Nurses, Patient Safety, and the Future of Health Care

1. Nurses, Patient Safety, and the Future of Health Care Sean Clarke, RN, PhD, CRNP, CS Associate Director, Center for Health Outcomes and Policy Research University of Pennsylvania School of Nursing Philadelphia, PA

2. Outline • Nurses--What the workforce trends indicate • Patient safety: What we are learning about the connections between working conditions and patient outcomes • The future: Where do we go next?

3. NURSES ...

4. Nursing Shortage:A Supply and Demand Issue • Demand: • Patient acuity levels and care needs • Agency hiring practices/staffing patterns • Demographic trends • Supply: • Entry into profession • Aging and retirement • Attrition from jobs and from profession

5. Demand

6. Medicine used to be simple, ineffective, and relatively safe. Now it is complex, effective, and potentially dangerous. Sir Cyril Chantler Dean, London Guy’s Hospital Lancet 355(1999), 1178-81. In Wachter & Shojania, 2004

9. Supply

10. 2020 1980 Source: U.S. DHHS, July 2002

11. October 2001, NOAA Active Satellite Archive

12. The “Perfect Storm” • Demographic trends in the profession • Financial pressures within health care • Demand for health care and demand for nursing services within the health care system

13. … PATIENT SAFETY ...

15. Harvard School of Public Health Patient Safety Poll, Spring 2002 • Experienced a mistake in their medical care or that of a family member at some time • 35% of physicians • 42% of the public • 29% of physicians observed an error causing serious harm to a patient in the past year • 60% of these physicians believed it was somewhat or very likely that they would see a similar one at the same institution within the next year

16. Current Perspectives on Quality and Safety Problems • Strong focus on failings of individual workers (a.k.a. “blame and shame”) • Turning to systems factors as determinants of safety of care

17. A Systems Perspective on Safety in Health Care

18. Nurse Practice Environments, Nurse Staffing, and Outcomes Nurse Practice Environments Resource adequacy Administrative support Nurse-physician relations Hospital Leadership Nurse Staffing RN:patient ratios Staffing skill mix

19. Nurse Practice Environments, Nurse Staffing, and Outcomes Nurse Practice Environments Resource adequacy Administrative support Nurse-physician relations Process of care, including surveillance/early detection of complications Nurse Staffing RN:patient ratios Staffing skill mix Patient outcomes

20. Nurse Practice Environments, Nurse Staffing, and Outcomes Nurse Practice Environments Resource adequacy Administrative support Nurse-physician relations Nurse job outcomes Process of care, including surveillance/early detection of complications Nurse Staffing RN:patient ratios Staffing skill mix Patient outcomes

21. Nurse Practice Environments, Nurse Staffing, and Outcomes Nurse Practice Environments Resource adequacy Administrative support Nurse-physician relations Nurse job outcomes Process of care, including surveillance/early detection of complications Hospital Leadership Nurse Staffing RN:patient ratios Staffing skill mix Patient outcomes

22. A Generic Model for Our Thinking Human Resources / Context of Care Leadership Decisions Process of Care Patient Outcomes

23. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Satisfaction Linda H. Aiken, PhD, RN Sean P. Clarke, PhD, RN Douglas M. Sloane, PhD Julie Sochalski, PhD, RN Jeffrey H. Silber, MD, PhD October 23/30, 2002. Journal of the American Medical Association, 288, 1987-1993 Funding Source : National Institute of Nursing Research, National Institutes of Health

24. Effect of Nurse Staffingon Mortality • For every one patient-per-nurse increase in nursing workload in a Pennsylvania hospital: 14% increase in risk of death within 30 days for an individual patient • After controlling for full set of hospital and patient variables: 7% increase in risk of death

25. Other Key Results of the JAMA Paper • A parallel increase of 7% in risk of death for patients with complications for every 1 patient per nurse increase in average workload in a hospital • 23% and 15% increases in the risks of burnout and job dissatisfaction for nurses in hospitals for every additional patient per nurse (~11,000 nurses studied)

26. Education Levels of Hospital Nurses and Patient Mortality • Aiken, Clarke, Cheung, Sloane, & Silber (September 24, 2003, Journal of the American Medical Association) • The proportion of hospital staff RNs holding baccalaureate or higher degrees as their highest (not initial) credential ranged from 0 to 77% across the hospitals.

27. Excess Surgical Deaths (Observed-Expected) per 1000 Cases Across PA Hospitals With Differing Proportions of BSN/MSN-Educated Nurses More deaths than expected Fewer deaths than expected Proportion of Nurses with BSNs/MSNs

28. Patient deaths after surgery are lowest in hospitals where nurses care for fewer patients on average and have higher levels of education Patient-to-nurse ratios Deaths per 1000 patients % Bachelor’s-prepared nurses

29. Needleman, Buerhaus, et al. (2001). Nurse Staffing and Patient Outcomes in Hospitals. (Report available at www.hrsa.gov/dn) • Main analyses involved 1997 discharges from 799 hospitals across 11 states (AZ, CA, MA, MD, MI, NV, NY, SC, VA, WI, WV) • the study found statistically significant relationships between nursestaffing variables andthe following patient outcomesin acute care : • Medical Patients: urinary tract infection, pneumonia, shock,upper gastrointestinal bleeding, length of stay • Patients Undergoing Major Surgery: urinary tract infection, pneumonia, failure to rescue (defined as the death rate among patients with sepsis, pneumonia, shock, upper gastrointestinal bleeding, or deep vein thrombosis)

30. Needleman, Buerhaus, et al. (2001). Nurse Staffing and Patient Outcomes in Hospitals. (Report available at www.hrsa.gov/dn) • high RN staffing associated with 3-12% decrease in likelihood of events, high total nursing staffing associated with 2-25% decrease • no effects of staffing on mortality in either medical or surgical patients • published in New England Journal of Medicine in May 2002

