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Nursing and Patient Safety
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Background

Doctors are perceived—by patients and clinicians—as being the captain of the health care team, with good reason. But, physicians may spend only 30 to 45 minutes a day with even a critically ill hospitalized patient, whereas nurses are a constant presence at the bedside and regularly interact with physicians, pharmacists, families, and all other members of the health care team. Of all the members of the health care team, nurses therefore play a critically important role in ensuring patient safety by monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, and performing countless other tasks to ensure patients receive high-quality care.

Nurse staffing and patient safety

Nurses' vigilance at the bedside is essential to their ability to ensure patient safety. It is logical, therefore, that assigning increasing numbers of patients eventually compromises nurses' ability to provide safe care. Several seminal studies have demonstrated the link between nurse staffing ratios and patient safety, documenting an increased risk of patient safety events, morbidity, and even mortality as the number of patients per nurse increases. The strength of these data has led several states, beginning with California in 2004, to establish legislatively mandated minimum nurse-to-patient ratios; in California, acute medical–surgical inpatient units may assign no more than five patients to each registered nurse.

The nurse-to-patient ratio is only one aspect of the relationship between nursing workload and patient safety. Overall nursing workload is likely linked to patient outcomes as well. A sophisticated 2011 study showed that increased patient turnover was also associated with increased mortality risk, even when overall nurse staffing was considered adequate. Determining adequate nurse staffing is a very complex process that changes on a shift-by-shift basis, and requires close coordination between management and nursing based on patient acuity and turnover, availability of support staff and skill mix, and many other factors. The process of establishing nurse staffing on a unit-by-unit and shift-by-shift basis is discussed in detail in an AHRQ WebM&M commentary.

Nursing skill mix and training may also be linked to patient outcomes. One classic study showed lower inpatient mortality rates for a variety of surgical patients in hospitals with more highly educated nurses. This finding has resulted in calls for all nurses to have at least a baccalaureate education. Irrespective of educational level, the quality of nurses' on-the-job training may also play a role in patient outcomes. As discussed in an AHRQ WebM&M commentary, nurses do not currently have a standardized transition to independent practice training requirement (analogous to medical residency training). Less experienced nurses may therefore lack mentorship and training in dealing with systems issues and complex clinical scenarios.

Nurses' working conditions and patient safety

The causal relationship between nurse-to-patient ratios and patient outcomes likely is accounted for by both increased workload and increased stress and risk of burnout for nurses. Burnout among clinicians (both nurses and physicians) has consistently been linked to patient safety risks, and some studies show that higher numbers of patients per nurse is correlated with increased risk of burnout among nurses.

The high-intensity nature of nurses' work means that nurses themselves are at risk of committing errors while providing routine care. Human factors engineering principles hold that when an individual is attempting a complex task, such as administering medications to a hospitalized patient, the work environment should be as conducive as possible for carrying out the task. However, operational failures such as interruptions or equipment failures may interfere with nurses' ability to perform such tasks; several studies have shown that interruptions are virtually a routine part of nurses' jobs. These interruptions have been tied to an increased risk of errors, particularly medication administration errors. While some interruptions are likely important for patient care, the link between interruptions and errors is one example of how deficiencies in the day-to-day work environment for nurses is directly linked to patient safety.

Longer shifts and working overtime have also been linked to increased risk of error, including in one high-profile case where an error committed by a nurse working a double shift resulted in the nurse being criminally prosecuted. Nurses who commit errors are at risk of becoming second victims of the error, a well-documented phenomenon that is associated with an increased risk of self-reported error and leaving the nursing profession. In their daily work, nurses are also frequently exposed to disruptive or unprofessional behavior by physicians and other health care personnel, and such exposure has been demonstrated to be a key factor in nursing burnout and in nurses leaving their job or the profession entirely.

All of these factors—the high-risk nature of the work, increased stress caused by workload and interruptions, and the risk of burnout due to involvement in errors or exposure to disruptive behavior—likely combine with unsafe conditions precipitated by low nurse-to-patient ratios to increase the risk of adverse events. Using a systems analysis perspective, active errors made by individual nurses likely combine with these aligned holes in the "Swiss Cheese Model of Medical Errors" to result in preventable harm.

Current context

The National Quality Forum endorsed voluntary consensus standards for nursing-sensitive care in 2004. These included patient-centered outcomes considered to be markers of nursing care quality (such as falls and pressure ulcers) and system-related measures including nursing skill mix, nursing care hours, measures of the quality of the nursing practice environment (which includes staffing ratios), and nursing turnover. These measures are intended to illustrate both the quality of nursing care and the degree to which the working environment at an institution supports nurses in their patient safety efforts.

