Addressing the nurse shortage to improve the quality of patient care

Nurses are the largest group of health care professionals providing direct patient care in hospitals, and the quality of care for hospital patients is strongly linked to the performance of nursing staff, according to an Institute of Medicine report. This paper describes the Robert Wood Johnson Foundation's (RWJF's) work in nursing, which focuses on improving the hospital work environment to attract and retain high-quality nursing staff, with the ultimate goal of improving patient care and outcomes in hospitals. Other organizations' efforts to address the nurse shortage are also explored.     

Nurses' reports on hospital care in five countries

The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physicians appear satisfactory, core problems in work design and workforce management threaten the provision of care. Resolving these issues, which are amenable to managerial intervention, is essential to preserving patient safety and care of consistently high quality.     

Strengthening hospital nursing

Hospitals, nurses, the media, Congress, and the private sector are increasingly concerned about shortages of registered nurses (RNs) and the impact on safety and quality of patient care. Findings from a growing number of studies provide evidence of a relationship between hospital nurse staffing and adverse outcomes experienced by medical and surgical patients. These findings have policy implications for strengthening the nursing profession, monitoring the quality of hospital care associated with nursing, and improving the relationship between hospitals and the nursing profession.     

Hospital staffing, organization, and quality of care: cross-national findings.

OBJECTIVE: To examine the effects of nurse staffing and organizational support for nursing care on nurses' dissatisfaction with their jobs, nurse burnout, and nurse reports of quality of patient care in an international sample of hospitals. DESIGN: Multisite cross-sectional survey. SETTING: Adult acute-care hospitals in the United States (Pennsylvania), Canada (Ontario and British Columbia), England, and Scotland. STUDY PARTICIPANTS: 10 319 nurses working on medical and surgical units in 303 hospitals across the five jurisdictions. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Nurse job dissatisfaction, burnout, and nurse-rated quality of care. RESULTS: Dissatisfaction, burnout, and concerns about quality of care were common among hospital nurses in all five sites. Organizational/managerial support for nursing had a pronounced effect on nurse dissatisfaction and burnout, and both organizational support for nursing and nurse staffing were directly, and independently, related to nurse-assessed quality of care. Multivariate results imply that nurse reports of low quality care were three times as likely in hospitals with low staffing and support for nurses as in hospitals with high staffing and support. CONCLUSION: Adequate nurse staffing and organizational/managerial support for nursing are key to improving the quality of patient care, to diminishing nurse job dissatisfaction and burnout and, ultimately, to improving the nurse retention problem in hospital settings.     

Deploying and measuring a risk and patient safety program

Health care continues to evolve at a rapid rate. Over just the past decade, the industry has seen the introduction and widespread implementation of an electronic health record, increase in presence of nurse practitioners and physician assistants to help manage the shortage of physicians, and the introduction of accountable care organizations. It is with these changes that new challenges and opportunities emerge. One such challenge is the increase in the severity of medical malpractice claims throughout the nation. 1 Another emerging challenge is the introduction of outcome‐based reimbursements, 2 with providers potentially losing a portion of their payment should the patient experience result in a preventable adverse event. These trends are resulting in providers continuously seeking innovative approaches to reducing risk and improving patient safety.     

A data-integrated simulation-based optimization for assigning nurses to patient admissions

The health care system in the United States has a shortage of nurses. A careful planning of nurse resources is needed to ease the health care system from the burden of the nurse shortage and standardize nurse workload. An earlier research study developed a data-integrated simulation to evaluate nurse-patient assignments (SIMNA) at the beginning of a shift based on a real data set provided by a northeast Texas hospital. In this research, with the aid of the same SIMNA model, two policies are developed to make nurse-to-patient assignments when new patients are admitted during a shift. A heuristic (HEU) policy assigns a newly-admitted patient to the nurse who has performed the least assigned direct care among all the nurses. A partially-optimized (OPT) policy seeks to minimize the difference in workload among nurses for the entire shift by estimating the assigned direct care from SIMNA. Results comparing HEU and OPT policies are presented.     

Hospital registered nurse shortages: environmental, patient, and institutional predictors

OBJECTIVE: To examine the characteristics of acute-care hospitals that report registered nurse shortages when a widespread shortage exists and when a widespread shortage is no longer evident. DATA SOURCE: Secondary data from the American Hospital Association's Nursing Personnel Survey from 1990 and 1992 were used. The study population was all acute-care hospitals in the United States. STUDY DESIGN: Outcome variables included whether a hospital experienced a shortage in 1990, when many hospitals reported a nursing shortage, or whether a hospital reported a shortage in both 1990 and 1992. Predictor variables included environmental, patient, and institutional characteristics. Associations between predictor and outcome variables were investigated using probit analyses. PRINCIPAL FINDINGS: Location in the South, a high percentage of nonwhite county residents, a high percentage of patients with Medicaid or Medicare as payer, a higher patient acuity, and use of team or functional nursing care delivery consistently predicted hospitals reporting shortages both when there was a widespread shortage and when there was no widespread shortage. CONCLUSIONS: Although some characteristics under the direct control of hospitals, such as nursing care delivery model, are associated with their reporting a shortage of nurses, shortage is also strongly associated with broader population characteristics such as minority communities and a public insurance payer mix. Awareness of these broader factors may help inform policies to improve the distribution of nurse supply.     

