Speakers: Dr. Linda Aiken, Prof. Anne Marie Rafferty and Naseer Ahmad
Nursing´s impact on patient outcomes
Linda Aiken (Pennsylvania, United States)
The first question is: Why don’t proven clinical interventions have their intended outcomes? There is no direct relation between interventions and outcomes. However, it has been described that several patient outcomes are associated with Patient-to-Nurse Staffing Ratios:
- Mortality
- Failure to rescue
- Patient safety
- Sepsis and sepsis survival
- Hospital associated infections
- Falls with injuries and pressure ulcers
- Outcomes of hospital resuscitation
- Readmissions
- Length of hospital stay
- ICU utilization
- Patient satisfaction
- Nurse job satisfaction, burnout
Recent USA data show that 63% of the nurses work in a chaotic environment (Reports from RNs in 357 USA hospitals, 2021).
So, what is the problem to solve?
- Research shows that unfavorable clinician wellbeing does not “cause” poor patient outcomes.
- Poor clinical outcomes and unfavorable patient outcomes are both explained by poor nurse staffing and work environment.
- Clinicians are openly hostile to resilience training and other interventions focused on improving their adjustment to poor conditions.
And what are the implications for Practice and Research?
- A large research literature shows that effective clinical interventions are necessary but not sufficient to produce the best patient outcomes under prevailing conditions in many care settings.
- Prevailing conditions in care environments must be modified.
- Clinical practice conditions are modifiable if clinicians and researchers include labor metrics and work environment measures along with clinical metrics in quality audits to provide evidence to inform management and health policy interventions to improve patient outcomes.
Nurses as agents of care
Anne Marie Rafferty (London, United Kingdom)
The main message of the talk is that shortage of nurses should be treated as a global health emergency. It highlights the conclusions of a paper that in 2019 took the 70th Anniversary of the National Health Service (NHS) in the United Kingdom as an opportunity to reflect upon the strategic direction of nursing policy and the extent to which nurses can realise their potential as change agents in building a better future for health care (Nurses as change agents for a better future in health care: the politics of drift and dilution. Health Econ Policy Law. 2018;13(3-4):475-49). It argues that the policy trajectory set for nursing at the outset of the NHS continues to influence its strategic direction, and that the trajectory needs to be reset with the voices of nurses being more engaged in the design, as much as the delivery, of health policy. There is a growing evidence base about the benefits for patients and nurses of deploying well-educated nurses at the top of their skill set, to provide needed care for patients in adequately staffed and resourced units, as well as the value that nurses contribute to decision-making in clinical care. Yet much of this evidence is not being implemented. On the contrary, some of it is being ignored. Policy remains fragmented, driven by short-term financial constraints and underinvestment in high quality care. Nurses need to make their voices heard, and use the evidence base to change the dialogue with the public, policy makers and politicians, in order to build a better future for health care.
Studies are needed to know more about the role of professional judgement in staffing methodologies, or its contribution to decision-making, such as the one that has been made in England and Wales. The summary of findings of this study are:
- Despite national policy differences in England and Wales, the role of professional judgement in nurse staffing systems followed a common pattern.
- Two kinds of professional judgement were deployed in nurse staffing systems: the judgement of clinical nurses and the judgement of senior nurse managers.
- Nurse staffing systems comprised: an operational system (managing daily fluctuating capacity and demand) and a strategic system (establishment setting).
- Nurses’ professional judgement was central to the generation of data, its interpretation and conceptualisation.
- Healthcare organisations relied on the professional judgements of clinical nurses and senior nurse managers in making operational decisions to mitigate risk, where real-world understanding of the status of the organisation was privileged over formal data.
- Nurses expressed concerns that formal measurement systems did not capture important aspects of care quality or staff wellbeing, which made it difficult to articulate their professional judgement for the purposes of workshop planning.
Using a ‘whole systems’ approach to enable wound care to be prioritised when resources are tight. The journey of Manchester to M.A.R.S.
Naseer Ahmad (Manchester, United Kingdom)
Dr Ahmad is the Clinical Director of the Manchester Amputation Reduction Strategy (M.A.R.S.).
1000 lower limb amputations were performed annually in Greater Manchester (GM), of which half were preventable. The path to an amputation begins with an ulcer that is inadequately treated in people with diabetes, peripheral arterial disease, venous disease and lymphoedema. Programs to reduce amputations normally focus on diabetic patients, but 50% of amputations occur in non-diabetic patients.
M.A.R.S. aims to reduce major limb amputations across GM. This is achieved through the development and implementation of a commissioning strategy designed to prevent, manage, and heal chronic foot and leg ulcers faster. Existing resources are redistributed to create a single community referral pathway, a coordinated lower limb management pathway and specialist wound care teams (podo-vascular assessment and treatment, ultradistal complex surgeries, “lifestyle clinics” for prevention). The strategy is informed by a ‘whole systems analysis’ and deep dive service review to ensure population-based service transformation.
The plan is to:
- Reduce inequity in service provision and outcomes by harmonising protocols and establishing the so-called “vascular tube map” with integrated pathways between community care and hospital setting.
- Improve communication between health professionals and patients through technology and in the “same language”.
- Make patients “move more” and improve their lifestyle.
- Diagnose more, with nursing education.
In summary, the M.A.R.S. plan is based on the principle that an amputation is the culmination of a number of steps, and therefore that each phase, in the iceberg of disease leading to an amputation, requires an intervention. It is equally important to improve care and reduce costs, by both preventing and aggressively healing chronic ulcers.
