Patient Safety Advances Lagging

A decade after the release of an IOM report warning of serious threats to patient safety associated with nurses' work environments, things haven't changed as much as might have been expected.

One might think that these words heard a decade ago, "The typical work environment of nurses is characterized by many serious threats to patient safety" would have sounded an alarm for nurses and healthcare organizations to do everything they could to improve safety and quality.

But ten years after the release of an IOM report on patient safety, things haven't changed as much as might have been expected. "While we've moved in the right direction, we're not there yet," says said Robert Wood Johnson Foundation Senior Program Officer Maryjoan D. Ladden, PhD, RN, FAAN. "Ten years seems like a very long time to not be there."

The Robert Wood Johnson Foundation has released an issue brief examining how nurses' work environments have changed in the years since that IOM report was released—and also what hasn't changed. The brief, Ten Years After Keeping Patients Safe: Have Nurses' Work Environments Been Transformed? says, "despite notable achievements in improving healthcare quality since that time, patients remain at risk of serious harm."

"Any time an issue like quality and safety is raised, it's extremely important to keep it alive," Ladden says, adding that IOM reports like these get a lot of money and resources poured into them and get a lot of attention when they're first released. But then, they can have the tendency to sit on the shelf.

Some Progress
"We're raising the issue again," she says, and in doing so, the RWJF issue brief has found that some things have indeed changed.

"I think that what has changed is much more attention to the issue," Ladden says. "Front-line clinicians like nurses realize they have a very, very important role in keeping patients safe, and they've really stepped up more. [When] you give frontline clinicians the tools to identify and create solutions to some problems that they see, that they do step up."

She points to the RWJF program Transforming Care at the Bedside (TCAB). The issue brief referenced a 2011 study of TCAB's impact on a group of 13 medical-surgical units in 10 hospitals, which found the "majority of units studied saw a significant decrease in injury-producing patient falls and 30-day hospital readmission rates.

While voluntary nurse turnover remained essentially unchanged, nurse engagement in quality improvement rose, and TCAB innovations spread to other hospital units. TCAB units also reduced staff overtime, translating to an average net financial gain of $625,603 per TCAB unit over three years."

In addition to programs like TCAB, Ladden also says over the past decade national organizations such as the Joint Commission and the ANA have paid more attention to issues such as promoting collaboration and giving patients a voice.

But in spite of such efforts, Ladden says too often, nurses still aren't heard or don't even speak up to begin with. She draws a comparison with Homeland Security's if you see something, say something anti-terrorism message, which encourages travelers to tell authorities if they see something suspicious. Ladden says such a campaign needs to be part of healthcare, too. Unfortunately, cultural barriers often stand in the way, and culture is a notoriously difficult thing to permeate and change.

"Organizations have their own culture, and often the culture does not allow for people to speak up," she says, adding that it's not enough for nurses to be able to identify situations or practices that aren't safe.

Speak Up
Nurses also need to be encouraged to speak up, without fearing punishment. Nurse leaders should ensure that their nurses know whom to speak with when they see problems. It's also important to have processes in place to actually change issues when they're brought to light.

"Make sure that nurses have the ability but also the tools to identify quality and safety issues and to communicate them to others and…work on the solutions," she says.

Ladden also says nurses should be on the boards of hospitals and healthcare organizations, but usually aren't. In fact, the new RWJF issue brief points to data from the American Hospital Association which shows that nurses make up only 6% of voting members on hospital boards.

"Because nurses are the most trusted because they are at the front lines of care, they need to have a larger voice in not just quality and safety, but in higher positions," Ladden says. "It's really important to have those front line providers represented… so that they can raise the voices and raise the view of front-line providers."

She adds, "I think it's astonishing when boards of governing bodies of organizations continuously rotate and have new members and they don't realize that they don't really have anybody who represents the front lines of care."

Nurse leaders can take steps, too, to help close the gap between the IOM's decade-old recommendations and the realities of working nurses. First, they can establish and disseminate to their nurses clear channels for communicating issues.

Also, Ladden suggests that nurse leaders help knock down the silos between healthcare providers to ensure better communication and collaboration. She says physicians, nurses, pharmacists, and others are educated separately, then thrown together to work.

"I think a big message for nurse leaders in healthcare organizations is to reach out to their academic partners… about how they can work better together," she says, "to not just prepare the next generation of nurses but [to show] how they can work together to model good collaboration and to have the students see that."