A hospital administration's approach to organizing its nursing staff can save lives.
That's the conclusion of a University of Pennsylvania study measuring the effects of nursing autonomy, control and status on the Medicare mortality rates of 234 hospitals.
The study revisited a group of 39 hospitals singled out in previous studies as "magnets" for nurses-
institutions that attract nurses because they're good places to work.
The original purpose of identifying these magnet hospitals was to address the nursing shortages of the 1980s by studying facilities with low rates of turnover and vacancy, said Linda H. Aiken, lead researcher on the study, and professor of nursing and sociology at the university.
The hospitals weren't selected for their nursing organization, but subsequent study determined they shared characteristics that distinguished them from most hospitals, Ms. Aiken said.
Still unresolved was whether those characteristics had any bearing on the final outcome of patient care. The university study sought to compare the magnet hospitals with 195 other hospitals matched in all respects except for their organization of nursing.
After stripping the comparison of other variables that could influence the outcome, researchers found the magnet hospitals had five fewer deaths per 1,000 Medicare discharges. The study was published in the August issue of the journal Medical Care.
Staffing issues.The results show that nurse staffing isn't just a numbers game, Ms. Aiken said. Hospitals pay a lot of attention to staff issues, but the attention is centered on staffing levels and ratios of registered nurses to nonlicensed caregivers-not on how the staff can make best use of its expertise.
"The vast majority of hospitals are not optimally organized to provide patient care," she said. "People argue that it's only a matter of how many nurses there are, and that's not the case."
Among the study's findings was that the magnet hospitals had a significantly higher ratio of registered nurses to total nursing personnel and a nurse-to-patient ratio slightly higher than the comparison group. But while those facts underscored the commitment to patient care of the magnet hospitals, they didn't explain the difference in mortality, Ms. Aiken said.
That doesn't mean registered nurse staffing levels aren't important, she added-the industry can't cut back beyond a generally recognized "floor" of registered nurse mobilization on the hospital unit. But the current variation of staffing levels above that minimum doesn't have much influence on patient outcomes, she said.
Organizational factors.According to the study's conclusions, the difference in outcomes rests in the ability of nurses to make on-the-spot decisions and control medical resources without going through layers of superiors or adhering to rigid decisionmaking rules.
A healthy dose of nurse autonomy allows the caregivers closest to the situation to act on their evaluation of the patient's condition and sudden changes that call for quick action, Ms. Aiken said.
If nurses have to get clearances in too many instances, they'll be constrained from doing what they're trained to do. And if they're not expected to act on their own, they'll not only be uncomfortable with making timely decisions but also won't feel accountable for the outcome, she said. That's not a situation conducive to good care, "especially with very sick people where you don't have a lot of time," Ms. Aiken said.
A hospital influences this autonomy not only in the way it organizes a patient-care hierarchy but in the support it gives nurses for decisions made against the grain. Those decisions include judgments on whether a patient is ready for discharge as well as clinical decisions tempered by business considerations and demands of utilization reviewers, she said.
The study found that in the hospitals assembled for comparison with magnet hospitals, "individual autonomy is not held in as high regard," Ms. Aiken said.
Control of resources and the patient's environment also can affect care. For example, she said, a nurse should be able to determine a patient is too frail or sick to be taken to the radiology department for an X-ray, and to order the X-ray done in the patient's room instead.
The magnet hospitals also "have well-worked-out arrangements on inter-reactions between doctors and nurses," which are important for making decisions about patients whose physicians aren't in the hospital, she said.
Finally, the culture of magnet hospitals signifies nursing as important in the overall mission, the study said. The importance is reflected in such practices as paying salaries instead of hourly wages, investing in continuing education and generating supervisory support of nurse decisionmaking.
Best use of staff.The study found that magnet hospitals not only minimize supervisor levels and maximize autonomy, but they allow nursing units to make decisions on the use of staff and the minimum credentials of nurses rather than imposing staffing ratios or other constraints.
One result of that latitude is an organization of clinical responsibility at the unit level to promote accountability and continuity of care, which also means fewer nurses "floating" among units to equalize staffing, the study said.
Another finding is that nurse decisionmakers limit the proportion of new nursing graduates in a unit, recognizing the role of a certain level of experience on a unit's ability to act and react to sudden changes in patient conditions, Ms. Aiken said.
The study suggests that reductions in mortality are within reach for hospitals that attend to their nursing organization, and that hospitals don't have to be large and well-heeled to afford it.
"There is considerable variability among magnet hospitals in hospital size, teaching status, ownership and financial status, all of which suggests that replication (of the study's results on mortality) is not bound by hospital type," the study said.