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Nurses Caring for Patients: Who They Are, Where They Work, and What They Do1

An organization’s workers and their work environment have a reciprocal relationship, each influencing the other in an ongoing, dynamic interplay that affects the level of safety within the organization (Cooper, 2000). To construct a nursing work environment that maximizes patient safety, the characteristics of the nursing workforce, the settings in which they provide care, and the nature of their work, as well as the implications of these elements for patient safety, need to be considered. This chapter does so, focusing predominantly on the role of nurses in hospitals and nursing homes, where the greatest amount of study has been conducted on patient safety.

WHO IS DOING THE WORK OF NURSING?

“When average citizens report that ‘I saw the nurse,’ or ‘I talked to the nurse,’ they could mean any of a vast array of workers” (Ward and Berkowitz, 2002:44). The word “nurse” is often used to refer to registered

1  

Portions of this chapter draw on four papers commissioned by the committee: “The Nursing Workforce: Profile, Trends and Projections” by Julie Sochalski, Ph.D., of the University of Pennsylvania School of Nursing; “The Work of Registered Nurses, Licensed Practical Nurses, and Nurses Aides in Acute Care Hospitals” by Barbara Mark, Ph.D., of the University of North Carolina at Chapel Hill School of Nursing; “The Work of Nurses and Nurse Aides in Long Term Care Facilities” by Barbara Bowers, Ph.D., of the University of Wisconsin-Madison School of Nursing; and “The Work of Nurses and Nurse Assistants in Home Care, Public Health, and Other Community Settings” by Karen Martin of Martin Associates.



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Keeping Patients Safe: Transforming the Work Environment of Nurses 3 Nurses Caring for Patients: Who They Are, Where They Work, and What They Do1 An organization’s workers and their work environment have a reciprocal relationship, each influencing the other in an ongoing, dynamic interplay that affects the level of safety within the organization (Cooper, 2000). To construct a nursing work environment that maximizes patient safety, the characteristics of the nursing workforce, the settings in which they provide care, and the nature of their work, as well as the implications of these elements for patient safety, need to be considered. This chapter does so, focusing predominantly on the role of nurses in hospitals and nursing homes, where the greatest amount of study has been conducted on patient safety. WHO IS DOING THE WORK OF NURSING? “When average citizens report that ‘I saw the nurse,’ or ‘I talked to the nurse,’ they could mean any of a vast array of workers” (Ward and Berkowitz, 2002:44). The word “nurse” is often used to refer to registered 1   Portions of this chapter draw on four papers commissioned by the committee: “The Nursing Workforce: Profile, Trends and Projections” by Julie Sochalski, Ph.D., of the University of Pennsylvania School of Nursing; “The Work of Registered Nurses, Licensed Practical Nurses, and Nurses Aides in Acute Care Hospitals” by Barbara Mark, Ph.D., of the University of North Carolina at Chapel Hill School of Nursing; “The Work of Nurses and Nurse Aides in Long Term Care Facilities” by Barbara Bowers, Ph.D., of the University of Wisconsin-Madison School of Nursing; and “The Work of Nurses and Nurse Assistants in Home Care, Public Health, and Other Community Settings” by Karen Martin of Martin Associates.

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Keeping Patients Safe: Transforming the Work Environment of Nurses nurses (RNs), licensed practical nurses/licensed vocational nurses (LPNs/ LVNs), or nursing assistants (NAs). In this report, we refer collectively to all three of these groups of personnel as nursing staff. There are over 5 million nursing staff in the United States. Of these, 2.2 million are actively employed as RNs2 and 683,800 as LPNs/LVNs. RNs and LPNs/LVNs are licensed by the state in which they provide nursing care. Another 2.3 million unlicensed health care workers (Bureau of Labor Statistics, undated) supplement the work of licensed nurses by performing basic patient care activities under the supervision of an RN or LPN/LVN. These unlicensed health care personnel hold a variety of job titles, including nurse assistants, nurse aides, home health aides, personal care aides, ancillary nursing personnel, unlicensed nursing personnel, unlicensed assistive personnel, nurse extenders, and nursing support personnel. In this report, we refer collectively to these workers as NAs. Jobs for NAs are expected to be among the most rapidly expanding in the workforce as the overall U.S. population ages, and the need for postacute and chronic care increases. Indeed, the number of employed NAs increased by 40 percent between 1980 and 1990, more than twice the growth rate of the overall U.S. workforce. The greatest growth was in aides working in home care, whose numbers more than doubled from 1988 to 1998. From 1998 to 2008, a 36 percent increase in NA jobs is predicted, compared with a 14 percent increase in all workforce jobs (GAO, 2001b). Variations in Education and in Experience and Expertise Among Members of the Nursing Workforce Education Each type of nursing personnel is educated differently. An overview of the education received by each is provided below. Education for RNs Basic RN education can be attained through three routes: 3-year diploma programs, 2-year associates degree (AD) nursing programs, and 4-year baccalaureate degree programs. In addition to any of these three types of academic preparation, individuals must pass a state examination to be licensed as an RN. The route chosen to receive entry-level, prelicensure RN education has changed considerably over the past two decades, with decreasing use of 3-year diploma programs and increased use of AD and baccalaureate programs. Between 1980 and 2000, the proportion of nurses receiving their 2   Although there were approximately 2.7 million RNs in the United States in 2000, only approximately 2.2 million of them were working actively as nurses.

