Inpatient Safety Linked to Nurse Work Environment

Troy Brown, RN

November 07, 2018

Patient safety is better in hospitals that have made improvements to the clinical work environment for nurses, according to a survey of registered nurses (RNs) and patients from 535 hospitals. Hospitals that fail to improve the clinical work environment may be slowing their own progress toward reducing patient harm, researchers say.

The study, by Linda H. Aiken, PhD, from the University of Pennsylvania, Philadelphia, and colleagues, was published online November 5 in Health Affairs.

In 2003, the Institute of Medicine published Keeping Patients Safe: Transforming the Work Environment of Nurses. The report contained a review of data showing that nurse staffing and work environments that supported nurses' performance were tied to better patient safety. The report also made eight recommendations aimed at improving nursing work environments.

To learn how much clinical work environments have improved and whether these improvements were associated with greater advancements in patient safety, Aiken and colleagues surveyed thousands of nurses and patients at 535 hospitals in four large states at two different time points between 2005 and 2016.

Only 21% of hospitals demonstrated substantial improvement of more than 10% during that time. The work environment was unchanged in 71% of hospitals and deteriorated by at least 10% in 7% of hospitals.

Among hospitals that made improvements to the clinical work environment, patients' ratings rose by 11%, and 15% more nurses said the quality of care at their hospital was excellent, compared with hospitals that did not make such improvements.

In the 7% of hospitals in which clinical environments worsened, the percentage of nurses who rated patient safety favorably dropped by 19% during the study, and 25% fewer nurses said patient safety was a top priority for management.

In contrast, in hospitals in which the clinical environment improved, there was a 15% increase in the proportion of nurses who reported excellent quality of care. Similarly, the proportion of nurse who gave high patient safety grades increased by 15% during the study, the percentage that said they were satisfied with their jobs increased by 16%, and the number that said they were not burned out rose by 12%.

Nurses Rate Patient Safety, Work Environment

Overall, 60% of RNs said the quality of care at the hospital where they worked was less than excellent; 68% rated their hospital 8 or lower on a 10-point scale (10 = excellent). More than half (54.9%) reported they would not definitely recommend their hospital to a friend or family member. Almost a third of RNs gave their hospitals unfavorable grades on patient safety (29.6%) and infection prevention (28.9%).

Many RNs reported that "staff feel like their mistakes are held against them" (50.1%), that "important information is lost during shift changes" (37.3%), that "things fall between the cracks" (41.9%), that "staff do not feel free to question authority" (36.9%), and that management's actions indicated patient safety is not a top priority (21.5%).

Eighty-one percent of RNs reported that their work environments were less than excellent; 27.1% said that much of their last shift had been spent on workarounds to address operational failures, including broken or missing equipment and supplies; and 30.7% said that they had spent much of their last shift on nonnursing tasks.

Most (69.4%) of RNs were less than very satisfied at work, and 30.8% had high scores on the Maslach Burnout Inventory.

Patients Weigh In

Of patients surveyed, 31.8% rated their hospital unfavorably, and 30.2% said they would not definitely recommend their hospital to friends and family. Fewer than one quarter of patients (23.9%) reported that nurses did not consistently communicate well with them, and 38.2% said hospital staff did not always help them quickly and did not always explain medications before administering them. Of those who needed medication for pain, 31.4% reported that their pain was sometimes poorly controlled.

Favorable patient responses increased even in hospitals in which the clinical environment deteriorated, although the favorable change was at least twice as large in hospitals in which the clinical environment had improved.

"Our findings confirm that nurses spend substantial time troubleshooting recurring operational problems, interrupting care and creating patient safety hazards. RNs are an expensive and scarce resource to use in this manner, when their greatest value is in direct patient care. The findings suggest that more attention by hospital management is needed to redesign work flows to permanently solve persistent operational failures that take nurses away from direct patient care," the researchers explain.

The research was supported by grants from the National Institute of Nursing Research of the National Institutes of Health, the Robert Wood Johnson Foundation, and the Agency for Healthcare Research and Quality. The authors have disclosed no relevant financial relationships.

Health Aff. Published online November 5, 2018. Abstract

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