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Reengineering and the Hospital Staff Nurse.

In the summer of 1998, a community hospital in the state of New York was put under state monitoring and came just short of being removed from participation in the Medicaid and Medicare programs. In the preceding two or so years, the staff had been trimmed through a management buyout of nursing staff followed shortly thereafter by an untimely reengineering effort. Lines of accountability changed, and workloads increased. State health inspectors in 1998 found significant problems in a number of areas, most notably with the quality of nursing care, staffing levels, and overall supervision. The state's report noted "a general and pervasive lack of direction, supervision, and accountability in nursing services, which resulted in nursing care which did not meet generally accepted standards of practice." This particular case is an extreme example of some of the nationwide changes that have happened in recent years to hospital staffing, and particularly to the pattern of nursing staffing. Because of the combined redu ction in staffing and admission of a more complex inpatient case mix, physicians and nurses have often exclaimed in recent years that "cuts go to the bone and the administrators have finally gone too far" (as in the case just outlined).

The recent changes in the role and workload of nurses have paralleled changes in healthcare delivery. Nursing opportunities have increased in settings outside of the hospital, and inpatient nursing positions have become increasingly complex (separate and apart from the evolution in the role of advanced practice nurses, a topic not covered in the articles in this issue nor in this editorial). As hospitals work to contain costs, nursing is pointed to as a high-cost item with the result that the re-engineering initiatives undertaken by many hospitals have led to further changes in the inpatient nurse's role and responsibilities. Through it all, however, what has not changed is the central role of registered nurses in the care of hospitalized patients. Consider, as an example, the critical role of nurses in the administration of medications to hospitalized patients. Errors leading to adverse drug events are most commonly due either to the ordering of medications by physicians or their administration by nursing; thus, nurses have an important role in the handling of these agents. Equally important, of the errors estimated to be due to physician ordering, half of them are intercepted-almost always by a nurse--before the patient is harmed (Leape, Bates, Cullen, et al. 1995). To inform reengineering or other reorganizational initiatives, it would be helpful to know how staffing or effort could be modified without reducing quality and to understand what nurses do and how it affects outcomes. For example, staff nurses currently spend an estimated 20 percent of their time doing paperwork (Pabst, Scherubel, and Minnick 1996), but it would be helpful to know if this is the appropriate type and level of effort relative to how the time would otherwise be spent.

The research on the determinants of nursing outcomes has often focused on registered nurse staffing levels and their relationship to improved mortality. To some extent this makes sense in that there is probably a level of staffing below which acceptable outcomes are not likely to be achieved. Above that level, it is probably useful to know about how nursing services are organized. Aiken, Smith, and Lake (1994) have contributed to our understanding of the possible role of the organization of nursing care, and its implications for professional autonomy and control, in improved hospital outcomes. Certainly, our case study highlights what can happen when these structures are removed. To more meaningfully inform reengineering and reorganizational efforts, however, it is necessary to know how the combined change in staffing levels and organizational structure gets translated into specific care activities and processes and, in turn, into outcomes.

In this issue of Health Services Research Lee, Chang, Pearson, et al. go to the heart of the matter when they identify this critical gap in the research. When advanced practice nursing studies are excluded, what do we know, based on empirical studies, about the effect of nursing care on hospitalized patients? Do nursing care processes exist that can be clearly delineated, replicated, and measured to determine the best practice in hospitals? Professional nursing has made enormous strides in the study of nursing practice through the research generated from the National Institute of Nursing Research. Now in its tenth year, the NINR has catapulted the art of nursing into the science of nursing and has done much to assist in the examination of conventional nursing care on the outcomes of patients. In doing so, much of the science has focused on clinical questions related to diagnoses such as dementia, cancer, and heart disease. In making the transition from that work to the question at hand (i.e., what does the b lack box of nursing care in hospitals hold, and what differences does it make?), Lee and colleagues have pointed out the limited peer-reviewed literature as it relates to the question of nursing practice in hospitals. The authors note, and we emphasize, that the body of literature on the effectiveness of advanced practice nurses in improving outcomes of hospitalized elderly is substantial. It is time, however, not only to address advanced practice, but also to expand our knowledge by identifying those care processes, delivered by registered nurses, that provide the best patient care outcomes. Studies do exist with data that could be extrapolated to address the question, but the logical next step is to take the research-based practice protocols and determine if they can be systematically used in practice in a sustained way. Conversely, practice approaches that are currently in use need to be examined.

