Patient Safety and Nurse Staffing

1. Patient Safety and Nurse Staffing Does it really make a difference?

2. Objectives • Discuss research on the relationship between staffing and quality of care • Analyze data on hospital staffing in the United States • Explore staffing-related policy options for ensuring quality of care

3. Objectives • Discuss research on the relationship between staffing and quality of care • Analyze data on hospital staffing in the United States • Explore staffing-related policy options for ensuring quality of care

4. What Do We Mean by Staffing? • Staffing of licensed personnel • Staffing of assistive and ancillary personnel • Staffing in hospitals • Staffing in long-term care facilities

6. Research on Nurse Staffing has Changed in Recent Years • In the 1990s: • IOM said there was insufficient evidence to determine whether nurse staffing changes were detrimental (Crossing the Quality Chasm, 1996) • ANA said there was insufficient scientific evidence to establish ratios (1999)

7. The newest research shows that nurse staffing is important • Evidence suggests that an increase in nurse staffing is related to decreases in: • risk-adjusted mortality • nosocomial infection rates • thrombosis and pulmonary complications in surgical patients • pressure ulcers • readmission rates • failure to rescue • Evidence that higher ratios of RNs to residents in long-term care has positive effects

8. The Most Influential Studies • Report for Health Resources and Services Administration • Use of administrative hospital data from states • Key outcomes associated with nurse staffing: • Urinary tract infections • Pneumonia • Length of stay • Upper gastrointestinal bleeding • Shock • Failure to rescue Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346, 1715-1722.

9. The Most Influential Studies • Survey of nurses about staffing and work environment in Pennsylvania, surveys linked to discharge data • For every patient added to the average hospital-wide nurse workload • 7% increase in mortality for every patient added to the • 7% increase in failure-to-rescue patients with complications • Patients in hospitals with 8:1 patient to nurse ratios have more than a 30% greater risk of death following common surgical procedures than patients in hospitals with 4:1 ratio • Some 4 million surgical procedures like the ones studied are performed annually in US hospitals. • If all patients were cared for in hospitals with 4 patients per nurse, up to 20,000 fewer deaths might be expected. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfactions. Journal of the American Medical Association, 288, 1987-1993.

10. The Most Influential Studies • Cross-sectional analyses of outcomes data for 232,342 general, orthopedic, and vascular surgery patients discharged from 168 nonfederal adult general Pennsylvania hospitals • Hospitals with more baccalaureate-educated RNs had lower: • 30-day mortality • Failure to rescue Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloan, D.M., & Silber J.H. (2003). Educational levels of hospital nurses and surgical patient mortality. . Journal of the American Medical Association, 290, 1617-1623.

11. The Most Influential Studies • Data for patients aged 18 years and older who were discharged between 1990 and 1996 were used to create hospital-level adverse event indicators. • Examined relationship between nurse staffing and four postsurgical adverse events: • venous thrombosis/pulmonary embolism • pulmonary compromise after surgery • urinary tract infection • pneumonia • Poor nurse staffing increased pneumonia rates Kovner, C., Jones, C., Zahn, C., Gergen, P.J., & Basu, J. (2002). Nurse staffing and postsurgical adverse events: An analysis of administrative data from a sample of U.S. hospitals, 1990-1996. Health Serves Research, 37, 611-629.

13. Nurse staffing also affects job satisfaction • High workload and poor staffing ratios are associated with: • Nurse burnout • Low job satisfaction • Increased nurse stress • Nurse stress is related to: • Adverse patient events • Nurse injuries • Quality of care • Patient satisfaction

14. Importance of Work Environment • Every blue ribbon commission report on solutions to cyclical nursing shortages since 1980 has recommended changes in nurses’ work environments • Recent reports: JCAHO, AHA, RWJF • However, on the whole nurses work environments have deteriorated over the past 2 decades

15. Nurses Highly Dissatisfied withHospital Practice • Job dissatisfaction 41% • High job burnout 43% • Intend to leave within year 23% • Under 30 leaving in year 33%

17. Sources of Dissatisfaction • Too few RNs for quality care 66% • Increased patient assignment 83% • Inadequate support services 57% • Quality care deteriorating 45% • Not confident patients can 66% manage at discharge

18. Another Aiken Study Aiken, L.H. et al. (2001). Nurses' reports on hospital care in five countries. Health Affairs, 20(3), 43-53. • Reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999 • Core problems in work design and workforce management threaten the provision of care

19. Percent of Nurses Leaving Essential Nursing Care Undone Last Shift U.S. Canada Germany • Comforting patients 40 44 54 • Skin care 31 35 31 • Oral hygiene 20 22 10 • Teaching patients/families 30 26 30 • Discharge planning 13 14 13 • Care planning 41 47 34

20. Percent of Nurses Performing Non-Nursing Tasks on Last Shift U.S. Canada Germany • Food trays 43 40 72 • Housekeeping 34 43 na • Transport 46 33 54 • Ancillary services 69 72 28

21. RNs Reporting AdverseEvents as “Not Infrequent” • Wrong medication or dose 16% • •Nosocomial infection 35% • •Falls with injuries 20% • •Patient/Family Complaints 49% • •Verbal Abuse of Nurses 53%

22. Patient to Nurse Ratios Importantin Nurse Retention • Higher burnout and greater job dissatisfaction are strongly related to patient-to-nurse ratios. • An increase of 1 patient per nurse increases the probability of • high levels of burnout by 23% • job dissatisfaction by 15% Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfactions. Journal of the American Medical Association, 288, 1987-1993.

