ANA Statement for the Institute of Medicine's Committee on Work Environment for Nurses and Patient Safety (9/24)

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Good morning, Mr. Chairman and members of Committee, I am Barbara Blakeney, President of the American Nurses Association. As many of you know, the American Nurses Association is the only full-service association representing the nation's registered nurses through its 54 constituent member associations. Our members include registered nurses working and teaching in every health care sector across the United States. My own clinical practice involves being the director of Health Services, for the Homeless Services Bureau with the Boston Public Commission in Boston, Massachusetts.

I am pleased that the Institute of Medicine has convened a committee dedicated to examining the current work environment for registered nurses and, more important, analyzing the impact of this environment on patient safety. In its 1999 report, To Err is Human, Building a Better Health Care System, the Institute defined patient safety as: "Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur." I will tell you that as admirable as that goal is, nurses believe we must also strive for systems and processes that continually improve the quality of health services delivered. It is not enough to have patients leave hospitals and other care settings relieved that they've suffered no harm. It is as important they leave knowing they have received superb, high-quality care.

This Committee is considering two very important issues. The first, to discover the factors in today's work environment that makes it so toxic for registered nurses and impacts the overall safety and health of patients. The second, to identify 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.

The issue of patient safety has always been the cornerstone of nursing. In fact, the third plank of the Code of Ethics for Nurses states: "The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient." More specific to today's discussion, the Code also states: "The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action."

The Changing Health Care Delivery System and Its Toxic Effects

The landmark IOM report To Err is Human described a fractured health care system that is prone to errors and detrimental to safe patient care. This problem is readily apparent to the registered nurses who have been caught inside the topsy-turvy world of our rapidly changing health care delivery system. We have seen market forces, reimbursement changes, and new technologies revolutionize health care. Unfortunately, these changes have not always resulted in better patient care.

In the past decade, the advent of managed care and changes in Medicare Reimbursement have exerted downward pressure on provider margins. As a result, health care facilities have employed radical cost reduction programs. Throughout the 1990s, new models of health care delivery were implemented, and highly-trained, experienced personnel were eliminated or redeployed. As registered nurses typically represent the largest single expenditure for hospitals and health systems, we were among the first to feel the pinch through downsizing, layoffs, and salaries that only kept pace with inflation. At the same time, elimination of nurse manager positions decreased the support, advocacy and resources necessary to ensure that staff nurses can provide optimum care. Consequently, this action also removed nursing from decision-making directly affecting the primary service for which consumers are admitted to facilities - - nursing care.

Recent advances in medical technology have resulted in better treatments and procedures. These advances are extending and improving the quality of lives. They are also increasing the complexity of health care. It is clear that today's hospitals are now largely critical care units; with providers in nursing homes, home health agencies, schools and other community settings providing far more complex services than in the past and managing sophisticated technology in settings that frequently lack the resources -- including education, training and support -- to ensure the expertise of providers and the safety of consumers. Today's registered nurses are engaged in the delivery of highly sophisticated and labor-intensive care for an aging and increasingly vulnerable patient population. The time allotted for care is shorter than before-whether because of length of stay or increasing case loads. And complicating all of this, the nurse works longer hours with fewer support mechanisms and increasing administrative duties.

Key Aspects of the Work Environment and Implications for Patient Safety and Professional Practice

The issue of staffing shortages has been, and continues to be, a priority for ANA. Staffing shortages exist in hospitals and other healthcare facilities across the U.S. and create a range of problems for both the providers and the consumers of nursing services. According to the American Hospital Association, there are 126,000 hospital vacancies -- or an 11% national registered nurse vacancy rate in hospitals. Perhaps more disheartening is a finding by Drake, Beam, Morin, a human resources consulting firm, which surveyed 44 medical and surgical hospitals with regard to their turnover rates. This 2001 survey found the turnover rate for registered nurses to be 18%. The turnover rate was even higher for other members of the health care team - technologists and radiologists were the highest at 25% followed by education and training personnel at 24%, and pharmacists at 23%. The turnover problem is even more acute within nursing home settings. An American Health Care Association survey of 5,892 nursing home facilities done in 2001, found a 55% registered nurse turnover rate and a vacancy rate of 18%.

