The modern patient safety movement was founded more than two decades ago. While significant progress has been made in improving patient safety since then, the risk of patient harm due to errors and other adverse events during medical care remains a serious concern. According to estimates from the World Health Organization (WHO), roughly 10% of patients worldwide are harmed while receiving care as a result of such events, with nearly half of those events considered preventable. In the United States alone, more than 250,000 patients experience an adverse event each year. In addition to their impact on patient health and well-being, these events exact a tremendous financial toll, costing health care systems billions of dollars each year. A nurse’s role in patient safety cannot be overstated. Nurses spend considerable time with patients — more than any other health care professionals — and bear numerous responsibilities that, when executed effectively, help ensure patient safety. A host of factors, like staffing and shift length, can undermine a nurse’s ability to prevent adverse events and keep patients safe from harm. Nurse leaders can manage these factors to create a positive work environment and put their staff in the best position to succeed, which ultimately benefits patients.
The Role of a Nurse in Promoting Patient Safety
Inadequate staffing and poor working conditions strain health care workers and can lead to an increase in adverse patient safety events, such as diagnostic or medication administration errors. Nurses are one of the first lines of defense against these events.
The primary role of a nurse in promoting patient safety is that of a patient advocate who is a constant presence at patients’ bedsides. Nurses also regularly interact with other medical professionals — physicians, pharmacists, radiologists, and more — putting them in the unique position of being able to influence patient safety across the entire continuum of care. Nurses have a broad range of responsibilities that have a direct bearing on patient safety. Some of these duties include:
- Monitoring a patient’s condition
- Identifying and reporting changes in a patient’s condition
- Detecting diagnostic and treatment errors
- Administering medications
Each of these is a vital aspect of nursing care. Ensuring patient safety is one of a nurse’s most important obligations, and they have a number of methods by which to fulfill it.
Ways Nurses Can Promote Patient Safety
Nurses employ many tactics designed to promote and improve patient safety. They include:
- Monitoring. Observation is a key aspect of a nurse’s role in patient safety, because they typically spend more time with patients than other health care professionals. They need to be vigilant and monitor for all manner of complications, from bedsores to infections. Additionally, technological advancements — such as medication bar code scanning and infrared thermometers — allow nurses to more effectively monitor patients.
- Communication. Nurses frequently interact with physicians and other members of the medical team and, as patient advocates, are responsible for recognizing and communicating errors and other issues. They need to possess an understanding of a patient’s condition and any medications, procedures, or treatments the patient is receiving to identify potential issues.
- Patient Education. Noncompliance with treatment plans, like medication regimens and wound care, is a common source of adverse patient safety events. As the primary point of contact for patients and their families, nurses are in an ideal position to educate patients on their conditions and how to properly treat them.
How Does Nurse Staffing Affect Patient Safety?
Adverse events during medical care — such as inaccurate or delayed diagnoses, infections, surgical errors, and medication administration errors — are among the leading causes of death and disability in the world, according to the WHO. Adverse events result in millions of deaths each year across the globe.A nurse’s ability to prevent such events often depends on their capacity to effectively observe and interact with patients. Having too many patients under their care can compromise a nurse’s ability to do this, which is why nurse staffing is a critical component of patient safety. Several factors can influence staffing decisions, such as:
- The complexity of a patient’s condition and the level of care they need
- The number of admissions, discharges, and transfers
- The skill level of staff
- The geography of the nursing unit
- The availability of technical support and other resources
- The layout of the facility
Low staffing and high admissions are a potentially dangerous combination, increasing nurse workloads and undermining their ability to provide quality care. Numerous studies have linked inadequate staffing with an increased risk of adverse patient safety events and even deaths. Conversely, proper staffing can enhance a nurse’s role in patient safety. Adequate staffing is associated with lower rates of readmission, improved treatment compliance and recovery, and reduced patient mortality. A nurse with fewer patients under their care can spend more time with each individual patient. This means more time to monitor and assess the patient’s condition, educate them on their treatment, and provide emotional support to them and their family.
One of the ways health care systems strive to ensure optimal staffing is by determining an appropriate nurse-to-patient ratio. This approach can help organizations manage nurse workloads and ensure quality of care.
Staffing ratios vary across different health care settings. In a hospital intensive care unit (ICU), for example, a ratio of two patients per nurse is typically considered ideal, while in an acute medical-surgical unit, a 5-1 ratio may be appropriate. In a nursing home, where the staff numbers are much smaller, the ratio of nurses to patients is measured by how much time a nurse spends with each patient per day. For example, in 2020, the national average was 45 minutes per day per patient, according to a study conducted by researchers at the University of California, San Francisco and UC Davis Health. As in other settings, adequate staffing in nursing homes is associated with fewer adverse patient safety events.These ratios aren’t uniform but rather based on patient need, staff skill level, and a variety of other factors. They may change on a shift-by-shift basis and often vary across state lines.
Legislation on Nurse Staffing
Some states have taken steps to address nurse staffing issues through legislation. More than a dozen states currently have laws in place that regulate staffing decisions at hospitals.
According to the American Nurses Association (ANA), state staffing laws generally fall into one of the following three approaches:
- Hospitals are required to create staffing committees driven by nurses to form staffing plans based on the needs of the patient population and the skill level of the nursing staff.
- Lawmakers mandate specific nurse-to-patient ratios.
- Facilities must disclose staffing levels to the public and/or a regulatory body.
