This month we're publishing a letter from Sharon Rodriguez, RN, who wrote to describe her hospital's change of an intermediate critical care unit into a medical-surgical unit (see Letters, page 16). The nurses' caseload doubled from three to six slightly less acutely ill patients each. Many nurses left, Rodriguez wrote.
And who can blame them? The adequate staffing of nurses is the issue of greatest consequence in health care. And despite the body of evidence showing the importance of nurses' work, some nurses and others still say that we haven't done enough research to say what adequate staffing is.
But that isn't the case. In this issue of AJN economist Lynn Unruh, PhD, RN, synthesizes the research, showing a link between adequate nurse staffing and improved clinical, staff, and financial outcomes (see page 62). Nurses need to read this work-and so do hospital CEOs and board members, policymakers, and journalists-in order to understand without question that nurses themselves are a cost-effective patient-safety intervention. Unruh includes some criticism of the research, noting, for example, studies' inconsistencies in definitions of nurse staffing. But while it's valid to criticize research, no one should say there's insufficient evidence.
Work environments have to change, as well. We have about 3 million nurses in this country, and the current "shortage" is occurring during a time of unprecedented demand for nurses: nurses are better educated and have more professional options than ever before; patient acuity is higher; and our population is aging. The Workforce Commission of the American Academy of Nursing (AAN) has recognized that we'll never produce enough nurses to fulfill demand and called for finding ways to reduce the unnecessary demands on nurses' time, such as having to "hunt and gather" supplies and equipment.
At a press conference on November 7, outgoing AAN president Linda Burnes-Bolton, DrPH, RN, FAAN, and commission chairperson Pamela Cipriano, PhD, RN, FAAN, described their work on a project called Technology Targets: A Synthesized Approach for Identifying and Fostering Technological Solutions to Workflow Inefficiencies on Medical/Surgical Units, funded by the Robert Wood Johnson Foundation. Nurses spend just 30% of the workday with patients, and the project aims to increase that amount. The idea is to focus on technologies that improve care and efficiency, such as radiofrequency systems that can track wheelchairs, rather than on those that consume more time than they free up, such as poorly designed physician order entry systems.
The project involved 25 national sites representing more than 200 patient care units. Staff on the units engaged in workflow analyses and identified 812 processes of care needing improvement, including documentation, medication administration, and coordination of care, among others. They then identified 1,214 potential technologic solutions to these problem. Nurses expressed frustration with bedside technology that doesn't work, takes up more time instead of less, and adds more pieces of equipment that are seldom compatible with each other, forcing nurses to wear pagers, alarm indicators, handheld computers, and locators, for example. The project's preliminary recommendations include
* developing public policies requiring health information systems to adopt technology that enhances quality and safety, such as computerized physician order entry systems that work.
* challenging the designers of technology to involve nurses in setting priorities for and designing new products.
* getting those making purchasing decisions to refuse to buy technology that has not been developed and tested with frontline staff.
Sadly, Burnes-Bolton noted, after an initial meeting, the project was unable to engage technology companies in supporting the groups' recommendations. But that may change if nurses unite in supporting the project. Go to http://www.aannet.org/committees/workforce.asp.