On any given day, in the same hospital, three to five different approaches may be in use for any one specific clinical problem. For example, comfort measures for individuals who are in the post-operative course may vary by nurse clinician preference in terms of positioning techniques, medication administration, the use of family for support, the use of distractions/music therapy, and the use of therapeutic devices such as hot packs, cold packs, and so on. These different approaches vary in their implications for staffing and reengineering efforts. It is highly likely that in each case the selected clinical intervention is the appropriate intervention for that patient at that time. However, where we fall down is in the evidence to support that high likelihood. Nursing practice can and must delineate the actions in the nursing intervention, the reasons behind them, and the proof that those actions have the desired positive effect on the patient's clinical problems. The Iowa Nursing Intervention Classification (NIC) System, funded by the National Institute of Nursing Research, has done much to help standardize and codify the language. It includes the full range of direct patient interventions done by nurses to prevent or treat illness, and it also includes indirect care interventions (such as checking and maintaining emergency supplies). The NIC classifies 433 nursing interventions along with a description of the intervention and a set of specific activities done by the nurse. The future lies in testing the activities against the desired nursing care outcomes.

In our experience with the NICHE (Nurses Improving Care for the Hospitalized Elderly) program, a national program funded by the John A. Hartford Foundation that is now in its tenth year, clinical protocals for best practice around common geriatric syndromes (delirium, incontinence, sleep problems, falls, etc.) are in great demand, can be measured for effect, and have been shown to improve practice (Stetler et al. 1999; Inouye, Acampora, Fulmer, et al. 1993).

The hospital in our case mentioned earlier illustrates what can happen if a hospital responds to economic pressures (as it frequently must) with limited available information on the best use of nursing resources, one of the most costly items in the hospital budget and one of the most critical staffing elements in the modern hospital. While research continues to examine nursing processes of care and best practices, the problems experienced by our example hospital remind us of the need in the short run to attend equally to fiscal responsibility and to the monitoring of patient outcomes for the effects of the changes that we put in place.

Terry Fulmer, R.N., Ph.D., FAAN

Mathy Mezey, RN., Ed.D., FAAN

Albert L. Siu, M.D., M.S.P.H.

The New York University Division of Nursing and the Mount Sinai School of Medicine, New York City


Aiken, L. H., H. L. Smith, and E. T. Lake. 1994. "Lower Medicare Mortality Among a Set of Hospitals Known for Good Nursing Care." Medical Care 32 (8): 771-87.

Inouye, S. K., D. Acampora, T. Fulmer, L. Hurst, and L. Cooney. 1993. "The Yale Geriatric Care Program: A Model of Care to Prevent Functional Decline in Hospitalized Elderly Patients." Journal of the American Geriatric Society 41 (12): 1345-52.

Leape, L. L., D W. Bates, D. J. Cullen, J. Cooper, H. J. Demonaco, T. Galivan, R. Hallisey, J. Ives, N. Laird, G. Laffel, R. Nemeskal, L. A. Petersen, K. Porter, D. Servi, B. F. Shea, S. D. Small, B. J. Swetizer, B. T. Thompson, and M. V. Vliet. 1995. "Systems Analysis of Adverse Drug Events." Journal of the American Medical Association 274 (1): 35-43.

Pabst, M. K., J. C. Scherubel, and A. F. Minnick. 1996. "The Impact of Computerized Documentation on Nurses' Use of Time." Computers in Nursing 14 (1): 25-30.

Stetler, C., B. Corrigan, K Sander-Buscemi, and M. Burns. 1999. "Integration of Evidence into Practice and the Change Process: Fall Prevention Program as a Model." Outcomes Management for Nursing Practice 3 (3): 102-11.
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Publication:Health Services Research
Geographic Code:1USA
Date:Dec 1, 1999
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