Finding Solutions for Stressed Out, Exhausted Nurses, and Potentially Depressed RNs

A new survey of more than 3,300 registered nurses (RNs) shows that a majority were extremely stressed out due to lack of sleep, long hours, and numerous other workplace issues.

These high levels of stress and fatigue could lead to medical errors, and negative patient outcomes, as well as an increase in nurse burnout, further aggravating the current nursing shortage, according to the study by the Vickie Milazzo Institute, a legal nurse consulting training institute.

Among the findings, 64 percent of respondents indicated that they rarely get seven to eight hours of sleep and 33 percent said they hardly ever get that amount. Twelve-hour shifts and on-call shifts after regular shifts and overnight shifts contribute to the fatigue problem, according to the study. Fatigue and irregular sleep patterns can also lead to health problems for nurses, including increased risk of depression and anxiety disorders.

An INQRI-funded study, published in the May/June 2012 issue of the journal Clinical Nurse Specialist, looked at how depression and musculoskeletal pain among nurses impacts workplace productivity and quality of patient care. Researchers found that nurses experience depressive symptoms at a rate twice as high—18 percent—as the general public. The team found that pain and depression were significantly associated with presenteeism, which was significantly associated with patient falls, medication errors, and the perceived quality of care. Additionally, depressed workers often exhibit low mood, have difficulty concentrating, and are accident-prone.

The researchers analyzed surveys from 1,171 hospital nurses in North Carolina and found that the productivity loss due to pain and/or depression was $14,339 per nurse and $876.9 million for the state of North Carolina. If these numbers were extrapolated to the nation, the productivity loss would be $22.7 billion.

Addressing the Problems

According to the Milazzo study, other factors contributing to high levels of stress for RNs are an unhealthy work/life balance, lack of authority, recognition, and fair pay in the workplace, and lack of effective management. To address these issues, the study recommends that hospitals:

• Make work hours for RNs realistic and sane;
• Provide access to nutritious food;
• Allow experienced RNs to have the authority to do their jobs and provide RNs with management opportunities; and
• Improve management style to recognize RN’s unique contributions and provide fair pay, adequate paid time off, and a positive work environment.

As the INQRI study points out, it is also imperative to devote more attention to depression screening and early treatment for nurses. Advanced practice nurses can educate staff RNs about the high prevalence of depression in nurses, who, like the general population, may be reluctant to get screening and treatment, due to the social stigma attached to mental illness. The study identified Web-based screening as a confidential and cost-effective means of reaching the nursing population.

Other strategies for assisting nurses with depression include increasing staff nurses and managers’ awareness of and sensitivity to depression, advocating policies that support good mental health and treatment for those with problems, and promoting supportive work environments, according to the study.

The Effects of Nurse Presenteeism on Quality of Care and Patient Safety was led by INQRI grantees Susan Letvak and Christopher J. Ruhm.

The Vickie Milazzo Institute survey results are available here.

Rates of Infections, Falls, Pressure Ulcers, Other Hospital Acquired Conditions Drop

Hospitals saw a nine percent decrease in harms experienced by patients from 2010 to 2012, according to a new report from the U.S. Health and Human Services Department (HHS). There were reductions in adverse drug events, falls, infections, pressure ulcers, and other areas, estimated to have prevented nearly 15,000 deaths and 560,000 cases of patients being harmed in hospitals.

The HHS report also shows that the incidences of hospital-acquired infections dropped from 145 per 1,000 discharges in 2010 to 132 per 1,000 discharges in 2012, resulting in 560,000 few incidents in two years, FierceHealthcare reports. Falls and trauma declined 14.7 percent and pressure ulcers fell 25.2 percent.

In addition to lives saved, the reduction in harm to patients saved $4.1 billion according to the report, which credits factors such as diverse public-private partnerships, active engagement by patients and families, and new tools provided by the Affordable Care Act (ACA), with the improvement. In 2011, under the ACA, HHS launched the Partnership for Patients, a nationwide public private initiative to keep patients from being harmed in hospitals and heal without complication. The Partnership shares best practices with more than 3,700 hospitals enrolled in the initiative.

INQRI grantees have conducted a number of studies into how nurses can lead efforts to reduce medical errors and patient harm, including:

• Reducing central line-associated bloodstream infections was the focus of an INQRI-funded study led by David Thompson and Jill Marsteller. Their study, involving 45 intensive care units in 35 hospitals in 12 states, tested a nurse-led intervention that used a bundle of evidence-based practices to reduce infections. The intervention was successful in significantly reducing infections and also highlighted the importance of promoting a culture of safety and communication. It also established that nurses should play a central role in quality improvement interventions.
• The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and Jay Kim, an engineer.
•  INQRI grantee Patti Dykes worked with a team to develop the Falls: Tailoring Interventions for Patient Safety (Falls TIPS) online tool kit to educate patients and families about how they can work with nurses and other providers to prevent falls. The toolkit was developed based on the Fall TIP: Validation of Icons to Communicate Fall Risk Status and Tailored Interventions to Prevent Patient Falls study, which involved developing and validating a set of icons designed to communicate fall risk status, and developing tailored interventions to prevent patient falls in hospitals.

The full HHS report is available here.

One in Three Nursing Home Patients Are Harmed By Medical Errors

A recent government survey found that approximately one-third of patients who were discharged from hospitals to skilled nursing facilities, were harmed by treatments they received in the facilities. Most of the incidents could have been prevented, according to the report, which was conducted by the U.S. Health and Human Services Department, Office of the Inspector General.

The survey was based on a large sampling of Medicare patients discharged from hospitals to skilled nursing facilities during a one-year period from 2011-2012, NPR reports. Problems observed in the nursing homes included errors related to patient monitoring, and medication errors.

Approximately 60 percent of nursing home residents were harmed by their treatment were readmitted to the hospital as a result, and the report estimates that such readmissions cost Medicare about $2.8 billion a year.

The American Health Care Association, which represents the nursing home industry, responded to the report, telling NPR that this study was conducted before the Association’s quality improvement initiative, which has been showing progress in skilled nursing facilities across the country.

An INQRI-funded study led by Linda Flynn and Dong-Churl Suh examined the “Impact of Nursing Structures and Processes on Medication Errors.” The multidisciplinary research team identified changes in nursing care processes needed to prevent medication errors as well as adjustments in nurse staffing and the practice environment that can facilitate interception of such errors.

Sound Bending Invention Could Reduce Stressful Hospital Noise

Excessive hospital noise is stressful for both patients and nurses and can lead to medical errors due to alarm fatigue. To address these issues, Eve Edelstein, an associate professor at the University of Arizona, is collaborating with University of California San Diego Music and Sonic Arts Professor Peter Otto on unique noise reduction strategies, KPBS Radio reports.

Edelstein, a neuroscientist and architect, measured sound levels in emergency departments during shift changes and found levels as high as 100-110 decibels, equivalent to the noise levels of a jet engine. To explore new ways of reducing the noise, Edelstein partnered with Otto, who developed a “sound bender,” a small machine that directs sound in a specific direction without allowing it to spill over to other locations.

In a hospital setting, the sound bender could be used to channel the sound and restrict it specifically to the people who need to hear it, Otto told KPBS. For example, announcements or alarms could specifically be directed to nurses’ stations without disturbing patients or other staff.

Otto is also exploring the effects of different building materials, room sizes, and room shapes on acoustics in hospitals, according to the article.

Hospital’s Communications, Medical Teams Join Forces to Highlight Medical Errors

By combining the expertise of a multi-disciplinary medical team and the Communications Department, the University of Texas MD Anderson Cancer Center is creating visual story-telling presentations to highlight medical errors, ClinicalOncology.com reports.
 
The Center, based in Houston, Texas, produces “video stories,” which contain recommendations based on adverse drug-related events, in combination with photos, audio recordings and video re-enactments. The presentations are shown during staff and committee meetings and are available on the hospital’s intranet site.

The presentations illustrate gaps in everyday medical processes that can lead to medical errors. For example, a presentation may explore the drug use processes ranging from prescribing to administration and analyze where errors might occur.

Errors are identified every month by a multidisciplinary team that includes a nurse, pharmacist, and patient safety specialist. The group selects three events or topics and then another larger multidisciplinary group of nurses, pharmacists, and mid-level providers choose one topic to be developed into a visual presentation.

Between October 2012 and June 2013, hospital leaders accessed the eight once-monthly videos nearly 3,500 times, according to ClinicalOncology.com. The response from hospital leaders, as well as front-line nurses, pharmacist and physicians, has been overwhelmingly positive, according to the project’s administrators.

An INQRI-funded study led by Linda Flynn and Dong-Churl Suh examined the “Impact of Nursing Structures and Processes on Medication Errors.” The multidisciplinary research team identified changes in nursing care processes needed to prevent medication errors as well as adjustments in nurse staffing and the practice environment that can facilitate interception of such errors.

Bedside Shift Changes for Nurses Can Reduce Errors, Improve Patient Satisfaction

Performing nurses’ shift changes at the patient’s bedside can reduce potential medical errors and increase patient satisfaction, according a new study highlighted on ScienceDaily.com.  The study findings were published in the Journal of Nursing Care Quality.

Traditionally, nurses exchange patient information between shifts through recordings or verbal briefings. With the bedside handover method, nurses exchange pertinent patient information such as clinical conditions, allergies, and care plans with the patient in his or her room. With this system, nurses and patients see each other sooner and patients are able to ask questions and clarify information with both the nurse leaving for the day, and their new nurse. This process can relieve anxiety and improve patient satisfaction, according to the article.

Study participants described bedside handover as engaging, personal, and informative. However, researches noted the importance of recognizing and being sensitive to patients’ preferences, which often differ. Bedside handover can be beneficial for nurses as well, since they can assess all patients’ conditions and prioritize care within the first 15 minutes of a shift.

An INQRI-funded study led by Linda Flynn and Dong-Churl Suh examined the “Impact of Nursing Structures and Processes on Medication Errors.”  The multidisciplinary research team identified changes in nursing care processes needed to prevent medication errors as well as adjustments in nurse staffing and the practice environment that can facilitate interception of such errors.

A Longitudinal Pridit Approach to Explaining Hospital Quality

Health outcomes can vary between high- and low-quality institutions, and research has been conducted to identify variables that determine hospital quality. However, new analysis by Robert D. Lieberthal and Dominique M. Comer builds on the prior investigation of hospital quality by evaluating a method originally developed for the detection of healthcare fraud, Pridit.

Pridit allows the ranking of hospitals, with respect to quality of care, using process measures and demographic attributes of the hospitals. Researchers developed a theoretical model to justify the application of Pridit to the hospital quality setting and then applied the method to a national, multiyear data set on U.S. hospital quality variables and outcomes. The results demonstrate how Pridit can be used to predict future health outcomes based on currently available quality measures. The empirical results obtained in this study may be of use to health insurers and policymakers who aim to improve quality in the hospital setting. The research content is available through the Wiley online library.

An INQRI study, Nursing Workforce Impact on Performance Improvement in the CMS/Premier Hospital Quality Incentive Demonstration Project (HQID), examined the impact of nurse staffing and nurses' work environment on hospital performance improvement in the HQID project. HQID is the first CMS demonstration on the impact of hospital pay-for-performance. Ira Moscovice and Mary Wakefield led the research team.

New JAMA Study Underscores Why the Business Case for Nursing Is Problematic

A new study to be published tomorrow in the Journal of the American Medical Association (JAMA) finds that hospitals profit when patients have complications during surgery. According to a report in the Washington Post's Wonkblog, this counter-intuitive finding is a function of the payment structure in our nation's health care system. Hospitals earn money for every procedure done, even if that procedure is necessary to correct an error that occurs during surgery.

It's for just this reason,according to Olga Yakusheva, Douglas Wholey and Kevin Frick, that it has been so difficult to make a business case for investing in nursing care. In their article in the INQRI Medical Care supplement published last month, the INQRI researchers point out that because investments in nursing care improve patient outcomes, they hurt hospitals' bottom line. The authors go on to suggest that the roll out of the Affordable Care Act, which includes penalties for high rates of hospital acquired infections among, will help to address this confounding issue. They, like the authors of the JAMA study, also encourage taking more aggressive steps to make health care payments outcome-based, rather than service-based.

