotic and waste clinicians’ time," Aiken says.  "Despite good science showing how to prevent healthcare associated infections, our study finds that almost one-third of bedside care nurses give their hospitals unfavorable grades on infection prevention. Among the 535 hospitals we studied, those that had improved their work environments more than 10 percent over the decade had significantly better grades on infection prevention. And in our research, we have found that job dissatisfaction among all staff and staff turnover is higher in hospitals with poor clinical care environments." 

The researchers investigated whether this key NAM recommendation corresponded to improved patient safety, as reported by patients and nurses. According to their study, published in the November 2018 issue of the journal Health Affairs, between 2005 and 2016, only 21 percent of hospitals substantially improved their clinical work environments; 71 percent made no improvements and 7 percent experienced deteriorating work environments. Hospitals that improved their work environments saw their patient safety indicators improve as well, with favorable nurse and patient appraisals of patient safety increasing by 11 percent to 15 percent. Grades on patient safety remained the same for hospitals in which work environments remained the same, and favorable grades on patient safety fell by 19 percent in hospitals with worsening care environments.

“A key recommendation of the National Academy of Medicine in 1999 for improving patient safety was to transform nurse work environments in hospitals to ensure adequate nurse staffing and clinical work environments that freed nurses to spend their time in direct patient care,” says Aiken, who is also the Claire M. Fagin Leadership Professor in Nursing at Penn. “Our recent study of nurses and patients suggests that those recommendations have not been uniformly adopted by hospitals, which may be hampering progress toward improving patient safety and preventing patient harm.”

The study included 535 hospitals in four large states in two time-periods -- 2005 and 2016 -- and reports from 53,644 RNs and 805,881 patients who practiced or received care at these hospitals. Nearly 30 percent of hospital nurses in 2015-16 gave their hospitals unfavorable grades on patient safety, and 55 percent would not definitely recommend their hospital to a family member or friend who needed care.  
Patients also expressed concern about quality and safety with 30 percent reporting that they would not definitely recommend their hospital. Nearly 40 percent of patients said that they did not always receive help quickly from hospital staff, and nearly 40 percent reported that medications were not always explained before given. 

“Patients’ and nurses’ appraisals show patient safety in hospitals remains a concern almost 20 years after the NAM originally called for national action to reduce patient harm,” says Aiken. “Our findings show that clinicians continue to face challenging but modifiable work environments that interfere with their ability to implement safety interventions consistently. Improving work environments through organization and culture change is a comparatively low-cost intervention to improve quality of care and patient safety.”
Only 21 percent of hospitals significantly improved their clinical work environments over the past decade; most made no improvements and 7 percent experienced deteriorating work environments.
The survey is a wake-up call for hospitals, especially since close to 30 percent of nurses gave their hospital an unfavorable grade on infection prevention.

"Ours is a panel study where we have tracked infection prevention grades over a decade comparing each hospital's infection prevention scores to its own baseline," says Aiken. "Only in hospitals that significantly improved work environments did infections grades improve significantly. These results thus show a causal relationship between improving nurse staffing and clinical work environments and improved infection control. We know that recommended clinical care bundles are successful in preventing central line infections, but research shows the bundles must be fully implemented 95 percent of the time. In poor work environments, nothing can be assured at 95 percent fidelity, and hence infections continue." 

Hospitals that significantly improved their care environments experienced much greater improvements in patient safety indicators and implementing a culture of patient safety than hospitals that did not improve clinical care environments as recommended by the National Academy of Medicine. Hospitals in which the work environment worsened exhibited a 25 percent decrease in the percentage of nurses saying that patient safety is a top priority of management.

Despite aggressive healthcare reform initiatives, pay-for-performance strategies and quality improvement campaigns, improvement is sluggish in many healthcare systems.

"Nurse staffing and quality of work environments are not reportable on Hospital Compare or the equivalents in nursing homes and home care and thus institutions do not identify investments in nursing as safety interventions or infection prevention interventions," Aiken explains.  "We recommend that the Centers for Medicare and Medicaid Services (CMS) requires Medicare providers to submit patient to nurse ratios and the National Quality Forum endorsed PES-NWI to hospital compare so that institutions than benchmark themselves and consumers could have greater access to important information that will help keep them safe.  

Aiken recommends interventions that poor-performing hospitals must make to improve: "Hospitals that are performing poorly on infection prevention should improve their nurse staffing and work environments," she says. "The prevention of costly infections would offset the costs of adding more nurses.  And improving clinical work environments is a low-cost intervention to prevent infections; it primarily involves greater engagement of all clinicians in hospital decision-making and creating a blame-free culture that is foundational to a learning organization."

Aiken continues, "Increasing staff engagement in decision-making is key to improving clinical work environments and fostering interprofessional communication and collaboration. Our research shows that hospitals with good work environments have higher functioning interdisciplinary teams. The Magnet Recognition program is highly evidence-based and has developed a blueprint for successfully transforming institutions to engage staff and those engaged staff help implement innovations that improve care. Magnet is not just for nurses but improves outcomes of all who work in hospitals and their patients."

Co-authors of the paper include Douglas M. Sloane, PhD; Hilary Barnes, PhD, CRNP; Jeannie Cimiotti, PhD; Olga F. Jarrín, PhD, RN; and Matthew D. McHugh, PhD, RN, all CHOPR Senior Fellows. This research was funded by the National Institute of Nursing Research, National Institutes of Health and the Robert Wood Johnson Foundation.