护士连续排班模式的应用与体会

目的探讨基层医院如何开展护士连续排班模式,更好地解决护士拖班问题,确保护理质量和病人安全。方法将不同层级、不同工作能力和工作经验的护士分成几个小组进行排班,根据病区住院人数、护理工作量、护士定编等情况弹性安排每班人数不等的护士上班。结果实现了护士分层级管理,老护士的责任感加强了,工作价值感提升了,护士拖班率降低89.5%,实现了"三满意",即医生、护士、患者满意。结论基层医院结合实际工作特点开展连续排班模式,更好地保障了中午和夜间病人的安全,真正体现了"以病人为中心"的服务理念;减少交班次数,有效节省时间,提高工作效率,减少安全隐患;实现了护士分层级管理,提高护士价值感。     

Keeping nurses. How one hospital and two systems cured their staffing ills

The nurse shortage is threatening to reach crisis proportions for hospitals around the nation. But one hospital and two health care systems have virtually eliminated their nurse vacancy rates through strategies that respect and energize their nursing staffs.     

The nursing shortage: a worldwide problem

A worldwide shortage of nurses has been acknowledged by the multidisciplinary Global Advisory Group of the World Health Organization. The shortage is caused by an increased demand for nurses, while fewer people are choosing nursing as a profession and the current nurses worldwide are aging. The shortage applies to nurses in practice as well as the nurse faculty who teach students. The inter-country recruitment and migration of nurses from developing countries to developed countries exacerbates the problem. Although public opinion polls identifies the nurse as the person who makes the health care system work for them, the conditions of the work environment in which the nurse functions is unsatisfactory and must change. Numerous studies have shown the positive effects on the nurse of a healthy work environment and the positive relationships between nursing care and patient outcomes. It is important that government officials, insurance companies, and administrators and leaders of health care systems acknowledge and operationalize the value of nurses to the health care system in order to establish and maintain the integrity and viability of that system.     

追踪法在急诊危重患者质量管理中的应用

目的：探讨追踪法在急诊危重患者质量管理中的应用价值。方法：采用追踪法对急诊危重患者所接收的医院护理服务进行追踪调查,分析造成护理安全隐患的因素并对原因进行分析,进一步提出改进方案并实施,统计实施追踪法前后急诊科室投诉情况发生率和,并进行比较。结果：通过采用追踪法进行分析和评价,迅速找到了原因;改进方案的实施大大降低了全院的投诉率,二者之间差异具有统计学意义（X2=4．45,P〈0．05）,从而降低了急诊危重患者的护理风险,提高了患者满意度,改善了护患关系。结论：追踪法在急诊危重患者质量管理中具有重要应用价值,保障了患者安全,提升了护理服务质量,是急诊危重患者质量管理改进的起点。     

Incorporating nurse absenteeism into staffing with demand uncertainty

Increased nurse-to-patient ratios are associated negatively with increased costs and positively with improved patient care and reduced nurse burnout rates. Thus, it is critical from a cost, patient safety, and nurse satisfaction perspective that nurses be utilized efficiently and effectively. To address this, we propose a stochastic programming formulation for nurse staffing that accounts for variability in the patient census and nurse absenteeism, day-to-day correlations among the patient census levels, and costs associated with three different classes of nursing personnel: unit, pool, and temporary nurses. The decisions to be made include: how many unit nurses to employ, how large a pool of cross-trained nurses to maintain, how to allocate the pool nurses on a daily basis, and how many temporary nurses to utilize daily. A genetic algorithm is developed to solve the resulting model. Preliminary results using data from a large university hospital suggest that the proposed model can save a four-unit pool hundreds of thousands of dollars annually as opposed to the crude heuristics the hospital currently employs.     

