Nurses deliver great care despite burdens

A ground-breaking study into nurse workloads in NSW public hospital medical and surgical wards reveals a multitude of factors that have greatly increased the work burden on hospital wards.

The study, called ‘Glueing it together: nurses, their work environment and patient safety’, was conducted by a research team at the University of Technology, Sydney. It was commissioned with great fanfare by Morris Iemma in 2003 when he was Minister for Health and analyses data between 2001 and early 2006.

It paints a portrait of a complex workplace environment for nurses with a high level of variability across nursing units producing a demanding and unpredictable workplace. In the words of the authors, ‘there is no typical ward.’

The study focussed on specific wards rather than overall hospital data, recognising that the nursing ward/unit is ‘the operational and business unit of the hospital.’

The report says the importance of nursing leadership at the ward level to job satisfaction, satisfaction with nursing and intention to leave, which ultimately impact on patient safety, cannot be overstated.

Pressure mounts in the ward

The study recognised there had been extra resources added to the NSW Health system but found these were primarily ENs, TENs and AiNs rather than RNs and this increase had not been uniform across all types of hospitals.

The report says there are various contributing factors that are increasing the pressure on nurses.

The average number of different case types per ward (DRGs), while starting at a high level in 2001, had increased by 2005.

‘This means nurses who work on medical and surgical units must understand the care requirements, the pharmacology, the treatments, the protocols and preferences of specialist medical staff for an increasingly various patient assignment,’ says the report.

‘Churn’ or the movement of patients on and off nursing wards is a significant but poorly recognised factor in increasing the work burden for nurses.

Nurses must be involved in these movements, especially when a patient is frail, a fall risk, suicidal, an absconding risk, on high-dose chemotherapy or oxygen, agitated or bleeding. Accompanying a patient to another ward or service may take a nurse away from his/her assignment of patients or tasks for an unknown period of time, the study reports.

The report found patient acuity had increased over time in principal referral hospitals. This increase was particularly prevalent on medical and surgical wards.

Shorter hospital lengths of stay had concentrated the need for nursing into shorter and shorter time periods, with a given amount of patient care delivered in a shorter period of time. This tested the resources of regional hospitals, in particular, where there was a decrease in nursing hours per patient.

Excellent care despite the pressures

The study finds nurses believe they are giving a high standard of care despite these intense and increasing pressures, and contrary to public perceptions generated by the media about the standards of care in our hospitals.

Most of the nurse respondents described the quality of nursing care on their last shift as excellent (25.8%) or good (57.1%), while only 17% regarded the standard of nursing care as fair or poor on that shift. 78% indicated the quality of patient care given on their wards had improved or remained the same over the past 12 months.

Nurses did report a frustration at their difficulty in delivering more personal care. There was a lack of time for a range of comfort measures such as talking with patients, back rubs and skin care, oral hygiene, turning patients, documentation and the taking of vital signs.

More than one-third (39.5%) of nurses reported they were unable to comfort and talk to their patients on the most recent shift, the report says.

More RNs improve patient care

The report provides ample evidence that an increase in the number of RNs would greatly improve patient care.

A skill mix with a higher proportion of RNs produced significantly decreased rates of nursing sensitive, negative clinical outcomes.

An extra RN would reduce the incidence of decubitus ulcers by 20 per 1000 patients, pneumonia by 16 per 100 patients and sepsis by 8 per 1000 patients.

A proportional increase in RN hours is associated with statistically significant decreases in decubiti, GI bleeding, physiological/metabolic derangement, pulmonary failure, sepsis and shock and failure to rescue.

Patients were less likely to fall and suffer injury as RN hours increased.

The presence of a nurse educator on the ward and an increased proportion of nurses working on their ‘usual’ ward were associated with fewer medication errors.

The study found violence, or the threat of violence, was widespread and had consequences that flowed on to patients.

Patients were more likely to experience a medication error where nurses experienced threats of violence.

The government has announced it will establish an advisory committee to consider the report’s findings.

Key findings

  • The quality of the working environment for nurses is emerging as an important factor for patient and nurse safety.
  • Patient acuity has risen.
  • There is considerable movement of patients on and off wards. This ‘churn’ increases the work burden for nurses.
  • On average, approximately one hour per day of additional care above that actually provided is required to meet each patient’s needs.
  • Skill mix is more critical to patient outcomes than hours of nursing provided.
  • The work environment, including nurse leadership, the presence of a nurse educator on the ward, adequate resources, nurse autonomy and nurses’ control over their own work practice are important for providing safe patient care.
  • Stability of the ward staffing improves patient outcomes.

The full report can be downloaded at www.health.nsw.gov.au/pubs/2007/nwr_report.html