Journal of Nursing Administration:
Departments: Spotlight on Transitions
Author Affiliations: Principal, Joan Ellis Beglinger Designing Tomorrow, Madison, Wisconsin, and Consultant, Tim Porter O’Grady Associates, Inc, Atlanta, Georgia.
The author declares no conflicts of interest.
Correspondence: Ms Beglinger, 3528 Timber Lane, Cross Plains, WI 53528 (email@example.com).
JONA is dedicated to the dissemination of administrative research. I am focusing this month’s spotlight on the important transition that occurs from experience-based practice to evidence-based practice, when the new knowledge generated by research is deemed strong enough to warrant a change in how we do things. We have witnessed this many times over in the clinical arena, but our knowledge base lags in management circles. It remains far more common, in management practice, to approach our work “the way we’ve always done it.”
This month, I am going to make the case that the evidence that has emerged linking nurse staffing and practice environments to patient outcomes has reached that critical point where management practice changes are required. I will use the analogy of the clinical practice changes we have all experienced, in response to emerging evidence over the years. When viewed through this lens, it is difficult to imagine that there would not be consensus on the important work that lies ahead.
Consider an example that is very familiar to anyone who has been associated with patient care over the past few decades: care of the surgical patient. This care historically involved the use of indwelling urinary catheters, antibiotics to prevent infection, strategies to prevent postoperative deep vein thrombosis (DVT), and hair removal from the site, as examples. There was a great deal of variability in the specific approaches, as these largely depended on surgeon preferences, which were often shaped during training. Outcomes proved to be as variable as the approaches, and new knowledge emerged linking specific approaches to the best outcomes. National standards evolved that eliminated individual preferences as an option. Through the Surgical Care Improvement Project (SCIP),1 there is now universal acceptance of the essential elements of care that include antibiotic selection and timing, blood glucose control, hair removal technique, urinary catheter removal, perioperative temperature management, and DVT prophylaxis and timing. It is inconceivable that the hospital and medical staff leaders of any organization would tolerate an individual surgeon or nurse deviating from the standard in the face of such compelling evidence. It is considered a matter of patient safety.
We have seen the care of many other patient populations follow a similar trajectory. Care of ventilated patients and patients with indwelling central venous catheters is now standardized under bundles of care. Patients who experience stroke, acute myocardial infarction, congestive heart failure, and pneumonia are cared for utilizing well-defined standards based on best available evidence.
Let us now apply the lessons from clinical practice to executive decision making. We know that the number of patients the RN is assigned significantly impacts the risk of mortality, failure to rescue, readmission rates, and preventable complications.2-7 The evidence has been emerging and strengthened, and we can demonstrate practices that have been understood by clinical practitioners for a long time. There is a point at which the nurse is stretched too thin to observe subtle changes in patient condition, adequately prepare the patient for self-care after discharge, and effectively coordinate care, to name a few of the critical functions that fall to those who are at the point of care. Yet, staffing practices continue to be perpetuated that should be considered unacceptable such as allowing a surgeon to refuse to adhere to SCIP measures. We continue to hear disturbing stories from the field that are in direct conflict with the evidence. As examples, some colleagues describe a budgeting process in which a finance professional determines the resources available for patient care. In some settings, healthcare executives define the bottom quartile as the staffing target for their organizations, with no knowledge of the outcomes being produced at the lowest tier. Determining appropriate staffing requires sophisticated expertise. It involves a deep understanding of patient care, analysis of the patient population being served and the capacity of nursing organization, application of the best available evidence, and meaningful voice from the direct care nurse.
Our patients present with specific requirements for care. The staffing levels and practice environments of the professional nurse directly impact the ability to meet these requirements, and thus patient outcomes may vary greatly. Our product is patient care. Unlike the manufacturer of a piece of furniture, who can decide to make a fine piece from a beautiful hardwood (for a price) or utilize an oak veneer and charge less, patient care requirements do not vary based on finances. The presenting condition is accompanied by needs that must be addressed. We are ethically obligated to provide care the patient needs, not the care we think we can afford. Integrity demands that, when allocating limited resources, we start with the point of care as our highest priority. If an organization cannot appropriately respond to the needs of its patients, it raises serious questions about whether that organization can ethically be in the business of patient care. Nurse executives must uniformly reject the false argument that inadequate patient care resourcing is the “new normal.”
David Marx8 introduced many of us to the principles of Just Culture, which are used to evaluate the choices individuals make and their impact on patient safety. He taught us that the most important duty we have is to avoid causing unjustifiable risk or harm. Many of us use these principles in our organizations to determine if an individual’s behavioral choice is human error, at risk, or reckless. We console the error, coach the at-risk, and punish the reckless. We do not tolerate at-risk behavior that persists after coaching.
History holds important lessons for those who are willing to learn from them. In the 1970s, the executives of the Ford Motor Company were in pursuit of a car that would compete with the Japanese cars of the era in size and price.9 The Ford Pinto was born. It soon became apparent that the design of the car was flawed.9 If rear ended, there was an increased risk of injury or death to the passengers from the fire that would result. The executives calculated the cost-benefit of correcting the flaw and opted to risk the relatively small increased number of casualties of the problematic design. That decision cost Ford—monetarily and in the public trust.
When we add a patient to the workload of the RN, knowing it will significantly increase the risk of mortality, failure to rescue, and preventable complications, is that not a violation of our most important duty to avoid causing unjustifiable risk? How does this decision differ from the executives of Ford in the case of the Pinto design? Is it not time to apply the same standard to our executive choices as to the behavioral choices of our clinical colleagues? Zero tolerance for serial at-risk behavior. We reveal the content of our character by the things we do, not the things we say. We know too much to turn back now.
2. Aiken LH, Cimiotti JP, Sloane DM, et al. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011; 49: 1047–1053.
3. Aiken LH, Sloane DM, Cimiotti JP, et al. Implications of the California nurse staffing mandate for other states. Health Serv Res. 2010; 45: 904–921.
4. McHugh MD, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Medical Care. 2013; 51: 52–59.
5. McHugh MD, Berez J, Small DS. Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Aff. 2013; 32: 1740–1747.
6. Needleman J, Buerhaus PI, Stewart M, et al. Nurse staffing in hospitals: is there a business case for quality? Health Aff. 2006; 25: 204–211.
7. Needleman J, Buerhaus P, Pankratz VS, et al. Nurse staffing and inpatient hospital mortality. N Engl J Med. 2011; 364: 1037–1045.
8. Marx D. Whack a Mole: The Price We Pay for Expecting Perfection
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