THE conditions in which nurses work can influence the likelihood of errors and the quality of care afforded to patients. Key elements of the workplace include staffing levels, working hours, physical environment, workflow design, and organizational culture. Past research has examined the association between the working conditions in which nurses provide patient care, the quality of care provided, and patient outcomes.1-3 These conditions include how work is organized, workload, management and leadership style and capability, workplace characteristics, and communication. Last year, the Institute of Medicine released a seminal report on the impact of nurses' working conditions on patient safety. This report, Keeping Patients Safe: Transforming the Work Environment of Nurses,4 was an important step in providing insight into the implications of unfavorable, adverse, and poor working conditions for nurses, who are the backbone of healthcare.

Research funded by the Agency for Healthcare Research and Quality (AHRQ) has taken this knowledge a step further.5 In addition to discussing the major factors influencing working conditions-human factors, staffing levels, and effective leaders and managers-some key insights from AHRQ research also will be discussed.

A PATIENT-SAFETY-DRIVEN CULTURE RECOGNIZES THE INFLUENCE OF HUMAN FACTORS ON ERRORS

Caring for patients relies heavily on human decision making and action. Nurses are vulnerable to being part of errors because the process of patient care leaves them exposed to the inevitable results of human fallibilities that occur throughout the entire process of care, the complexity of healthcare, or a combination thereof. These fallibilities involve human behaviors, sensory capacities, and cognitive capabilities.6 Because nurses care for patients within the complex structure and process of healthcare delivery systems, they are often at the "sharp end"7 of errors by being the last barrier a patient has to being the victim of an error. Nurses have a critical patient advocacy role: the total number of errors would be greater if nurses did not intercept 86% of all potential errors that could result in patient harm.8

According to Reason,9 humans are involved in errors because of active failures (eg, performing a patient procedure incorrectly because of distractions or interruptions) in complex systems. Research funded by AHRQ in inpatient settings has found a correlation between active failures and errors. Assessment of the cognitive process behind the work of nurses found that interruptions and keeping pace with the changing needs of assigned patients can expose nurses to being part of patient safety errors by impairing or confusing clinical decision making.10 Taking this a step further, preliminary findings of this same study revealed that errors tended to occur within 30 minutes after the occurrence of certain factors (such as incomplete patient information and sudden changes in patient needs in an environment dominated by distractions and interruptions), regardless of the amount of experience of the nurse.11

Organizations that strive to improve patient safety recognize the importance of fostering a culture of safety because nurses are subject to latent factors associated with the structure of working conditions within organizations.9 A large part of patient safety centers on the right working conditions for nurses within a climate of patient safety-a climate that recognizes when errors occur, provider negligence is the factor we should consider last. Several AHRQ-funded studies found that effective systems-level approaches to foster a patient safety culture include a blame-free environment emphasizing continual learning based on voluntary reporting of errors, which inform an evidence-based approach to amend current practices and to focus on patient-centered.12 When this approach is not taken, adverse working conditions can result, which affect patient safety and can also indirectly impact nurses' stress level, health, and job satisfaction.13

RECOGNIZE THE TRUE CAUSES OF ERRORS: IMPACT OF NURSE STAFFING LEVELS AND PATTERNS

Other latent causes of errors, such as staffing levels, staffing ratios, educational preparation of staff, turnover rates, and hospital procedures, have been identified as factors in threats to patient safety.14-16 One of the ways to improve patient safety is to consider how many patients each nurse is assigned daily, reflecting both patient acuity and skill/education of the nurse. Other measures of the quality of care attributable to nurses, such as indicators sensitive to nursing, do not have consensus and need to be tested further.17

Measurement consensus is important because, as illustrated by one survey, more than 90% of nurses believed that the quality of their nursing care had declined as a result of inadequate staffing levels.18 However, defining an adequate staffing level is controversial. Although several states, including California, have sought to mandate nurse staffing ratios, there is controversy over what the optimal ratio is across different settings. Research has demonstrated that adequate staffing ratios directly influence patient outcomes in hospitals.1,19,20 Hospital nurse staffing ratios and nurse education/skill mix21 can influence the quality of care and patient outcomes such as length of stay21-23 as well as the incidence of urinary tract infections, gastrointestinal bleeding, shock, and pneumonia.21 Nursing home nurse staffing ratios and skill mix also can impact the quality of care residents receive,24,25 but it is not clear if they affect patient outcomes as well.26 Research currently underway will provide needed insight into understanding staffing ratios across settings.

THE IMPORTANCE OF LEADERSHIP AND MANAGEMENT SUPPORT OF THE WORK OF NURSING

Previous research, focusing specifically on intensive care units, found that the capability of management can indirectly affect patients' length of stay, nurse turnover, and provider-rated quality of care.3 Research funded by AHRQ has found that it is important for healthcare leaders to communicate patient safety as a priority, to empower staff, and to both champion patient safety and reward innovation. It is also important for managers to use data and information to identify the true cause of errors and to inform improvement initiatives for patients.27 Without such leaders and managers, patient safety improvement efforts are likely to have only short-term benefits. Tools for assessing the influence of hospital-based leadership and management, such as the Hospital Unit Safety Climate measure,28 can be used to better understand the effectiveness of error reporting and aspects of the safety climate in a hospital.

WHERE DO WE GO FROM HERE?

Patient safety research funded by AHRQ will continue to provide key insight into how various aspects of working conditions for nurses can be changed to improve patient safety and patient outcomes. As we learn more about what causes patient safety errors, we will develop an evidence base to support patient-safety-driven working conditions. The healthcare community needs to take this evidence and the evidence that is forthcoming and begin institutionalizing an organization-wide commitment to safety if they have not already done so. The evidence on working conditions continues to demonstrate what needs to be done to lower threats to patient safety: proactively reduce the effect of human factors, improve the flow of information (including the use of computer-based technology), and institutionalize patient safety as something championed by both healthcare leaders and managers.

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