Substantial Changes Required in Nurses' Work Environment


    "Because the supply of nurses is unfortunately stretched thin right now, they must be supported by work processes, work spaces, hours, staffing practices, and a culture that better defends against errors and readily detects and mitigates errors when they occur. Nurses will be more likely to stay in health care organizations that implement the management and work-design practices recommended in this report."

    Date: Nov. 4, 2003
    Contacts: Christine Stencel, Media Relations Officer
    Chris Dobbins, Media Relations Assistant
    Office of News and Public Information
    202-334-2138; e-mail <>


    Substantial Changes Required in Nurses' Work Environment
    To Protect Patients From Health Care Errors

    WASHINGTON -- The work environment of nurses, the largest segment of the nation's health care work force, needs to be substantially transformed to better protect patients from health care errors, says a new report from the Institute of Medicine of the National Academies. The report calls for changes in how nurse staffing levels are established and mandatory limits on nurses' work hours as part of a comprehensive plan to reduce problems that threaten patient safety by strengthening the work environment in four areas: management, work-force deployment, work design, and organizational culture.

    "No one or two actions by themselves can keep patients safe," said Donald M. 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. "Rather, creating work environments that reduce errors and increase patient safety will require fundamental changes in how nurses work, how they are deployed, and how the very culture of the organization understands and acts on safety. We present a comprehensive plan to address all these areas."

    The nation's 2.2 million registered nurses (RNs), 700,000 licensed practical and vocational nurses, and 2.3 million nursing assistants constitute 54 percent of all health care providers. Nurses are the health professionals who interact most frequently with patients in all settings, and their actions -- such as ongoing monitoring of patients' health status -- are directly related to better patient outcomes. Studies show that increased infections, bleeding, and cardiac and respiratory failure are associated with inadequate numbers of nurses. Nurses also defend against medical errors. For example, a study in two hospitals found that nurses intercepted 86 percent of medication errors before they reached patients.

    Despite the growing body of evidence that better nursing staff levels result in safer patient care, nurses in some health care facilities may be overburdened. For instance, some hospital nurses may be assigned up to 12 patients per shift. Available methods for achieving safer staffing levels -- such as authorizing nursing staff to halt admissions to their units when staffing is inadequate for safe patient care -- are not employed uniformly by either hospitals or nursing homes.

    The decade-old regulations that specify minimum standards for staffing in nursing homes need to be updated, the report says. The U.S. Department of Health and Human Services should require nursing homes to have at least one RN within the facility at all times. HHS also should specify staffing levels that increase as the number of patients increases and that are based on the department's 2001 report to Congress on minimum staff-to-patient ratios for nursing homes. The committee recommended that nursing homes increase internal oversight of their staffing practices and effects on patient safety whenever staffing falls below one RN for every 32 residents, one licensed nurse per 18 residents, and one nurse assistant per 8.5 residents per day. Similarly, hospital intensive care units should increase internal oversight when staffing falls below one nurse for every two ICU patients. Federal and state report cards on nursing homes should include information on nursing staff levels, and measures of staffing levels should be developed for hospital report cards. Whenever possible, health care facilities should avoid using nurses from temporary agencies to fill staffing shortages.

    Long work hours pose one of the most serious threats to patient safety, because fatigue slows reaction time, decreases energy, diminishes attention to detail, and otherwise contributes to errors. While most nurses typically work eight- to 12-hour shifts, some work even longer hours. At the same time, patients admitted to hospitals typically are more acutely ill and require technologically more complicated care than in the past. State regulatory bodies should prohibit nursing staff from working longer than 12 hours a day and more than 60 hours per week, the committee said.

    Along with changes in staff levels and hours, hospital restructuring initiatives begun in the mid-1980s led to substantial changes in how nurses work. As hospitals tried to respond to the financial pressures resulting from modifications to public and private insurance payment systems, their efforts altered the ways in which nurses are organized to provide care and, in many cases, undermined trust between nurses and management. As a key step toward improving nurses' work environments and restoring trust, 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 nursing staff turnover, and determine appropriate staff levels for each unit.

    Orientation programs for newly hired nurses and continuing education programs are being scaled back due to cost pressures, although surveys indicate that many newly licensed nurses do not possess the overall preparation to provide care to today's patient population. Also, many RNs are not receiving ongoing education and training to keep up with the ongoing growth of new medical knowledge and technology. Health care organizations should dedicate financial resources to support nursing staff in the ongoing acquisition and maintenance of knowledge and skills, the report says.

    The committee's recommendations are made in a climate of high rates of turnover among nursing staffs, as well as a nursing shortage that is predicted to worsen in the future. Implementation of the recommended changes in nurses' work environments would likely help health care organizations recruit and retain nurses, the report says. "It may be tempting to think that these recommendations can wait for increases in the supply of nurses, but evidence on nursing retention indicates just the reverse is true," Steinwachs said. "Because the supply of nurses is unfortunately stretched thin right now, they must be supported by work processes, work spaces, hours, staffing practices, and a culture that better defends against errors and readily detects and mitigates errors when they occur. Nurses will be more likely to stay in health care organizations that implement the management and work-design practices recommended in this report."