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Keeping Patients Safe: Transforming the Work Environment of Nurses basic education from a diploma program decreased from 60 to 30 percent, while the proportion of those receiving basic education from AD or baccalaureate programs increased from 19 to 40 percent and 17 to 29 percent, respectively. However, these data do not fully characterize the educational level of the RN workforce, as many RNs pursue additional education after being licensed. In 2000, the distribution of RNs according to their highest degree was as follows: diploma preparation (23 percent), AD (34.3 percent), baccalaureate degree (32.7 percent), and master’s or doctoral degree (10 percent). The educational level of RNs varies by place of employment. RNs in nursing homes generally have a lower level of education than those in other settings. In 2000, only 27 percent of RNs employed by nursing homes were prepared at the baccalaureate level, compared with 43 percent in hospitals. Nurses with advanced-practice credentials are also less well represented in nursing homes: 7.6 percent of hospital nurses were prepared at the masters or doctorate level, compared with 4.3 percent of nursing home nurses (Spratley et al., 2000). Research on the effect of different educational paths to RN licensure on nurse performance and patient outcomes has been inconclusive. Such research has examined the characteristics, abilities, and work assignments of nurses with and without baccalaureate degrees, but has not been as thorough in examining the quality of the care they provide (including patient safety) (Blegen et al., 2001). However, an analysis of educational preparation and years of experience in the nursing workforce from the National Sample Survey of Registered Nurses (NSSRN) suggests that baccalaureate-prepared nurses have tended to stay in the workforce longer and accrue more years of work experience than those not thus prepared (Sochalski, 2002). Further, limited data from studies of magnet hospitals (i.e., hospitals characterized by their ability to attract and retain nurses) indicate that those hospitals have higher percentages of baccalaureate-prepared nurses (50 percent) as compared with the national hospital average of 34 percent (Aiken et al., 2000a). Education for LPNs/LVNs LPN/LVN training programs are shorter than those for RNs, taking 12 to 18 months, and emphasize technical nursing tasks such as monitoring vital signs, administering medications, and completing treatments (GAO, 2001b). In 2000, approximately 1,100 state-approved programs provided LPN/LVN education. Students attending these programs were enrolled predominantly in vocational/technical schools and community and junior colleges. A state licensing examination also must be completed successfully following the LPN/LVN training program (Bureau of Labor Statistics, 2003). Education for NAs Training for NAs depends on their place of employment. Those working in Medicare- or Medicaid-reimbursed nursing homes

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Keeping Patients Safe: Transforming the Work Environment of Nurses (the majority) and home health agencies must meet certain minimum training requirements and competency standards and acquire state certification to become certified nurse aides (CNAs). An individual may become a CNA either by completing a nurse aide training program and a competency evaluation (a written or oral test and skills demonstration) or by passing a competency evaluation alone. A minimum of 75 hours of training is required through a state-approved CNA program, although many state programs exceed the minimum. At least 16 of the 75 hours must be practical training under the direct supervision of an RN or LPN. For CNAs working in nursing homes, states are required to keep a registry of those who have passed their competency evaluations (GAO, 2001b). There are no similar federal requirements regarding training, certification, competency evaluation, or registries for NAs working in hospitals (GAO, 2001b). Experience and Expertise Experience and expertise refer to the knowledge and skill obtained apart from (often subsequent to) formal preparation in an academic institution. Experience is acquired when an actual practice situation “refines,” “elaborates,” or “disconfirms” knowledge that has been acquired previously through the study of theory or principles or participation in events. Expertise is the result of an individual’s accumulation of knowledge and skill from such experiences (Benner, 1984:3–5). Thus, workers with similar formal education can possess varying degrees of expertise. A new graduate and a seasoned nurse of 20 years are both nurses, but their experience and expertise are very different. The varying levels of expertise and skill acquired by learners have been identified through studies of different types of workers and learners within and outside of health care. These levels have been labeled as “novice,” “advanced beginner,” “competent,” “proficient,” and “expert” (Dreyfus and Dreyfus, 1986). As applied to nursing, they have been described as (1) novice—beginners who have no experience with the situations in which they must perform; (2) advanced beginners—individuals who have marginally acceptable performance based on a foundation of experience with real situations; (3) competent—individuals with 2 or 3 years in a similar situation; (4) proficient—wherein perception allows meanings to be understood in terms of the “big picture” rather than as isolated observations; and (5) expert—based on a wealth of experience enabling an intuitive grasp of situations and quick targeting of problem areas (Benner, 1984). According to this framework, expertise is subject matter–specific; thus, for example, RNs may be expert in one area of practice, such as critical care, but not in another, such as psychiatric nursing, just as a highly expert obstetrician may be less than proficient in managing an adult with neurological problems.

