YEARS OF INVESTIGATION into the factors that influence nurse satisfaction and patient safety have yielded an increasingly strong, evidence-based link between good working conditions for nursing staff and positive patient outcomes. Good working conditions, however, do not refer only to generous salaries, signing bonuses, and flexible work schedules. Instead, recent findings have identified several variables that healthcare organizations interested in promoting both nurse satisfaction and patient safety should consider.
According to a 2007 study sponsored by the US Agency for Healthcare Research and Quality (AHRQ), components of working conditions, including a hospital's organizational climate, staffing, and overtime, were found to influence outcomes in the elderly patients in hospital intensive care units (ICUs). Other recent AHRQ-funded studies on nurses' working conditions and patient outcomes have found a significantly greater risk to patient safety when nurses worked beyond their regularly scheduled number of hours. These findings come at a time of accelerating demands on the nursing profession and on our healthcare system that have yet to find satisfactory responses.
A 2006 report from the Health Resources and Services Administration projected that the shortage of registered nurses (RNs) will steadily grow over the next several years, from an estimated 218,000 in 2005 to 1 million by 2020.1 The nursing shortage occurs at the same time when the leading edge of the baby-boom generation begins to retire, putting unprecedented demands on the healthcare system.
COMPREHENSIVE VIEW OF NURSE WORKING CONDITIONS
Today, healthcare organizations are increasingly adopting a systems approach to improve overall quality and enhance patient safety. Until recently, however, evidence has not been available to link a comprehensive set of nurses' working conditions to improved patient safety.
To test the effects of multiple working condition variables on patient outcomes, researchers led by Patricia Stone, PhD, MPH, an associate professor of nursing at Columbia University in New York, conducted an observational study of more than 15,000 elderly patients in ICUs at 31 hospitals.2 Researchers examined the following patient outcomes related to the quality of nursing care: central line-associated bloodstream infection (CLBSI), ventilator-acquired pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), decubiti, and 30-day mortality.
Working condition variables included organizational climate as measured by nurse survey (1,095 nurses participated); objective measurement of staffing, overtime, and wages; hospital profitability; and Magnet Recognition, a designation that reflects nursing excellence. Organizational climate was defined as employees' perceptions about an institution's accepted norms, including decision making and collaboration. Researchers tested this variable using the Perceptions of Nurse Work Environment scale, a validated, 42-item instrument. It asks questions such as whether staff nurses are involved in the hospital's governance, whether they have enough staff to get the work done, and whether a teamwork atmosphere exists between physicians and nursing staff.
Because nurses make up the largest portion of a hospital's workforce, researchers sought to determine whether profitability was associated with human resource decisions, which in turn could affect patient safety. Magnet Recognition, a program developed by the American Nurses Credentialing Center, was included as a working condition variable, as it has been shown to promote positive patient outcomes.3 However, its influence on outcomes in combination with other working conditions had not previously been determined.4
Higher staffing boosts patient outcomes
Overall, rates of infections among the elderly patients in the ICU were low, ranging from 0.95% for CLBSI to 1.5% for VAP and 1.7% for CAUTI.2 The average 30-day mortality was 22%, and the percentage of patients who acquired a decubitus ulcer was 2.0%. Patients who were admitted to the ICU with more nurse hours per day had significantly lower rates of CLBSI, VAP, 30-day mortality, and decubiti. While patients admitted to an ICU in which nurses perceived a more positive organizational climate had slightly higher odds of developing a CLBSI, they were 39% less likely to develop a CAUTI. The study did not find an association between nurses' wages and any of the patient safety outcomes.
A mixed picture emerged in the analysis between hospital profitability and patient outcomes. Hospitals with the lowest profit margins (as determined by 2002 Medicare cost reports) had fewer adverse outcomes for CAUTI, VAP, and decubiti. But low-profit hospitals had the highest rates of CLBSI, according to the study findings. Magnet accreditation was not associated with any of the patient outcomes measured in the study.
Nursing overtime compromises outcomes
Notably, the study found a significant association between nurse staffing per ICU patient and rates of CLBSI, VAP, 30-day mortality, and decubiti. Although skill mix has been found to be an important staffing variable in some settings, researchers did not find sufficient use of nurses' aides or licensed vocational nurses in the ICU to examine this variable.
Increased overtime by nurses working in the ICU was found to affect patient safety outcomes. Stone and colleagues found that increased overtime was associated with a risk of CAUTI and decubitus ulcer. Less overtime was associated with a lower incidence of CLBSI, a finding that researchers suggested could be related to the role of interdisciplinary care in identifying and preventing these infections.
