also found this commentary in jama re aiken's research:
meeting the challenge of nursing and the nation's health
edward o'neil, mpa, phd; jean ann seago, rn, phd
the confluent issues that create the current crisis in nursing in the united states are complex, interrelated, and long-term in their nature. a number of recent studies and reports point to a common set of concerns including an aging professional population, a shrinking cohort of entry-age workers, increasing economic pressure on the hospital care setting (a large cohort of aging baby boomers who will need and demand more hospital-based care), new health care and information technology, changing nature of work in general, new life and work values for workers, and a historical sense of disenfranchisement by the general nursing population from the decision-making process in health care, particularly in the in-patient setting.1-3
in this issue of the journal, aiken and colleagues
4 have once again, as they have for more than a decade, provided an analysis of one very important dimension of this crisis: the direct relationship between the level of nurse staffing and its effect on patient safety, outcomes, and the satisfaction of the nursing professionals in the hospital. they found that each additional patient per nurse was associated with a 7% increase in both patient mortality and deaths following complications and a 23% increase in nurse burnout.
these findings provide significant information to the leadership of the health system as it targets efforts to address the gap in quality and performance.
an earlier assessment of the literature around these issues in the context of the california legislation mandating the ratio of nurses to filled beds found a tendency in the direction of better outcomes and higher levels of professional satisfaction with lower ratios,5 but nothing as conclusive as the study by aiken et al. refinements of this study will compare the skill mix and outcomes on different hospital units as they improve their ability to make the most effective use of nursing skills and talents.
to move this important research to action, however, points to the complexity surrounding nursing issues. of primary concern is the supply of nurses. after the california legislature passed the nurse staffing bill in the face of a deep nursing shortage, one frequently made comment was that, given the current supply of nurses, it would have been better if the legislature had enacted mandatory health, as both measures would be about as equally achievable. a recent study revealed significant nursing shortages in all but 1 of the 15 markets examined.2 even if hospital executives were committed to enriching the staffing mix, few places in the country have a readily available supply of nurses. it does not appear that large numbers of licensed nurses work at other jobs or at home waiting for pay to increase or the job environment to change. a recent study projected the gap between supply and demand for registered nurses to be 808 000 by 2020.1 therefore, a step toward improved nursing ratios will be to increase the number of nurses available for employment. this will mean making education more available and attractive, and making the process of education more effective and efficient.
expanded and improved nursing education programs that do not have full classes will not help. the work environment must make the career more attractive. moving toward improved nursing ratios will, of course, contribute to such a change but other concerns must also be addressed in such a transition. in focus groups conducted over the past 2 years, nurses have consistently identified a nonsupportive, demeaning and, at times, hostile relationship with physicians as one of the most important factors deteriorating the quality of work life for nurses.6 these focus groups also revealed dissatisfaction with pay, lack of investment in information technology to support nursing, and a lack of opportunity to deploy the skills and competencies of nurses to improve patient care and the workings of the system.2, 6 a recent report by the american hospital association has covered this set of issues and how all involved in nursing might address them.3
these improvement strategies are essential but may not be adequate to achieve the level of change that must come about if the nursing profession is to meet the challenges it faces. accepting the existing practice model for nursing as a given and more richly staffing may be desirable, but also may be unaffordable. in the context of improving patient-to-nurse staffing ratios, it is important to consider exactly what registered nurses do and when, how, and where they add value to the quality and outcomes for patient care. identifying how and where this value might be enhanced or provided less expensively by other health care workers, new technologies, or new patterns of practice would be useful. although the current system continues to operate as if the practice models throughout health care were given, it is clear that modification in nursing practice should be a part of any overall solution. changes in the practice model will require the concerted effort of the nursing profession, including both labor and management. the deep collaborative commitment that will be needed to sustain such efforts is evident in only a few places. one of the most promising is the labor-management partnership created by several california labor unions and kaiser permanente.6 the partnership serves nurses, allied health care professionals, and nonclinical workers.
it is also essential to consider changes in the professional model for the organization and governance of nursing. for example, nursing education and practice have spent the better part of a century separating from one another. the challenges of the current and future crisis may require much closer collaboration and, perhaps, new integration. the professional employee model for much of nursing practice also needs to be reconsidered. in almost every location, nurses bring their professional skills to practice as employees while other health professionals, such as dentists, psychologists, speech therapists, and physical therapists, practice as independent professional groups. perhaps it is time to begin exploring how the organization, governance, and financing of nurses as professional groups might move closer to other models of professional organization in hospitals such as with radiologists and anesthesiologists. in many ways, the story of nursing in the 20th century is one of an incomplete revolution in which the independence and autonomy of the profession remained fettered and unable to demonstrate fully its potential contributions to care and health.7 to complete the revolution will require encouragement from outside of nursing as well as significant leadership from within. without such a change, the promise of nursing will remain unrealized.
the nursing shortage is a part of a wider range of problems that beset health care in general. efforts to address the shortage of nurses, and to do so in the context of hospital care, must recognize that in many ways a hospitalization remains an expensive failure of the overall health system. that is, many, if not most, hospitalizations represent a failure to prevent an unintentional injury, properly manage a chronic disorder, or use an appropriate alternate therapy such as hospice. the policy question should not be limited to including only how a more intensive ratio of nurses in the hospital can be provided, but, given limited resources, where the addition of nursing care and service can be best applied both for the patient as well as for society. would an expanded and aggressive public and community nursing program provide more benefit? or could giving every patient access to primary care using nurse practitioners, physician assistants, and physicians actually reduce the demand for in-patient care and the need for more nurses in hospitals? these and other difficult questions must be answered to meet the needs of an aging society and to ensure effective use of human and economic resources.
aiken et al have provided an important piece of scholarship
that helps us to understand more completely the contributions of more intensive nurse staffing to patient safety, outcomes, and the job satisfaction of nurses. policy makers and institutional leaders must be mindful of this as they move to respond to issues in nursing and in health care. it will be essential to pose these larger questions continuously to seek the best answers and outcomes for the profession of nursing, the patients they serve, and society as a whole.