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Keeping Patients Safe: Transforming the Work Environment of Nurses The levels of experience and expertise of nursing staff have not been well measured. Experience is typically assessed using a proxy measure—the number of years an individual has been employed in nursing. This measure may capture exposure to opportunities for experience and the gaining of expertise, but as noted above, such exposure is not always a guarantee of expertise. Using years of nursing work as a proxy measure, however, experience has been associated with better patient care. In an analysis of data from two studies (involving 42 inpatient units in one large tertiary-care hospital and 39 patient care units in 11 other hospitals), nursing units whose nurses had more years of experience were found to have lower rates of medication errors and patient falls (Blegen et al., 2001). Likewise, a 1996–1998 analysis of nurses and errors in a Japanese cardiology ward found that nurses with less than 3 years of experience made significantly more rule-based and skill-based errors than those with more than 3 years of experience (Narumi et al., 1999). Further support for the beneficial effects of years of experience and expertise in providing nursing care to individuals with particular clinical conditions can be inferred from similar studies of physicians. Such studies have revealed better patient outcomes when clinical procedures are carried out by physicians who have performed greater numbers of those procedures and when care of patients with certain clinical conditions, such as AIDS, is rendered by physicians with more experience in treating those conditions. The Agency for Healthcare Research and Quality’s (AHRQ) recent evidence-based report on the effect of health care working conditions on patient safety presents evidence that in a number of types of clinical care, greater experience of health professionals is associated with better patient outcomes (Hickam et al., 2003). Currently, the experience level of nursing staff is threatened by high turnover rates in all health care delivery settings. Nationally in 2000, an estimated 21 percent of all acute care hospital nurses left the position in which they were practicing. Most hospitals reported turnover rates of 10 to 30 percent, but some experienced even higher rates (The HSM Group, 2002). The turnover rate is even higher in long-term care facilities. A 2001 national survey of the American Health Care Association (AHCA) revealed turnover rates of 78 percent for NAs, 56 percent for staff RNs, 54 percent for LPNs/LVNs, and 43–47 percent for directors of nursing and RNs with administrative duties (AHCA, 2002). If all these nursing personnel left their positions to take new positions in settings offering similar clinical services, the level of expertise of the nursing workforce would not be threatened.3 3   Although safety would still be threatened by nurses’ unfamiliarity with new HCO structures, policies, and practices.

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Keeping Patients Safe: Transforming the Work Environment of Nurses However, NSSRN data show that a number of these nurses are leaving the field of nursing altogether. In 2000, 18.3 percent of licensed nurses were not working in the field of nursing. Evidence indicates that these are not just retired older nurses. Almost 3 percent of women and 2 percent of men graduating from nursing schools between 1988 and 1991 were not working in nursing within the first 4 years following graduation. By 9 to 12 years after graduation, 11 percent of women and 6 percent of men had departed from the profession. More recent graduating classes have higher departure rates. Among 1996–1999 graduates, 4.1 percent of women and 7.5 percent of men left the profession within 4 years of graduating (Sochalski, 2002). This loss of experienced nurses can represent a threat to patient safety. Unique Demographic Characteristics of the Nursing Workforce Most data on the nursing workforce are collected on RNs; less is known about LPNs/LVNs and NAs, who together make up 42.6 percent of nursing staff. It is known, however, that nursing staff overall are predominantly female and ethnically different from the workforce at large and those they serve. RNs are older than the total U.S. workforce and aging more rapidly. NAs are often poor and without health insurance—unable to receive the services they provide to others. A small portion of nursing staff are not employees of the health care organizations (HCOs) in which they work, but provide care to patients as “contingent” workers. Predominance of Women The RN workforce is predominantly female (94.6 percent), although the small proportion of male RNs rose from 2.7 percent in 1980 to 5.4 percent in 2000 (Spratley et al., 2000). The NA workforce is similarly largely female. Women are estimated to make up 79.6 percent, 90.9 percent, and 89.2 percent of hospital, nursing home, and home care aides, respectively (GAO, 2001b). Although data are unavailable on the gender of LPNs/LVNs, they are likely predominantly female as well. The high proportion of women in the nursing workforce has a number of implications. Conflicts in nurse–physician relationships have been attributed in part to gender conflicts and inequalities in society at large (McMahan and Hoffman, 1994). In addition, responsibilities at home, such as caring for children or older family members and performing household chores, may contribute to the commission of errors in two ways. First, family obligations may add to the long hours worked by many nurses in their professional workplace and contribute to the sleep deficits and fatigue that are associated with the commission of errors. Of nurses employed in the field in 2000, 55 percent had children living at home (Spratley et al., 2000).