The federal government requires hospitals that participate in Medicare to maintain "adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care" that meets the needs of all of its patients. The vague language in the law has led states to take action on their own and for nursing groups to push for stronger federal legislation. Groups like the ANA and National Nurses United support legislation that establishes minimum nursing staff levels that can be adjusted based on patient needs. California and Massachusetts are the only states that currently have such requirements in place. California requires a minimum ratio of nurses per patient to be maintained at all times by hospital unit, while Massachusetts’s mandate applies exclusively to ICUs with either a 1-1 or 1-2 nurse-to-patient ratio, depending on the condition of the patient.Additionally, both groups stress the importance of nurse involvement in staffing decisions — rather than leaving it up to executives and hospital administrators — as nurses best understand the importance of individualized patient care.
The Impact of Nurse Working Conditions on Patient Safety
The effectiveness of a nurse’s role in patient safety often depends on the quality of their work environment. Nursing can be a high-stress profession, and having optimal working conditions is essential to ensure patient safety. A subpar work environment may compromise a nurse’s ability to care for patients and prevent errors and other adverse events, whereas a favorable environment can positively impact patient safety. A 2018 report from the journal Health Affairs showed that hospitals that improved clinical care environments experienced increased positive grades on patient safety from both patients and nurses. Multiple studies have reported a similar correlation between nurse working conditions and patient safety.
Various factors influence working conditions for nurses. Interruptions, for example, are considered a routine part of nurses’ jobs but have been linked to an increased risk of all sorts of errors, particularly medication administration errors. Some of the other factors that can affect a nurse’s work environment include:
As previously noted, staffing levels can have a significant impact on a nurse’s workload. Nurses who are stretched thin due to inadequate staffing are more likely to experience stress, make mistakes, and have lower job satisfaction, which in turn impacts the quality of patient care.
Longer shifts and overtime can lead to nurse fatigue, a serious issue in the profession that contributes to burnout. Fatigue can cause inattentiveness and poor judgment, which often leads to adverse patient safety events. Evidence suggests that nurses who work multiple shifts in excess of 12.5 hours are more likely to commit medication errors. A study out of South Korea also revealed that nurses who worked less than 40 hours a week had fewer adverse patient safety events than those who worked more than 50 hours a week.
Effective leadership is considered a crucial aspect of a nurse’s role in patient safety and crafting a positive work environment. Nurse leaders are responsible for managing staffing and shift length, which naturally impact working conditions. Additionally, leadership that empowers and motivates staff can reduce burnout and help foster a culture of patient safety.
Burnout and Nurse Resilience
Burnout can stem from the aforementioned factors and, in itself, lead to adverse events during medical care. Nurses experiencing burnout are less attentive and more prone to committing errors that lead to patient safety incidents. Burnout among nurses was a concern prior to the COVID-19 pandemic, with more than 15% of all nurses reporting feelings of burnout, according to a 2019 report from PRC. During the pandemic, that number soared. The International Council of Nurses (ICN) reported that 76% of all health care workers experienced some degree of burnout at the height of the pandemic. Perhaps unsurprisingly, the ICN also reported that the U.S. nurse-to-patient ratio tripled during this time. Developing strategies to improve resilience among nurses is critical to combating burnout and improving patient safety. Health care organizations can employ various strategies to develop nurse resilience, including mindfulness interventions and ensuring staff have the proper amount of support from leadership.
How Nurses Influence Patient Outcomes
The link between patient safety and patient outcomes is clear. Patient harm as a result of adverse events is one of the leading causes of morbidity and mortality in the world, according to the WHO. Because of the enormous role nurses play in patient safety, they can also have a significant impact on patient outcomes. Nurses spend more time with patients than other health care professionals. A study published in The American Journal of Medicine estimates that nurses spend roughly a third of their shift in direct contact with patients, compared to just around 15% for physicians. This provides nurses with ample opportunity to influence care and advocate on behalf of their patients. A nurse’s ability to positively influence patient care is often dependent on their work environment. There is a clear link between the work environment of nurses and the risk of adverse events and/or adverse outcomes. When the quality of the former goes down, the latter two often rise. Numerous studies have shown that the following factors can influence patient outcomes:
- Nurse-to-patient ratio
- Shift length
Therefore, facilitating optimal working conditions for nurses benefits not only nursing staff but their patients as well.
Ample evidence also suggests that having more highly educated and well-trained nurses on staff can lead to improved patient safety and outcomes.
Role of Nurse Leaders
To craft an ideal work environment that prioritizes patient safety, nurse leaders have a responsibility to manage staffing, shift lengths, and other variables, including operational issues like equipment failures and interruptions. By improving workflows and addressing other concerns that take nurses away from direct patient care, nurse leaders can ensure staff are better positioned to focus on patient safety.
Additionally, nurse leaders and administrators need to promote a culture of patient safety. One way to do this is by empowering nursing staff to call out errors, as well as making them feel comfortable admitting their own mistakes. Fear of disciplinary action — up to and including losing their job — makes some health care workers reluctant to report issues. If they’re afraid to speak up, staff are more likely to ignore patient safety concerns, which can jeopardize patient outcomes.
Keeping Patients Safe: An Essential Nursing Duty
Preserving patient safety is one of a nurse’s foremost responsibilities. A nurse’s role in patient safety is significant and can be influenced by a number of factors, like their work environment and the level of leadership support they receive. By managing these factors, nurse leaders can promote a culture of patient safety, improving clinical outcomes in the process.
Individuals interested in learning about the role of nurses in patient safety should explore Hawai’i Pacific University’s Master of Science in Nursing (MSN) program. The program’s curriculum is built around the MSN essentials set by the American Association of Colleges of Nursing, focusing on fundamentals like quality improvement, safety, and transformational leadership. Learn more about how the program can set you on the path to a career as a nurse leader.