Saving Lives Through Investments in Nursing

1. Saving Lives Through Investments in Nursing Linda H. Aiken, PhD, RN Center for Health Outcomes Research University of Pennsylvania laiken@nursing.upenn.edu L. Aiken, Univ. of Pennsylvania

2. 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 Nightingale’s example by compiling evidence of the link between poor care environments, nursing, and patient outcomes

3. 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

4. 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 Nightingale’s 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)

5. The Quality Health Outcomes Model Care Environment Nurse Interventions Outcomes Client Source: American Academy of Nursing (Mitchell, Ferketich, Jennings, Image: J. Nursing Scholarship 30:43-46, 1998

6. Onerous Nurse Workloads and Chaotic Environments: Latent Errors Waiting to Happen L. Aiken, Univ. of Pennsylvania

7. Issues of Greatest Concern to Hospital CEOs (Top 3 Rankings) Source: ACHE, 2004

8. 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 L. Aiken, Univ. of Pennsylvania

9. 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

10. Empirically Quantifying Differences in the Care Environment Across Large Numbers of Hospitals

11. Nurse A Nurse B Nurse C NurseD MD-RN Relations

12. 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

13. Distribution of UPENN Study Hospitals by Quality of Nurse Work Environment, N=168 N = 42 Better = 25% N = 83 Mixed = 49% N = 43 Poor = 26%

14. Percent Distribution Hospital Nurse Outcomes by Quality of Practice Environment

15. Percent Distribution Nurse Assessed Quality of Care by Type of Practice Environment

16. 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

17. 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

18. 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) L. Aiken, Univ. of Pennsylvania

19. 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 L. Aiken, Univ. of Pennsylvania

20. 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

21. Mortality Rates in Hospitals with Differing Workloads and Percentages of BSNs L. Aiken, Univ. of Pennsylvania

22. 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

23. The Tipping PointMalcolm 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)

24. 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.

25. 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

26. 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

27. What Impact Could Improved Nurse Work Environments Have on Lives Saved? • If all hospitals had “better” nurse practice environments, 4:1 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 Nightingale’s reforms of hospitals, investments in nursing now could prevent thousands of unnecessary deaths.