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Keeping Patients Safe: Transforming the Work Environment of Nurses Nursing home and home health aides are also two to three times more likely than other workers to be unmarried and to have children at home (GAO, 2001b). Second, while research has shown that men and women both experience stress in balancing work and family obligations, multiple studies on the division of household tasks have found that women continue to perform far more chores than do men (Wentling, 1998). An Older and More Rapidly Aging Nursing Workforce The entire U.S. workforce is aging, largely as a result of the aging of baby boomers. As noted, however, the RN workforce is already older than the total U.S. workforce and is aging more rapidly. The average age of the RN workforce was 37.4 in 1983 (Buerhaus et al., 2000), but had increased to 45.2 years by 2000 (Spratley et al., 2000). In the 1980s, the majority of nurses were in their twenties and thirties; by 2000, this distribution had changed substantially, with four times more 40-year-old than 20-year-old nurses. The average age of RNs is projected to increase and peak at 45.5 years in 2010 (Buerhaus, et al., 2000). In contrast, the Department of Labor forecasts the age of the overall labor force to reach only 40.7 years by 2008 (Bureau of Labor Statistics, 1999). The more rapid aging of the RN workforce is attributed to three factors. First, large cohorts of the existing RN workforce are in their fifties and sixties—a function of the baby boom. Only when RNs born in the 1950s reach retirement age in approximately 2020 is the age distribution of the RN workforce projected to shift back toward younger ages (Buerhaus et al., 2000). Also, fewer young people are choosing to become RNs, so the proportion of younger nurses among all RNs is declining (Buerhaus et al., 2000; Spratley et al., 2000). Finally, in recent years, new graduates of basic nursing programs have tended to be older, and thus the average age of entrants into the RN workforce has been higher (Spratley et al., 2000).4 This aging workforce has implications for nurses’ work environments. The loss of strength and agility that often accompanies aging affects the ease with which nurses can perform patient care activities that require them to turn, lift, or provide weight-bearing support to patients. Focus groups of nurses have revealed that among nurses who plan to stay in the field, many are concerned that they will be unable to do so as they age because of the heavy physical demands of the job (Kimball and O’Neil, 2002). Ergonomic 4   In contrast, NAs are younger than RNs, and their age distribution has remained comparatively stable. From the late 1980s to the late 1990s, the mean age of NAs working in hospitals, nursing homes, and home health care changed from 36.3 to 38.0 years, 36.6 to 36.4 years, and 46.7 to 42.8 years, respectively (Yamada, 2002).

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Keeping Patients Safe: Transforming the Work Environment of Nurses patient and staff furniture and work tools will be needed to decrease the risk of injuries to patients (and nurses as well). Changes in hearing and vision also have implications for the design of work and technology used in patient care—for example, the need for increased lighting and larger size of print material (Curtin, 2002). There could be implications as well for shift lengths and rotations. Research has shown that adapting to shift work is more difficult for workers over age 40. A recent study of the effect of age on performance found that older individuals (mean age 43.9) had less ability to maintain performance on standard neurobiological tests across a 12-hour shift compared with younger individuals (mean age 21.2) (Reid and Dawson, 2001). A Workforce That Does Not Yet Fully Reflect the Racial and Ethnic Diversity of the U.S. Population The U.S. population is becoming more racially and ethnically diverse. At the beginning of the 1900s, one of every eight Americans identified himself or herself as a race other than “white.” At the end of the century, one of four did so, as the white population had grown more slowly than every other racial/ethnic group. This increase in diversity accelerated in the latter half of the century. From 1970 to 2000, the population of races other than “white” or “black” grew considerably, and by 2000 was comparable in size to the black population. The black population represented a slightly smaller share of the total U.S. population in 1970 than in 1900, while the Hispanic population more than doubled from 1980 to 2000. In the 2000 census, 36 percent of the population reported belonging to “two or more” races (the 2000 census was the first to include this reporting category). The racial/ ethnic composition of the U.S. population according to the 2000 census was as follows: 75.1 percent white, 12.3 percent black, 3.8 percent Asian or Pacific Islander, 0.9 percent American Indian or Alaska Native, 2.4 percent claiming two or more races, and 5.5 percent claiming a race other than those already cited. Individuals (of any race) claiming Hispanic origin constituted 12.5 percent of the U.S. population (Hobbs and Stoops, 2002). The nursing workforce does not yet fully reflect this diversity. In 2000, a higher proportion of RNs (88 percent) than the general U.S. population (75.1 percent) was white; however, the 12 percent of racial/ethnic minority RNs was an increase from the 5 percent of 1980. Significantly, the increase in the overall RN population between 1996 and 2000 is attributed largely to the growth in the numbers of RNs from racial/ethnic minorities (Spratley et al., 2000). In contrast, the NA workforce has a higher proportion of such minorities than the U.S. population overall. Approximately 40–50 percent of NAs working in hospitals, long-term care facilities, and home health care are nonwhite racial/ethnic minorities (GAO, 2001b).

