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Creating the environment for nursing excellence

basic nursing care

It’s not easy to define basic nursing care in terms relevant to academia, research, and practice. Yet ensuring the delivery of basic care has never been more important. As Pipe and colleagues wrote in 2012, “As the work of nursing becomes increasingly more complex and significantly more technical…, nurses are beginning to find that the basic nursing interventions that were once the hallmark of good nursing care are being left behind.”

Articulating when basic care is not done, termed “missed” care, has advanced work in this area. In the last 6 years, studies have shown that significant amounts of care are missed in acute care hospitals. Missed care is important not just from a patient safety and quality of care perspective, but also from a business perspective. Hospital reimbursements are reduced or eliminated for acute care services when any one of a common set of complications occurs.

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What can be done? Staff and leaders must shape a safety culture through practices that show safety is a priority. We must put systems in place that engage the workforce and encourage staff to speak up and report errors, mistakes, and hazards that threaten safety—their own or their patients’. When nurses feel valued and safe, the work environment improves and patients are safer.

Implement shared governance

The shared decision-making that comes with shared governance is vital not just to patient safety but also to nursing’s future. Examples of how to engage frontline staff in shared decision-making include appointing unit-based champions for specific issues and establishing unit, departmental, and organizational practice councils, which enhance staff communication networks while increasing accountability for practice. Such engagement pays off. For example, a recently implemented CHRISTUS Health System shared governance structure for the emergency services service line led to quick triage policy standardization by staff nurses on the committee. They accomplished in record time what usually takes months.

Articulate the business case for nursing

Many researchers have made the business case for nursing through effective nurse staffing. For example, studies associate better nurse staffing with shorter stays and complications, which results in lower costs. Such results highlight why hospitals should focus on nursing care to improve clinical quality and patient safety, use research that links nursing care with clinical outcomes, and ensure nurses have time at the bedside to care for patients.

Stop wasting nurses’ time

Nurses are the primary hospital caregivers. Increasing the efficiency and effectiveness of nursing care is essential to hospital function and delivery of safe patient care. Yet evidence shows inefficiency is common in nursing practice. A 2008 study of medical-surgical nurses found they spend more time documenting (28% of their shift time) than on any other activity. How much of that documentation is really relevant to the patient’s outcome as opposed to being collected because of legal and regulatory requirements? Excessive documentation is a prime example of what’s called type I waste in lean terms: a non-value-creating activity made necessary by the way hospitals organize work.

The same study found nurses walk about an hour per shift. But variation in distance traveled was greater within a single unit than among units of very different physical layout. That’s because a major factor in how far nurses walk is how closely their patients are to each other—something easily under our control through scheduling and assignments.

Nurses in this study also classified 7% of their day as “dead waste.” If we could eliminate all of the dead waste and half of the type I waste just from walking and excessive documentation, we’d free up about one-quarter of all nursing hours. And that’s even if we do nothing about the waste in the rest of a nurse’s workday. If properly conducted, redesigning processes and work can improve worker retention.

Forging a partnership

With healthcare reform, new technology, and a solid base of evidence for the powerful influence of nursing care over patient outcomes, the time is ripe for staff nurses and nurse leaders to partner in creating a work environment that fosters solid basic nursing care.

Selected references

Aiken LH, Clarke SP, Sloane DM, et al. Nurses’ reports on hospital care in five countries. Health Aff (Millwood). 2001;20(3):43-53.

Buerhaus PI, Donelan K, DesRoches C, Hess R. Registered nurses’ perceptions of nurse staffing ratios and new hospital payment regulations. Nurs Econ. 2009;27(6):372-6.

Hendrich A, Chow MP, Skierczynski BA, Lu Z. A 36-hospital time and motion study: how do medical-surgical nurses spend their time? Perm J. 2008;12(3):25-34.
Kalisch BJ, Landstrom GL, Hindshaw AS. Missed nursing care: a concept analysis. J Adv Nurs. 2009;65(7);1509-17.

Lucian Leape Institute at the National Patient Safety Foundation. Through the Eyes of the Workforce: Creating Joy, Meaning, and Safer Health Care. 2013. Boston: National Patient Safety Foundation. www.patientcarelink.org/uploadDocs/

Pipe TB, Connolly T, Spahr N, et al. Bringing back the basics of nursing: defining patient care essentials. Nurs Adm Q. 2012;36(3):225-33.

Swihart D, Hess RG. Shared Governance: A Practical Approach to Transforming Interprofessional Healthcare. 3rd ed. Danvers, MA: HCPro; 2014.

Lillee Gelinas is Editor-in-Chief of American Nurse Today.

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