The researchers speculated that one reason for the inconsistent findings between organizational climate and patient outcomes could be because of the roles of ICU team members. Specifically, urinary catheter insertion and care are typically performed by staff nurses, but subclavian catheter insertion, a major risk factor in CLBSI, is typically performed by medical staff. Nursing care, however, is important in preventing CLBSI because nursing staff performs a vital role in surveillance of patients for early signs of infection.
Despite the limits of an observational study, the findings by Stone and colleagues draw an important road map for nursing and healthcare leadership focused on improving patient outcomes. They underscore support for a systems approach and for improved working conditions, such as limited use of overtime to meet staffing needs, to attain better patient safety.
NURSE FATIGUE AND MEDICAL ERRORS
Stone's findings on the relationship between overtime and patient safety echo those from Ann E. Rogers, PhD, RN, one of the nation's leading researchers on the impact of nurse fatigue and medical errors. Dr Rogers' work, also supported by AHRQ, has identified the prevalence, nature, and impact of fatigue-related medical errors. She is currently studying factors that make it harder for nurses to recover from work-related sleep deprivation and the impact of interventions, such as scheduled napping during a shift, on the occurrence of errors.
A tragic example of cumulative work hours on nurses' risk of errors occurred last year at St. Mary's Hospital in Madison, Wisconsin.5 A nurse who had worked two 8-hour shifts the day before mistakenly administered an epidural anesthetic intravenously to a 16-year-old patient, who died as a result. The nurse had ended her shift the previous day at midnight and began her shift the following day at 7, according to news reports.
Remaining vigilant in critical care units
According to research by Rogers and colleagues, although nurses' fatigue-related mistakes do not typically result in a patient's death, they increase the risk that death or injury could occur.6 Her recent studies have identified overtime hours with a 3-fold risk of medical errors and a compromised ability by nurses working in critical care units (CCUs) to remain vigilant during long shifts.
In a 2004 study of nearly 400 nurses, Rogers and colleagues found that nurses who work more than 12.5 consecutive hours have 3 times the risk of making an error than nurses who work fewer hours.6 Possible errors, which also applied to nurses who worked unplanned overtime at the end of a scheduled shift, included giving patients incorrect medications or dosages, according to the study.
Long work hours also can impair the vigilance needed by critical care nurses, who must be alert to subtle changes in patients' conditions and able to respond appropriately. Patients in CCUs may be more vulnerable to the effect of medical errors because they are more seriously ill and are exposed to more medications and treatments than patients in general care units. Of the 5 million patients admitted to CCUs each year, all will experience at least 1 preventable adverse event.7
To examine the impact of nurses' long work hours on vigilance in CCUs, Rogers and colleagues collected data from 502 randomly selected critical care nurses in the United States over a 28-day period. Information included the number of hours worked, time of day worked, overtime hours, days off, and sleep-wake patterns.8 Nearly two thirds (65%) of the nurses reported that they struggled to stay awake at work at least once during the study period, while 20% said they fell asleep at least once during their work shift. In total, nurses reported that they had difficulty staying awake during 1,203 shifts and actually fell asleep during 178 shifts, according to the study.
More than one quarter (27%) of the nurses reported making at least 1 error, and more than one-third (38%) reported that they almost made a mistake during the study period. The majority of errors (56%) and near-errors (28%) involved administering medication; in 1 instance, the error required that the patient return to the operating room.
Consistent with reports of long work hours by nurses in other hospital units, critical care nurses who participated in the study said that they rarely left the hospital at the end of their scheduled shift. Although shifts were extended by a mean of 49 minutes, the overtime came on top of a 12.5-hour shift.
Such extensive work hours conflict with recommendations of the Institute of Medicine in its 2003 report, Keeping Patients Safe: Transforming the Work Environment of Nurses.9 In the report, commissioned by AHRQ, the Institute of Medicine recommended that nurses provide direct patient care for no more than 12 hours in any given 24-hour period and less than 60 hours in a 7-day period. AHRQ called for the report in recognition of the key role of nurses in patient safety.
CONCLUSIONS
As these findings illustrate, a hospital's nursing staff is inextricably linked to patient safety and outcomes. They also demonstrate the upper limits of hours that nurses can work without jeopardizing the safety of their patients. Given the pressures on many hospitals to maintain minimum nurse-patient ratios in light of the national nursing shortage, we recognize that solutions are neither easy nor permanent.
Nonetheless, nurses and nursing researchers must continue to advocate for remedies that acknowledge the strong, evidence-based link between good working conditions and positive patient outcomes. We also must continue to address the research and public policy questions that ask how we can provide high-quality patient care while protecting the safety and well-being of our nurses and their patients.
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