Saving Lives Through Investments in Nursing

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Saving Lives Through Investments in Nursing

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

L. Aiken, Univ. of Pennsylvania
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Patient Safety in Modern Hospitals

• The care environment in hospitals is still
  hazardous
• Institute of Medicine estimates that medical
  errors are among the 5 leading causes of death
• Contemporary researchers are following
  Nightingales example by compiling evidence of
  the link between poor care environments, nursing,
  and patient outcomes

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Types of Errors

• Active errors are unsafe acts that can have
  immediate adverse consequences
• Latent errors are the result of decisions taken
  at higher levels of an organization, whose
  damaging consequences may become evident only
  when they combine with trigger factors
• Managerial decisions with damaging consequences
• Understaffing failure to correct problems in
  clinical care culture of poor team
  communication under education of managers and
  clinicians
• Triggers acute casemix, inexperience, fatigue,
  chaos

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Importance of Latent Error to Patient Safety

• Fixing latent system errors is more likely to
  result in safer systems than attempts to minimize
  active errors at the point at which they occur
• Analogous to Nightingales approach to reducing
  deaths in Crimea which was highly successful
• Consistent with Mitchell et al. Quality Health
  Outcomes Model
• (IOM, To Err is Human, 2000 Reason, Human
  Error, 1990)

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The Quality Health Outcomes Model
Care Environment
Nurse Interventions
Outcomes
Client
Source American Academy of Nursing (Mitchell,
Ferketich, Jennings, Image J. Nursing
Scholarship 3043-46, 1998
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Onerous Nurse Workloads and Chaotic Environments
Latent Errors Waiting to Happen
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Issues of Greatest Concern to Hospital CEOs (Top
3 Rankings)
Source ACHE, 2004
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Investments in Nursing Link with Nurse,
Patient, Institutional Outcomes

• Good surveillance keeps bad things from
  happening.
• Nurses are the surveillance system for early
  detection and intervention for adverse
  occurrences
• Surveillance is influenced by nurse staffing,
  education, communication
• Once a problem is identified, organizational
  features of practice environment determine the
  success of patient rescue.
• Investments in nursing pay for themselves through
  prevention of costly adverse patient outcomes and
  improved nurse retention

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Nurse Burnout

• Close to 50 hospital staff nurses score in high
  burnout range on standardized tests
• Burnout erodes nurse surveillance, vigilance, and
  clinical decision-making
• Error reduction is dependent upon reducing
  burnout
• Burnout is associated with inadequate staffing
  and poor practice environment

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Empirically Quantifying Differences in the Care
Environment Across Large Numbers of Hospitals
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Nurse A
Nurse B
Nurse C
Nurse D
MD-RN Relations
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Measuring Quality of Nurse Practice Environment

• Nursing Work Index, a nurse survey-based
  instrument, selected by National Quality Forum in
  2004 for National Voluntary Consensus Standards
  for Nursing Care Performance
• Staffing adequacy
• Nursing foundations for quality
• Nurse manager ability leadership
• Nurse-physician relations
• Nurse involvement in hospital affairs

Aiken and Patrician, Nursing Research, 2000
Lake, Research in Nursing Health, 2002
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Distribution of UPENN Study Hospitals by Quality
of Nurse Work Environment, N168
N 42
Better 25
N 83
Mixed 49
N 43
Poor 26
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Percent Distribution Hospital Nurse Outcomes by
Quality of Practice Environment
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Percent Distribution Nurse Assessed Quality of
Care by Type of Practice Environment
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Hospital Nurses Reports that Medical Errors
Occur Frequently by Poor versus Better Nurse Work
Environments

• Occur Frequently
• Medication errors 73 more likely
• Patient falls with injuries 90 more likely
• Nosocomial infections 55 more likely

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Odds on Dying Following Common Surgical
Procedures

• Odds on dying reduced by 19 in hospitals with
  better vs. poorer nurse practice environments
  after accounting for differences in patient
  characteristics, nurse staffing, education,
  physician qualifications, hospital
  characteristics

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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)
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Variation in Nurses Education and its
Consequences

• The proportion of hospital staff nurses with BSNs
  in 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

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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
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Mortality Rates in Hospitals with Differing
Workloads and Percentages of BSNs
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How realistic is it to set the bar higher for the
hospital care environment?

• 25 of hospitals have been able to create
  better care environments and they are working
  under the same fiscal constraints as all hospitals

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The Tipping Point Malcolm Gladwell, 2000

• Change is possible people and institutions can
  radically transform their behavior in face of the
  right kind of impetus.
• Tipping point is about how little things can make
  a big difference within institutions/across the
  nation.
• Examples in nursing
• Advanced practice nursing (completed)
• Magnet recognition (in process)
• Baccalaureate education for nurses (potential)

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Advanced Practice Nursing

• Advanced practice nursing was an innovation
  developed by leaders in nursing and medicine
• Object To improve access to primary care.
• Many different applications of the concept.
• Timing was good shortage of primary care MDs
  and managed care introduced new incentives.
• Research documented safety.
• Consumers voted with their feet 1/3rd see a
  non-physician provider each year by choice.

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Magnet A Catalyst for Change

• Established feasibility
• Research showing magnet outcomes are better
• ANCC Magnet Recognition is a blueprint that
  produces better work environments
• Success demonstrated across hospital type
• A critical mass and rapid growth 180 magnets
  250 applications pending
• Recognition outside nursing US News 100 best
• Magnet could create tipping point for major
  improvement in nurse practice environments

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Employers May Break the Impasse Over RN
Qualifications

• 2005 AONE policy supporting baccalaureate
  preparation for nurses may act to neutralize
  entry into practice battles just like APNs have
  been integrated into practice by employers
  without fully changing legal basis for practice
• Employers may also be motivated to hire BSNs to
  reduce their costs of upgrading nurses education
  to desired entry level
• Growing consensus within nursing about BSN
  qualifications

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What Impact Could Improved Nurse Work
Environments Have on Lives Saved?

• If all hospitals had better nurse practice
  environments, 41 RN staffing ratios, and 60
  BSNs, about 12,000 deaths following common
  surgical procedures could be prevented annually
• These procedures account for 12 admissions and
  have a lower mortality rate than non-surgical
  patients
• Total lives saved annually if all hospitals
  improved the quality of their nurse practice
  environments to the level in the better 25 of
  hospitals, would be greater than 30,000
• As in Nightingales reforms of hospitals,
  investments in nursing now could prevent
  thousands of unnecessary deaths.