Nurses are a stalwart player on the patient care team. But even the most dedicated face a series of challenges that make the delivery of safe patient care challenging.
Here are four, all of which can contribute to medication and clinical errors.
1. Nurse Shortages
The U.S. has had nursing shortages in the past, but the current rate of nurses retiring or changing careers combined with the reduced number of nurses entering the workforce is making our current shortage worse. The Bureau of Labor Statistics estimates there will be more than a million registered nurse openings by 2024, twice the rate seen in previous shortages.[1]
It’s due to a perfect storm of aging baby boomers, more patients needing complex care, a new wave of retirements among trained nurses, and nurse education bottlenecks such as faculty shortages, too few nursing school slots, and not enough clinical sites for training.[2] National nursing and hospital organizations are working diligently to solve this issue using stop-gap methods such as hiring travel and international nurses as well as working to increasing the number of nurses in the educational pipeline.
2. Nurse-Patient Ratios
Tighter hospital budgets, a greater focus on profits, and the impact of the nursing shortage has resulted in nurse-to-patient ratios being pushed to unsafe levels, according to nurse advocacy and other patient safety organizations.
When one nurse is forced to care for a rising number of patients, safety suffers. One study showed that for every extra patient on a nurse's caseload, mortality rates increased by 7 percent. Another study published in the Annals of Intensive Care found intensive care unit patients exposed to a high workload-to-nurse ratio for one or more days had lower risk-adjusted odds of survival to hospital discharge compared to patients exposed to normal ratios.
And a study performed in Denmark found that readmission rates rose as nursing staff diminished, indicating that patients were discharged prematurely or not treated entirely before being sent home.
For years, nurses have been working at the legislative level to explain the impact that nurse-patient ratios have on safety and the health and fatigue of nurses, which creates a vicious cycle of nurse turnover. Although 14 states have laws that address safe staffing, only California has a mandated minimum requirement of one nurse to five patients.
That may be changing soon. Pennsylvania Gov. Tom Wolf (D) and 49 state legislators in Pennsylvania have co-sponsored bills in the House and Senate that seek to establish mandated nurse-to-patient staffing ratios in hospitals.[3]
3. Burnout
A recent CareerBuilder study indicated that 70% of nurses feel burnt out in their current job. Feeling overworked, too much paperwork, and lack of job enjoyment are several of the reasons that nearly half of America’s nurses are considering leaving the profession, according to a survey by RNnetwork.
This is truly a cause for alarm when you consider that nurse burnout can impact patient infections, patient satisfaction and quality of care. If you work in a hospital or health system I can almost guarantee that a portion of your post-adverse event analyses find that the medical or medication is traced back to a shift on which a nurse or other provider was fatigued, overworked, or distracted with non-patient care issues.
Addressing the issue of nurse burnout is vital to maintaining a culture of safety. At a time when nursing shortages and nurse-patient staffing ratios are up, no healthcare organization can afford constant nursing turnover. Keeping nurses happy and productive can also be a gain to the bottom line. Hospitals in which burnout was reduced by 30% had a total of 6,239 fewer infections, for an annual cost saving of up to $68 million.[4]
4. Handoffs and Communication Breakdowns
A “handoff” is the real-time process of passing patient-specific information from one caregiver to another or from one team of caregivers to another to ensure the continuity and safety of that patient’s care.[5]
The Institute of Medicine reported that communication failures, such as those in handoffs, account for most adverse outcomes in hospitals[6]. That’s because when handoffs are done poorly, important information does not get passed from one nurse or provider to the next nurse or provider caring for the patient. The result is errors, care omissions, treatment delays, inefficiencies from repeated work, inappropriate treatment, adverse events with minor or major harm, increased length of stay, avoidable readmissions, and increased costs.[7]
Over the last fifteen years, many hospitals have implemented standard protocols for handoffs - checklists of key data points and whiteboards in patient rooms that are visible to providers as well as family members and the patient him or herself are two such examples.
Despite good progress, handoffs continue to be one of the top root causes of sentinel events reported to the Joint Commission. Ongoing review of a the factors that contribute to these failures, as well as diligence in an organization’s quality improvement efforts is essential to ensuring that nurses as well as other providers deliver safer care.[8]
[1] https://www.reuters.com/article/us-usa-healthcare-nursing/short-on-staff-nursing-crisis-strains-u-s-hospitals-idUSKBN1CP0BD
[2] https://www.reuters.com/article/us-usa-healthcare-nursing/short-on-staff-nursing-crisis-strains-u-s-hospitals-idUSKBN1CP0BD
[3] https://www.healthcaredive.com/news/fight-for-mandated-nurse-to-patient-ratios-heats-up/525225/
[4] https://www.ncbi.nlm.nih.gov/pubmed/22854376
[5]https://www.jointcommission.org/assets/1/18/SEA_58_Hand_off_Comms_9_6_17_FINAL_(1).pdf
[6] Kohn L, Corrigan J, Donaldson M. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000
[7] http://ajcc.aacnjournals.org/content/22/2/158.full#ref-1
[8]https://www.jointcommission.org/quality_reliability__leadership/the_art_of_handoff_communication/
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