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HL20: Linda Aiken, PhD, RN—Advocate for Healthcare Quality and Nursing

 |  By cclark@healthleadersmedia.com  
   January 04, 2013

In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Linda Aiken, PhD, RN.

This profile was published in the December, 2012 issue of HealthLeaders magazine.

 "It doesn't cost a lot of money to change the work environment. It's the No. 1 thing hospitals should be doing rather than just throwing a lot of money into staffing without changing some of these other factors."

When researcher Linda Aiken, PhD, RN, speaks to large groups about problems hospitals face delivering quality care, she often asks the nurses in her audience about their pillows.

"I ask, 'Do you spend time looking for pillows for your patients?' And every time, they all jump up, thousands of them, waving their arms. Now isn't this a major ridiculous thing, in a multibillion-dollar business, where nurses are paid a lot of money, they're spending so much time searching for pillows, and even hoarding pillows?"

Sometimes, they need five or six pillows to position their patients to avoid pressure ulcers, or to help patients after surgery, Aiken explains. "It's the same thing for IV poles, stretchers, medications that don't show up on time, or meals that don't come. Nurses have to go looking for them. These are the things nurses troubleshoot all the time, which interrupts them mid-task and takes them away from taking care of patients."

Aiken, a former heart surgery nurse, is now professor of nursing and sociology and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. She also is arguably the most well-known investigator of how nursing workforce issues affect hospital quality and outcomes, specifically inpatient mortality and nursing shortages.

Her three key subject areas are patient-nurse ratios (lower them), nursing educational levels (raise them), and the nurse work environment (include nurses in decisions).

 

Patient-nurse ratios
Aiken's most famous projects involve studies that link lower patient-to-nurse staffing ratios with better outcomes.

In 2002, Aiken's research revealed that every time another general surgical patient is added to a nurse's workload, there's a 7% higher mortality rate for the patients, and the nurses have more burnout and job dissatisfaction.

And in 2010, she found that if Pennsylvania and New Jersey, two states with no patient-nurse ratio legislation, staffed hospitals at the levels mandated by California's nurse staffing mandate, implemented in 2004, in-hospital mortality for patients undergoing common surgical procedures would drop between 10.6% and 13.9%.

The California law says one nurse should care for no more than five patients on a medical-surgical unit, two in the intensive care unit, and three in a labor and delivery unit.

When lawsuits threatened the 1999 California law, nursing organizations successfully used Aiken's 2002 research as a defense before the state Supreme Court.

Hospitals started to pay more attention to the issue.

"Now we have a patient-nurse ratio bill pending in Pennsylvania, and many other states have legislation under consideration," she says. Half of all states either have some other form of nurse staffing legislation passed or in the works, she says.

Aiken doesn't pin her success on passage of laws, however, but on the public debate they provoke. "We've changed the way a broad group of stakeholders thinks about nursing, that it is a resource to contribute to better patient care, as compared to just a flat-out operating cost, which is how hospital executives often think about it," she says.

Education
On education, her paper in 2003 found that every 10% increase in the proportion of nurses with a bachelor's degree was associated with a 4% decline in mortality. Her team looked at hospitals where the proportion of nurses with bachelor's degrees varied from 90% to none, a wide variation throughout the country.

"It was," she says, "myth-busting of the notion, especially in the United States, that doctors need a lot of education ... but nurses didn't really need an education. All they needed was experience."

A big success "was getting the American Organization of Nurse Executives to say that a baccalaureate degree was the preferred educational credential for a hospital nurse." That was followed by the Institute of Medicine report in 2010, which called for 80% of the nursing workforce to have a baccalaureate degree by 2020, up from about 50% today.

Work environment
Her third issue may be the most challenging: the nursing work environment.

"We found that if you put aside ratios and educational level, the work environment itself is highly associated with differences in mortality across hospitals," she says.

By work environment, she means that nurses and physicians have good communication, trust, and teamwork; that management listens to nurses' concerns and acts to solve problems; that the organization has adequate staffing for all types of jobs; that employers invest in nurses' continuing education; and that the organization involves nurses in its major decisions.

"We consistently find that it doesn't cost a lot of money to change the work environment. It's the No. 1 thing hospitals should be doing rather than just throwing a lot of money into staffing without changing some of these other factors," Aiken says.

Since the passage of the Patient Protection and Affordable Care Act, Aiken says, providers are starting to realize how important the nursing staff is to achieve high quality scores and reduce readmissions, two areas where performance is keyed to Medicare payment incentives and penalties.

"We've been influential because we've been able to convince hospitals that if they really want to have these better outcomes and meet these performance targets set by CMS, they need to look at their nurse staffing, nurse education, and the quality of the nurse work environment.

"That's what we're famous for and I think that's where we've had the biggest overall impact, and not just in the United States."

In addition to her domestic work, Aiken's impact is now global. She's involved in numerous projects to examine nursing shortages and nursing migration in 30 countries, funded by the National Institute of Nursing Research and the European Union.

How does Aiken think the nurse's role will change in the next 10 years?

"The majority of nurses will have bachelor's degrees, and nurses will have more responsibility in hospitals, nursing homes, and every other setting." 

And, we may hope, all nurses will have enough pillows for their patients.

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