Roger Watson, Editor-in-Chief
This year's International Council of Nurses (ICN) theme for International Nurses Day is about effectiveness of nurses in terms of care and cost. Intuition tells us that nurses are effective and cost-effective and we cite this in terms of readmission rates, pressure ulcers and infection rates, for example. It seems obvious that, when nursing levels are sufficient to deliver nursing care, it is better than insufficient levels and that better qualified nurses are better then less qualified nurses where 'better' means better patient care and cost-savings. However, as sound as intuition often is and that common sense would appear to dictate these things, intuition and common sense do not have much influence on budget holders who, in developed countries, spend vast amounts of money on hospital budgets, the largest proportion of which is always spent on the nursing workforce. They want evidence.
At JAN we take a great deal of interest in manuscripts related to any aspect of nursing workforce and this year have published two articles relevant to the ICN theme of care effective and cost effective. As with all research, the evidence is ambiguous. For example, in a systematic review titled: This review was unable to determine conclusively whether or not changes in nurse staffing levels and/or skill mix is a cost-effective intervention for improving patient outcomes due to the small number of studies, the mixed results and the inability to compare results across studies.' On the other hand, in a study of understaffed shifts on nurse-sensitive outcomes, Twigg et al. (2015a) showed that understaffing of wards had significant detrimental effects on: 'surgical wound infection, urinary tract infection, pressure injury, pneumonia, deep vein thrombosis, upper gastrointestinal bleed, sepsis and physiological metabolic derangement.' Clearly, these are different types of studies but in one - the single study - the effect of insufficient nursing is clear; however, the synthesized evidence is less clear. One thing is clear: more research is needed and that agreed outcomes and ways of measuring nursing care and staffing levels are necessary.
In the search for the evidence of cost-effectiveness we must not lose sight of the fact that it may not be there and may not be evident in all circumstances. For example, another study by Yang et al. (2105) titled: 'The impact of three nursing staffing models on nursing outcomes' and published in JAN showed unexpected relationships between staffing models and medication errors; models with 100% RNs as opposed to models with RNs and nurse aides led to more medication errors. The reason appeared to be that checking and administering as opposed to checking an allowing an nurse aide to administer was more error prone. It is a single study but also a lesson in not jumping to the wrong conclusion about nurse staffing levels.
As Editor-in-Chief of JAN, I am convinced that nursing is effective and cost-effective and I support the ICN slogan for this year's International Nurses Day. However, I think that globally we need to be more united and systematic in our efforts to study and report on the care effective and cost effective aspects of nursing. As a recent editorial by Fawcett et al. (2104) stated: Nursing today stands again at its Rubicon. Today’s 'gilded galley’ must be able to navigate the treacherous waters of failed accountability, broken trust and lost devotion. Though not all pervading, our professional gild has become tarnished and the vessel damaged. Picture a Roman galley moving through the waters of the Mediterranean with twin banks of oarsmen working together to pull the craft through the waves. The oarsmen work together, pulling in unity, almost as one. If nursing is to take its ‘gilded galley’ forward, it too needs unity and a common purpose to succeed. The pioneering nurses of the past can inspire us but it is today’s nurse leaders who must set the direction of travel and set course for better times. We have failed to direct the agenda and for too long we have been without a collective, visionary voice and an authoritative pride in our profession. We have looked in the mirror and we see a nursing profession that needs to take ownership of itself and take the lead, from grass roots front line nurses to those who are educators, researchers and policy makers.
Fawcett, T. N., Holloway, A. and Rhynas, S. (2014), If I have seen further it is by standing on the shoulders of giants: finding a voice, a positive future for nursing. Journal of Advanced Nursing. doi: 10.1111/jan.12556
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