Linda Aiken - RN4CAST

Nurse Work Environments Are Linkedto Patient Safety and Nurse Retention• “Organizational behavior is as important asclinical practice” in keeping patients safe. WorldAlliance for Patient Safety, 2009• “The typical work environment of nurses ischaracterized by many serious threats to patientsafety.” Institute of Medicine, 2004• “Improving hospital care environments bychanging organizational behavior results inhigher value investments through better quality,safety, and nurse retention.” RN4CAST, 2011

Preventable Deaths in British Military Hospitals duringCrimean War, 1855 by Florence NightingaleKeyBlue – Preventable DeathsPink – Deaths from WoundsGray – Deaths, all other causesSource: Notes on Matters Affecting the Heath,Efficiency and Hospital Administration of theBritish Army, 1858.

RN4CAST ConsortiumBelgiumUnited StatesEnglandFinlandGermanyGreeceIrelandNetherlandsNorwayPolandSpainSwedenSwitzerlandCatholic University LeuvenUniversity of PennsyvaniaKing’s College LondonKuopio UniversityTechnical University BerlinUniversity of AthensDublin City UniversityUMC St RadboudNorwegian Nurses AssoJagiellonian UniversityInstitute of HealthKarolinska InstituteBasel UniversityBotswanaChinaSouth AfricaUniversity of BotswanaSun Yat-sen UniversityNorth-West University

RN4CAST: EU-Funded Study of Hospital Nurse Workforce12 Europecountries617 hospitals 2,087 nursing units34,000 nurses11,318 patientssurveyedPatient outcomesfrom hundreds ofthousands…………Ensuring an effective workforce for an aging population6

Patients’ Assessments ofHospitals: Lots of Room forImprovementIn percentRate hospital 9 or 10RecommendHospitalBelgium 47 60Switzerland 60 78Germany 48 66Spain 35 56Finland 61 67Greece 42 53Ireland 61 74Poland 55 57United States 59 64

Measuring Quality of Nurse PracticeEnvironment• Practice Environment Scale/Nursing Work Index– Staffing adequacy– Nursing foundations for quality– Nurse manager ability & leadership– Nurse-physician relations– Nurse involvement in hospital affairs• Summary measure divides hospitals into quartiles byPES scores in Europe and US separatelyAiken and Patrician, Nursing Research, 2000;Lake, Research in Nursing & Health, 2002

Hospitals with Better Work Environments:Lower Nurse Burnout Every CountryWorseBest

Hospital Safety Grade is Higher in Hospitals withBetter Work Environments Every Countryby Nurse Work EnvironmentExcellentGoodAcceptableBelgium England Finland GermanyFairExcellentIreland Netherlands Norway PolandGoodAcceptableFairExcellentSpain Sweden Switzerland United StatesGoodAcceptableFair2 2.5 3 3.5 2 2.5 3 3.5 2 2.5 3 3.5 2 2.5 3 3.5Nurse Work Environment

Patient Satisfaction Is HighlyAssociated with Nurse Satisfaction• How well nurses arefaring in terms of jobsatisfaction, burnout,intent to leave is abarometer of patientsatisfaction• Same environmentfactors result indissatisfaction of bothnurses and patients

Using Administrative Data toStudy How Nursing EffectsMortality• Next step inRN4CAST• Underusedresource in Europe

England: Mortality Rates are SignificantlyLower in English Hospitals In Which NursesCare for Fewer Patients, 1999Crude mortality rate %2.82.62.42.221.81.61.41.212Lowest Pt:NurseRatios2.22.42.7Highest Pt:NurseRatiosRafferty, Clarke, Aiken, et al., IJNS 2007

Belgium Study of Nurse Staffing andMortality Following Elective Cardiac SurgeryVan den Heede, Sermeus, Aiken et al., IJNS 2009• Mortality in generalpost operative unitswas significantlylower when patientsreceived more hoursof nursing care

Penn Multi-State Nursing andPatient Safety Study, 2006-08• Uses same research protocolas RN4CAST• Study 25% of all U.S. hospitals• Every patient added to anurses’ workload increasesmortality by 7%Funded by National Institute of Nursing Research, National Institutes of Health

Impact of Better Staffing & NurseEducation on Mortality is Contingentupon Quality of Work Environment, US• Nurse Staffing: Decrease of 1 patient per nurselowers mortality by– 9% in best environment hospitals– 4% in mixed practice environments– No effect in hospitals with poor environments• Nurse Education: Hospitals with 20% more thanaverage BSNs– 12% lower mortality best environments– 3% lower mortality mixed environments– No effect poor environments

US Experiences Positive Changes inNurse Outcomes Compared toEngland & Germany 1999-2006

Attractiveness of Nursing Increasingin U.S.• Staffing: half states havesafe staffing legislation• Environments: Close to7% hospitals Magnet• Employers prefer BSNs• Wages not major sourcedissatisfaction• Nursing “hot” careerchoice

Good Work Environment Is Essential• Feasibility: Most countries have one or morehospitals with better work environments• Cost: Most elements of better workenvironments are not costly• Value: Better nurse staffing is costly and has novalue added in hospitals with poor workenvironments• Value: Better educated nurses are associatedwith better patient outcomes & potential forsmaller nurse workforce• Quality/Safety: Hospital work environment issingle most important organizational factorexplaining patient and nurse outcomes

• For more findings and policy discussionby Consortium members andstakeholders• Friday, May 6 10:30 am to 11:50 am• Symposium in M A Grima Hall• S_210www.rn4cast.eu