Studies linking low patient satisfaction scores and high frequency of hospital-acquired infections with overburdened nurses are getting lots of media attention-not to mention attention of administration-but one researcher always found a “missing link” in these stories.
“There’s so much data on nurse to patient ratios and hours worked but it simply being overworked doesn’t seem to tell the whole story,” said Jeannie Cimiotti, DNSc, RN, executive director of New Jersey Collaborating Center for Nursing and associate professor at Rutgers University School of Nursing. “What is it about nurse staffing that can promote infection?”
Quantifying Nurse Engagement
Cimiotti’s “burning question “about the connection between overscheduled nurses and increasing infections led her to Christine Maslock’s theory of burnout and found the culprit.
“The burnout theory just fit,” she explained. “People in Professions with constant public contact with the public (firefighters, police offers, nurses) become burned out and cognitively detach. If a nurse suffers a high level of burnout and detaches, things start to go wrong. Maybe they don’t adhere to hand hygiene or the device stays in a little longer than it should.”
The scenario Cimiotti described is only too familiar to experienced nurses. Chaos is breaking out on the unit and the nurse pulled in 1,000 different directions. Maybe one patient bonded with the nurse and requests only her care repeatedly.
When detachment sets in, Cimiotti described, it seems easier to leave the catheter in the patient rather than removing it, changing sheets and putting pads on the bed. Though they have the knowledge that removing the catheter is the most important step to prevention infection, the stress of the job has caused the nurse to emotionally pull away from the environment and take the easy route.
Comparing catheter-associated urinary tract infection (CAUTI) rates with nurses’ patient loads (5.7 patients on average), Cimiotti and researchers from the University of Pennsylvania School of Nursing found that for each additional patient assigned to a nurse, there was roughly one additional infection per 1,000 patients (or 1,351 additional infections per year, calculated across the survey population).
Additionally, each 10% increase in a hospital’s high-burnout nurses corresponded with nearly one additional CAUTI and two additional SSIs per 1,000 patients annually (average rate of CAUTIs across hospitals was nine per 1,000 patients; for SSIs it was five per 1,000 patients).
Researchers focused on CAUTIs because these infections can occur on any floor.
From a financial standpoint, Cimiotti estimated a savings of $41 million and 4,100 CAUTIs in Pennsylvania alone if nurse burnout could be eradicated.
Targeting Shift Length
Post-doctoral fellow Amy Witkoski-Stimpfel, PhD, RN, tackled nurse burnout via another quality indicator in her research.
Though the University of Pennsylvania School of Nursing scholar suspected a connection, Witkoski Stimpfel’s study of 22,000 nurses in California, Pennsylvania, New Jersey and Florida revealed lower patient satisfaction when nurses were working shifts of 13 hours or more.
Patient satisfaction decreased 1% with every 10% increase in the nurse’s shift length.
“The trend in scheduling is 12 to 13-hour shifts but, where there were higher proportions of shorter shifts, patients were more satisfied,” noted Witkoski Stimpfel.
Hospital administrators have shown a great deal of interest in her findings, but find themselves at a quandary, she said.
“They know nurses want to work 12-hour shifts and most facilities accommodate that,” she said. “I do get the sense hospitals are concerned about the safety aspect but everybody’s fearful of changing the shift length because nurses might leave. It’s a fine balance.”
Witkoski Stimpfel said reducing overtime might be an effective compromise or at least a starting point. Furthermore, the literature supports 4 to 6-hour shifts as it offers flexibility for nurses with family responsibilities.
“With a short shift, nurses can deal with admission and discharges while still going to lunch and taking a break,” she said. “Even combining 8- and 12-hour shifts is a good idea because the nurse isn’t consistently working 12 hours”
Not only are patients less satisfied, but many nurses logging long hours at the hospital are reporting intent to leave their employer within the year. Witkoski Stimpfel said nurses working 10 hours or more are 55% more likely to report wanting to seek new opportunities.
Low Cost Solutions
While abolishing nurse burnout altogether probably isn’t realistic, Cimiotti said there is a solution. And it’s easier and cheaper than recruiting more nurses.
“A lot of research shows that, even if staffing isn’t optimal, nurses don’t become burned out if there’s a healthy work environment,” she said. “This can cost almost nothing. Nurse salaries are a huge part of the hospital budget.”
Cimiotti likened the healthy work environments to the principles of Magnet. She noted that the hospitals don’t necessarily have to undertake a Magnet initiative but incorporating some of the practices like approachable management and a visible CEO can have economic ramifications.
“One of my former employers opened the auditorium for a luncheon every June between nurses and residents,” Cimiotti recalled. “There’s always a divide between nurses and residents but we remembered breaking bread together and sought each other out on the floor. Something like this just takes some administrative direction but makes nurses comfortable calling doctors.”
is a contributing editor at ADVANCE.