The health of our health care system depends on nurses-to demean, diminish, or eliminate them puts the entire system in jeopardy. - Claire Fagan
Linda Aiken, a keynote speaker at the 2006 Emergency Nurses Association Annual Meeting talked about Saving Lives through Investments in Nursing. In her presentation, she identified yet another role that nursing plays in healthcare. She remarked that through surveillance, nurses play a key role as early detectors of healthcare issues.
In addition to being early detectors, nurses, including advanced practice nurses (APNs), play other key roles in identifying critical healthcare issues such as (1) What factors in the work environment make it so toxic for RNs? (2) What factors impact the overall safety and health of patients? (3) What can be done to create an environment that promotes excellence in healthcare delivery; that protects patient safety and improves outcomes; and that ensures the health and safety of registered nurses and all care providers (American Nurses Association [ANA], 2002)?
In a statement to the Institute of Medicine (IOM) Committee on Work Environment for Nurses and Patient Safety, ANA advocated for the following stating that
1. "Nurses must have decision-making authority and professional autonomy at the point of care delivery and in all arenas where decisions related to care delivery are made." RN salaries represent the largest single expenditure for hospitals and were sometimes targeted when budget cuts were necessary in the past. In addition to the obvious problems of decreasing bedside nursing positions (no longer an issue in the face of the current nursing shortage), the elimination of nurse manager, educator, and clinical nurse specialist positions has decreased the support, advocacy, and resources necessary to ensure that clinical nurses can provide safe, state-of-the-art care. Decreasing or eliminating these positions also directly removes nursing from decision making and affects the very service for which patients are admitted to hospitals: nursing care.
2. "Provide safe and appropriate nurse staffing levels." Staffing shortages still exist in hospitals and other healthcare facilities across the United States and create a range of problems for both the providers and the consumers of nursing services. If work environment issues are not addressed, the remaining nurses will not be able to sufficiently care for and protect patients. To address these concerns, the ANA developed the Principles for Nurse Staffing (ANA, 2002).
3. "All healthcare facilities and agencies should be required to participate in the collection and external reporting of standardized nursing-sensitive data-both to assess the sufficiency of staffing and to quantify the safety and quality of care for consumers and payors." This recommendation is at the heart of a key issue that nurses are concerned about-patient safety. Recently, the Joint Commission on Accreditation of Healthcare Organizations released a revised standard and identified a range of indicators from which facilities could select and collect to demonstrate the sufficiency of nurse staffing. There were many of these indicators that the ANA identified and recommended regarding nurse staffing. These indicators were then used to develop the data needed to demonstrate the linkage between nurse staffing and patient outcomes. As a result of the need to develop nursing-sensitive indicators, the National Database for Nursing Quality Indicators (NDNQI) was established. The purpose of that quality initiative is to provide ongoing education on quality measurement; develop nursing-sensitive indicators; establish a national database for nursing-sensitive indicators; provide database participants with useful and timely benchmarks; and inform public policy on the issues of quality of patient care and the working environment for nurses.
4. "Actively invest in research around staffing, fatigue, safety, and outcomes."
Investments in nursing to prevent nursing burnout via work team indices were also enacted. While previous studies had demonstrated a very clear link between nurse staffing and patient outcomes, the ANA (2000) released the findings of its study called "Nurse Staffing and Patient Outcomes in the Inpatient Hospital Setting." This study found that adverse patient outcomes, including pneumonia, postoperative infections, pressure ulcers, urinary tract infections, and length of stay, were reduced when staffing levels were higher. The study also stated that in addition to staffing levels, nurses need to determine what are the safe limits for work time. Nurses also need to address clinical nurse fatigue and patient safety by examining the hours worked by nurses and the effects of these hours on patient safety (ANA, 2002).
Recently, the IOM report confirmed the ANA's belief that the answer lies in better working conditions for nurses (IOM, 2006). Examples of how these actions can improve patient care are found, for example, in Magnet hospitals across the country. Key among the strategies are those that incorporate direct care nurses in decision making about patient care issues and the working conditions of nurses.
In summary, all nurses, especially APNs, play a key role as early detectors of healthcare issues and as such need to continue to develop and implement strategies that address the work environment to improve patient and provider safety and patient outcomes. It is imperative that APNs continue to advocate for patients and do their utmost to detect patient care issues before they can compromise care-primum non nocere (first, do no harm). Florence Nightingale championed these concepts at the birth of professional nursing; it is our responsibility to carry her lamp forward.
K. Sue Hoyt, RN, PhD, FNP, APRN, BC, CEN, FAEN
Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA
Jean A. Proehl, RN, MN, CEN, CCRN, FAEN
Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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