Concerns About Staffing Levels and Patient Care in Acute Care Settings

1. Concerns About Staffing Levels and Patient Care in Acute Care Settings Carol Diemert, RN, MSN Minnesota Nurses Association August 1, 2002

2. Causative Factors • Nursing shortage • Restructuring of health care delivery system • Increased demand for nursing services (and health care in general) • Workplace issues, e.g., excessive workloads, stressful job, increases in illness and injury, low levels of morale and job satisfaction • Focus on patient safety

3. Critical Public Health Issue “I believe this [nursing shortage] is the issue in health care for the next 10 years. It will supercede other issues, as more and more of the public find themselves unable to access care when they need it.” -Daniel Sisto, President, Healthcare Association of New York State “Shortage of Nurses Worsens: ‘Doorstep of a crisis’ reached as demand outpaces supply.” Newsday, February 26, 2001

4. Fundamentally Different RN Shortage • Steep demand growth will continue while supply growth will slow and then decline significantly after 2010 • Two decades of decline in younger RNs • Less status perceived in nursing career • Years of dwindling RN graduations • Lower real and relative RN wages • Unremitting cost pressures • Economy-wide workforce shortages

5. RN Supply-Demand Relationship • Slow but steady growth in supply of RNs, but peak & decline on horizon • Rapid and steep increase in demand • Diverging supply & demand curves • Shortage generally considered “demand-driven” for now • Both supply and demand will fuel RN shortage in the near future

6. Demand curve, American Health Care Association, February, 2001 • March, 2000 RN FTEs = 1.9 million, National Sample Survey of Registered Nurses: Preliminary Findings, February, 2001 • 2000 supply = 2020 supply, Buerhaus, et. al., “Implications of An Aging Registered Nurse Workforce”, JAMA, June 14, 2000

7. Restructuring of the Health Care Delivery System The focus on cost containment driven largely by managed care has included a marked and often unsafe, decrease in the utilization of registered nurses. American Nurses Association, 1999 The downsizing, structuring of jobs and increased use of unlicensed assistive personnel were dominant factors resulting in decreased quality of care. Schindul-Rothschild, 1996. Where Have All The Nurses Gone, AJN

8. Demand for Nursing Services Estimated U.S. increases in demand for nursing services, 1991 - 2020 • 54% increase projected for All Settings • 41% increase projected for Short Term Hospitals • 66% increase projected for Nursing Homes • 270% increase projected for Home Health Agencies Source: American Health Care Association, February, 2001

9. Demand for Patient Services Increases per 1000 Minnesota health plan members, 1995 - 1999: • 38% increase in outpatient surgeries • 19% increase in preventative care visits • 11% increase in inpatient hospital admissions • 5% increase in office visits Pharmaceutical costs and greater service volumes are driving healthcare spending Source: Minnesota Council of Health Plans

10. Workplace Issues 2001 ANA Staffing Survey 75% of RNs feel quality of nursing care declined over past 2 years at their facilities 54% of RNs would not recommend the nursing profession to their children or friends 40% of RNs would not feel comfortable having a family member or someone close to them cared for in the facility in which they work American Nurses Association, February 6, 2001

11. Workplace Issues 2001 ANA Staffing Survey con’t 78% of RNs indicated they are skipping meals and breaks to care for patients 58% of RNs stated they are pressured to work voluntary overtime 52% of RNs stated they suffer from increased stress-related illness American Nurses Association, February 6, 2001

12. Workplace Issues RN Illnesses & Injuries • Hospitals report more non-fatal workplace injuries than any other private sector industry according to the Bureau of Labor Statistics. • 90 percent of intensive care unit nurses have symptoms of post-traumatic stress disorder. The disorder is more common among ICU nurses than in any other segment of the population studied – including Israeli soldiers, Vietnam War veterans, rescue workers and medical students. “Not Enough Nurses”, Virginian Pilot ( Norfolk, VA) Jan. 14, 2001

13. Workplace Issues They came, they saw, they went “Dr. