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Nursing's Triple Threat

Wednesday September 5, 2007
<B>Principal investigator Patricia W. Stone, RN, PhD, associate professor of nursing at Columbia University School of Nursing, and her co-investigators found a link between certain types of infections and nurse working conditions in the ICU.</B>
Principal investigator Patricia W. Stone, RN, PhD, associate professor of nursing at Columbia University School of Nursing, and her co-investigators found a link between certain types of infections and nurse working conditions in the ICU.
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Almost every nurse has a story that relates to some near disaster or problem that can be attributed to either understaffing, working overtime, or just plain being overworked. The impressions from these anecdotes pointed to the dangers to patients inherent in an overworked, tired, nursing staff making decisions about care in critical situations. Now there is concrete evidence that patients are bearing the consequences of difficult working conditions, in the form of a study recently reported by researchers at Columbia University Medical Center in New York City.

Using information routinely reported to the Centers for Disease Control and Prevention about hospital-acquired infections, principal investigator Patricia W. Stone, RN, PhD, associate professor of nursing, Columbia University School of Nursing, and her co-investigators Andrew W. Dick, PhD, senior health economist, RAND Corporation, and Elaine Larson, RN, PhD, FAAN, CIC, associate dean, Professor of Pharmaceutical and Therapeutic Nursing, Columbia University School of Nursing, and others were able to demonstrate a link between some types of infections and nurse working conditions in the intensive care unit. They reviewed outcome data for 15,846 patients in 51 ICUs in 31 hospitals, and found that the working conditions of the nurses in the unit had a definite impact on patient outcomes.

The nursing intensity index in intensive care

Comparing information from hospitals all over the country has many pitfalls. The study controlled for the differences in the care of patients with various problems by allowing for the intensity of nursing care. They investigators used the Nursing Intensity Work Index to assess the amount of care needed for individual patients. The Nursing Intensity Work Index is a case mix indicator that assigns a level of intensity to each patient based on factors like the diagnosis-related group (DRG) and the amount of nursing care needed. The index scores patients from one to six, six being the most intense level of care. As the investigators compared cases, they took into account the index of each patient.

Comparing apples to apples

To be sure they compared apples to apples, the investigators controlled for hospital size and teaching status. They used Intensive Care Unit statistics, where the nurse/patient ratio is generally lower than on general nursing units. All of the patients were Medicare patients, since Medicare has common requirements for review and reporting.

"We used Medicare patients because it made sense to compare these patients to one another, but even moreso because these patients are among the most vulnerable and the most at risk from complications," says Stone.

They measured overtime by using payroll records, rather than self- reporting by the nurses. One limitation, says Stone, was that they could not tell whether the overtime was mandatory or not. Mandatory overtime adds stress to staff.

"Intensive care units all collect data regarding infections as part of what was called at the time the National Nosocomial Infection Surveilance System," says Stone. Data regarding the infections were gleaned from the reports that hospital submit to the CDC.All tof he hospitals collected the data in the same way, and by using these reports, the CDC was able to compare hospital-acquired infections across the variety of institutions.

The investigators measured the perception of the organizational climate by surveying nurses. Organizational climate included the overall perception of nurses of their work environments. Magnet status was considered, and the overtime and staffing levels were objectively measured.

The number of nurse hours per patient over twenty-four hours was the measurement of staffing. For example, if there was a nurse/patient ratio of 1:1 for the entire 24-hour day, then each patient received twenty-four nursing hours. If the ratio varied, then the number of nursing hours varied proportionately. A ratio of 1:1 for the day shift, 1:2 for the evening shift, and 1:4 for the night shift would receive 8 hours (days) + 4 hours (evenings) + 2 hours (nights) for a total of 14 nursing care hours during the 24-hour period. The mean number of hours for the units in the study was 17.

The bottom line

The results of the study confirmed what nurses have suspected for years: nurse working conditions have a measurable effect on patient outcomes. Stone notes that different issues seem to be related to various problems.

Variation of nursing hours (staffing) had an effect on blood stream infections, ventilator-associated pneumonia, 30-day mortality rates and the incidence of decubitous ulcers. Certainly, overtime is usually caused by a need for staff, so the effects of overtime can, to some extent, be attributed to staffing difficulties as well.

Overtime seemed to have more of an effect on urinary tract infections than did staffing, although both effected the incidence of decubiti. Stone suggests that this is because of the nature of the nursing care needed to prevent these complications, as well as the nature of overtime. When overtime work is needed, it is almost always because of short staffing problems. Catheter insertion, perineal care, and the turning and positioning that prevent decubitus ulcers are all nursing functions. Nurses who work overtime are more likely to be tired, and as humans are, more likely to make mistakes.

"I think we need to look at ways to be sure there is a flexible, qualified, work force available," says Stone. "Most nurses don't like to float, but when there is a fluctuation in the number and acuity of patients, there has to be a way to provide care."

Work environment is important

The feeling of support that contributes to nurses being able to function in a variety of settings contributes to the way nurses perceive their work environment. Organizational climate, or the perception of the nurse working environment, had an impact on urinary tract infections, says Stone. Where the nurses perceived a poor organizational climate patients were 39% more likely to get a urinary tract infection. Organizational factors included Magnet status and working environment. Pay was not generally a determining factor in the perception of the nurses of their working environment. High wages may attract staff, but coupled with poor working conditions high turnover rates often result, and that is a problem for the patient, the staff and the organization's administration. Stone notes that nurses, in all cases, tried their best to give good care to patients. As with so many healthcare problems, the issues seem related to the system in which the nurses practice, rather than to any individual nurse or nurses.

"We need to fix the working conditions for nurses," says Stone. "Administrators and policy makers have to look at the big picture. Pay will attract nurses, but it won't keep them."

The study demonstrates conclusively that working conditions are more than niceties. The "triple threat" is important in terms of patient safety issues. Thinking outside the box to educate staff so that they are comfortable moving from one type of unit to another is one way to alleviate the stresses of being understaffed and overworked.

Marylisa Kinsley, RN, BSN, is a contributing writer to Nursing Spectrum. To comment on this story, e-mail jspillane@gannetthg.com.