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Patient safety suffers with poor work conditions
Overtime, organizational climate linked to infections
A new study provides the most compelling evidence yet for improving staffing and working conditions of nurses: Patients in intensive care units are more likely to develop serious and possibly deadly infections if units were understaffed and nurses worked more overtime.
Managerial support and physician-nurse collaboration also have an impact on patient outcomes and employee injuries, the researchers say.
The study of 1,095 nurses in 51 ICU units at 31 hospitals found that patients were more likely to develop a catheter-associated urinary tract infection (CAUTI) and decubitus ulcer (or bed sore) if the nurses worked high rates of overtime. ICU's with more RN staffing per patient had significantly lower levels of central line-associated bloodstream infections, ventilator-associated pneumonia, 30-day mortality, and decubitus ulcer.
Patients in units in which nurses perceived a better organizational climate were 39% less likely to develop a CAUTI.1
In a related study, the researchers found a link between working conditions and needlesticks and other work-related injuries.2
"When you look at the body of research, [it appears] that the same things that impact employee safety also affect patient safety, as well as employee turnover," says lead author Pat Stone, PhD, assistant professor of nursing at the Columbia University School of Nursing in New York City. "They're not mutually independent in any way. They're actually synergistic."
National patient safety measures do not incorporate working conditions, such as overtime, notes Stone. "I think people should be measuring these variables more frequently in their operations," she says. "I think a lot of them have not looked at overtime."
Yet Stone acknowledges that resolving staffing issues may be challenging. For example, while you want nurses to understand the repercussions of unplanned absences on their colleagues, you don't want nurses to come to work sick — and expose co-workers and vulnerable patients to an infectious disease. Cross-training of staff to cover in other units may help balance staffing and avoid overtime, suggests Stone.
"We need a flexible, qualified work force," she says. "It's not as simple as nurse-patient ratios. You don't want to just keep putting tired nurses out there. You need fresh, qualified nurses."
The payoff of better staffing is not only better patient outcomes but improved worker safety. You'll have better retention of nurses, too, Stone says.
Steps toward a better climate
By hiring new nurses or cross-training current employees, perhaps you can reduce your overtime and boost your staffing. But how can you improve your "organizational climate"?
That may seem like an elusive goal. But there are steps that can make nurses — and other employees — feel that they are part of a collaborative work environment.
For example, some hospitals have a written policy that sets an expectation for employees, managers, and administrators to treat each other respectfully, says Stone. Administrators may make rounds and ask employees for input. Nurses and other frontline workers join managers, administrators, and physicians on committees that set policies.
Career ladders, which give nurses points — and extra pay — for taking on other duties, such as committee assignments, can play a role in improving organizational climate, she says.
New patient safety tool
A new patient safety tool published by the Agency for Healthcare Research and Quality (www.ahrq.gov) includes questions about managerial support and communication.
Yet as you evaluate working conditions, don't just look at the hospital as a whole. Individual units may function much differently and may have a different organizational climate.
A study of four ICUs in a single hospital showed that employee perceptions varied widely among units. The study measured teamwork climate, perceptions of management, safety climate, stress recognition, job satisfaction, and work environment.3
Nurses assessed their working conditions significantly more poorly than did physicians, and they had lower perceptions of management. Nursing directors overestimated the sense of teamwork among ICU staff.
When you seek to improve working conditions, start with units that have higher injury rates or patient safety problems, advises Stone. "Don't go where everything is running right," she says. "Find the units that are having problems and see what you can do to help those."
1. Stone PW, Mooney-Kane C, Larson EL, et al. Nurse working conditions and patient safety outcomes. Med Care 2007; 45:571-578.
2. Stone PW, Gershon RR. Nurse work environments and occupational safety in intensive care units. Policy Polit Nurs Pract 2006; 7:240-247.
3. Huang DT, Clermont G, Sexton JB, et al. Perceptions of safety culture vary across the intensive care units of a single institution. Crit Care Med 2007; 35:165-176.