Patient Safety Through Nurse Workplace Transformation

RWJ FoundationNew RWJF Policy Brief Examines Progress Since 2004 IOM Study

Princeton, NJ — A decade ago, a report from the Institute of Medicine (IOM) offered the startling conclusion that, “The typical work environment of nurses is characterized by many serious threats to patient safety.” The IOM offered a series of specific recommendations about how hospitals and other institutions needed to change to reduce the number of health care errors—recommendations that together constituted a fundamental transformation of nurses’ work environment. Ten years later, a new issue brief from the Robert Wood Johnson Foundation (RWJF) examines progress toward those goals.

The IOM report, Keeping Patients Safe: Transforming the Work Environment of Nurses, found that hospitals and other health care organizations did a poor job of managing the high-risk nature of the health care enterprise. Accidents were too common, and the management practices in the industry did little to create a culture of safety.

The new brief from RWJF, Ten Years After Keeping Patients Safe: Have Nurses’ Work Environments Been Transformed?, details a series of programs designed by and for nurses that have “spurred the creation of work environments that foster health care quality and patient safety.”

“We’ve made important gains in the past decade, but we have a lot more work to do,” said RWJF Senior Program Officer Maryjoan D. Ladden, PhD, RN, FAAN. “Some of the changes needed are systemic, and will require collaboration among nurses, doctors, educators, policy-makers, patients, and others. But nurses also have a critical responsibility to transform their individual workplaces, asserting leadership at the unit level and beyond to help identify and solve problems that affect patient safety.”

Among the initiatives highlighted in the brief:

  • Transforming Care at the Bedside (TCAB). The RWJF-backed TCAB initiative, developed in collaboration with the Institute for Healthcare Improvement, seeks to empower frontline nurses to address quality and safety issues on their units, in contrast with more common, top-down efforts. Evaluations of the program point to fewer injuries from patient falls, lower readmission rates, and net financial gains.
  • Quality and Safety Education for Nurses (QSEN). Also backed by RWJF, QSEN seeks to improve patient safety by helping prepare thousands of nursing school faculty to integrate quality and safety competencies into nursing school curricula at the undergraduate and graduate levels.
  • Nurse-Patient Policies. In some jurisdictions, policy-makers have addressed patient safety through nurse staffing policies, focusing both on nurse-patient ratios and on the composition of the nursing workforce. To date, California is the only state to establish a limit on the number of patients a nurse may be assigned to care for in acute care hospitals. Other jurisdictions have policies intended to encourage lower ratios. Research on the impact of such efforts on patient safety has been mixed to date. In addition, the IOM’s 2010 Future of Nursing: Leading Change, Advancing Health report gave new impetus to efforts to increase the share of nurses with baccalaureate degrees or higher, and various institutions have begun to address that recommendation through hiring requirements, tuition-reimbursement policies, and more.
  • Disruptive Behavior on the Job. Professional discourtesy and other disruptive behavior in the workplace is another barrier to patient safety, particularly given the growing importance of teamwork and collaboration. Noting that the consequences of poor behavior can be “monumental when patients’ lives are at stake,” the brief highlights programs at Vanderbilt Medical Center (Nashville) and Johns Hopkins Hospital (Baltimore) designed to deter such problems.

The CNF brief goes on to cite a series of initiatives by government agencies, professional associations, the public service sector, and credentialing organizations, all designed to advance patient safety and transform nurses’ work environments toward that end. It concludes with an “emerging blueprint for change” that urges providers, policy-makers, and educators to follow through on:

  • Monitoring nurse staffing and ensuring that all health care settings are adequately staffed with appropriately educated, licensed, and certified personnel;
  • Creating institutional cultures that foster professionalism and curb disruptions;
  • Harnessing nurse leadership at all levels of administration and governance; and
  • Educating the current and future workforce to work in teams and communicate better across the health professions.

Finally, the brief provides policy-makers, health care organizations, educators, and consumers with a listing of available tools to help in their efforts.

This issue of Charting Nursing’s Future is a publication of RWJF created in collaboration with the George Washington University School of Nursing.