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Keeping Patients Safe: Transforming the Work Environment of Nurses This phenomenon is not unique to nursing. Differences in the racial/ ethnic and cultural composition of the health care workforce and the patient population have been a source of concern across all health professions. Such differences can be obstacles to fully understanding patient care needs. Language differences, in particular, can be a major barrier to care delivery. If nursing staff cannot communicate with patients effectively, health assessment, explanations of alternative treatments, informed consent, health education, involvement of patients in self-care, and discharge instructions are all compromised. Patients cannot be full partners in monitoring for threats to their safety if they do not understand the interventions being applied on their behalf. Other implications of racial/ethnic and cultural differences include, for example, limited understanding of the use of alternative therapies and other health- and illness-related practices of patients and their families, and the effects of those practices on planned care. In a previous study, the Institute of Medicine (IOM) found that greater racial and ethnic diversity in the health professions strengthens patient–provider relationships. The benefits of this diversity are believed to accrue broadly to the health professions and help expand their ability to conceptualize and respond to the health needs of the increasingly diverse U.S. population (IOM, 2003). Hospital RN Salaries Might Be Increasing; Many NAs Live at or Below Poverty Level The U.S. Department of Labor characterizes the earnings of licensed nurses as “above average” (Bureau of Labor Statistics, 2003). Although there is documentation of the need or desire of some RNs for higher salaries (Kimball and O’Neil, 2002), other studies of RNs find a lack of substantial dissatisfaction with their salaries (GAO, 2001a). Of 13,471 RNs surveyed in Pennsylvania, 57 percent reported their salaries were adequate (Aiken et al., 2001b). Only 26 percent of a national random sample of nurses identified “not making enough money” as a great concern when reflecting on their own experience (Kaiser Family Foundation and Harvard School of Public Health, 1999). The average annual salary in 2000 for RNs employed full time in their principal position was $46,782, although this figure varied by setting of care and position. RNs working full-time in hospitals5 earned on average about $47,759 per year, while those working in nursing homes earned less—about $43,779 per year. In contrast to nurses working in administrative, research, or educational positions, staff nurses providing di- 5   This included nurses in administrative positions as well as nurses providing direct patient care.

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Keeping Patients Safe: Transforming the Work Environment of Nurses rect care to patients (the majority of employed nurses) earned an average of $42,133 annually in 2000 (Spratley et al. 2000). These salaries, when adjusted for inflation, have not changed greatly since the 1980s (Health Resources and Services Administration, 2002). However, recent data indicate that hospital nurses received base salary increases of approximately 8 percent in 2002 (Bolster and Hawthorne, 2003). LPNs/LVNs are paid, on average, about two-thirds of what RNs in staff positions earn (Bureau of Labor Statistics, undated). Many NAs, in contrast, are among the working poor. In particular, NAs working in nursing homes and home care are much more likely than other workers to live below the poverty level, to be uninsured, and to receive public benefits such as food stamps and Medicaid. A U.S. General Accounting Office (GAO) analysis of 1998, 1999, and 2000 data from the Current Population Survey (CPS) of the U.S. Census Bureau and the Bureau of Labor Statistics found that the average wages of full-time, full-year NAs in hospitals, nursing homes, and home health care agencies ranged from $19,216 to $21,432. These wages place 17.8 percent, 18.8 percent, and 8.1 percent of NAs working in nursing homes, home health care, and hospitals, respectively, at or below the federal poverty level. Additionally, 13.5 percent, 14.8 percent, and 5.3 percent, respectively, receive food stamps, while 25.0, 32.1, and 14.2 percent, respectively, are uninsured (GAO, 2001b). The stresses and distractions caused by their poverty, insurance status, and related conditions undoubtedly have an adverse effect on these workers’ ability to provide maximal attention to work requirements and adapt to new workplace practices. RNs Employed as “Contingent Workers” “Contingent workers” are those who provide their services to an organization on a short-term or periodic basis. They include temporary staff, independent contractors, and seasonal hires (Rousseau and Libuser, 1997). In 2000, only 2 percent of RNs working in their principal nursing position did so through a temporary employment service; most were employed by the organization in which they worked. However, this 2 percent represented a 36 percent increase over that reported in 1996 and reversed a declining trend observed between 1988 and 1996. Further, in 2000 an additional 71,490 RNs reported working through temporary service agencies in positions that were in addition to their principal positions. Taken together, the total number of nurses employed through a temporary employment service was 110,994—a 65.6 percent increase over 1996 and considerably higher than 1988 and 1992 estimates (Spratley et al., 2000). It is not clear whether this one-time measurement indicates a trend in nursing; the proportion is close to that observed nationally across all indus-

