琳达.艾肯 是宾夕凡尼亚大学，健康效应与政策研究中心的教授及研究员。

是罗伯特。伍德.约翰逊基金会的副主席

艾肯博士和她同事一起发表了在五个国家做的护理人力资源对病人护理影响的研究发现

* Linda H. Aiken, PhD, RN, FAAN is a professor and researcher at the University of Pennsylvania's Center for Health Outcomes and Policy Research. Formerly, she was the vice president of the Robert Wood Johnson Foundation.

* Dr. Aiken and her colleagues have begun to publish findings from a five-nation study of critical issues in nurse staffing and their impact on patient care.

* These findings add to a growing body of research about the effects of staffing levels and the workplace environment on patient outcomes and staff retention.

* Staffing mandates and the Nurse Retention and Quality of Care Act of 2001, a new policy development related to magnet status, are discussed in the interview.

* Dr. Aiken offers strategies to CNO's facing the need to make immediate changes in the face of pressure for improved performance in terms of quality, retention, and financial outcomes.

LINDA H. AIKEN, PhD, RN, FAAN, is the Claire M. Fagin Leadership Professor of Nursing, professor of sociology, and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. Dr. Aiken is a research associate in Penn's Population Studies Center, a senior fellow at the Leonard Davis Institute for Health Economics, and directs the Behavioral and Social Sciences Program of Penn's Center for AIDS Research. Prior to joining the faculty of the University of Pennsylvania in 1988, she was vice president of the Robert Wood Johnson Foundation. While vice president, she designed a $100 million demonstration project to improve care for the chronically mentally ill for which she received an unusual Joint Secretarial Commendation from the Secretary of the U.S. Department of Health and Human Services and the Secretary of the U.S. Department of Housing and Urban Development.

Professor Aiken is a member of the Institute of Medicine of the National Academy of Sciences, a former president of the American Academy of Nursing, a member of the American Academy of Arts and Sciences and the National Academy of Social Insurance, and a former member of the Physician Payment Review Commission. She has been an active participant in health policy issues as a health policy researcher, as a member of national policy commissions, and as an architect of a number of national multiple site demonstrations testing new ways of organizing and financing health care.

She was educated at the University of Florida (1964, BSN Cum Laude, Nursing and 1966, MN, Nursing) and the University of Texas at Austin (1973, PhD, Sociology and Demography). She was a postdoctoral research fellow in Medical Sociology at the University of Wisconsin at Madison (1973-1974).

She was recently honored by the Sigma Theta Tau International with the Episteme Award for her groundbreaking research, particularly in the area of nurse shortage issues. This award acknowledges a major breakthrough in nursing knowledge that has resulted in a significant and recognizable benefit to the public. In addition, she was honored by the American Academy of Nursing with the 2001 Media Award and The Friends of the National Institute for Nursing Research Pathfinder Award for her work in staffing issues and patient outcomes

Study Design & Results: International Turmoil

NE: You have completed a large multi-nation study and initial findings have been released from this body of research. Can you briefly describe the original study and some of the major findings?

Aiken: The study involved a survey of over 43,000 nurses from the United States, Canada, England, Scotland, and Germany. We examined the effects of nurse staffing and work environment issues on patient outcomes and nurse satisfaction. The first published findings from this project appeared in Health Affairs (Aiken et al., 2001). Data were gathered regarding nurse perceptions of burnout, work climate, managerial support, nonnursing task workload, and patient quality of care. Four of five countries reported that 30% to 40% of nurses had higher burnout scores than other medical workers. More than 40% of nurses in the U.S. sample were dissatisfied with their jobs, and almost one in four nurses intended to leave their jobs within a year. In terms of work climate, nurses reported having positive relationships with physicians across all nations. However, nurses reported staffing as being inadequate to get nursing and other work completed. Nurses had similar concerns about the support that they felt by administration. In most nations, nurses reported a limited opportunity for professional growth and advancement. In the United States and Canada, 35% to 45% of nurses reported spending time on nonnursing tasks like food delivery, transport, and housekeeping while a similar percent reported not having adequate time to complete needed nursing care tasks. Thirty to forty percent of nurses reported that quality of care had deteriorated in the past year.

NE: It was surprising to see that wages do not appear to be a top concern or dissatisfier for nurses. Should issues related to organizational culture and

environment be a higher priority for hospital leaders?

Aiken: While wages are not the top of mind dissatisfier among nurses, they are important. Specifically, wages play an important role in vacancy rates. When wages stagnate, hospitals increase the number of nurse positions but fewer nurses are interested in taking them, creating increased vacancy rates. Nurses' top concerns relate to inadequate staffing and poor practice environments that prevent them from providing care of high quality.