According to the Post blog, the JAMA study found that a hospital's profit margin jumped from $16,936 to $55,953 when there was a surgical complication.

INQRI in the News

Check out some recent news coverage of INQRI projects...

Last week, we told you about a new journal article authored by INQRI grantees who found that a combination of strategies and practices can reduce deadly hospital acquired infections.  These findings were the topic of two new articles:

• "Proven Strategies Reduce Deadly Hospital-Acquired Infections," HealthCanal.com
• "Proven strategies successful in reduction of deadly hospital-acquired infections," MedicalXpress.com

An INQRI journal article published in August continues to receive press.  This project found that better work environments for nurses led to fewer medication errors.  It was recently covered on three more sites:

• "Study: Supportive Nursing Environment Linked to Reduced Medication Errors," Becker's Hospital Review.com
• "Medication Errors," OncLive.com
• "Nurses’ interception practices reduce costly errors," Nurse.com

Reducing Central Line Infections

Researchers at the Johns Hopkins Children's Center recently found that hospitals can use a set of basic precautions to reduce the number of dangerous central line infections in pediatric cancer patients.  Their new article, scheduled for publication next month in Pediatrics, encourages family members to serve as patient advocates when they witness noncompliance with the protocol.  The research team also suggests that an honest evaluation be conducted regarding each infection to determine cause.

A team of INQRI researchers at Johns Hopkins University conducted the first randomized-control trial to reduce central line associated blood stream infections among ICU patients. This study, conducted in ICUs in 12 states, has shown that substantial reductions in infections can be widely achieved and this project did so with nurses leading the infection control efforts. 

Click here to learn more about the pediatric study on Nurse.com.

Click here for more information about the INQRI team at Johns Hopkins University.

INQRI Team Finds that Better Environments for Nurses Mean Fewer Medication Errors

The findings of an INQRI study led by Linda Flynn were published in the Journal of Nursing Scholarship recently.  The article explains that nurses’ error interception practices—including independent comparisons between the medication administration record and patient record at the beginning of a nurse’s shift; determining the rationale for each ordered medication; requesting that physicians rewrite orders when improper abbreviations are used; and ensuring that patients and families are knowledgeable regarding the medication regimen so that they can question unexplained variances—are associated with lower rates of nonintercepted medication errors, further quantifying the important role of nurses in enhancing patient safety.

Click here to read more about the study.

Click here to read coverage on this study by Equities.com.

Click here to read the coverage on PharmaLive.

Practice Environment Impacts Medication Error Interceptions by Nurses

INQRI grantees Linda Flynn, Dong Suh and their team were recently published in the Journal of Nursing Scholarship with their article, "Nurses' Practice Environments, Error Interception Practices, and Inpatient Medication Errors."  They concluded that supportive practice environments enhance nurses' medication error interception practices.

Click here to access the article.

Nurses Deflect Medical Errors In Cardiac Operating Room

A study published in this month's edition of the Association of periOperative Registered Nurses Journal found that circulating nurses prevented or corrected on average 11.11 medical errors related to cardiac surgical procedures. This research demonstrates the important role that nurses play in promoting high-quality care in the operating room, in addition to other areas of healthcare.

To read more about this study at Cardiovascularbusiness.com, click here.

To access the Abstract and Full-Text (subscription required) for this study, click here.

Temp ER Nurses a Safety Threat to Patients, Study Shows

According to new research from Johns Hopkins University School of Medicine, temporary emergency room nurses who are unfamiliar with their surroundings may inadvertently be a threat to the patients they serve. As reported by John Commins, for HealthLeaders Media, the study found that the temporary help was twice as likely as permanent staff to be involved in medication errors in the hectic and fast-paced environs of the ER.

Click here to read the news article.

Click here to read additional blogposts related to nurse staffing.

