Patient Safety Tip
of the Week
May 29, 2018
More on Nursing
Workload and Patient Safety
There have been
numerous studies linking poor nurse:patient
ratios with adverse patient outcomes. But in our March 6, 2018 Patient Safety
Tip of the Week “Nurse
Workload and Mortality” we
emphasized that simple nurse:patient ratios may not
accurately reflect nursing workload and that it is likely workload that has a
closer relationship with patient outcomes.
A recent study from Finland measured nursing workload by the
RAFAELA system and compared workload to patient safety incidents and patient
mortality (Fagerström 2018). The RAFAELA system uses daily data on patients’ care needs and the workload
per nurse. It was developed in Finland in the 1990’s to help plan for better
nursing staffing allocation than a simple nurse:patient
ratio.
The authors conclude that in the latter situation nurses
have more time for caring and observing each patient, resulting in reduction of
the risk for adverse events and preventing the patient’s health condition from
deteriorating.
The findings were statistically robust and clearly
demonstrate the importance of nurse workload, rather than simple nurse:patient staffing levels, in
relation to adverse patient events and mortality.
Many state
legislatures have or are planning to mandate minimum nurse staffing levels
based on number of patients per nurse. Massachusetts is one such state
considering this mandate. In support of this mandate, the Massachusetts Nurses Association released results of a survey
of a random selection from a complete file of the 100,000 nurses registered
with the Massachusetts Board of Registration in Nursing. 90
percent of nurses responding admitted they lack adequate time to properly
comfort and assist patients. An overwhelming majority of respondents felt that
having to care for too many patients at one time was their most significant
challenge in delivering high-quality care and that unsafe patient assignments
were a problem. They linked such circumstances to medication errors, patient
readmissions, and other patient injury or harm. Most also said hospital
management does not typically adjust patient assignments to meet patients'
needs.
The US is not the only country where such concerns have been
voiced. In the UK, 55% of 30,000+ nursing staff responding to a 2017 survey
reporting a staffing shortfall on the last shift they worked (Royal
College of Nursing 2018). The Royal College of Nursing analyzed of nearly
18,000 nurses’ responses and identified 6 key themes from responses:
- Care undone (missed care)
due to lack of time
- Too much time spent on
non-nursing duties
- Time to support relatives
and those of importance to patients
- Concern about skill mix of
nursing staff
- Are staffing level
concerns addressed?
- Morale of nursing staff
36% of nurses said they had to leave necessary patient care undone due to lack of time. This
resulted in patients having to wait for treatment and care, including having
access to toilet and washing, pain relief, and care such as action to prevent
bed sores, ulcers and infections. Care left undone correlates with patient
mortality. In our July 11, 2017 Patient
Safety Tip of the Week “The
12-Hour Shift Takes More Hits”
we discussed a study by Ball and colleagues (Ball
2017a), using survey data from the RN4CAST
study to correlate measures of nurse-reported quality with shift duration. They
found the rate of “care left undone” was 1.13 times higher for nurses working
≥12 hours. A previous study by Ball (Ball
2017b) showed that a 10% increase in the amount of care left undone by
nurses was associated with a 16% increase in mortality.
In the UK survey, 41% of all shifts reported being short of
one or more health care support workers. And 55% reported they spent too much
time on non-nursing activities. This was especially noted when nursing skill
mix was suboptimal and when staffing had to be supplemented by agency nurses,
who were not familiar either with the patients or the intricacies of the IT
systems. In our numerous columns on the “weekend effect” we’ve pointed out how
non-nursing activities (due to lack of non-nursing ancillary personnel and lesser
experienced nursing personnel) keep nurses from important patient care
activities.
And, of course, it is difficult to divorce the nursing
workload issue from the fatigue issue. Given the shortage of nurses in most
locations, more and more nurses are working long shifts, whether voluntary
12-hour shifts or overtime. We’ve done many columns on the (mostly but not
always negative) aspects of the 12-hour shift (see full list of columns below).
One of the factors contributing to patient safety is collaboration (nurse-nurse
and nurse-physician collaboration). A recent study (Ma
2018) found that overtime (more nurses working overtime or longer overtime
hours) was associated with lower collaboration at the unit level. On the other
hand, shift length was not. We might anticipate that one unintended consequence
of mandated nurse staffing levels may be to increase the amount of overtime
worked, perhaps subtracting somewhat from the benefit we expect to see from better
nurse:patient ratios. In an
ideal world we’d have an adequate supply of nurses so that we could optimize
nursing workload without resorting to overtime.
