How Nurses Work
A Key Factor in
Nurses serve as the front line of defense against medical errors, often catching mistakes -- such as inaccurate drug doses -- before they reach patients. But because of inefficient work processes, inadequate staffing levels, and other systemic problems, nurses also cause or contribute to medical mishaps.
A great deal of attention has focused on the nationwide nursing shortage and the hours that nurses and other health professionals work. However, a recent report by the Institute of Medicine dispels the notion that there is a single "magic bullet" solution to reducing errors.
"Making sure that there are enough nurses on duty and that they are not working overly long hours certainly are important steps, but no one or two actions by themselves can improve patient safety," said Donald Steinwachs, chair of the committee that wrote the report, and chair, department of health policy and management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. "Keeping patients safe requires fundamental changes in the organization of nurses' work, how they are deployed, their involvement in management and decision-making, and how health care organizations understand and act on safety."
In addition to recommending that nurses' work hours be limited to no more than 12 per day and that report cards on nursing homes and hospitals include information on their nursing staff levels, the report calls on regulators and health care organizations to devise strategies to reduce the onerous burden of paperwork and documentation, which consumes up to 28 percent of registered nurses' time in hospitals.
To restore trust among nurses that was eroded during health care restructuring initiatives begun in the mid-1980s, the report urges health care organizations to involve nurse leaders in all levels of management and to solicit input from nursing staff on decisions about work design and implementation. Nurses are in prime positions to help pinpoint inefficient work processes that could contribute to errors, identify causes of staff turnover, and determine appropriate staff levels for each unit. In addition, organizations should dedicate a portion of their budget to helping nurses maintain and acquire new knowledge and skills through ongoing training programs.
Although the nursing shortage makes it seem difficult to implement some of the report's recommendations, the committee urges immediate action. "Because the supply of nurses is unfortunately stretched thin right now, they must be supported by a system that better defends against errors and readily detects and mitigates them when they occur." -- Christine Stencel
Keeping Patients Safe: Transforming the Work Environment for Nurses. Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Institute of Medicine (2004, 488 pp.; ISBN 0-309-09067-9; available from the National Academies Press, tel. 1-800-624-6242; $44.95 plus $4.50 shipping for single copies).
The committee was chaired by Donald Steinwachs, chair, department of health policy and management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore. The study was funded by the Agency for Healthcare Research and Quality of the U.S. Department of Health and Human Services.