Reengineering and the Hospital Staff Nurse

Health Services Research, Dec, 1999

In the summer of 1998, a community hospital in the state of New York was put under state monitoring and came just short of being removed from participation in the Medicaid and Medicare programs. In the preceding two or so years, the staff had been trimmed through a management buyout of nursing staff followed shortly thereafter by an untimely reengineering effort. Lines of accountability changed, and workloads increased. State health inspectors in 1998 found significant problems in a number of areas, most notably with the quality of nursing care, staffing levels, and overall supervision. The state's report noted "a general and pervasive lack of direction, supervision, and accountability in nursing services, which resulted in nursing care which did not meet generally accepted standards of practice." This particular case is an extreme example of some of the nationwide changes that have happened in recent years to hospital staffing, and particularly to the pattern of nursing staffing. Because of the combined redu ction in staffing and admission of a more complex inpatient case mix, physicians and nurses have often exclaimed in recent years that "cuts go to the bone and the administrators have finally gone too far" (as in the case just outlined).

The recent changes in the role and workload of nurses have paralleled changes in healthcare delivery. Nursing opportunities have increased in settings outside of the hospital, and inpatient nursing positions have become increasingly complex (separate and apart from the evolution in the role of advanced practice nurses, a topic not covered in the articles in this issue nor in this editorial). As hospitals work to contain costs, nursing is pointed to as a high-cost item with the result that the re-engineering initiatives undertaken by many hospitals have led to further changes in the inpatient nurse's role and responsibilities. Through it all, however, what has not changed is the central role of registered nurses in the care of hospitalized patients. Consider, as an example, the critical role of nurses in the administration of medications to hospitalized patients. Errors leading to adverse drug events are most commonly due either to the ordering of medications by physicians or their administration by nursing; thus, nurses have an important role in the handling of these agents. Equally important, of the errors estimated to be due to physician ordering, half of them are intercepted-almost always by a nurse--before the patient is harmed (Leape, Bates, Cullen, et al. 1995). To inform reengineering or other reorganizational initiatives, it would be helpful to know how staffing or effort could be modified without reducing quality and to understand what nurses do and how it affects outcomes. For example, staff nurses currently spend an estimated 20 percent of their time doing paperwork (Pabst, Scherubel, and Minnick 1996), but it would be helpful to know if this is the appropriate type and level of effort relative to how the time would otherwise be spent.

The research on the determinants of nursing outcomes has often focused on registered nurse staffing levels and their relationship to improved mortality. To some extent this makes sense in that there is probably a level of staffing below which acceptable outcomes are not likely to be achieved. Above that level, it is probably useful to know about how nursing services are organized. Aiken, Smith, and Lake (1994) have contributed to our understanding of the possible role of the organization of nursing care, and its implications for professional autonomy and control, in improved hospital outcomes. Certainly, our case study highlights what can happen when these structures are removed. To more meaningfully inform reengineering and reorganizational efforts, however, it is necessary to know how the combined change in staffing levels and organizational structure gets translated into specific care activities and processes and, in turn, into outcomes.

In this issue of Health Services Research Lee, Chang, Pearson, et al. go to the heart of the matter when they identify this critical gap in the research. When advanced practice nursing studies are excluded, what do we know, based on empirical studies, about the effect of nursing care on hospitalized patients? Do nursing care processes exist that can be clearly delineated, replicated, and measured to determine the best practice in hospitals? Professional nursing has made enormous strides in the study of nursing practice through the research generated from the National Institute of Nursing Research. Now in its tenth year, the NINR has catapulted the art of nursing into the science of nursing and has done much to assist in the examination of conventional nursing care on the outcomes of patients. In doing so, much of the science has focused on clinical questions related to diagnoses such as dementia, cancer, and heart disease. In making the transition from that work to the question at hand (i.e., what does the b lack box of nursing care in hospitals hold, and what differences does it make?), Lee and colleagues have pointed out the limited peer-reviewed literature as it relates to the question of nursing practice in hospitals. The authors note, and we emphasize, that the body of literature on the effectiveness of advanced practice nurses in improving outcomes of hospitalized elderly is substantial. It is time, however, not only to address advanced practice, but also to expand our knowledge by identifying those care processes, delivered by registered nurses, that provide the best patient care outcomes. Studies do exist with data that could be extrapolated to address the question, but the logical next step is to take the research-based practice protocols and determine if they can be systematically used in practice in a sustained way. Conversely, practice approaches that are currently in use need to be examined.