Additional Findings: Achieving Patient and Nurse Outcomes

NE: The consistency of responses across nations is remarkable, especially given the differences in the health care systems in each country. Since nurses tend not to talk to one another across shifts and units, I doubt they are talking to one another across borders to arrive at such consistent answers. Have there been additional findings extending from this work?

Aiken: Indeed, what ails hospitals knows no country boundaries as we reported in the International Journal for Quality of Health Care early this year (Aiken, Clarke, & Sloane, 2002). Nurse staffing levels and the organizational environment for nursing practice are independently predictive of patient outcomes. Hospitals providing less organizational support for nursing care were more than twice as likely to have staff burnout scores greater than norms for medical personnel. Nurses in these organizations were twice as likely to perceive quality of care in their organizations as fair to poor. This work is consistent with prior work done exclusively in the United States. We found that a positive nurse practice environment led to higher satisfaction among staff and lower burnout scores as well as fewer adverse outcomes for patients. In hospitals with administrative support for nurses and where staff resources were adequate, outcomes for both patients and nurses were better.

The degree to which respondents perceived that key structures were in place and that management philosophies were operative determined the degree to which hospitals were perceived as having administrative support for nurses. These perceptions were evaluated using the following nine factors:

* Adequate support services allowing them to spend time with patients.

* Good working relationships with physicians.

* Good teamwork between nurses and physicians.

* Control over nursing practice.

* Enough time to discuss patient care problems with other nurses.

* Enough nurses to provide quality care.

* Freedom to make important work and patient care decisions. Freedom from pressure to perform tasks against their better judgment.

* Patient care assignments promoting continuity of care.

We were the first group to develop a method to empirically measure these aspects of practice across a large number of hospitals and from country to country.

NE: How did you assess the adequacy of staffing resources?

Aiken: Staffing levels were determined by the survey respondents reporting the actual number of patients for whom they had cared on their last shift. We found that even the best-staffed hospitals needed to demonstrate strong environmental characteristics, as well, in order to achieve good patient and nurse outcomes.

NE: How accurate are nurses' perceptions of patient outcome and how did you measure patient outcomes in this study?

Aiken: We did validate that nurses' assessments of the quality of care actually reflect patient outcomes. In the past, I have received calls from the media asking me to validate the claims made by nurses that the quality of patient care is declining. This study compared nurses' assessments of quality with actual patient outcomes derived from independent sources of data. Hospitals in which nurses rate quality of care as fair or poor had higher severity-adjusted mortality and higher "failure to rescue." Failure to rescue is a death of a patient developing a serious complication after admission. Failure to rescue measures appear to validly document the ability of nurses and the support mechanisms at a nurse's disposal to identify and act upon changes in a patient's condition. Nurses assessments of poor quality of hospital care are also associated with adverse events that do not result in death, such as falls with injuries and nosocomial infections, but are major sources of suffering and increased cost. In short, nurses do accurately perceive the quality of care, and appear to be able to separate their own complaints from those that impact negatively on patients.

Policy Implications: From Minimum Staffing to Magnet Designation

NE: I understand that discussions regarding minimum staffing levels are still being debated in Washington. Are these one-dimensional policies an adequate solution to such an intricate problem?

Aiken: Staffing mandates are complicated and controversial. Our research documents that inadequate nurse staffing is a major factor in nurses' decisions to leave their hospital jobs. Nurse staffing mandates have the potential to attract more nurses back to hospital practice and result in better nurse retention. However, it is not clear that staffing mandates will actually lead to better staffing. Hospitals that are currently staffing over the minimum standards could reduce staffing in response to policy changes. Additionally since the mandates are unfunded, hospitals might respond by reducing other categories of personnel essential to the support of nursing care. Research has revealed that more registered nurses result in better patient outcomes. California has recently announced a schedule for implementing minimum staffing mandates in hospitals by mid 2003. The evaluation of this experience will help us learn what these standards bring in terms of benefits as well as unintended consequences. This approach must be followed over time.

NE: Are there any other promising policy developments that could make a measurable difference in the current state of nursing?

Aiken: Senators Clinton (D-NY) and Smith (R-OR) introduced the Nurse Retention and Quality of Care Act of 2001. This legislation offers financial incentives in the form of grants to hospitals to develop and implement models of proven practice that would improve the workplace environment (NursingWorld, 2001). These models include those consistent with "magnet" designation by the American Nurses Credentialing Center, a subsidiary of the American Nurses Association.