In talking to nurses from across the country, I know that where these staffing shortages exist, measures to counter them include extensive use of overtime (both voluntary and involuntary). A recent study done by the Service Employees Internal Union noted that nurses in acute care hospitals work an additional eight and half weeks of overtime on average per year. As onerous as overtime has become, "floating" of nursing staff to patient care units - whether or not they are sufficiently experienced and oriented - is another frequently utilized tool to fill the gaps in available RN staff.

For the registered nurse, these practices take an emotional toll. Concerns revolve around patient safety, as well as professional liability and inability to appropriately attend to personal needs and responsibilities beyond the workplace. Resulting stress, compounded with fatigue that comes from extending the workday, sap the energy and potentially affect critical thinking skills for the professional nurse. These factors also predispose the nurse to work-related accidents, illnesses and injuries. Patients are at significant risk as well, as news stories abound detailing incidents of medication errors, missed symptoms and failure to rescue.

Potential Improvements for Patient Safety and Professional Practice

Charged by members to speak to the crisis in health care, ANA has undertaken many activities, chief among them convening the nursing community to come together to address the unholy trinity: patient injuries and healthcare error, staffing shortages, and the looming nursing shortage. Last September, nurses from all care settings and representing 60 of the 100 nursing and specialty organizations, came together to address these concerns through the development of a strategic and tactical plan called Nursing's Agenda for the Future. In a four-day summit meeting, participants outlined priorities and specific objectives designed to mitigate the looming shortage; address the current professional and workplace obstacles that hamper the delivery of safe, quality care; and identify changes that will help retain the current nursing workforce while recruiting the next. One of the 10 areas identified for specific focus is the work environment.

Work environment is a particular focus for the ANA because we believe that this is the intersection of the trinity. If the problems in the work environment are not addressed, nurses will not be able to sufficiently protect patients; the nursing workforce will be lost to injury and burnout; and the profession will never be able to recruit the next generation of nurses.

ANA believes that we must make the following changes to ensure a work environment that is conducive to safe patient care and promotes better patient outcomes.

First, 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.

Research has demonstrated where certain factors exist in the practice environment, better outcomes occur for patients. In 1983, the American Academy of Nursing established a Task Force on Nursing Practice in Hospitals and ultimately published a critical document, Magnet Hospitals Attraction and Retention of Professional Nurses. The focus of this work was to identify the organizational elements associated with success in recruiting and retaining professional nurses. Numerous government reports and commissions had already talked about high vacancy rates and the associated problems of the nursing shortage, but there had been no evaluation of hospitals that were succeeding in recruiting and retaining nurses.

Following intensive group interviews of administration and staff nurses employed in hospitals nominated as excellent workplaces, the Task Force identified fourteen "forces of magnetism" that reflect a culture that allows for nursing excellence. Autonomous nursing care is defined as "the ability of the nurse to assess and provide nursing actions as appropriate for patient care." Control over nursing practice is defined as "organizational autonomy or the freedom to take the initiative for shaping unit and institutional policies for patient care and assessing the organizational resources required for providing care." Not only do hospitals that provide for professional autonomy and control over nursing practice have better retention rates for nursing staff, they also have better outcomes for patients.

Second, provide safe and appropriate nurse staffing levels.

Nurses across the country are calling for safe staffing levels. They are also desperately looking for tools to help in the development and assessment of staffing systems that will determine safe and appropriate nurse staffing levels.

Over the past decade, tempering the realities of cost containment with the priority of safe, quality care has been very difficult, in part, because of the paucity of empirical data to support the value of sufficient nurse staffing and its relationship to patient safety and outcomes. Nurses and other health professionals were unable to convince a prior IOM task force, charged in1994 with determining the sufficiency of nurse staffing in hospitals and nursing homes, that diluting the skill mix of direct care staff with more unlicensed personnel would be detrimental to the safety of patients.

