In 1999, the National Academy of Medicine, then-called the Institute of Medicine, released a landmark report "To Err is Human" that concluded nurse work environments needed to improve to reduce patient harm, yet nurses at many hospitals say patient safety remains a concern, according to a study published this month in Health Affairs.
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For the new study, researchers looked at nurses' perception of their work environment as well as nurses' and patients' assessments of patient safety at individual hospitals at two points between 2005 and 2016. The study included 535 hospitals located in four large states: California, Florida, New Jersey, and Pennsylvania. The hospitals account for more than one-quarter of discharges in the country.
Work environment improvement appears slow
Overall, 80.7% of RNs said their work environment was less than excellent and 60.4% said their hospitals' quality of patient care was less than excellent.
The researchers found work environment scores improved by more than 10% at 21% of hospitals over the study period. Among the 21% of hospitals that saw improvements, favorable hospital ratings reported by patients increased by 11% and the number of patients who would recommend the hospital increased by 8%. In addition, these hospitals saw both the percentage of nurses reporting excellent quality care and a favorable safety grade increase by 15%.
Meanwhile, 7% of hospitals involved in the study saw work environment scores decline. Among those hospitals, the percentage of nurses giving favorable patient safety grades dropped by 19%.
About half of the RNs overall surveyed agreed that "staff feel like their mistakes are held against them," while around 40% agreed that "important information is lost during shift changes" and that "things fall between the cracks." In addition, over one-third of the surveyed RNs agreed that "staff do not feel free to question authority."
Linda Aiken, lead author on the study and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, said it's "very surprising given all the research and hundreds of studies have come out that there hasn't been more attention on nurses' working environment." She added that, despite millions of dollars dedicated to solving the problem, "patient safety is improving at a very slow rate."
Aiken cited another study she co-authored that found patients who received resuscitation in hospitals with poor nurse work environments had survival rates 22% lower than those in good nurse work environments. She added, "Making organizational change sounds like a soft thing compared to a 'magic bullet' like buying a new piece of equipment, but there is so much evidence now that it is essential."
How hospitals can improve
In its 1999 report, the then-IMO provided a few recommendations on how hospitals can improve their work environments. They include prioritizing:
- Adequate nurse staffing;
- Creating governing boards focused on safety, leadership, and evidence-based practices;
- Effective nursing leadership;
- Promoting inter-professional collaboration;
- Support for continued learning and improved decision-making; and
- A work design that promotes safety.
These changes require "a culture of openness, mutual trust, and respect between management and clinicians," Kacik writes.
There are also policy changes that could help, Aiken said. For example, CMS' Hospital Compare tool should include nurse-to-patient staffing ratios and a measurement of the hospitals' work environment, she said (Kacik, "Transformation Hub," Modern Healthcare, 11/5; Aiken et al., Health Affairs, November 2018).
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