The landmark Institute of Medicine report "To Err is Human" said improving nurses' work environment could be a key way to prevent patient harm.
But years later, many hospitals lag behind in needed fixes, according to a new study published Monday in Health Affairs.
Led by a team at the University of Pennsylvania, researchers studied data from 535 hospitals in Pennsylvania, California, Florida and New Jersey from between 2005 and 2015. They found that just 21% made substantial gains in improving the work environment and 7% actually worsened in that window.
The researchers also looked at survey data from nurses from between 2008 and 2016. They found a 19% decrease in how nurses ranked the safety of the hospitals if they also reported a worsening work environment, according to the study. By comparison, the researchers found a 15% increase in positive patient safety rankings from nurses working at hospitals where they said the work environment was improving.
Overall, 60% of nurses surveyed in 2015 said care quality in their hospitals was “less than excellent,” and 81% said the same about their work environments. About one in five said that management takes actions that suggest they’re not making patient safety a priority.
The study’s lead author, Linda Aiken, Ph.D., a nursing professor and director of Penn’s Center for Health Outcomes and Policy Research, told FierceHealthcare that as the industry seeks a “magic bullet” to improve patient safety, other suggestions may fall by the wayside. Especially as researchers have uncovered some of these potential “magic bullet” solutions, it can be hard for hospital leaders to visualize the change needed to address something like the work environment, she said.
“It’s not a flashy recommendation, but it’s a foundation recommendation,” Aiken said. “You’re not going to find a magic bullet that lets everything else stay as it is now. We really realize that we have to deal with culture and organization.”
The study’s findings, she said, indicate that cultivating a culture of safety within the hospital remains “the next frontier” in reducing harm. Hospitals that want to take on this challenge must first be armed with data to determine where their strengths and weaknesses lie, Aiken said.
In addition to internal surveying to gauge, for example, patient-to-nurse ratios, stakeholders should develop quality measures that assess the work environment. These measures will allow hospitals to benchmark and measure progress in these areas.
Nurses also need to feel that they can report incidents of patient harm, Aiken said. As they spend most of their time on the front lines of care, they’re perfect stewards for this information, but many feel uncomfortable speaking up.
Half of nurses surveyed in 2015 said they feel their mistakes are “held against them,” for example, which would make them less likely to report these incidents. One solution, Aiken said, could be routine, anonymous surveys similar to those given to patients, so they’re less afraid to speak up.
“[Patient surveys] are very useful, but we should have the equivalent for the clinicians, who are really at the sharp end of care and can really see and be discerning,” Aiken said.