The magnet approach remains the most proven strategy to achieve improved patient and nurse outcomes. I think the process of applying for magnet designation is a reforming process in and of itself. The act of analytically exploring the nursing structure and culture within the context of a larger organization is eye opening. Undergoing self-study, benchmarking processes, defining standards, and empowering champions to create change -- all part of the magnet application process -- seem to yield positive change whether or not magnet recognition is obtained.

Another policy vehicle with potential to improve hospital care is mandatory publication of nurse staffing ratios by hospital. Many states now require hospitals to submit staffing data. States could make these data available to the public just as some states still publish some medical care outcomes by hospital. The act of making understandable information easily accessible to the public for their use and decision making creates pressure through free market forces to improve quality.

NE: Has the LeapFrog Group caught wind of your research? Do you envision staffing ratios and magnet characteristics standing among the three existing tenets of physician computer order entry, ICU hospitalists, and survival rates for key procedures? (Note: The LeapFrog group is a coalition of Fortune 500 companies that have organized to define quality standards for use in determining employee health benefit contracts. For more information, visit www.leapfrog.org)

Aiken: I am not aware of a major focus on nursing issues by the LeapFrog Group. However, I am currently working on a grant that would examine how much of the "hospital volume effect" on outcomes is actually due to nursing care. The LeapFrog Group proposes referral patterns that favor high-volume hospitals in order to improve outcomes and reduce costs. However, the link between volume and outcomes is poorly understood. It may be that nurse staffing and organization are key features responsible for the better results in high-volume hospitals. Our study may be a good lever to interest the LeapFrog Group more directly in nursing.

NE: Hasn't your AIDS research resulted in similar findings with regard to nursing factors having a more significant impact on outcomes than a pure "volume effect"?

Aiken: Interestingly, our research on the care and outcomes for patients with AIDS revealed that patients had more positive outcomes when they were cared for on an AIDS specialty unit or when they were cared for in magnet hospitals as compared to conventionally organized hospitals treating AIDS patients on general medical units (Aiken Sloane, Lake, Sochalski, & Weber, 1999). Patients cared for in magnet hospitals, institutions with low AIDS volume, had the best outcomes, even better than those of hospitals with dedicated AIDS units. These findings formed the basis of our study on volumes. Our findings suggest that if AIDS care was regionalized to high-volume hospitals, some of the best-performing hospitals would no longer be available to AIDS patients.

Next Steps: Turning Research into Leadership

NE: This research is extremely exciting and brings several new dimensions to the issues facing nursing and health care. Other policy initiatives afoot also give a glimmer of hope. However, the reality for most CNOs is that they are being held accountable for even tighter financial performance and they do not have the human resources to meet the demand for care from their community. In addition, the prospects for filling vacancies are few, expensive, or undesirable. If you were a CNO, where would you start to turn this ship around?

Aiken: Nurses know best. This research proves what we have intuitively believed for some time. Trust your staff. Historically, re-engineering has been led by nonnurses using an industrial model that was retrofitted for health care. It has never been proven to work. I would ask my staff how we could deliver care within our budgetary constraints. They will figure it out with appropriate information, tools, guidance, and support.

In addition, nurse executives are held accountable for their labor costs, but they are not given credit for the offsets in cost that are due to the expenditure of their labor resources. Good nursing care avoids complications, which reduces length of stay and a whole host of other ancillary resources associated with caring for patients with complications for prolonged periods of time. Our research in AIDS also revealed that patients cared for in magnet hospitals had lengths of stay that were half as long as patients cared for in nonmagnet hospitals. They also had fewer ICU days and lower ancillary expenditures. In summary, nurse executives should be sure to measure and take credit for reductions in nonlabor resource use because of reductions in complications associated with nurse staffing.

NE: Nursing also appears to absorb "decentralized tasks" like phlebotomy, IV therapy, and respiratory therapy. Do you have thoughts on this common phenomenon?

Aiken: Nurses not only absorb those patient care functions, but they also absorb pure nonclinical support functions. As I mentioned before, our earlier study demonstrated that. 35% to 45% of U.S. nurses reported that they perform patient transport, meal serving, and housekeeping functions. A similar percent of nurses also reported being unable to perform basic patient care, patient teaching, and documentation.

Nurses must perform fewer nonnursing tasks. Work must be redesigned in a way to achieve this. I believe that all health professionals should be positioned to work upstream, not downstream. There are simply not enough people who want to be nurses to use them so indiscriminately in hospitals. The care delivery team must be reconstructed with a richer team of professionals (such as physical therapists, pharmacists, and respiratory therapists) and more support infrastructure rather than trying to substitute lower-level employees in clinical roles.