At the conclusion of this presentation the learning will be able to:

1. Appropriate Staffing for a Healthy Work EnvironmentNancy Blake, PhD, RN, CCRN, NEA-BCChildren’s Hospital Los Angeles

2. At the conclusion of this presentation the learning will be able to: • List and describe the traditional domains of administrative decision making which has specific impact on direct care delivery • List two research sources which describe a relationship between nurse staffing and patient outcomes • Describe one new form of technology that can assist in matching nurse staff competencies with patient needs

4. Ever changing healthcare environment… • Shorter lengths of stay • Decreased reimbursement so we are asked to do more with less • Patients are more critical in the hospital than ever before • Increased nursing hours result in fatigue which results in more errors • There is a relationship between the nurse-to-patient ratios and positive outcomes • Appropriate staffing is one of the essential elements of a Healthy Work Environment

5. Essential Elements of a Healthy Work Environment • Skilled communication • True Collaboration • Effective Decision Making • Appropriate Staffing • Meaningful Recognition • Authentic Leadership

6. Appropriate Staffing Staffing must ensure an effective match between patient needs and nurse competency

7. Appropriate Staffing – Critical Elements of the Organization (HWE Standards) • Staffing policies that support nurses to provide high quality care • Nurses participate in all aspects of the staffing process • Formal processes to evaluate effective staffing decisions • A system in place that facilitates the team’s use of staffing and outcomes to develop staffing models • Supports services to ensure nurses can focus on care of the patient and family • Adopts technologies that increase the effectiveness of care delivery

8. ANA’s Principles for Nurse Staffing, 2nd Ed. 2012 • Appropriate nurse staffing must be considered an asset, not just a cost • Evidence demonstrates that the nursing care has an direct impact on overall quality of services received • When RN staffing is adequate, adverse events decline and overall outcomes improve • Emphasis needs to change on the importance of nurse staffing

9. Traditional Domains of Traditional Decision Making which had an Impact on Patient Care Delivery • Task based tools • Staffing based on a matrix of the number of patients, not taking into account the acuity of the patients • Then acuity tools came into place, but many were still based on tasks and not upon nursing judgment in the early days

10. Research on Nurse Staffing

11. Nurse Staffing and Patient Outcomes 1998Blegen, Goode and Reed • Objective – Describe at the nursing unit the relationships among total hours of nursing care, RN skill mix and adverse patient outcomes • Methods – Correlations among staffing variables and outcome variables • Results – Controlling for acuity, the proportion of RN hours of care was inversely related to the unit’s rates of decubiti, complaints, and mortality. • Conclusion – The higher the RN skill mix, the lower the incidence of adverse occurrences on inpatient care units

12. Nurse Staffing Levels and the Quality of Care in Hospitals 2002Needleman, Buerhaus, Mattke, Stewart, Zelevinsky • Objective – Determine if lower levels of staffing by nurses in hospitals are associated with increased risk of complications • Methods – Retrospective data review for 799 hospitals in 11 states to examine the relation between the amount of care provided by nurses and patient outcomes • Results – For medical patients, the higher number of RN hours per day, the lower the length of stay and lower the infections; for surgical patients, the higher number of RN hours of care per day, the lower the UTI rate and the lower the failure to rescue (death) • Conclusion – A higher proportion of hours by an RN per day, the better the outcomes

13. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction 2002Aiken, Clarke, Sloane, Sochalski, Silber • Objective – To determine the association between the patient-to-nurse ratio and patient mortality, failure-to-rescue among surgical patients and nurse retention in Pennsylvania hospitals • Methods – Cross-sectional analysis of linked data from 10184 staff nurses in Pennsylvania and 232,342 patients discharged • Results – The odds of dying increased by 7% for each additional patient in a nurse’s workload. In addition, they found that for each additional patient per nurse was associated with an 23% increase in burnout and 15% increase in job dissatisfaction • Conclusion – Hospitals with high nurse-patient ratios had a higher risk-adjusted 30 day mortality/failure to rescue and higher burnout and job dissatisfaction

14. Nurse-Patient Ratios: A Systematic Review on the Effects of Nurse Staffing on Patient, Nurse and Hospital Outcomes 2004Lang, Hodge, Olson, Romano, Kravitz • Objective – Determine whether the literature supports specific, minimum nurse-patient ratios and whether nurse staffing is associated with patient, nurse or hospital outcomes • Method – Systematic review of studies published between 1980 and 2003 to determine whether they could guide minimum ratios • Results – 2897 articles published, 43 met the inclusion criteria -Evidence suggests that richer nurse staffing is associated with lower inpatient mortality and shorter stays • Conclusion – The literature offers no support for specific, minimum nurse-patient ratios

15. Mandated Nurse Staffing Ratios in California: A Comparison of Staffing and Nursing-Sensitive Outcomes Pre- and Post-regulation 2007Burnes-Bolton, Aydin, Donaldson, Brown, Sandhu, Fridman, Aronow • Objective – Explore nurse staffing and nurse sensitive indicators (CALNOC) pre and post ratios to see if there is a difference in outcomes • Methods – Exploratory examination of the relationship between staffing and nurse-sensitive patient outcomes (falls, pressure ulcers and restraints) • Results – Did not identify the contributions of nurse staffing to a decrease in patient falls or pressure ulcers • Conclusion – Anticipated significant improvements in nurse-sensitive indicators of patient care quality and safety, the incidence of falls and the prevalence of pressure ulcers, were not observed.