23. The Research Has Limits • Data on hospitals do not recognize different staffing on different units • Studies at the nursing unit level involve primary data collection and are costly • Single-year studies cannot prove a causal relationships • No study identifies the “ideal” staffing ratio

24. Objectives • Review research on the relationship between staffing and quality of care • Present data on staffing in the United States • Explore staffing-related policy options for ensuring quality of care

25. There are many sources for nurse staffing data • American Hospital Association • State data • Original surveys

26. There are many ways to measure nurse staffing • Nurse-to-patient ratios • 1:4, 1:8, 1:12 • Hours per patient day (HPPD) • Full-time equivalent employment (FTEE) • Someone who does 100% patient care = 1 FTEE • Someone who does 50% administration and 50% patient care = 0.5 FTEE • Skill mix (how many RNs, LPNs, BSNs, PCTs??)

27. There is Wide Variation in HPPD Nationally Source: AHA

28. What is Staffing in “Best Practices” Hospitals? • Best practices hospitals identified by: • American Nurses Association Magnet Hospitals • JCAHO Commendation of CA hospitals • US News rankings – national honor roll • USA Today Top 100

29. Average HPPD in Best Practices Hospitals Source: AHA

30. Objectives • Review research on the relationship between staffing and quality of care • Present data on hospital staffing in the United States • Explore staffing-related policy options for ensuring quality of care

31. Rules and Regulations

32. Some States Have Adopted Some Rules • California • Hospitals must have a patient acuity system to determine staffing (1995) • Kentucky and Virginia (1998) • Hospitals must establish appropriate staffing methodology • Nevada (1999) • Hospitals must have a staffing methodology based on acuity

33. Some States Have Adopted Some Rules • Oregon (2001) • Hospitals must develop and implement staffing plans • Provisions for inspections and penalties established • Texas (2002) • Hospitals must adopt, implement, and enforce a written staffing plan • California • Hospitals must meet specific minimum nurse-to-patient ratios (1999, implemented 2004)

34. Florida 2005 • HB 1117 proposed the creation of the Safe Staffing for Quality Care Act, which would require ratio limits on nursing units • Critical care units 1:2 nurse-to-patient ratio • Labor and delivery units 1:2 • Emergency departments 1:3 • Step-down units 1:3 • General medical/surgical 1:4 • Died in the Health Care Regulation Committee 05/06/05

35. Florida 2005 • Senate Bill 1176 also referred to the Safe Staffing for Quality Care Act and aimed to prescribe staffing standards for health care facilities. • Died in Committee on Health Care05/06/05

36. Florida 2005 • Both Bills were • Supported by the Nurse Alliance of Florida, a labor union in south Florida • “Staffing ratios are crucial to patient safety, nurse satisfaction and hospital costs.” • Maria Sanchez, member of the Alliance • Opposed by the Florida Nurses Association • “First of all, it is a nursing judgment to decide what care patients need. Second, ratios make all nurses the same. Every nurse, no matter how much experience or schooling she has, becomes a number. It’s demeaning to the profession, and when you put numbers on units, there’s no flexibility. It ties the hands of the nurses themselves.” • Barbara Lumpkin, Associate Executive Director, FNA

37. Approaches to Staffing Standards Patient acuity/patient classification systems Fixed ratios Formula-based ratios Skill-mix requirements

38. Patient Acuity/Patient Classification Systems • Input: # of patients, acuity of illness • Output: appropriate staffing levels • Widely marketed systems and home-grown systems • Problems: • Systems best for long-term, not short-term, prediction • Difficulty of staffing up if necessary • Enforcement – hard to monitor

39. Fixed Ratios • Fixed, specific nurse-to-patient ratios are mandated • Problems: • Minimum staffing could become average staffing • Hospitals could eliminate ancillary and support staff • Enforcement – do you close hospitals? • Loss of flexibility and innovation

40. Formula-based Ratios • Nurse workload = function of: • RN staff expertise • Patient acuity, work intensity • Support staff, MD availability • Unit physical layout • Problems: • Defining the function • Establishing new staffing ratios every week/month/year • Enforcement

41. Skill-mix Requirements • Hospitals must have a minimum fixed ratio of licensed staff relative to all staff • Problems: • What is the appropriate ratio? • Minimum ratio could become average (like speed limit) • Total staffing may not be adequate • Loss of flexibility and innovation • Enforcement

42. An Overriding Question • How much are we willing to spend to increase quality of care? • Do we take money from schools? • Do we take money from salaries? • Do we increased the number of uninsured?

43. What Next? • More nurses lead to better patient outcomes • Legislative approaches have potential pitfalls • To improve nurse staffing: • Hospitals need money to pay more staff • More nurses are needed in the labor market

44. Responses to Hospital Nursing Shortages • Responding to a nursing shortage in the early 1980s, the American Academy of Nursing embarked on the “magnet hospital” project • Identify hospitals that attract and retain nurses. • 1993 - the "magnet" concept by was formalized by the ANCC by establishing the Magnet Hospital Recognition Program for Excellence in Nursing Services McClure, M.L., & Hinshaw, A.S. (Eds.). (2002). Magnet hospitals revisited. Silver Spring, MD: American Nurses Association.