Reinforcing the patient safety message: NZNO's patient safety campaign is backed up by a number of overseas studies. It all depends on investing in and valuing nurses.

SAFE STAFFING is an NZNO priority. Nurses are sick of excessive workloads, staff shortages, unpaid overtime and inadequate organisational support, all of which threaten patient safety.

This has been confirmed by numerous overseas' studies. The Institute of Medicine (IOM) in the United States (US) released a report in November 2003 showing a clear link between the nursing work environment and patient safety. (1) Many of its findings and recommendations to improve health care working conditions leading to safer care will be applicable in New Zealand.

Many people die in hospitals from errors and not as a result of their illnesses. In its 2000 report, the IOM estimated up to 98,000 patients die in the US each year as a results of errors in their care. This is greater than the numbers who die from car crashes, breast cancer or AIDS. (2)

Impact of nurses on safety

Research is now telling us what we have known for a long time--how well we are cared for by nurses affects our health, and sometimes is a matter of life and death. Studies have shown that critical care nurses do the majority of patient assessment, evaluations and care in ICU; (3) nursing actions, such as monitoring, are directly related to better patient outcomes; (4) and an analysis over 10-years showed fewer nurses are associated with increased hospital acquired infection, pneumonia and pressure ulcers and increased length of stay. (5)

The IOM report has clearly identified that the threats to patient safety can arise from a combination of factors in nurses' working environment. No one part of the environment is more important than the other and each of an organisation's four basic components must be targeted for improvement. These are management practices, workforce deployment practice, work design and organisational culture. Management practices: The report identified factors many New Zealand nurses would identify with. These included:

* Loss of trust and poor communication make it difficult for health providers to make fundamental changes essential for safe care.

* The reduction in clinical nursing leadership, with whole nursing departments lost and senior nursing director positions marginalised, hampers nurses' ability to adequately fix problems as they arise. Workforce development: Nurses in the US have the same difficulties as their New Zealand colleagues.

* Nurses have lost the authority to halt admissions to their unit when staffing is inadequate to provide safe care.

* The aged-care sector regulations do not specify minimum staffing levels for caregivers who provide most of the care.

* There are many examples where hospitals have reduced orientation programmes and ongoing in-service training.

* Staffing levels have not been adjusted to take account of new methods of care, and changing practices. Various studies estimate that documentation takes up to 13-28 percent of a hospital nurse's time. (6)

Work design: Excessive work hours affect safety. Some nurses work in excess of 12-hour days, with some doing double shifts, working on days off or holding another job elsewhere.

Non-nursing roles, such as fetching and carrying blood samples, laboratory specimens and increased time spent on documentation take nurses away from patient care. Inadequate information systems and poorly designed nursing workspaces compromise safety.

Organisational culture: No single action can keep patients safe from error. Changes are needed across the organisation. How work is designed, how staff are deployed and the organisation's attitude to patient safety requires leadership that can change, not just the physical environment, but the beliefs and practices of nurses and other health workers, as well as those responsible for the policies and practices. Nurses' participation in the management of an organisation is crucial.

The IOM report specifically records that there should be nurse leaders of all levels of management who can participate in executive decisions within an organisation; represent nursing to management and gain their trust; achieve communication between nursing and other clinical leadership; and facilitate direct care, and nursing input to operational decision making.

The report makes absolutely clear the need for adequate numbers of nurses with clinical knowledge and skills, if the gaps that affect patient safety are to be filled. Nurse/ patient ratios is one method to ensure this goal is achieved.

The IOM report points out what NZNO has been saying for a long time and what we have said in our recent submissions to the Review of ACC Medical Misadventure--a culture of blame is not conducive to minimising error. All organisations are fallible, as are individuals. To blame or discipline a nurse for error will not prevent another error from occurring. What is required is behaviour that demonstrates that a culture of safety exists within the organisation. Such organisations recognise that errors are created by systemic organisational detects and not deliberate individual incompetence. Those organisations support staff and foster learning.

Improved patient safety cannot be achieved without investing in and valuing nursing.

REFERENCES

1) Page, A. (ed) (2003) Keeping Patients Safe; Transforming the Work environment of Nurses. The Institute of Medicine of the National Academies. Washington: The National Academies Press.

2) Kohn, L. T., Corrigan, J. (eds) (2000) To Err is Human: Building a Safer Health System. The Institute of Medicine of the National Academies. Washington: The National Academics Press.

3) Brilli, R., et al. (2001) Critical care delivery in the intensive care unit: Defining clinical roles and the best practice model. Critical Care Medicine; 29: 10, 2007-2019.

4) Kahn, K., et al. (1990) Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system. Journal of the American Medical Association; 264: 15, 1969-1973.

5) Seago, J. (2001) Nurse staffing, models of care delivery, and interventions. In: Shojania, K., Duncan, B., McDonald, K., and Wachter, R. eds. Making health care safer: A critical analysis of patient safety practices. Evidence Report/Technology Assessment; 43. Rockville: AHRQ.

6) Pabst, M., et al. (1996) The impact of computerized documentation on nurses' use of time. Computers in Nursing; 14: 1, 25-30.