16. Does the research reflect a relationship between nurse staffing and patient outcomes? • Yes, there is a relationship between a higher level of RN staffing and few patients per RN • There is not an answer to the question how many patients per nurse is a good number • ANA and AACN do not support a ratio, but support that there needs to be the right balance of RNs to patients, but there is not a magic number

17. State Mandated Staffing Laws

18. States with Laws Regarding a Staffing Committee or Required Staffing Plans • Texas (2009) • Nevada (2009) • Ohio (2008) • Connecticut (2008) • Washington (2008) • Illinois (2007) • Oregon (2005)

19. States with Mandated Ratios • California (1999) • Florida (2006)

20. States with Public Disclosure Laws about Staffing • Illinois (2007) • New York (2009) • Vermont (2006) • Rhode Island (2005) • New Jersey (2005)

21. Removed Staffing Legislation Requiring Ratios • Maine (2004) • Washington DC (2004)

22. Staffing Systems and New Technologies

23. Various Staffing/Acuity Systems • Cerner Clarvia • Optilink • API/Concerro • Grasp • Catalyst • McKesson

24. Cerner Clarvia • Acuity and Staffing System • Care Coordination • Productivity Management • Pull clinical data from the electronic health record to provide information on the nursing outcomes classification which will result in an overall acuity score • Allows for real-time adjustments of staffing • Also allows for monitoring where the patient should be based on their DRG and allows for care coordination around a standard that everyone can see in the system

28. AACN Synergy Model

29. AACN Synergy Model • Was developed on the principle that patient characteristics drive patient acuities • The goal of the model was to match the nurse’s competencies with the patient needs/characteristics, resulting in synergy • Model was based on work done by Martha Curley and the AACN Certification Corporation • This model has been implemented in several hospitals for staffing • This model is used as a professional practice model at Baylor Health System in Texas

30. “Professional nursing practice occurs in a healthy work environment where patient needs are assessed and matched to nurse competencies. This synergy results in Safe Passage for patients.”John Dixon, 2008

31. Synergy Patient Characteristics • Stability • Complexity • Vulnerability • Resiliency • Predictability • Resource Availability • Participation in care • Participation in decision making

32. Synergy Nurse Characteristics • Clinical judgment • Advocacy/moral agency • Caring practices • Collaboration • Systems thinking • Response to diversity • Clinical inquiry • Facilitator of learning/Patient family educator

33. Synergy model overview • Patient Characteristics are given a level of 1 – 5 which is minimally stable to highly stable • Nurse Characteristics are given a level of 1 – 5 from Competent to Expert • There is an effort to match the needs of the patient with the competency of a nurse • New graduates would get the less complex patient and the expert nurse would get the more complex patient

34. Newer Research on Staffing Hours and Patient Safety

35. The Working Hours of Hospital Staff Nurses and Patient Safety 2004Rogers, Hwang, Scott, Aiken, Dinges • Objective – Study the effect of extended nursing hours on patient safety • Method – Descriptive correlational study to determine the relationship between the nurses hours (work schedule, overtime) and errors or near errors • Results –The risk of making an error were significantly increased when work shifts were longer than twelve hours, when nurses work overtime or when they worked more than 40 hours in a week • Conclusion – Nurses’ long hours may have an effect on patient care

36. Nurses’ Work Schedule Characteristics, Nurse Staffing, and Patient Mortality 2011Trinkoff Johantgen, Storr, Gurses, Liang, Han • Objective – To determine if, in hospitals where nurses report more adverse work schedules, there would be increased patient mortality • Method – Cross-sectional design with data from a 2004 survey of 633 nurses working in 71 acute care hospitals in North Carolina and Illinois. Staffing and outcome data were also used. • Results – Pneumonia deaths were more likely where nurses reported long hours and lack of time away, MI was associated with weekly burden for nurses (hrs/week; days in a row) • Conclusion – In addition to staffing, nurses’ work schedules are associated with patient mortality. This suggests that work schedule has an independent effect on patient outcomes.

37. Summary • There is a relationship between higher registered nursing hours of care and better patient outcomes • There is no magic number for nurse to patient ratios • Organizations need to conduct systematic and regular evaluations of the impact of staffing plans on patient outcomes • The nurses’ schedule, including the number of hours in a day, the number of total hours in a week and the amount of time away, has an impact on patient care • It is important to match the patient’s needs with the nurses competencies

38. References • In addition to those already referenced in the document • www.aacn.org • A handout of all of the references will be available during the presentation

39. Questions