From Nursing Spectrum
Working Conditions Critical for
Nurses and Patients Alike
Karla A. Knight, RN, MSN
Masthead Date July 01, 2002
13,471 nurses, 210 hospitals, and 232,342 patients-in Pennsylvania alone...
An ongoing international study of staffing, organizational culture, and patient outcomes is demonstrating what many nurses have always understood: that inadequate staffing and dissatisfaction with work do indeed impact what happens to patients.
The International Hospital Outcomes Study (IHOS) is led by University of Pennsylvania School of Nursing researchers, including principal investigator Linda Aiken, RN, PhD, FAAN, FRCN, and Sean Clarke, RN, PhD, CRNP, and colleagues from the school's Center for Health Outcomes and Policy Research and around the world. The researchers collected data from nurses and hospitals in Canada, Germany, England, Scotland, and Pennsylvania.
The study results reflect the ongoing crisis in hospitals, according to Clarke. "We're facing a nursing shortage, and at the same time, the media has the public focused on the safety and quality of healthcare," he says. "We want to get the message across of the importance of nurses' working conditions on outcomes."
The researchers surveyed nurses in acute care hospitals to determine the organizational climate, nurse job satisfaction and burnout, nurse-reported quality of care, and patient outcomes, such as patient falls and medication errors. Data on staffing and other hospital characteristics was collected from regulatory bodies and the American Hospital Association; nurses surveyed were also asked about their patient load on the last shift worked.
Hospitals' organizational climates were measured as the nurses' perceptions of their workplace. Nurses responded to questions about support from their nurse managers, decision making and autonomy of nurses, continuity of patient care, staff training, and perceived clinical competence of nurse colleagues. Nurses were asked about their job satisfaction and burnout levels, and they also rated the quality of care on their units.
The researchers examined mortality and failure-to-rescue rates across 232,342 surgical patients in Pennsylvania. Failure to rescue is a way of measuring how well hospitals look after patients. Jeffrey Silber, MD, PhD, also of the University of Pennsylvania, developed this measurement because mortality rates may have more to do with patient characteristics and surgery types than with provider characteristics. Failure to rescue measures the probability of death following a complication that is not present on the patient's admission to the hospital.
Inadequate Staffing and Risk of Dying
The study results indicate that when even one additional patient is assigned to an average nurse's workload in a hospital, the risk of patient death increases. Moreover, similar increases in workload also raise failure-to-rescue rates, suggesting that heavier workloads interfere with nurses' appropriately recognizing complications and getting the necessary treatment and services for patients, which may play a role in preventable deaths.
Heavier nurse workloads were also found to increase the likelihood of patient falls and decrease patient-family satisfaction. Inadequate staffing is also associated with burnout and poor quality of care as rated by nurses.
"While some would suggest that these results conclusively demonstrate the need for mandated nurse-patient ratios, our research group is not ready to say that," says Clarke. "Intuitively, we as nurses do believe that somewhere there has to be a 'floor,' a point at which it is physically impossible to provide decent care. But we don't know what that floor is."
Climate Also Predicts Outcomes
Staffing is only part of the picture when looking at outcomes, says Clarke: "We like the idea of also concentrating on organizational climate because we believe that even the best-staffed hospitals aren't going to get good outcomes for patients and nurses if they don't have a good organizational climate-that is to say, if they don't have solid leadership, and if they don't invest in staff training so that staff have the tools that they need to do their jobs."
So far, the IHOS has linked poor organizational climate with increased levels of patient falls, nosocomial infections, medication errors, patient-family complaints, nurse sharps injuries, nurse-rated quality of care, nurse job dissatisfaction, nurse burnout, and nurses' intent to leave their current positions. "The effect of staffing levels on mortality provides more shock value," says Clarke, "but these outcomes associated with poor organizational climate also tell us about hospital conditions and quality of care."
The bottom line? "If we are going to hang onto nurses in hospitals, keep them working in hospitals, and keep them satisfied with their jobs," says Clarke, "we have to attend to these organizational climate issues-these issues about whether or not nurses have what they need to give quality care."
Research, Resources, and Realities
Aiken and Clarke have presented the results of IHOS to many groups, including other researchers, nurse executives, nursing school faculties, and hospitals applying for magnet status. Clarke also discusses the research findings with another important group-his senior nursing students. He acknowledges that nursing schools should be teaching the ideal-what nurses can do when resources are infinite-but he also believes that it's important to get students thinking about the realities of practice.
"New grads don't have to be passive in relating to the healthcare system," says Clarke. "If they understand our research and understand some of the trends, then maybe they can influence the way decisions get made, and ultimately, maybe they can become the leaders that reshape the system."
Those who hear the results of the research may question whether job satisfaction and burnout are all that important since most workers are stressed out in one way or another.
But Clarke has a ready response."In some ways," he says, "looking at burnout and satisfaction is more important than staffing. Nurses are twice as likely to burn out in hospitals when there is a bad organizational climate."
And burning out contributes to a worsening shortage of nurses and to negative views of the profession. "It is all interconnected" says Clarke. "The issues of the shortage and patient safety are intertwined more than anyone ever thought. A lot of things that are driving nurses away from hospital practice are the same things that are not making patient care particularly safe."
Even in the midst of the sometimes shocking results of the IHOS, Clarke and his colleagues remain hopeful about the future of hospital nursing. "What we want to do with this research is ensure that hospitals continue to be viable places to work, with the best possible outcomes for patients," he says. "We'd like the research not to discourage but rather to serve as an impetus for change."