Staffing Ratios in Times of Budgetary Crisis

1. Staffing Ratios in Times of Budgetary Crisis Amanda Lengerich, Kaitlyn Burke, Leslee Johnson, CydneyChomel, Brooke Delay, Hannah Crist, Nora Melvin, Shannon King, Lindsey Gamrat, KayleneLinkenheld

2. PICO Question • P: For a nurse manager • I: does staffing more registered nurses (RNs) and less unlicensed assistive personnel (UAPs) • C: compared to staffing less RNs and and more UAPs • O: lead to better patient care and more monetary savings for the hospital?

3. Management/Leadership Theory • Transformational leadership • encourage staff involvement • form a shared governance • increase work engagement • encouraging teamwork/peer reviews every 6 months • inspire more nurses to take on leadership roles • mandatory meeting every month (Sullivan, 2012)

4. Management/ Leadership Theory • Transformational leadership continued • We want the nurses to feel confident in delegation to Nursing techs • Knowing the scope of practice of the UAPs • ANA codes of standards of delegating and assigning tasks • Knowing the UAPs limitations and skill level • Continual evaluation of the tasks delegated to the UAPs • Praising fellow team members and recognizing their achievements (ATI, 2010)

5. Literature Review • “Cost Savings Associated with Increased RN Staffing in Acute Care Hospitals: Simulation Exercise” • Level A: Meta-analysis • More RNs leads to lower societal costs • More RNs is a greater cost to the hospital • Patient safety is a top concern however cost centers budget must also strongly be considered • Weakness of study: all societal costs were estimated – difficult to truly determine cost of a life (Shamliyan, T., A., Kane, R., L., Mueller, C., Duval, S., and Wilt, T.J., 2009)

6. Literature Review • “Unlicensed assistive personnel: a solution to dwindling health care resources or the precursor to the apocalypse of registered nursing?” • Level of evidence: C Systematic Review • Using more UAP’s over RN’s results in lower costs for the hospital • This supports our view of using more UAP’s and less RN’s • Weaknesses of the study: lack of focus on patient outcomes, cost of education for UAP’s (Huston, C. L., 1996)

7. Literature Review “The Impact of The Nurse Staffing on Hospital Costs and Patient Length of Stay” • Level of Evidence C: Systematic Review • Having a high ratio of Registered Nurses staffed benefits a unit by reducing: • Patient costs • Length of stay • Resource consumption • Adverse patient events • Weaknesses: under representation of all present research, reporting bias, no meta-analysis conducted (Thungjaroenkul, P., Cummings, G. G., & Embleton, A., 2007)

8. Literature Review Care in the Balance: UNISON Survey of Staff/Patient Ratios • Level of Evidence: Level C, Qualitative study • Summary: Non-regulated staff ratios are ineffective, staff feel that current ratios are: • not adequate for safe care (73%) • do not allow for adequate time with each patient (76.8%) • do not promote adequate staff mix (47.6%) • Require more overtime (62.2%) (Bradley, 2012)

9. Literature Review “Care in the Balance: UNISON Survey of Staff/Patient Ratios (cont.)” • Relates to our Problem: findings reinforce that there is a current problem with staffing, staff members are reporting dissatisfaction • Weaknesses: sample size unequal representation, possible bias, generalizability (Bradley, 2012)

10. Intervention Strategy • Based on the review of literature a strategy is going to be implemented to increase the number of UAPs to assist the RNs • We are going to determine RN staffing levels based on patient acuity first and determine where UAPs could be utilized • This strategy will be implemented on lower acuity units initially and then spread throughout the hospital • Meetings held to educate on scope of practice and increase nurses confidence to delegate • Educate nurses on leadership skills • Goal is to motivate staff to be interested and involved in this change process

11. Implementation • Further research needs to done to determine, by unit, what the optimum ratio of nurse to patient is without jeopardizing patient safety and minimizing hospital costs. • Once this ratio is determined, each nurse will be assigned an UAP each shift. Reevaluation will be done every 3 months of this policy to assure cost effectiveness, quality of patient care, and avoiding overstaffing the units. • Revaluation of the policy will cease after an effective ratio of UAP to nurse has been determined • Yearly audit then can determine policy change if needed.

12. Stakeholders Resources Use currently employed UAPs to help with education and orientation of the newly hired UAPs Look at neighboring hospitals who are already using these methods • Nurses • Unlicensed Assistive Personnel • Managers of the floors affected • Clinical Directors • Charge Nurses • Hospital board staff • Patient Care Directors

13. Evaluation Method • Benchmarking • Comparing different organizations who use transformational leadership as well as other units in the hospital • Patient satisfaction surveys • Monthly evaluations • NDNQI ex)medical errors, falls, length stay, call light time response, pressure ulcers • Monthly quality meetings • Collaborate with the staff on weaknesses and strengths of the new staffing change • Implement a survey with the staff to see how effective the unit is working (Sullivan, 2012)

14. In Conclusion…. • Hospitals need to determine a way to staff units that maintains patient safety while decreasing costs for the hospital. • The research has suggested that increasing the use of UAPs could be a solution to this problem. • Patient acuity on each unit will be determined and UAPs will be added where they can be utilized • The effectiveness of the intervention will be evaluated by looking at patient quality care indicators and staff and patient satisfaction.

15. References • Bradley, P. (2012). Care in the balance: UNISON survey on staff/patient ratios. British Journal of Healthcare Assistants, 6(5), 252-253. • Huston, C. L. (1996). Unlicensed assistive personnel: a solution to dwindling health care resources or the precursor to the apocalypse of registered nursing?.Nursing Outlook, 44(2), 67-73. • Nursing Leadership and Management Edition 5.0. (2010). Assessment Technologies Institute, LLC. Overland Park, Kansas. • Shamliyan, T., A., Kane, R., L., Mueller, C., Duval, S., and Wilt, T.J. (2009). Cost savings associated with increased rn staffing in acute care hospitals: simulation exercise. Nursing Economics, 27(5), p. 302-331. Retrieved from: http://content.ebscohost.com.ezproxy.lib.indiana.edu/pdf23_24/pdf/2009/22R/01Sep09/44682115.pdf?T=P&P=AN&K=44682115&S=R&D=aph&EbscoContent=dGJyMNLe80SeprE4zdnyOLCmr0uep7RSsKy4TLaWxWXS&ContentCustomer=dGJyMOfr4FPr1%2BeGudvmh%2FHq   • Sullivan, E., J. (2012). Effective leadership and management in nursing. 8th ed. Boston: Pearson. • Thungjaroenkul, P., Cummings, G. G., & Embleton, A. (2007). The impact of nurse staffing on hospital costs and patient length of stay: a systematic review. Nursing Economics, 25(5), 255.