1. Redman, Richard W. PhD

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On May 11, 2006, the research and health policy communities recognized the long-standing contributions to quality and patient safety made by one of their own: Ada Sue Hinshaw, PhD, FAAN. A symposium was held in Ann Arbor, MI, to recognize the substantial impact that Dr. Hinshaw has made to both the research and health policy agendas, both in the United States and internationally. This symposium was held in conjunction with her completion of 14 years as dean of the School of Nursing at the University of Michigan. Papers from leaders in nursing, health services research, and health policy were presented. It was a fitting way to celebrate this transition in her career. Also addressed in the symposium were critical issues in nursing knowledge development and the nursing shortage as they relate to patient safety. The leaders and their various perspectives are evident in the symposium program provided in Figure 1.

Figure 1 - Click to enlarge in new windowFIGURE 1. Leadership seminar honoring Dr. Ada Sue Hinshaw.

Dr. Hinshaw is best known for serving as the first director of what was then the National Center of Nursing Research at the National Institutes of Health. It was her productive research career that led to her appointment at the National Institutes of Health. Prior to that appointment, she had conducted numerous research projects addressing professional nurses who function in bureaucracies-their job satisfaction, job stress, and anticipated turnover. Before it was in the mind of most, she addressed the impact of these types of variables on quality of care and patient outcomes. She was also well established as an expert in measurement, developing and testing instruments used to assess patient satisfaction, job satisfaction of nurses, and anticipated turnover of nursing staff. Many of these instruments are used today in research addressing quality and work environments.


In addition to her research career, Dr. Hinshaw has been involved in a number of health policy initiatives. Foremost among these is her work with the Institute of Medicine (IOM). In addition to serving as a member of the IOM Governing Council, she served on IOM committees such as the Work Environment for Nurses and Patient Safety, on which she served as vice-chair, and the Nursing Research Panel of the Committee of Monitoring the Changing Needs for Biomedical and Behavioral Research Personnel. The Committee on Work Environment for Nurses and Patient Safety produced Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004), which provided the context for the leadership symposium held in recognition of her research and policy contributions to the improvement of quality in healthcare. Although the committee did not address the current nursing shortage in the United States, it examined in-depth the implications of that shortage on current work environments. It is this framework that has transformed the understanding of factors in the work environment of nurses that have an effect on patient safety.


When considering ways to improve patient safety, the issue of cost always arises. Using existing data from nonfederal acute care hospitals, researchers conducted simulations to examine the cost and quality implications when hospital nurse staffing is increased. Various approaches to increasing nurse staffing were employed, including raising the proportion of nursing hours provided by RNs and increasing the total number of nurses. All methods resulted in reductions of adverse patient outcomes and patient deaths as well as shortened lengths of stay. Depending on the modeling approach used, hospital costs were increased by 1.5% or less (Needleman, Buerhaus, Steward, Zelevinsky, & Mattke, 2006). However, reduction in adverse outcomes in the long run would likely reduce total costs to the overall system when current fixed payment systems and litigation are considered. It forces the question of examining the relationship of nursing care and patient safety within the context of cost. These data demonstrate the relationship of nursing hours to patient safety and the payoff in cost savings.


The nursing shortage and implications for healthcare in the United States have received extensive attention in the last decade. A recent examination of the workforce issues indicates that, although some improvements have been made, the shortage remains a critical issue for the long-term future (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2006). Important research on the impact of nurse staffing and quality-of-care outcomes has been conducted, such as increased mortality or increased occurrences of adverse events in hospital patients (Aiken, Clarke, Sloan, Sochalski, & Silber, 2002; Mark, Harless, McCue, & Xu, 2004; Tourangeau et al., 2006). Researchers have also examined the relationship between nurse staffing levels and error rates (e.g., medication errors; Blegen, Goode, & Reed, 1998; Carlton & Blegen, 2006). The numbers of nurses available and the hours they contribute to patient care without question are related to the incidence of errors and adverse outcomes.


The examination of the number of nurses available and the hours of care they can provide are only part of the equation, however. Unless changes in the work environment are designed and implemented, nurses will not be enabled to provide high-quality patient care. For example, the increased workload and stress faced by nurses when hospitals operate at or over capacity have been shown to add a 28% increase in the rate of adverse events (Weissman et al., 2007). Part of the shortage issues faced in hospitals is due to the reluctance of nurses to spend their careers in hospitals where work environments are stressful and dissatisfying, resulting in increased error rates and turnover rates among nurses (Curtin, 2003).


Initiatives such as "Transforming the Hospital Work Environment," currently underway by the Robert Wood Johnson Foundation (Hassmiller & Cozine, 2006), address the other part of the equation for patient safety, that of the work environment. It is the intersection of work environments and the nursing shortage where the critical nexus for addressing patient safety occurs. The IOM study panel, cochaired by Dr. Hinshaw, provided one landmark in identifying the essential contributions of work environment and organizational culture to the potential increased errors and the occurrence of adverse patient outcomes. Once again, in the symposium held in recognition of her contributions, Dr. Hinshaw has been at the forefront of this discussion. Her keynote paper uses the metaphor of a perfect storm to focus on the interaction effect of workforce shortages and organizational cultures and their combined effects on patient safety.


The papers and perspectives presented at this conference hold potential for being viewed as another landmark for the improvement of patient safety in the future. Through examination of these issues, from the perspectives of both practice environments and the health policy arena, insights to the critical issues are improved. As further research is conducted to refine understanding, and interventions are developed to improve the quality of patient care environments, the safety of patient care and the health of those who entrust us with their care can be expected to improve. Once again, Dr. Hinshaw can be thanked for pulling these issues to the forefront of both knowledge development and the delivery of patient care services.




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