1. Freda, Margaret Comerford EdD, RN, CHES, FAAN, EDITOR

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In the last issue of MCN, my editorial ("Hospitals are Nursing Institutions") described how nursing research has now demonstrated the absolute value of nursing care to the health of hospitalized patients, and how this means that hospitals must be reorganized into places where Nursing (with a capital "N") is nurtured. Is this a Pollyanna pipe dream on my part? Not at all. If you need proof that change is upon us, just look to the Institute of Medicine (IOM). This prestigious body studies the most important issues in healthcare. Its reports are not just documents to be shelved; its reports are described in all the major newspapers, and are actually acted upon by policy makers.


Now the IOM has issued a report (November, 2003) titled "Keeping Patients Safe: Transforming the Work Environment of Nurses" ( You should read the whole report, for it is groundbreaking. The report is based on a belief that nurses, who constitute 54% of all healthcare providers, are the professionals who interact most often with patients, and their actions are directly related to better patient outcomes. Cited studies show that increased infections, pneumonia, bleeding, cardiac problems, and respiratory failure are associated with inadequate numbers of nurses. The report states that it is nurses who are the defenders against medical errors. It cites one study where nurses intercepted 86% of medication errors before the errors reached patients. This report states that "the work environment of nurses, the largest segment of the nation's health care work force, needs to be substantially transformed to better protect patients from health care errors..."


Have you read the new Institute of Medicine's report on nursing?


It first describes how hospitals tried to respond to financial pressures in the 1980s and 1990s by reducing the number of nurses and reorganizing to eliminate departments of nursing. The result was that initiatives in work flow and patient care occurred with no nursing input, emphasizing efficiency over patient safety, and resulting in loss of trust in hospital administrations by nurses (Decker, 2001).


The report calls for widespread changes, suggesting that hospitals must refocus completely on patient safety, and in doing so they must solicit staff nursing input in every aspect of the refocusing effort. It also calls for many new strategies to strengthen nursing work environments, such as changing how nurse staffing levels are established, and eliminating mandatory overtime.


Here is a very short summary of several recommendations within the IOM report on nursing workforce environment: (1) Nurse leaders must be visible at all levels of management in healthcare organizations (HCO) and participate in executive decisions. Hospital boards need to be educated about the vital role played by nurses, as do policy makers at all levels of government. (2) Hospitals should involve direct care staff nurses in setting appropriate unit staffing levels, identifying causes of nursing staff turnover, and developing methods to improve nurse retention. (3) Hospital report cards should be issued to the public which describe nursing staff levels. (4) HCOs should dedicate budget resources equal to a percentage of the nursing payroll to support nursing staff in ongoing knowledge development. (5) HCOs should ensure that each staff nurse has an annual individualized plan and resources for educational development. (6) HCOs should foster interdisciplinary collaboration by adopting interdisciplinary rounds and formal training and education. (7) Mandatory overtime for nurses should be prohibited. (8) Schools of nursing should educate nurses about the threat to patient safety caused by nurse fatigue. (9) HCOs should provide nursing leadership with resources to enable them to design a nursing work environment to reduce errors, especially errors associated with patient transfers and handoffs, and nonnursing activities such as locating supplies and completing redundant documentation. (10) Regulators, healthcare leaders, and experts in nursing, law, informatics, and other related disciplines must unite to identify strategies to eliminate the burden of excessive documentation.


Download the IOM report and be sure that your hospital administration sees it. The time to change the nursing workforce environment is now.