Determining what appropriate staffing levels should be -- and by that I mean the appropriate number and mix of licensed and unlicensed staff --has been even more difficult because of the absence of comprehensive guidelines for factors that must be taken into account when considering safe and appropriate staffing.

To support this second priority for patient safety, ANA developed the Principles for Nurse Staffing. The Principles for Nurse Staffing have organized criteria into three categories: the patient care unit; the nursing staff; and the organization. Just as each patient is unique and has individual needs and circumstances that must factored into the organization of their care, each nurse is also unique. A nurse is not always interchangeable with another nurse, and can never be substituted for by an unlicensed care-giver. Equally important in all of the factors that must be in place for safe care is a supportive organizational culture that puts patient safety first and supports the nursing staff priorities for patient care.

Third, 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 gets to the heart of the issue we are all 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. Within those indicators are many that ANA had identified and recommended in 1995 -- acting on the recommendation of the IOM task force on nurse staffing to develop the empirical data needed to demonstrate the linkage between nurse staffing and patient outcomes.

As a result of this work, the National Database for Nursing Quality Indicators was established. The purpose of this 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. Presently, 300 acute care facilities, representing over 2,000 nursing units in 39 states, are providing data on a quarterly basis on several nursing-sensitive indicators of quality of care.

While some would still deny it, numerous studies have already demonstrated a very clear link between nurse staffing and patient outcomes. In May 2000, ANA released the findings of its study called Nurse Staffing and patient Outcomes in the Inpatient Hospital Setting. The study found that adverse patient outcomes including pneumonia, post-operative infections, pressure ulcers, and urinary tract infections and length of stay were reduced where staffing levels were higher. This is just one of many sound research studies that have come to similar conclusions - sufficient nurse staffing is clearly linked to better patient outcomes.

It is time to require the collection of data by every hospital and health system in order to demonstrate that the staffing practices in that facility are not putting patients and registered nurses at risk. In addition, it is absolutely critical that there be ongoing funding for the development of nursing-sensitive indicators.

Fourth, it is time to actively invest in research around staffing, fatigue, safety, and outcomes.

As mentioned earlier, nurses everywhere are working extended hours and abundant overtime to fill the gaps in staffing. We are all concerned about the implications of this for both patient safety and the safety of nurses. ANA is also concerned that nurses are frequently not allowed to make determinations about their ability to work safely, and to exercise their professional autonomy. Registered nurses should not be threatened with patient abandonment and potential loss of license when they are afraid that working additional hours will endanger patient safety! It is time to support their professional determination and go even further to investigate the fatigue and safety. Although nurses in various states are successfully lobbying state legislatures to prohibit or limit mandatory overtime, ANA believes we need to determine-for all healthcare workers-- what are safe limits on work time. ANA is pleased to have had the opportunity to collaborate with Dr. Ann Rogers at the University of Pennsylvania. Dr. Rogers' study will address staff nurse fatigue and patient safety in two ways. The first Phase of the study will focus on describing the hours worked by nurses and the effects of these hours on patient safety. ANA looks forward to the release of these findings. We believe this research will provide a foundation for policy recommendations related to hours of work and patient safety.

Thank you very much for the opportunity to participate in these important deliberations. ANA looks forwarded to an ongoing dialogue with this Committee.


American Nurses Association. (2000). Nurse staffing and patient outcomes in the inpatient hospital setting. Washington, D.C.: Author.

Caregiver job vacancies top 106,000. (2001, December). Provider 27(12), 9.

Romano, M. (2002). War of attrition: Turnover rates for hospital jobs reaching proportions, study warns. Modern Healthcare, 32(32), 21-22.

Scott, J.G., Sochalski, J., & Aiken, L. (1999). Review of Magnet Hospital Research: Findings and implications for professional nursing practice. Journal of Nursing Administration, 29(1), 9-19.

Service Employees International Union. The shortage of care: a study by the SEIU nurse alliance. Washington, D.C.: Author