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Keeping Patients Safe: Transforming the Work Environment of Nurses tries, where contingent workers constitute 3 percent of the workforce. The national use of contingent workers in all employment settings has remained relatively stable since the mid-1990s (Employment Policy Foundation, 2000). However, a 2001 survey of nurse executives in 693 acute care U.S. hospitals found that temporary staff or travelers were used by 54 percent of the respondents to fill vacancies (The HSM Group, 2002). Moreover, a 1997 survey of 187 employers of nurses in the District of Columbia found that 9.6 percent of hospital nursing staff were not hospital employees, but secured through nurse staffing agencies (Mailey et al., 2000). If the present high rate of vacancies in nursing positions (discussed below) continues, use of contingent workers may persist or even increase. Furthermore, the proportion of NAs who are employed by temporary agencies may be higher than the corresponding proportion of RNs: 35 percent of NAs report working in positions other than hospitals, home health agencies, and nursing homes; this large category of “other” includes temporary staffing agencies (GAO, 2001b). Although use of temporary employees can increase the number of nurses available to care for patients, it can also represent a threat to patient safety because these temporary staff are unfamiliar with a nursing unit and an HCO’s overall structure, policies, and practices. Temporary employees are less familiar with an organization’s information systems, patient care technology, facility layout, critical pathways, interdependency among work components, ways of coordinating and managing its work, and other work elements. Permanent nursing staff in hospitals and nursing homes describe the use of agency nurses as hindering continuity of care and reducing quality of care (Anderson et al., 1996; Bowers et al., 2000). These subjective impressions are supported by some objective analyses of patient safety indicators. Medication errors have been shown to increase with the number of shifts worked by temporary nursing staff and to decrease when permanent staff work overtime to ensure adequate staffing (Roseman and Booker, 1995). An observational cohort study in eight hospital intensive care units (ICUs) participating in the Centers for Disease Control and Prevention’s National Nosocomial Infections Surveillance System found that, after controlling for other risk factors, care by a “float” RN for more than 60 percent of central line days was independently associated with an increased risk for central line–associated blood-stream infections, and the risk increased in proportion to “float” days of care (Jackson et al., 2002). These observations in health care are consistent with those made regarding the use of contingent workers in other industries. The latter studies have found that increased use of contingent workers results in higher accident rates due to decreasing familiarity with on-site personnel and equipment, undercuts teamwork, and impairs communication. It also is associated with poor labor–management relations when contingent workers are

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Keeping Patients Safe: Transforming the Work Environment of Nurses homes, a requirement that individuals involved in an incident report submit to drug testing. NAs generally reported little training or support from management in dealing with such incidents. Separate focus groups with nursing directors from the six nursing homes confirmed that many incidents likely are not reported and that there is little support for NAs after such incidents occur. Directors of nursing cited resistance to drug testing and fear of job loss as reasons for failure to report incidents. Violence by residents against NAs was not viewed as a priority by administrators (Gates et al., 1999). The increased workloads associated with hospital reorganization and redesign initiatives, as discussed earlier, and hierarchical and bureaucratic management styles that overemphasize efficiency also have been identified as creating obstacles to the provision of emotional support (Miller, 1995). “Physical tasks can be recorded in medical records, used for reimbursement purposes, and easily quantified. Caring for patients’ psychological needs, which is not charted or paid for as a special service item, is missing from the usual litany of tasks and activities for which aides are responsible” (Foner, 1995:231), as was illustrated in Box 3-2. Educating Patients and Families Education of patient and families is another of the primary responsibilities of RNs. This education is aimed at providing patients and families with appropriate information so they can make informed decisions about their health care and treatments, and develop the knowledge, skills, and abilities needed to perform self-care (ANA, 1998, 2001). Surveys of individual nurses in clinical practice conducted in 1992 to validate the content of the NIC system and determine the frequency with which nurses performed each of the 336 nursing interventions identified teaching patients as an intervention used by more than 90 percent of nurses (Bulechek et al., 1994). However, shorter hospital stays challenge nurses to find the time to provide effective patient education. In a survey of 50 percent of RNs living in Pennsylvania and working in acute care hospitals between 1998 and 1999, 27.9 percent of respondents stated that they had left necessary patient or family teaching undone (Aiken et al., 2001a). Additional Activities Related to Hands-on Patient Care Integrating care The increasing complexity of health care often requires that patients be cared for by multiple providers with specialized expertise in diverse roles for a single or across multiple episodes of care (Shortell et al., 2000b). A patient may also be cared for by multiple HCOs or units within one organization, such as ICU, step-down unit, general medical–surgical unit, skilled nursing facility, and home health agency. The coordination of

