Linda Aiken

Pay attention because it’s about to get worse. That’s the resounding cry of Linda Aiken’s 15 years of research on the nursing workforce. Her work on the nation’s nursing shortage has made a splash in both academic and media outlets. In the same one week period, the director of Penn’s Center for Health Outcomes and Policy Research has snagged three high profile awards—the Baxter Episteme Award from Sigma Theta Tau International, the Nobel Prize equivalent in nursing; the Nursing Research Pathfinder Award from the Friends of the National Institute for Nursing; and the National Media Award from the American Academy of Nursing.

These honors highlight the critical link Aiken, Claire M. Fagin Leadership Professor of Nursing, has drawn between nurse-friendly facilities and mortality rates. The results are almost too scary to comprehend. The more overworked nurses are, the less adequate care they can give and consequently patients suffer adverse and sometimes fatal effects. She cautions that if the workloads of nurses aren’t redesigned then the healthcare industry will suffer extensively.

In a recent interview, Aiken talked about what it’s going to take to resolve this crisis.

Q. What are some of your findings?
A. The cyclical shortages of nurses is less due to not having enough nurses and more due to swings in the demands for nurses in the hospital sector. One of the major factors, of course, is wages. As nurses’ wages fall relative to other people that are employed in healthcare, hospitals want more of them because they are valuable in a hospital context. Hospitals can almost use an infinite number of nurses. In the past, nurses have had periods where their overall compensation fails to rise at the rate of the overall economy and that just makes them a better and better buy.

The country has tried to reduce hospital length of stay quite substantially and that has increased the demands of nurses, because every patient in the hospital is significantly sicker so you have to have more nurses per patient.

There’s a real need to both recruit more people into nursing and to redesign the work in the hospital so that the work can be accomplished with fewer nurses and more effectively.

Q. If this is a reoccurring problem, why is the public so focused on it now?
A. Two reasons. The first reason has to do with the fact that the patients that are actually in hospitals are so severely ill that the consequences of not having enough nurses is much more troubling now than it has been in years past. There are literally no people in hospitals any longer that are in waiting for tests or are in a recovery mode where they are able to take care of themselves. Everyone in there is very dependent and there are concerns from patients, families and nurses that having [an] insufficient number of nurses is extremely hazardous and unsafe. We have shown in our work that there is a relationship between nurses’ workloads and mortality so that it is really true that having too few nurses leads to adverse patient events, including death and also a number of other complications that delay recovery.

In years past, if you were going to have surgery, you’d be admitted days before to have various tests done. Now everyone is admitted the day of surgery. They’re never there when they’re well.

If you don’t have time to do the care, it’s of major consequence. Not like in the old days where if you didn’t have time to do the care, well you could always [do it] tomorrow. There’s just no time to ever catch up.

The second issue has to do with the demography of the nursing population and estimates that if we don’t make corrections to both how we use nurses and the recruitment of them, then we’re going to have a permanent shortage. The cyclical nature is going to become a chronic shortage. If we didn’t have enough nurses, we would start having to curtail services like surgery [and this] could create waiting lists.

Q. What are your policy recommendations?
A. Our research suggests that hospitals that have certain organizational characteristics are much more likely to attract and recruit nurses and have better outcomes.

This has to do with recruiting the best professional nurses we can and then giving them the professional autonomy to practice within the areas of their expertise, which means the institution acknowledges that these are highly educated and skilled personnel and is organized to promote nurses making decisions about patients just the same way that doctors make decisions about patients. It’s a philosophy where the nurses at the bedside know the best about what patients need.

The more nurses can do in a hospital context, the better it is for doctors because doctors also have these very sick patients. And unlike nurses who are actually at the bedside, the doctors are either in the operating room, spending a lot of time doing the next round of surgeries, or they’re seeing patients in offices. They are literally not in the hospital. They really need excellent nurses who are their eyes and ears, really an extension of them in some way.

Q. What is your future research agenda?
A. When we started this work, we thought if we could capture the attention of the leaders in the hospital sector, if we showed that there was a very strong relationship between nurse staffing and mortality rates and we’ve done [that but] there hasn’t been a groundswell of responsiveness to changing staffing rates. Now what we’d like to proceed with is to try to demonstrate that there is a link between nurse staffing and the organization of nurses and the financial health of hospitals. [We’d like] to take these clinical outcomes that we’ve found and convert them to financial metrics because many of the folks that run hospitals are business people. They think in financial terms, and they’re not easily able to convert these clinical findings into ideas and concepts that relate to the financial viability of the institution.

Q. Yet the public can make this link?
A. The public has no problem seeing these problems. The public understands that when you go to the hospital you should have a nurse. Everybody wants a nurse. They want a nurse when they call. They want a competent nurse, a nurse they can trust to be there, a nurse that can comfort them and take care of their pain. Everybody wants them.

The public understands, and when they go to hospitals they are afraid because they realize there are not enough nurses there. People don’t come when they call. They have to have family members standing by their side. So it’s really not a matter of the public understanding this. It’s really a matter of those of us working in the hospital sector and healthcare not making good enough responses.

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Gold medal nurses

Penn is no stranger to the Baxter Episteme Award, the top nursing research award in the world. We’ve had more recipients than any other institution. This year’s prize is Penn’s second in a row.

Here’s a list of previous Penn winners:

Dorothy Brooten took home the first Baxter Episteme award in 1989 for her work on the early discharge of infants with low birth weights.

Lois Evans and Neville Strumpf received the award in 1995 for research that led to a reduction in the use of restraints for frail older people in hospitals and nursing homes.

Ann Burgess snagged the award in 2000 for her studies in victimology, particularly how psychological clues can be used to solve sexual abuse crimes.

Linda Aiken is the 2001 recipient, receiving honors for her work on the nation’s nursing shortage.