    The study was sponsored by the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.

    Copies of Keeping Patients Safe: Transforming the Work Environment of Nurses are available on the Internet at Copies of the report will be available early next year from the National Academies Press; tel. 202-334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information (contacts listed above).

    Board on Health Care Services

    Committee on the Work Environment for Nurses and Patient Safety

    Donald M. Steinwachs, Ph.D. (chair)
    Professor and Chair
    Department of Health Policy and Management
    Bloomberg School of Public Health
    Johns Hopkins University

    Ada Sue Hinshaw, Ph.D., R.N. (vice chair)
    Professor and Dean
    School of Nursing
    University of Michigan
    Ann Arbor

    Joy Durfee Calkin, Ph.D.
    Professor Emeritus of Nursing
    University of Calgary

    Marilyn P. Chow, D.N.Sc., R.N., F.A.A.N.
    Vice President for Patient Care Services
    Kaiser Permanente
    Oakland, Calif.

    Paul D. Clayton, Ph.D.
    Chief Medical Informatics Officer
    Intermountain Health Care Inc., and
    Professor of Medical Informatics
    University of Utah
    Salt Lake City

    Mary Lou De Leon Siantz, R.N., Ph.D., F.A.A.N.
    Professor and Associate Dean for Research
    School of Nursing and Health Studies
    Georgetown University
    Washington, D.C.

    Charlene A. Harrington, Ph.D., R.N., F.A.A.N.
    Professor of Sociology and Nursing
    Department of Social and Behavioral Sciences
    School of Nursing
    University of California
    San Francisco

    David H. Hickam, M.D., M.P.H.
    Department of Medicine
    Oregon Health and Science University, and
    Staff Physician
    Portland Veterans Affairs Medical Center

    Gwendylon E. Johnson, M.A., R.N.C.
    Staff Nurse in Women's Health
    Howard University Hospital
    Washington, D.C.

    David A. Kobus, Ph.D.
    Certified Professional Ergonomist
    Pacific Science and Engineering Group
    San Diego

    Andrew M. Kramer, M.D.
    Professor of Medicine, and
    Division of Health Care Policy and Research
    University of Colorado

    Pamela H. Mitchell, Ph.D., R.N., F.A.A.N.
    Associate Dean for Research, and
    Professor of Biobehavioral Nursing and Health Care Systems
    School of Nursing
    University of Washington

    Audrey L. Nelson, Ph.D., R.N., F.A.A.N.
    Veterans Health Administration Patient Safety Center of Inquiry
    VHA Health Services Research Enhancement Program on Patient Safety Outcomes, and
    Associate Director for Clinical Research
    College of Nursing
    University of South Florida

    Edward H. O'Neil, Ph.D.
    Professor of Family and Community Medicine and Dental Public Health
    University of California
    San Francisco

    William P. Pierskalla, Ph.D.
    Department of Operation and Technology Management
    Anderson Graduate School of Management
    University of California
    Los Angeles

    Karlene H. Roberts, Ph.D.
    Haas School of Business
    University of California

    Denise M. Rousseau, Ph.D.
    H.J. Heinz II Professor of Organizational Behavior
    Carnegie Mellon University

    William C. Rupp, M.D.
    President and Chief Executive Officer
    Immanuel St. Joseph's - Mayo Health System, and
    Vice Chair
    Mayo Health System
    Mankato, Minn.

    INSTITUTE staff

    Ann E. K. Page, R.N., M.P.H.
    Study Director
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  3. by   pickledpepperRN
    About Time
    Thank you, Christopher Heredia, for spending time following RNs ("The Longest Day," Nov. 9). As an RN, I'm glad you spent time with us. I am an active member of the California Nurses Association, and the story proves that hospitals need to spend more time planning to implement the safe staffing bill instead of fighting it. Having worked with my colleagues at CNA since 2001, when the bill finally passed, I find it tragic that the California Healthcare Association and many hospital systems have spent billions of dollars to prevent putting RNs back at the bedside, where we belong.
    Nancy Lewis, RN FNP
    San Francisco

    I really appreciated the article "The Longest Day." I recently spent 12 hours in San Francisco General Hospital's emergency room, and several days on one of the floors. All of the staff was as passionate and professional as RN Esther Marania in your piece. I was in distress after being in a motorcycle accident. They are understaffed, but make up for it with a positive attitude and sheer energy. Once on one of the floors, the nurses were all friendly, compassionate, and detailed in their work. It was like a TV movie as the nurses attended drug overdoses, the mentally ill, even prisoners. These professionals work long and hard hours, and deserve the recognition your article gave them.
    Bob Balhatchet
    San Francisco