Most hospitals fail to improve their workplaces, harming patient care

Only 21% of 535 hospitals analyzed improved their work environment scores by more than 10% and 7% of providers' scores declined, according to data spanning 2005 to 2016 in the Health Affairs study released Monday. The hospitals represent about a quarter of the nation's discharges.

Where work environments deteriorated, fewer nurses (-19%) gave a favorable grade on patient safety.

"It is very surprising given all the research and hundreds of studies have come out that there hasn't been more attention on nurses' working environment," said Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania and the study's lead author. Despite millions of dollars that have been thrown at the problem, "patient safety is improving at a very slow rate," she said.

The report builds on the Institute of Medicine's 2003 study that found that having the appropriate number of nurses and operational infrastructure to respond quickly to patients improved outcomes. IOM's 1999 report, "To Err is Human," put a national spotlight on the issue when it reported that as many as 98,000 people die in hospitals every year due to preventable medical errors.

The institute demonstrated that hospitals can't prevent patient harm unless they change the underlying working conditions related to spending time at the bedside rather than tracking down supplies or mitigating staff shortages, Aiken said. It's disappointing that more progress hasn't been made, she said.

Aiken cited a related study she co-authored that found patients receiving in-hospital resuscitation in facilities with poor nurse work environments have 22% lower survival rates than patients in those with good environments. Each additional patient added to nurses' workloads is associated with 4% lower survival after in-hospital resuscitation.

"Hospital administrators may underestimate the value of a good work environment," Aiken said. "Making organizational change sounds like a soft thing compared to a 'magic bullet' like buying a new piece of equipment, but there is so much evidence now that it is essential."

Contrary to the rhetoric of healthcare executives, patient safety is not paramount, Aiken and her cohorts' research shows. Roughly 1 in 5 nurses surveyed said that the actions of management showed that patient safety is not a top priority.

Half of the RNs agreed that "staff feel like their mistakes are held against them," while roughly 4 in 10 agreed that "important information is lost during shift changes" and that "things fall between the cracks." More than one-third of the RNs reported that "staff do not feel free to question authority."

These factors contributed to 81% of RNs rating their work environment less than excellent. Twenty-seven percent reported that a large part of their last shift had been spent on workarounds to solve operational failures such as broken or missing equipment and supplies. Thirty-one percent reported spending a large part of their last shift on non-nursing tasks. Nearly 7 in 10 nurses were less than very satisfied with their job, and 31% were on their way to burning out.

The Institute of Medicine made a handful of recommendations to improve care environments: creating governing boards that focus on safety, leadership and evidence-based management structures and processes; effective nursing leadership; adequate nurse staffing; organizational support for ongoing learning and improved decisionmaking; mechanisms that promote inter-professional collaboration; and work design that promotes safety.

This requires building a culture of openness, mutual trust and respect between management and clinicians and making ongoing improvements. But administrators often do not involve front-line caregivers in operational adjustments, Aiken said. Also, the chaotic and fragmented nature of healthcare coupled with nurses' fear of condemnation do not allow organizations to learn from their mistakes, she said.

In 2015 to 2016, 60% of the registered nurses surveyed reported that the quality of care in their hospitals was less than excellent and 55% would not definitely recommend their hospital to a family member or friend in need of care, the study showed. Nearly 30% of the RNs graded their hospitals unfavorably on patient safety and infection prevention.

Thirty-two percent of patients gave their hospital an unfavorable rating, and 30% would not definitely recommend their hospital to family and friends in need of care. Slightly less than 1 in 4 patients indicated that nurses did not always communicate well with them, while nearly 40% said that they did not always receive help quickly from hospital staff and that staff did not always explain medicines before giving them. More than 30% of patients who required medication for pain indicated that their pain was not always well-controlled.

"Hospitals tend to be bureaucratic, hierarchical organizations," Aiken said. "Management make decisions, but doctors and nurses don't have too much say although they often know what isn't working and how best to fix it."

Outside of increasing clinician engagement, some policy changes could help, she said. CMS' Hospital Compare tool should include facilities' nurse-to-patient staffing ratios and a measure of the hospital work environment, Aiken said.

There are enough nurses coming into the pipeline to adequately staff hospitals, with the exception of some rural areas, said Aiken, noting about 160,000 new nurses enter the workforce every year compared to about 70,000 15 years ago.

"It's almost entirely related to having too few budget positions for nurses or having a poor work environment, so no one will stay at the hospital," she said.