Speaking of the 12-hour nursing shift, a new AHRQ-funded
study will attempt to answer some of the lingering questions about the impact
of such shifts on both patient safety and nurse health and well-being (Hatch
2018). The Washington State University study will involve 50 nurses working
day shift and 50 nurses working night shift. Participants will report to the
WSU Health Sciences campus for testing immediately following three consecutive,
12-hour day or night shifts. They’ll also be tested following three consecutive
days off. Various methods will be used to test reaction times and cognitive
capacity of the nurses. Nurses will also wear wrist-worn sensors to monitor
sleep cycles. They’ll be tested in the College of Nursing’s Simulation
Laboratory to see how well they perform a range of nursing skills like
inserting an IV or monitoring vital signs. They’ll be asked to mentally
calculate medication dosages. And finally, they’ll use simulators in the WSU
Sleep and Performance Research Center to test their driving skills. The study will
last 3 years but, hopefully, may answer some of our most serious concerns about
the impact of 12-hour nursing shifts on patient care.
Efforts, for example
by state legislatures, to mandate minimum nurse staffing levels based on number
of patients per nurse are appropriate but may not go far enough. We need to
refine measures of nurse workload and use such measures to allocate nursing
resources more optimally. Even adjustments for patient acuity are not enough.
The RAFAELA classification system seems to be a better measure of nurse
workload. Given its success in Scandinavian countries, we need to look at adopting
and refining it or similar measurement systems in other countries. We hope that hospitals and legislative or
regulatory bodies will begin to look closer at measuring nursing workload via RAFAELA or the other measurement systems discussed
in our March 6, 2018 Patient Safety Tip of the Week “Nurse
Workload and Mortality”.
Some of our other columns on missed nursing care/care
left undone:
November 26, 2013 “Missed
Care: New Opportunities?”
May 9, 2017 “Missed
Nursing Care and Mortality Risk”
March 6, 2018 “Nurse
Workload and Mortality”
Our previous columns
on the 12-hour nursing shift:
November 9, 2010 “12-Hour
Nursing Shifts and Patient Safety”
February 2011 “Update
on 12-hour Nursing Shifts”
November 13, 2012 “The
12-Hour Nursing Shift: More Downsides”
July 29, 2014 “The
12-Hour Nursing Shift: Debate Continues”
October 2014 “Another
Rap on the 12-Hour Nursing Shift”
December 2, 2014 “ANA
Position Statement on Nurse Fatigue”
September 29, 2015 “More
on the 12-Hour Nursing Shift”
July 11, 2017 “The
12-Hour Shift Takes More Hits”
References:
FagerströmKinnunenSaarela. Nursing workload, patient safety
incidents and mortality: an observational study from Finland.
http://bmjopen.bmj.com/content/8/4/e016367
MNA (Massachusetts Nurses
Association). MNA: 'State of Patient Care in Massachusetts' Survey Released for
National Nurses Week Finds Nurses Sounding the Alarm Over Deteriorating
Conditions for Hospitalized Patients and Need for Safe Patient Limits. (Press
Release). PR Newswire 2018; May 8, 2018
Royal College of Nursing (UK). Staffing for Safe and
Effective Care: Nursing on the Brink. 13 May 2018
Ball J, Day T, Murrells T, et al. Cross-sectional
examination of the association between shift length and hospital nurses job
satisfaction and nurse reported quality measures. BMC Nursing 2017; 16: 26
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-017-0221-7#CR25
Ball JE. Nurse
Staffing Levels, Care Left Undone, & Patient Mortality in Acute Hospitals.
Karolinska Institutet; Stockholm 2017
Ma C, Stimpfel AW. The Association
Between Nurse Shift Patterns and Nurse-Nurse and Nurse-Physician Collaboration
in Acute Care Hospital Units. Journal of Nursing Administration 2018; Published
Ahead of Print Post Author Corrections: May 04, 2018
Hatch A. Study focuses on impacts of 12-hour shifts on
nurses. WSU Insider 2018; May 1, 2018
https://news.wsu.edu/2018/05/01/study-focuses-impacts-12-hour-shifts-nurses/
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