Hazard Alerting Loop Proving Successful in Washington

The Washington Hospital Center is successfully using a "Hazard Alerting Loop" system (HAL) to avoid patient safety problems. HAL is a reporting system which allows front-line personnel to report potential problems to the HAL coordinator who can then address the issue with supervisors and staff.

Click here to read more in the Washington Post article, "Washington Hospital Center safety program seeks to catch ‘near-misses.'"

The Nurse Staffing Standards for Patient Safety and Quality Care Act of 2011

Representative Jan Schakowsky (D-IL) has introduced legislation to establish federal standards for hospital nurse-to-patient ratios. Schakowsky hopes that passage of the bill will help to prevent errors caused by understaffing of nurses.

“Nurses are overworked and hospitals are understaffed, leading to disastrous results for patients everywhere,” said Schakowsky said. “By creating a workplace in which nurses are asked to do the impossible, we drive nurses away and jeopardize the quality of patient care. The bill is a common-sense solution to improve the quality of patient care and address the nursing crisis in our hospitals.”

Click here to read more about the Nurse Staffing Standards for Patient Safety and Quality Care Act of 2011.

Johns Hopkins Creating Patient Safety Institute

According to Dr. Edward Miller, dean and chief executive of Johns Hopkins Medicine: "Fewer things are more important in health care right now than improving patient safety and the quality of health care. All of us acknowledge these imperatives, but few of us have taken the steps to formally erect a framework that will tackle these issues head on."

To that end, Johns Hopkins plans to use a $10 million gift from C. Michael Armstrong, chairman of Johns Hopkins Medicine's board of trustees, to launch an institute for patient safety. The Armstrong Institute for Patient Safety and Quality will develop quality improvement methods for worldwide use that could be used to prevent medical errors.

Click here to learn more.

Scary Statistics... Unsafe Injection Practices

According to an article on the Wall Street Journal's Health Blog, unsafe injection practices continue to occur, despite education efforts to reduce risk of infections.

Laura Landro writes, "In the U.S., failure to follow safe practices in delivering intravenous medications and injections has resulted in more than 30 outbreaks of infectious disease including hepatitis C, and the notification of more than 125,000 patients about potential exposure just in the last decade, according to health-care purchasing alliance Premier Inc."

Click here to read the story.

New Edition Focuses on Reducing Errors, Improving Safety

Check out this newly released edition focused on reducing health care errors:

Error Reduction in Health Care: A Systems Approach to Improving Patient Safety, 2nd Edition
Patrice L. Spath (Editor)

Completely revised and updated, this second edition of Error Reduction in Health Care offers a step-by-step guide for implementing the recommendations of the Institute of Medicine to reduce the frequency of errors in health care services and to mitigate the impact of errors when they do occur. With contributions from noted leaders in health safety, Error Reduction in Health Care provides information on analyzing accidents and shows how systematic methods can be used to understand hazards before accidents occur. In the chapters, authors explore how to prioritize risks to accurately focus efforts in a systems redesign, including performance measures and human factors. This expanded edition covers contemporary material on innovative patient safety topics such as applying Lean principles to reduce mistakes, opportunity analysis, deductive adverse event investigation, improving safety through collaboration with patients and families, using technology for patient safety improvements, medication safety, and high reliability organizations.

Health Affairs Article: "Preventing Bloodstream Infections: A Measurable National Success Story in Quality Improvement"

This week, we'll be highlighting papers published in the new edition of Health Affairs, entitled "Still Crossing the Quality Chasm." This edition explores the question of quality as raised in the 2001 Institute of Medicine report, Crossing the Quality Chasm, and explores how far we have come since its publication... while also anticipating the road ahead.

"Preventing Bloodstream Infections: A Measurable National Success Story In Quality Improvement"
Authors: Peter J. Pronovost, Jill A. Marsteller and Christine A. Goeschel

The authors discuss the collaborative efforts undertaken to successfully reduce and end central line-associated bloodstream infections (CLABSIs) in a 45 state initiative.  This program has demonstrated continual results in reducing hospital-associated infections and deaths.

Click here to read the piece.
Click here to read about the team's INQRI-funded project, a nurse-led initiative to reduce CLABSIs.