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Keeping Patients Safe: Transforming the Work Environment of Nurses BOX 3-2 Time Required for Emotional Support: A Case Example Foner (1995:232–235) describes the following example of a situation in which the time needed to provide emotional support to patients is undervalued relative to speed and efficiency in accomplishing the physical tasks of nursing: Gloria James and Ana Rivera (pseudonyms) were exact opposites. Ms. James … was mean and verbally abusive of patients…. Ana was gentle, considerate and kind. Yet Gloria was the nurses’ favorite, while Ana was constantly criticized by the nursing coordinator in charge of the floor…. Why was Ms. James so favored by the nurses? Mainly for being quick, efficient, and neat…. Ms. James’ rooms … were immaculate. By lunchtime the beds were neatly made … items in the drawers were properly in place and neatly folded. The yellow trays by the sink were sparkling, lined with paper towels to keep toothbrushes and other toilet articles clean. Ms. James was typically the first nursing aide in the day room at lunchtime getting residents ready to eat. She was a fast worker. She … was punctilious about getting her paperwork done neatly and on time…. Ms. James’ attitude toward dressing, bathing, and feeding patients was much the same as her attitude toward her other chores. She was determined to get them done quickly whether patients liked it or not…. She had no tolerance for patients’ resistance which slowed her down. Besides, she could get in trouble if, for example, their nails were not cut or their weights not done…. Ms. James’ behavior to patients was far from gentle … she bullied and taunted them; she badgered and yelled…. Ms. James humiliated and verbally abused patients … in front of nurses, administrators, doctors and visitors. Yet she received the best evaluation on the floor and had privileges denied other aides … when the two nurses were away from the floor, it was Ms. James whom they left in charge. Ana is an expert in … the emotional work of caring: holding, cuddling, calming, and grieving. My first view of Ana was typical…. Ana patient care services across these people, functions, activities, and sites over time is referred to as “clinical integration” (Shortell et al., 2000a). RNs spend a large amount of time integrating patient care as part of planning for patients’ discharge from hospitals or other health care facilities to enable continued care in the home, school, or long-term care facility; educating the patient and family about the patient’s disease, course of

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Keeping Patients Safe: Transforming the Work Environment of Nurses quietly fed a frail and weak resident, cradling her with one arm and gently calling her “Mama” as she coaxed her to eat…. One of her residents, Ms. Calhoun, was a witty, sarcastic woman with Parkinson’s disease whose mental status, as the problem book noted, fluctuated from alert and oriented to disruptive and verbally abusive. One afternoon she went out of control, screaming and shaking when a new rehabilitation aide mistakenly put a restraint on her chair. Ana gently removed the restraint and gently stroked Ms. Calhoun’s head for several minutes as she calmed her down. “She [the rehabilitation aide] didn’t know, its her first time,” she tried to explain to Ms. Calhoun. “Calm down now, calm down. You’re better now.” With completely disoriented and unresponsive patients, Ana assumed a maternal air; with the alert, she chatted and joked as an equal, asking them what they wanted to wear, explaining the tasks she was doing or was about to do, and trying to reassure them about the anxieties they had…. Ana empathized with the residents’ situation and was aware of their family and personal histories. “It’s not just a job,” she explained. “Some of them are lonely. They have nobody; they need love and understanding.” Beyond emotional work, Ana was fastidious about keeping residents clean. She was careful about the way she gave baths and made sure to wash and lubricate residents before changing their undergarments. But … her efforts were unappreciated by the coordinating nurse…. One day she was berated for not doing tasks in the right order; another for not having a resident dressed on time for lunch…. Slowness was part of the problem. Though Ana maintained a steady even pace throughout the day, she was sometimes late in completing her tasks … sometimes behind schedule weighing patients; and she did not always have her paperwork finished on time. Sometimes she ended up staying late just to complete her basic chores…. Ana’s trouble, paradoxically, was that she had the misfortune to work on what the administration then judged to be the best floor, under the best registered nurse in the facility…. At every level of the nursing department, from aides to registered nurses, efficiency and organization were valued over compassion to residents. therapy, medications, self-care activities, and other areas of concern to the patient; and preventing gaps in care delivery, or discontinuities in care that can result in a loss of information relevant to patient care or interruptions in care. Patient transfers—e.g., from unit to unit, facility to facility, or hospital to home—are a common occurrence resulting in a high potential for