31. Needlestick Injuries • In hospital units studied in 1991, lower staffing levels and weaker working environments were associated with doubled to tripled risks of needlesticks (Clarke et al., 2002a, Am J Public Health) • In hospitals with above-average reputations (mostly reputational and certified magnets) in 1998, lower staffing levels and weaker working environments were associated with 50% increases to doubled risks of needlesticks (Clarke et al., 2002b, Am J Infection Control)

32. Annual Needlestick Rates Among Nurses in Hospitals with Fewest vs. Most Professional Development Elements % of Nurses with 1+ Injuries Investments in Orientation/Education/Standards

33. Hospital Conditions Associated with Lower Surgical Patient Mortality • High standards of care • Preceptorship program • Clinically-competent nurses • CNSs/expert clinicians • Support in pursuing degrees • Involvement in policy • Collaborative RN-MD practice • Highly-specialized units

34. Summary • Across a variety of study designs and clinical populations: • HIGH levels of nurse staffing and/or skill/education among nurses • work environmentswhere nurses feelSUPPORTED are associated with DECREASED rates of poor patient outcomes and poor nurse job outcomes in inpatient care

35. Our central premises at Penn’sCenter for Health Outcomes and Policy Research Organizational features are very important determinants of patient and nurse safety in hospitals The same features that make hospitals good, safe places for patients are also the same things that make them safe, healthy work environments for nurses

36. Possible mechanisms for the effect when it is found: • More nursing interventions can be carried out (preventive measures) • Better surveillance for patient problems • Higher skill in carrying out tasks • Better communication and collaboration with physicians and members of other disciplines • Lower levels of psychological stress

37. Successful Rescues When Complications Arise • Surveillance • Interpreting cues • Taking appropriate immediate actions • Bringing the right personnel to the bedside • Instituting appropriate definitive corrective treatment in time Clarke & Aiken, 2003

38. Recent Policy Documents ... • American Hospital Association. (2002). In our hands: How hospital leaders can build a thriving workforce. • Joint Commission on Accreditation of Healthcare Organizations. (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. • Institute of Medicine. (2003). Keeping patients safe: Transforming the work environment of nurses.

39. Some Relatively Recent Developments in Patient Safety • Root cause analysis for sentinel events • Aggressive dissemination of best practices that improve patient safety • Management of workplace design and development of a “culture of safety”

40. Other Factors Affecting Safety • Other health professionals (especially shortages of pharmacists, technicians, etc.) • Information technology

41. … AND THE FUTURE OF HEALTH CARE

42. Number of Medicare Beneficiaries The number of people Medicare serves will nearly double by 2030. 76.8 61.0* 45.9 Medicare Enrollment (millions) 39.6* 34.3 28.4* 20.4 * Numbers may not sum due to rounding. Source: CMS, Office of the Actuary.

43. 10 Occupations Expected to Show the Greatest Growth in the U.S. 2002-2012February 2004, www.bls.gov/emp Registered Nurses 623,000 College professors and teachers 603,000 Retail salesperson 596,000 Customer service representative 460,000 Fast-food worker 454,000 Cashier 454,000 Janitor 414,000 General manager 376,000 Waiter 367,000 Nursing aides, orderlies, attendants 343,000

44. The New Generations in the Workplace(Tulgan, 1996 and others) • will not sacrifice their family for their job • primary goal is self-sufficiency • less motivated by promises of overtime pay • motivated by personal satisfaction with their jobs • trust themselves rather than employers and believe in advancement based on performance, not longevity • will change jobs often seeking opportunity • looking for meaningful work that helps others • very technologically sophisticated • want to work with a highly motivated team of committed people • very sensitive to social justice and equity issues

45. FTE Employment of Registered Nurses By Age and Country of Birth, 1994-2002 Thousands Source: Buerhaus et al, 2003, Health Affairs; US Bureau of the Census

46. Update, Spring 2003 Fitch sees no relief to the current nursing shortage … [and] believes health care providers’ financial stability will continue to be challenged, especially with modest reimbursement increases and rising expenses in other areas ... Health Care Staffing Shortage Health Care Special Report Fitch Rating Service (www.fitchratings.com) May 13, 2003

47. The Value of Investment in Health Care--Better Care, Better Lives 470,000 more deaths Where would we be in 2000 without healthcare advances? 2.3 million more disabled persons $2254 per capita in savings 206 million more days in hospital AHA, 2004

48. Gallup Poll--2000% of Respondents Rating that Various Professions Have Very High/High Honesty and Ethics Nurses 79% Druggists, pharmacists 67 Veterinarians 66 Medical doctors 63 Grade & high school teachers 62 Clergy 60 College teachers 59 Dentists 58 Engineers 56 Police officers 55 Car salespeople 7 83% in 2003 http://www.gallup.com/poll/releases/pr001127.asp

49. Trends to Contend With • Cost controls, skyrocketing demand in healthcare, ? future of health insurance • industry turbulence (no shortage of work, but will it be well-paid?) • Anxieties and expectations about working conditions and salaries will rise across in health care • competition created by newer workers substituting for highly-educated, traditional-track health professionals • Demands for health care workers • revolution in health professions education--new models coming ... • increased flexibility--competency-based education • increased demands for articulation • new recruitment and retention goals/strategies

50. Two of the Major Policy Options for Dealing with Health Care Issues • Providing incentives • Funding (PAY FOR PERFORMANCE?) • Tax relief • Regulation • Setting criteria for operation, licensure (PUBLIC DISCLOSURE OF STAFFING/SAFETY DATA?) • Enforcement