Improving Quality through Nursing
LINDA H. AIKEN
Both the public and physicians rank nurse understaffing of hospitals as one of the most serious threats to patient safety (Blendon et al. 2002). Two-thirds of hospital bedside nurses concur that there are not enough nurses in their hospitals to provide high-quality care, and close to half score in the high-burnout range on standardized tests. Almost one in four intends to leave his or her job in the hospital within a year (Aiken et al. 2001). Federal estimates suggest that the shortfall of nurses could approach 275,000 by 2010 and 800,000 by 2020 (U.S. DHHS 2002). Until very recently, policymakers and health care leaders have not associated hospital nurse understaffing and burnout with medical errors and adverse patient outcomes, as evidenced by the few references to nursing in the Institute of Medicine's first two major quality reports (Institute of Medicine 2000, 2001). This chapter explicates the link between nursing and quality and discusses the implications for the nation's quality improvement agenda.
Nursing is the care of the sick (and those who may become sick) and the maintenance of the environment in which care occurs (Diers 2004). Nurses are responsible for fulfilling those aspects of the medical regimen delegated to them by physicians, such as administering medication, but they are legally and professionally responsible for their own actions when fulfilling delegated tasks. In the case of administering medications, nurses are responsible for ascertaining that the dose is correct for the age of the patient and that the route of administration is proper. Nurses have a professional and legal scope of practice that is complementary to that of physicians and includes assessing and intervening within their areas of expertise, such as skin and wound care, managing pain and providing comfort, and teaching patients and their families how to manage their care after hospital discharge, among myriad other responsibilities. Nurses are also responsible for maintaining a safe and patient-centered care environment. Thus, nurses routinely step in when non-nursing support services are not available or are inadequate to maintain a clean environment. They ensure that patients receive adequate nourishment, enforce infection control practices, and prevent hazards such as