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Keeping Patients Safe: Transforming the Work Environment of Nurses gaps in care. Gaps also occur from shift to shift or from provider to provider (Cook et al., 2000b). Integrating activities to prevent these gaps requires that nursing staff communicate and coordinate with a wide variety of health care workers who participate in a patient’s health care, including multiple physicians, other nursing personnel, pharmacists, social workers, nutritionists, housekeeping and maintenance personnel, and community care providers. Communication, collaboration, and interactions between physicians and nurses have been shown to result in better patient care (Knaus et al., 1986; Mitchell and Shortell, 1997; Shortell et al., 1994). The activities that RNs perform in integrating and coordinating patient care have sometimes been classified as “indirect” patient care13 (McCloskey et al., 1996), and the amount of time nurses spend integrating or coordinating care is indicated, in part, by the amount of time they spend on indirect as opposed to direct patient care. Although the location of some indirect-care activities may be shifting to the bedside (as is the case with automated patient records), the numerous work sampling studies of hospital nursing care that have been performed (with varying degrees of divergence from the standard definitions of “direct” and “indirect” care), have found that RNs spend as much as 25–45 percent of their time in indirect-care activities (Hendrickson et al., 1990; Prescott et al., 1991). Documentation Documenting nursing work and other activities to meet facility, insurance, private accreditation, state, and federal requirements, as well as to furnish information needed by other providers, is uniformly cited across all care delivery settings as imposing a heavy demand on nurses’ time. See Chapters 1 and 6 for a discussion of the demands placed on nursing staff by various documentation requirements. Supervision RNs also supervise other nursing personnel—LPNs/LVNs and NAs, as well as other RNs. Supervision activities include assigning and scheduling work, collaborating with staff to make patient care decisions, overseeing nursing staff performance and patient care quality, resolving problems, and evaluating performance. In addition, as non-nursing patient care services have been decentralized and located at the nursing unit as part 13   Direct patient care activities are activities carried out in the presence of the patient and family, such as performing a physical examination of the patient, administering medications, and performing treatments and procedures. Indirect-care activities are those that are performed away from, but on behalf of, the patient, such as documenting care, communicating with other health care providers, seeking consultations, and preparing medications (Division of Nursing, 1978).

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Keeping Patients Safe: Transforming the Work Environment of Nurses of hospital reengineering initiatives, nurses have taken on responsibility for supervising non-nursing personnel (McCloskey et al., 1996). Effective supervision is associated with nurses’ satisfaction, recruitment, and retention (Aiken et al., 2001b), as well as with patient care quality. The impact of supervision is particularly clear in studies of nursing homes, where, as discussed earlier, NAs provide most of the care. Poor supervision is often a source of work dissatisfaction among NAs and associated with NA staff turnover (Parsons et al., 2003). Workplace Characteristics That Hinder Safe Nursing Care It has long been documented that, in addition to providing nursing care, RNs spend a significant portion of their time performing non-nursing activities. In 1954, the first work sampling study of nursing in three general hospitals in Michigan documented that 11–22 percent of nursing time was spent on activities typically the responsibility of other departments, such as housekeeping, dietary functions, and errands off the unit (Abdellah and Levine, 1954). Subsequent work sampling studies and surveys of nurses have documented the continuation of this phenomenon. Large proportions of nurses continue to spend substantial amounts of time performing non-nursing activities, including delivering and retrieving food trays; performing housekeeping duties, such as cleaning patients’ rooms; transcribing physicians’ orders; transporting patients; and ordering, coordinating, or performing ancillary services, such as delivery of medical equipment or supplies, blood products, or laboratory specimens (Aiken et al., 2001a). These tasks often prevent nurses from performing the patient care activities detailed above (Aiken et al., 2001b; Prescott et al., 1991; Upenieks, 1998). Other characteristics of the work environments of nurses have been documented as creating obstacles for their provision of appropriate patient care. These characteristics include low staffing levels, poor collaboration across health professions, inadequate decision support, poorly designed work and workspaces, and organizational cultures that inhibit nurses and other health care workers from raising patient safety concerns to management and creating mechanisms to prevent health care errors and adverse events. These problems and recommendations for their resolution are described in Chapters 4 through 7. REFERENCES Abdellah F, Levine E. 1954. Work-sampling applied to the study of nursing personnel. Nursing Research 3(1):11–16. AHA (American Hospital Association). 2002. Hospital Statistics 2002. Chicago, IL: Health Forum LLC, an affiliate of AHA.

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