On September 13, I was in a room with about 200 angry nurses. The topic was patient safety. Union and nonunion nurses attending a conference sponsored by the Pennsylvania Nurse Alliance of the Service Employees International Union listened to Anthony Wilson, special assistant to the Pennsylvania secretary of health, as he discussed the department's new patient safety initiative, including the goals that hospitals would be expected to meet, such as "no use of restraints."
The nurses reacted passionately, asking whether safe staffing was a goal (it's not), demanding to know how to keep nurses safe if patients are violent and restraints aren't an option, and describing working conditions that will impede the state's safety goals. Wilson later asked me for slides from a presentation I'd given on the connection between nurse staffing and patient safety. Shouldn't someone from the Department of Health understand this connection? But he didn't, and I realized, sadly, that he's not alone among policymakers.
In a superb editorial in the September-October issue of Nursing Research, associate editor Mary Blegen notes that certain initiatives, such as electronic medical records, rapid response teams, and executive walking rounds, are being promoted as patient-safety strategies without evidence to support either their usefulness or their cost effectiveness. The same cannot be said about the effects of nurse staffing on patient outcomes. Although collecting standardized data on outcomes sensitive to nursing care is said to be "much too expensive to implement," Blegen writes, there is substantial research demonstrating that adequate nurse staffing is crucial to patient safety.
Take the intriguing study by Rothberg and colleagues in the August 2005 issue of Medical Care that compared the effectiveness-in terms of dollars saved and deaths prevented-of various nurse-patient staffing ratios and standard practices such as thrombolytic drug therapy for acute myocardial infarction. The authors concluded, "Considered as a patient safety intervention, improved nurse staffing has a cost-effectiveness that falls comfortably within the range of other widely accepted interventions." But the research on nurse staffing and outcomes is being ignored.
Blegen challenges us to find better ways "to present what we know on the basis of evidence from nursing research." Here are two strategies to consider.
First, we must get the relevant research into the hands of nurses, facility executives, patient-safety leaders, policymakers, and journalists. After my presentation at the Pennsylvania conference, many staff nurses and nurse managers asked for copies of my slides; this was information they needed as they worked to improve staffing. Reviews of the literature are provided in the Institute of Medicine's 2004 report Keeping Patients Safe: Transforming the Work Environment of Nurses. And AJN will continue to report on research that examines the impact of nursing on clinical and financial outcomes.
Second, nurses must be better represented at decision-making and advisory tables that address patient safety. Are nurses on the boards of organizations discussing patient safety, such as hospitals and insurance companies? The Robert Wood Johnson Foundation has undertaken an initiative called Pipeline to Placement to review nurses' representation on national boards and advisory groups and develop a strategy for getting nurses onto them. Each of us can look to organizations, commissions, and task forces in our own states and communities, question when nurses are not represented, and recommend suitable nurse candidates. Local and state nursing organizations must also take up this cause.
Florence Nightingale knew about the importance of data in promoting change. She needed data on illnesses, deaths, and their causes to justify improving the British military hospital at Scutari during the Crimean War. She also knew that possessing data isn't enough. She worked with a London Times journalist to publicize stories of hospital conditions. We've learned her lesson about the importance of data; let's show that we've learned how to use them strategically.