Nurse Staffing in New Hampshire

1. Nurse Staffing in New Hampshire Implementing a Nurse Staffing Committee NH Staffing Toolkit July 2010

2. Objectives Toolkit contents will allow reader to: • Describe the events leading to the development of the Nurse Staffing Committee initiative. • Describe the role of the Chief Nursing Officer (CNO) in implementing a Nurse Staffing Committee. • Describe the duties of the staffing committee. • Describe the role of direct care nurses in implementing a Nurse Staffing Committee • Describe the yearly review of the facility wide nursing services staffing plan.

3. New Hampshire Staffing History • 2009 Legislation drafted by New Hampshire Nurses’ Association (NHNA) in response to: • Increasing calls from nurses re: staffing concerns • Concern about consequences of legislatively mandated patient/nurse ratios, e.g., access to care impacted due to closure of units and hospitals • Lobbyist representing another states’ collective bargaining organization filed to lobby in NH

4. History Cont’d • Dialogue between NHNA, NH Hospital Association and NH Organization of Nurse Leaders • Led to withdrawal of legislation in favor of: • Voluntary, non-legislative approach to safe staffing • Influencing practice verses being dictated to • Nurse Staffing Steering Committee formed: • Survey • Development of “tools” based upon results

5. Background • Ratios: legislative mandating of staffing minimums • Fixed – each nurse “must have” only so many patients • Shift – the shift average meets the minimum (some nurses may have more, some less) • Puts nursing decisions in the hands of legislators • Significant recruitment strategy for unions • traditional focus on staffing – “the nurse as worker” verses • the nurse as critical thinker delivering quality care

6. Background – Cont’d • Staffing Committees: • Clinical decision making is essential for professional practice • Provides a framework for evidence based staffing • Requires: • Education – both staff nurses and nurse leaders • Processes in place • Two options: • Legislative mandate (the drafted legislation proposed this) • Robust voluntary plan

7. Definitions • “Direct patient care” – care provided by a nurse with direct responsibility to carry out medical regimens or nursing care for one or more patients. • “Nursing care unit” - hospital or facility unit, including operating room or other patient care area, in which nursing care is provided to patients who have been admitted to the facility. • “Nurse” – a person who is licensed to practice as a registered or licensed practical nurse under RSA 328 of the Nurse Practice Act

8. Definitions • “Chief Nursing Officer” (CNO) – designated nurse executive with accountability for nursing practice within the facility • “Nurse Staffing Committee” – Standing Committee responsible for establishing staffing guidelines • “Staffing Guidelines” – Established pattern of assigning nursing hours to patient needs, also referred to as a staffing matrix, staffing plan

9. Sample Nurse Staffing Committee Composition

10. Surveys Pencil and paper Online Utilize committee members to design Unit specific staff meetings Open staff forums Open office hours Solicit emails from nurses Unit rounds Post drafts online for nurses to review and respond to Ask members of committee to hold unit meetings to discuss plan development Seek suggestions from Public Relations, Communications or Human Resources Obtaining Input from Direct Care Nurses

11. Nurse Staffing CommitteePurpose • Provide mechanism for collaboration • Establish minimum staffing guidelines • Meet patient needs • Provide healthy work environment • Recognize evidence-based standards

12. Core PrinciplesStructure of the Staffing Committee includes: • Not more than 13 members • At least 50% direct care nurses • Representation by shift and specialty • Designated term of service • Time and resources to participate • Access to periodic quality evaluation tools • Meeting minutes accessible to all staff • Led by CNO or designee

13. Core PrinciplesFunction of the Staffing Committee is to establish staffing guidelines which consider: • Individual patient needs • Aggregate patient needs • Qualification and competencies of nurses • Availability of equipment and technology • Requirements for equipment and technology • Geographic environment • Patient safety • Evidence based standards • Care delivery models • Available resources • Emergency plans

14. Committee Duties and Responsibilities • Review existing staffing guidelines for all units • Review current evidence based staffing standards • Offer revisions to staffing guidelines based on annual review • Annually review staffing guidelines using indicators • Patient satisfaction • Nurse satisfaction • Quality measures • Fiscal measures

15. Committee Duties and ResponsibilitiesOffer recommendations for nurse staffing guidelines that: • Are cost effective • Ensure competent staff • Ensure specialized skills • Meet patient needs • Consides complexity of care • Consider patient assessment • Consider patient acuity • Consider patient census • Consider volume of patient admissions/discharges/ transfer • Adjust staffing based on patient needs

16. Access to Staffing Guidelines • Facility shall provide access to the staffing guidelines to all direct care staff • Paper copy available in nursing department • Electronic document • Facility shall provide access to the staffing guidelines to patients and their families