When an article on the Bates study was published in The New England Journal of Medicine in January 2023, it spurred an outcry from the healthcare community over the high rate of reported adverse events. Despite decades of focus on patient safety, 13 industry experts concluded that the healthcare industry had not “produced the improvement we need,” and called for the industry to “rethink and reinvest in patient safety,” largely citing workforce issues, process changes, greater use of technology, and other solutions.
The Bates study identified, in a random sample of 2,809 admissions, at least one adverse event (AE) in 23.6% for a total of 978 instances. Among these 978 AEs, 222 (22.7%) were considered preventable, and 316 (32.3%) had a severity level considered serious. In response, Don Berwick, MD, MPP, FRCP, best known as the father of the “Triple Aim,” penned an editorial calling for “constancy of purpose for improving patient safety,” which he characterized as “missing in action.”
While all valid arguments, the voice of nursing was conspicuously absent from these discussions, even as 49-53% of medical errors in hospitals today involve newly graduated registered nurses (RNs) with <1 year of experience in patient care (patient falls, medication errors, and failure-to-rescue incidents being the most commonly documented). Wolters Kluwer Chief Nurse Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, gives her take on what's broken, why nursing is front and center on the challenges - and is essential to finding solutions - and how healthcare organizations can remedy a lot of their safety issues by improving support at the bedside and in the community.
Getting real on the experience-complexity gap
Woods believes that a very “real” patient safety issue today relates to an unprecedented number of newly graduated nurses at the bedside, largely due to the wave of retiring experienced nurses and junior nurses leaving to pursue roles in non-acute, primary care settings. A 2022 nursing workforce analysis found that the total supply of RNs decreased by more than 100,000 from 2020-2021, the largest drop in the past 4 decades.
This leaves an “experience-complexity gap,” with too few experienced nurses to supervise and support the incoming new ones. “We have to look at who is at the bedside right now,” says Woods, noting that the majority of today's novice bedside nurses aren't practice-ready upon graduation. “We know from research that they aren't practice-ready, and we can't let them flounder on their own,” she states, adding that healthcare systems need to ensure fresh hires have sufficient new nurse training and access to preceptors both to support career development and to protect patients.
Woods opines that much of what today's novice nurse lacks is clinical judgment, which is the ability to “recognize an issue, question it, and know what to do when an issue is discovered so an error doesn't occur.” She says at least some of the onus to improve clinical judgment skills falls on nursing schools, including providing more live and simulated practice opportunities. She advises that, once hired, the new hire orientation should not be “a quick training session before you put them on the floor.” Rather, new nurses should have at least 6 months to a year in a residency program. Upon completion, they should be assigned to an experienced nurse preceptor whom they can reach out to when they need help.
The role of the 'virtual resource nurse'
Woods believes the role of nurse preceptors has never been more critical and can be facilitated through live and virtual resources. Because of the experience-complexity gap, she emphasizes, “We need to pair new nurses with experienced nurses who can coach and mentor them based on their years of experience. All hospitals need to invest in this type of role.”
In addition to having an experienced nurse on the floor, Woods says healthcare organizations are also exploring “virtual resource nurses” who are only a video phone call away. In a virtual scenario, if a new nurse is in a patient's room and has a question, this could be as simple as hitting a call button and connecting with a virtual nurse in real time. “The virtual nurse has a view into the patient's room through a camera and audio,” Woods explains. “They can see what's going on, view the patient, and instruct the new nurse in the room on what to do to prevent an issue or address a pressing issue that is currently happening. A lot of hospitals are already trying this.”
“We need to look at team-based models,” says Woods, “to make sure we have enough experienced nurses overseeing the new ones.” As well, other support resources such as nursing assistants are crucial to success.
Investing in a safety culture
Woods adds that it is incumbent on healthcare system leaders to “invest in a safety culture.” This includes addressing staffing levels, burnout, and providing a safe environment to speak up on safety issues. “Make sure your staffing is not just based on the numbers but also patient acuity, as well as the competency and experience of the nurses caring for the patient,” she emphasizes. “When nurses bring up issues, listen instead of blaming or saying it's the organization's fault.”
Woods also urges leaders to “recognize you are in the business of caring for the community,” meaning that care doesn't stop when a patient is released from the hospital. This includes addressing social determinants of health to ensure patients have access to food, shelter, and transportation for follow-up healthcare visits.
“You want to prevent patients from being caught in a crisis by focusing on health with optimum wellness and chronic disease management,” Woods explains, “which reduces the number of times patients sling-shot back into an acute care setting,” driving up costs and impacting patient safety. Ultimately, “It's about being accountable. You can't provide skilled nurses if you don't have the right resources in place. Our healthcare organizations need to step up and ensure they supply adequate competent nurses and resources so care can be provided safely,” she concludes.
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