Editor's Note: Barbara A. Blakeney, MS, RN, is President of the 150,000-member American Nurses Association (ANA). A nurse practitioner and expert in public health practice, policy, and primary care, Ms. Blakeney is on leave from the Boston Public Health Commission, where she has been director of health care services for the homeless. She is the recipient of numerous awards and has been named to Modern Healthcare Magazine's list of the 100 most influential people in health care for the past 3 years.

Dr. Robert Wachter, Editor, AHRQ WebM&M: From your perspective, and that of the nursing field, how are we doing in patient safety compared with 5 or 6 years ago?

Barbara Blakeney: I think we understand better today what makes patients safer. The work that Linda Aiken did and others are doing now is giving us a much better handle on what it takes to keep patients safe. We can be much more scientific in thinking about how to create a staffing pattern that improves safety.

RW: What are the dominant issues in safety from the nursing perspective?

BB: Certainly, proper staffing is a huge issue. Systems factors that keep people safe are also important. For instance, medication administration is critical. Preoperative care is crucial as well—to make sure that the operation is occurring on the right part of the body, whether it's the right knee or left. Sometimes simple things make a huge difference in ensuring that the right procedures are being done on the right patient. But a hospital can have all the best systems in the world, and if you don't have enough appropriately prepared staff to work in and run those systems, then you're not going to create a truly safe environment.

RW: As we think about why many health care organizations don't have enough and the right kinds of people, how would you rate the causes? Is it that there's not enough money, or that the culture is not one that promotes recruiting and retaining people, or that the systems are inadequate, making the jobs undoable and unpleasant. How do all those fit together?

BB: It's hard to point to one specific thing and say this is the driver. But for the nurses who are already practicing, a clear driver is how they are supported in the environment. If nurses are not properly supported and if there are not enough of them, then it becomes a catch-22—the fewer nurses you have, the more difficult is the working environment, which leads to fewer nurses. So many nurses now feel that they are not heading to the kind of future that they want. Some leave hospital-based care and try other practice settings. But all too often, nurses, especially the young nurses, will leave the profession entirely. And that's a terrible loss.

RW: What do you mean when you say "supported"?

BB: I think different nurses will view it a bit differently. Many feel that they're doing everyone else's job in addition to their own. For example, I met a nurse recently who said, "What I need is a really good nursing assistant who can do all the tasks that don't require my analytical skills, but are critical for the patient. If I don't have that nursing assistant, I am doing not only my job, but also all that work. And that means that the work is much more stressful than it needs to be." One of the issues with staffing ratios, especially the ratio system in California right now [Editor's Note: California has a law, still somewhat controversial, mandating certain nurse-to-patient ratios], is that in order to fund the nurses to meet the ratios, many hospitals have laid off or cut a lot of ancillary positions—and the nurses depend on those people. So, even though the nurses have fewer patients, they are doing much more for those patients in terms of non-clinical or non-nursing functions. When it comes time to do the measurements that show whether having enough nurses makes a difference in patient outcomes, my concern is that we may not see that in California because the nurses are doing much more for fewer patients.

RW: What can make these changes happen? Is it regulation, creating a business case, more advocacy by the nursing community—what will compel the system to achieve appropriate nurse-to-patient ratios?

BB: The ANA supports ratios. We believe that an appropriate ratio process will make a huge difference in the recruitment and retention of nurses and in the safety and quality of patient outcomes. The question is how do you get there and how do you do ratios. We believe that there is a way to take the environment and the skill set of the nurses into account. "Safe staffing principles" (1) take into account the available support system and support staff; the geographic layout of the unit; the technology in the unit; the admissions, discharges, and transfers into and out of the unit; and the nurses' skill set. If it's an oncology unit, how many nurses are certified as oncology specialists? How many of your nurses are new graduates? We believe that you can be much more sensitive if you use these mechanisms, as opposed to a one-number-fits-all solution, as happens with legislated ratios. But, in saying that we believe there is a better way to do it, we still believe ratios are proper. We just believe that the people who are best able to determine what each unit needs are those who are on that unit day in and day out. In providing them with a process and with a methodology by which to determine what their numbers need to be, using the same methodology from institution to institution, it empowers the nurses to determine what they need to make that unit safe.

RW: In terms of empowering nurses, what have you been hearing from your members about the concept of rapid response teams?

BB: The nurses that I have talked to have been very high on the idea of being able to call an urgent response team. We have all had experiences where we know that patients are becoming unstable and we're trying to figure out what the issue is. They haven't coded, they haven't had an arrest, but they're becoming unstable. Nurses who have actually participated in urgent response teams tell me that the outcomes for the patients have been significantly improved. I was at a magnet hospital several weeks ago and they had instituted such a team and had activated it nine times. Out of the nine activations, eight of those patients survived the experience. This anecdote suggests to me that it is making a huge difference.

RW: Could you comment on how nurses and doctors are being trained to improve safety?

BB: None of the health care disciplines have really looked at where those common themes are—how can we educate together so that we're learning the same things and becoming more aware of what we can each bring to the table for patient care. To the extent that we don't have a full appreciation of each other's skill sets and knowledge base, we don't adequately and effectively use each others' skills. I have seen this repeatedly. We also need to think about the handoffs. We hand off patients and information from one discipline to another, and everything that we know from other safety fields tells us that the handoff situations create real opportunities for error. Finally, we need a culture in which safety is considered a problem-solving situation and not a punishment situation. That's not to say that when clinicians act incompetently it doesn't to be addressed. We cannot hide incompetent practice behind the idea of systems, but we must recognize that systems play a huge role in preventing mistakes. The tighter the system is, and the more we all look at it from an interdisciplinary perspective, the more that system will help prevent errors from occurring.

RW: As you think about nursing and safety 5 years from now, where do you think we are heading?

BB: Well, I have to be hopeful; I think that we can make a difference. I think that the current research could offer huge benefits. But I also think that if this research were being conducted in any other field—transportation, agriculture, mechanical engineering, you name it—the research would have started to make a difference already. People would have changed their approach in order to accomplish it. It is a continuing puzzle that health care does not respond to economic and research indicators the same way the rest of the country does. Some of that is clearly understandable from an economic perspective and from a human behavior perspective, and some of it is not. So when Linda Aiken talks about it [nursing's patient safety agenda being unfinished], I agree with her wholeheartedly and it's frustrating.

RW: I noticed that, when you gave examples of other fields that have translated safety research into practice, you didn't mention other medical fields. Would you say that there seems to be differential acceptance of the research in nursing vs. other medical areas?

BB: The medical area seems to get more attention more quickly. However, I think this issue pervades all of health care—this stagnation. For example, the ANA has kicked off a major program in ergonomics, and I have had ergonomics people say to me that they are amazed that our industry is so far behind the curve on these issues, given the present research and knowledge. They tell me that in other industries—car manufacturers, people who lift heavy items and move things—those issues were addressed long ago. The experts stand there, scratching their heads, wondering what in the world is wrong with the health care industry that we haven't done that.

Reference

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1. Gallagher RM, Kany KA, Rowell PA, Peterson C. ANA's nurse staffing principles. Am J Nurs. 1999;99:50, 52-53. [ go to PubMed ]