Keeping Patients Safe Transforming the Work Environment of Nurses (2004) / Chapter Skim
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3 Nurses Caring for Patients: Who They Are, Where They Work, and What They Do
3 Nurses Caring for Patients: Who They Are, Where They Work, and What They Do
Pages 65-107
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From page 65... ...
This chapter does so, focusing predominantly on the role of nurses in hospitals and nursing homes, where the greatest amount of study has been conducted on patient safety.
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From page 66... ...
supplement the work of licensed nurses by performing basic patient care activities under the supervision of an RN or LPN/LVN. These unlicensed health care personnel hold a variety of job titles, including nurse assistants, nurse aides, home health aides, personal care aides, ancillary nursing personnel, unlicensed nursing personnel, unlicensed assistive personnel, nurse extenders, and nursing support personnel.
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From page 67... ...
Nurses with advanced-practice credentials are also less well represented in nursing homes: 7.6 percent of hospital nurses were prepared at the masters or doctorate level, compared with 4.3 percent of nursing home nurses (Spratley et al., 20001. Research on the effect of different educational paths to RN licensure on nurse performance and patient outcomes has been inconclusive.
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From page 68... ...
At least 16 of the 75 hours must be practical training under the direct supervision of an RN or LPN. For CNAs working in nursing homes, states are required to keep a registry of those who have passed their competency evaluations (GAO, 2001b)
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From page 69... ...
In an analysis of data from two studies (involving 42 inpatient units in one large tertiary-care hospital and 39 patient care units in 11 other hospitals) , nursing units whose nurses had more years of experience were found to have lower rates of medication errors and patient falls (Blegen et al., 2001~.
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Women are estimated to make up 79.6 percent, 90.9 percent, and 89.2 percent of hospital, nursing home, and home care aides, respectively (GAO,2001b)
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Ergonomic 4In contrast, NAs are younger than RNs, and their age distribution has remained comparatively stable. From the late 1980s to the late l990s, the mean age of NAs working in hospitals, nursing homes, and home health care changed from 36.3 to 38.0 years, 36.6 to 36.4 years, and 46.7 to 42.8 years, respectively (Yamada, 2002)
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. Changes in hearing and vision also have implications for the design of work and technology used in patient care for example, the need for increased lighting and larger size of print material (Curtin, 20021.
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From page 73... ...
The average annual salary in 2000 for RNs employed full time in their principal position was $46,782, although this figure varied by setting of care and position. RNs working full-time in hospitals5 earned on average about $47,759 per year, while those working in nursing homes earned less about $43,779 per year.
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From page 74... ...
of the U.S. Census Bureau and the Bureau of Labor Statistics found that the average wages of full-time, full-year NAs in hospitals, nursing homes, and home health care agencies ranged from $19,216 to $21,432.
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Temporary employees are less familiar with an organization's information systems, patient care technology, facility layout, critical pathways, interdependency among work components, ways of coordinating and managing its work, and other work elements. Permanent nursing staff in hospitals and nursing homes describe the use of agency nurses as hindering continuity of care and reducing quality of care (Anderson et al., 1996; Bowers et al., 20001.
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From page 76... ...
health care system, and changes in the ways nursing care is delivered have shaped all nurses' work environments, but especially hospitals, nursing homes, home care and community-based organizations, and public health agencies. Hospitals Hospitals have historically been the largest employer of the nursing workforce and continue to be so today, although there has been a decline in Licensed nurses function in a variety of capacities in a diverse array of locations, including serving as educators, researchers, managers, lawyers, public policy analysts, and government officials.
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From page 77... ...
The deployment of nurses by hospitals has changed dramatically over the least two decades as hospitals themselves have changed. TABLE 3-2 Employment Settings of NAs, 1999 Location Percent of NAs Employed Nursing home Hospital Home health Othera 32 18 16 35 aIncludes a range of employment settings, such as residential care, social services, and temporary staffing agencies.
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From page 78... ...
By 1999, outpatient surgery constituted 50 percent of all hospital-based surgery an increase from 16 percent in 1980 (American Hospital Association and The Lewin Group, 20011. As a result of this downsizing and technological advances in care, patients admitted to the hospital today are more acutely ill than was the case in the previous decade (Medicare Payment Advisory Commission, 20011.
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From page 79... ...
to nursing units; redistribution of patients across nursing units; redesign of patient care processes; use of clinical pathways; and other changes in organization structure, decision-making processes, and responsibilities of management and patient care staff (Aiken et al., 2000b; Norrish and Rundall, 2001; Ritter-Teitel, 2002; Walston et al., 2000; Walston and Kimberly, 19971. In addition, redesign and reengineering have changed the way nursing staff are organized to provide patient care.
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From page 80... ...
In numerous surveys, nurses report inadequate 9Team nursing was preceded by "functional nursing," popular in the 1940s. Under the latter approach, patient care was organized like an assembly line; that is, one nurse was assigned to give baths, another to administer medications, another to do dressings and treatments, and so on (Mark, 2002)
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From page 81... ...
The 135 hospitals responding showed variation in nurse staffing levels even with the shift and type of patient care unit being held constant. Although the average RN-to-patient ratio in medical-surgical units on the day shift was 1:6, the range was from 1:3 to 1:12.
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From page 82... ...
population, there is a concomitant increased demand for services for older patients who have higher dependency needs. As a result, nursing homes (sometimes called long-term care or nursing facilities)
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From page 83... ...
Consistent with this observation, a higher ratio of RN staff to residents in nursing homes has been demonstrated to reduce adverse health care events for residents (CMS, 2000, 20021. Along with the growth in the number of nursing homes, nursing home beds, and patient acuity has come a significant expansion of the nursing home workforce.