The Magnet Hospital Recognition Program, administered by the American Nurses Credentialing Center (a subsidiary of the American Nurses Association), seeks to recognize hospitals that deliver superior patient care and, partly on this basis, attract and retain high-quality nurses. The program has its genesis in a 1983 study that sought to identify hospitals that retained nurses for longer than average periods of time. The study identified institutional characteristics correlated with high retention rates, an important finding in light of a major nursing shortage at the time. These findings led 10 years later to the formal Magnet Program.

As of March 2011, 15 states and the District of Columbia have enacted legislation or adopted regulations around nurse staffing ratios. Mandatory overtime for nurses is also restricted in 16 states.

 
What's New in Nursing and Patient Safety on AHRQ PSNet
ORGANIZATIONAL POLICY/GUIDELINES
Managing risk during transition to new ISO tubing connector standards.
Sentinel Event Alert. August 20, 2014;(53):1-6.
COMMENTARY
Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy.
Rainer J. J Nurs Care Qual. 2014 Jul 31; [Epub ahead of print].
STUDY
Predictors of unit-level medication administration accuracy: microsystem impacts on medication safety.
Donaldson N, Aydin C, Fridman M. J Nurs Adm. 2014;44:353-361.
UPCOMING MEETING/CONFERENCE
Beyond Medication Error Reporting: A New Approach for Understanding Medication Safety Risk.
Institute for Safe Medication Practices. September 18, 2014; 1:30–3:00 PM (Eastern).
UPCOMING MEETING/CONFERENCE
Using Health IT to Reduce Medication Errors and Improve Patient Safety.
Agency for Healthcare Research and Quality. August 26, 2014; 2:30–4:00 PM (Eastern).
REVIEW
Interventions to reduce medication errors in pediatric intensive care.
Manias E, Kinney S, Cranswick N, Williams A, Borrott N. Ann Pharmacother. 2014 Jul 24; [Epub ahead of print].
STUDY
The occurrence of adverse events potentially attributable to nursing care in medical units: cross sectional record review.
D'Amour D, Dubois CA, Tchouaket É, Clarke S, Blais R. Int J Nurs Stud. 2014;51:882-891.
 
Editor's Picks for Nursing and Patient Safety
From AHRQ WebM&M
Are We Pushing Graduate Nurses Too Fast?
Nancy Spector, PhD, RN. AHRQ WebM&M [serial online]. March 2011
Difficult Encounters: A CMO and CNO Respond.
Ernest J. Ring, MD; Jane E. Hirsch, RN, MS. AHRQ WebM&M [serial online]. October 2009
Nurse Staffing Ratios: The Crucible of Money, Policy, Research, and Patient Care.
Victoria Rich, PhD, RN. AHRQ WebM&M [serial online]. August 2009
 
From AHRQ PSNet
JOURNAL ARTICLE
Nurse staffing and inpatient hospital mortality. Classic icon
Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR, Harris M. N Engl J Med. 2011;364:1037-1045.
Nurse working conditions and patient safety outcomes. Classic icon
Stone PW, Mooney-Kane C, Larson EL, et al. Med Care. 2007;45:571-578.
The working hours of hospital staff nurses and patient safety. Classic icon
Rogers AE, Hwang WT, Scott LD, Aiken LH, Dinges DF. Health Aff (Millwood). 2004;23:202-212.
Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Classic icon
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. JAMA. 2002;288:1987-1993.
Educational levels of hospital nurses and surgical patient mortality. Classic icon
Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. JAMA. 2003;290:1617-1623.
BOOK/REPORT
Keeping Patients Safe: Transforming the Work Environment of Nurses. Classic icon
Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services, Page A, ed. Washington, DC: National Academies Press; 2004.
JOURNAL ARTICLE
Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Classic icon
Smetzer J, Baker C, Byrne FD, Cohen MR. Jt Comm J Qual Patient Saf. 2010;36:152-163, 1AP-2AP.
Association of interruptions with an increased risk and severity of medication administration errors. Classic icon
Westbrook JI, Woods A, Rob MI, Dunsmuir WTM, Day RO. Arch Intern Med. 2010;170:683-690.
Effects of nursing rounds on patients' call light use, satisfaction, and safety.
Meade CM, Bursell AL, Ketelsen L. Am J Nurs. 2006;106:58-70.
WEB RESOURCE
Nursing Care Quality at NQF.
National Quality Forum.
 
Last Updated: October 2012