陕西省护理人力资源现状调查与分析

目的了解陕西省护理人力资源现状,探讨护理人力资源与护理质量的关系。方法于2011年1月-2012年6月,应用护理人力资源问卷、护理差错问卷、病人满意度问卷,分别对陕西省二级及以上（专科医院及中医医院除外）的20家医院的1080名临床护士和620名住院病人进行调查。结果20家医院的平均医护比均低于国家标准;平均床护比基本达国家标准;护理人员编制严重不足,需要大量聘请合同制护士;高学历护理人员严重匮乏。相关关系分析显示,总护理差错与医护比未见相关,与床护比成正相关,与编制比和学历比成负相关;病人总满意度与医护比和编制比未见相关,与床护比成负相关,与学历成正相关。结论护理人力资源可对护理质量产生较大影响,加强护理人力资源配置并优化其结构可促进护理质量持续提高。     

Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety

BACKGROUND: Increases in adverse clinical outcomes have been documented when hospital nurse staffing is inadequate. Since most hospitals limit nurse staffing to levels for average rather than peak patient census, substantial census increases create serious potential stresses for both patients and nurses. By reducing unnecessary variability, hospitals can reduce many of these stresses and thereby improve patient safety and quality of care. THE SOURCE AND NATURE OF VARIABILITY IN DEMAND: The variability in the daily patient census is a combination of the natural (uncontrollable) variability contributed by the emergency department and the artificial (potentially controllable) peaks and valleys of patient flow into the hospital fromelective admissions. Once artificial variability in demand is significantly reduced, a substantial portion of the peaks and valleys in census disappears; the remaining censsus variability is largely patient and disease driven. When artificial variability has been minimized, a hospital must have sufficient resources for the remaining patient-driven peaks in demand, over which it has no control, if it is to deliver an optimal level of care. DISCUSSION: Study of operational issues in health care delivery, and acting on what is learned, is critical. Al forms of artificial variation in the demand and supply of health care services should be identified, and pilot programs to test operational changes should be conducted.     

"以顾客为中心",不断提高医院整体质量

文章将工业理论中的持续性质量提高理论运用于卫生领域，结合医院现代管理理念．提出医院在一定的质量标准下．通过对医院质量和病人满意度的调查，找出医院存在的问题．提出改进措施。文章认为提高医院的质量应该“以顾客为中心”．以提高管理质量和内部顾客(医务人员)的质量(临床质量和服务质量)为根本，不断改善医院总体质量，提高医院的经济效益和社会效益。     

The Role of the Built Environment: How Decentralized Nurse Stations Shape Communication,Patient Care Processes,and Patient Outcomes

Increasingly, health communication scholars are attending to how hospital built environments shape communication, patient care processes, and patient outcomes. This multimethod study was conducted on two floors of a newly designed urban hospital. Nine focus groups interviews were conducted with 35 health care professionals from 10 provider groups. Seven of the groups were homogeneous by profession or level: nursing (three groups), nurse managers (two groups), and one group each of nurse care technicians (“techs”) and physicians. Two mixed groups were comprised of staff from pharmacy, occupational therapy, patient care facilitators, physical therapy, social work, and pastoral care. Systematic qualitative analysis was conducted using a conceptual framework based on systems theory and prior health care design and communication research. Additionally, quantitative modeling was employed to assess walking distances in two different hospital designs. Results indicate nurses walked significantly more in the new hospital environment. Qualitative analysis revealed three insights developed in relationship to system structures, processes, and outcomes. First, decentralized nurse stations changed system interdependencies by reducing nurse-to-nurse interactions and teamwork while heightening nurse interdependencies and teamwork with other health care occupations. Second, many nursing-related processes remained centralized while nurse stations were decentralized, creating systems-based problems for nursing care. Third, nursing communities of practices were adversely affected by the new design. Implications of this study suggest that nurse station design shapes communication, patient care processes, and patient outcomes. Further, it is important to understand how the built environment, often treated as invisible in communication research, is crucial to understanding communication within complex health care systems.     

脊柱外科创建优质护理服务单元的体会

目的提高专科护理服务质量及患者的医疗满意度。方法通过改善住院环境,实施优质护理服务单元,全程无缝隙护理操作,加强人文关怀,丰富护理服务内涵,改进护理质量控制等措施提升脊柱专科护理服务质量。结果创建优质护理单元后住院患者满意度、护士对工作的满意度和后勤科室的保障支持满意度显著提高(P<0.05)。结论创建优质护理服务单元能有效地提高护理质量,提高患者满意度,提升护理人员自我成就感。     

Saving nurses, saving patients: responses to the labor crisis

While numerous task forces have spent enormous time and energy studying the size and scope of the nursing shortage, other organizations have been hard at work solving the difficulties faced by nurses and reducing the effects of the labor shortages on patient care. These efforts range from national legislative activities to grassroots innovations. Many of these efforts have already produced tangible results and take the form of major investments in professional development and improvements to the workplace environment. Physicians play an important role in the hospital work environment and can affect teamwork, a clear driver of nurse satisfaction.     

The evaluation of hospital restructuring efforts: satisfaction, quality, and costs

This article reports on study evaluating the effects of hospital restructuring on patient satisfaction, nurse satisfaction, cost of care, and clinical quality. The restructuring involved facility redesign, telecommunications enhancement, and implementation of patient care processes incorporating multiskilled personnel and case facilitation systems. The results indicate improved patient and nurse satisfaction, decreased length of stay and variable cost per patient day, and good clinical outcomes.