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From page 84... ...
However, a 1998 national study of 13,693 nursing homesite comparing those owned by investors with nonprofit and public nursing facilities found higher rates of deficiencies in the quality of care provided and lower staffing levels among the former. Chain ownership also was found to be associated with higher rates of deficiencies in quality of care.
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From page 85... ...
As with nursing home care, however, demands for home health services are expected to continue to grow because of reduced lengths of stay in acute care hospitals, advances in technology, and the aging of the U.S. population.
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From page 86... ...
Following the events of September 11, 2001, and associated concerns about bioterrorism, the public health infrastructure began receiving additional attention. Problems with Recruitment and Retention of Nursing Staff Across Clinical Settings Hospitals, nursing homes, home health agencies, and other community-based long-term care organizations all report difficulties in securing enough RNs and NAs to provide needed patient care (AHA Commission on Workforce for Hospitals and Health Systems, 2002; GAO, 2001b; Stone and Wiener, 20011.
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From page 87... ...
of nurses existed in 2000 and projects a growing shortfall in nursing personnel, up to a 29 percent deficit by 2020. This undersupply of RNs is more the result of a growing demand for nursing than of a decreasing supply of RNs (HRSA, 20021.
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Nurses working in hospitals and nursing homes reported the lowest levels of satisfaction 67 and 65 percent, respectively. Staff nurses (as opposed to nurses in administrative or management positions)
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From page 89... ...
. Heavy workloads, poor supervision, low wages and benefits, lack of involvement in work-related decisions, and a job that society holds in low regard cause significant stress among the NA workforce and contribute to difficulties in recruitment and retention of NAs in nursing homes, home health care agencies, and other long-term care settings (Parsons et al., 2003; Stone and Wiener, 20011.
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From page 90... ...
This cyclical, interactive method of thinking forms the foundation for clinical decision making by RNs (ANA, 19981. Variety of Ways in Which Direct-Care Nursing Staff Provide Patient Carei2 Direct-care nursing staff (i.e., those nurses providing hands-on patient care as opposed to nurses in administrative or educational positions)
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From page 91... ...
While some of these direct patient care activities implement treatments ordered by physicians, a substantial amount of nursing care is not provided in response to a physician's treatment order, but is performed independently by nurses based on nursing's professional practice standards and the nurse's clinical judgment. In addition, nursing staff perform a variety of indirect-care functions, such as documenting patient care, integrating care across settings and providers (discussed further below)
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From page 92... ...
The cognitive aspect of surveillance involves studying, interpreting, analyzing, and evaluating the data and information produced by the above methods. These cognitive processes require a high level of knowledge (Dougherty, 19991.
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. spend several hours per patient per shift collecting and integrating information and incorporating it into meaningful patient care.
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From page 94... ...
NAs also assess patient status based on their ongoing knowledge of the patient's "normal" health status. In this way, they serve as the foundation for the monitoring and surveillance system in nursing homes, and nurses are clepenclent upon NAs to bring abnormal finclings to their attention.
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From page 95... ...
Loss of functioning and resulting dependency can range from mild temporary weakness and malaise that accompanies the flu; to a temporary acute loss of strength and capacity to perform activities of daily living (ADLs) (i.e., bathing, dressing, eating, or other personal care activities)
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From page 96... ...
A survey of individual nurses in clinical practice conducted in 1992 to validate the content of the Nursing Interventions Classification (NIC) system and determine the frequency with which nurses performed each of 336 nursing interventions identified provision of emotional support as one of the six most frequently used nursing interventions and the one reported most often by nurses as being used in their patient care activities (Bulechek et al., 19941.
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From page 97... ...
Separate focus groups with nursing directors from the six nursing homes confirmed that many incidents likely are not reported and that there is little support for NAs after such incidents occur. Directors of nursing cited resistance to drug testing and fear of job loss as reasons for failure to report incidents.
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From page 98... ...
. RNs spend a large amount of time integrating patient care as part of planning for patients' discharge from hospitals or other health care facilities to enable continued care in the home, school, or long-term care facility; educating the patient and family about the patient's disease, course of
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From page 99... ...
NURSES CARING FOR PATIENTS 99 therapy, medications, self-care activities, and other areas of concern to the patient; and preventing gaps in care delivery, or discontinuities in care that can result in a loss of information relevant to patient care or interruptions in care. Patient transfers e.g., from unit to unit, facility to facility, or hospital to home are a common occurrence resulting in a high potential for
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From page 100... ...
Supervision activities include assigning and scheduling work, collaborating with staff to make patient care decisions, overseeing nursing staff performance and patient care quality, resolving problems, and evaluating performance. In addition, as non-nursing patient care services have been decentralized and located at the nursing unit as part i3Direct patient care activities are activities carried out in the presence of the patient and family, such as performing a physical examination of the patient, administering medications, and performing treatments and procedures.
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From page 101... ...
, as well as with patient care quality. The impact of supervision is particularly clear in studies of nursing homes, where, as discussed earlier, NAs provide most of the care.
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2001. Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model.
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From page 103... ...
CMS.2002. Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II Final Report: U.S.
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2001. Does investorownership of nursing homes compromise the quality of care?
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Paper commissioned by the Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety and presented to the Committee. McCloskey J
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2001. Chartbook #3: Nursing Home Trends, 1987 and 1996.
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From page 107... ...
2002. Profile of home care aides, nursing home aides, and hospital aides: Historical changes and data recommendations.
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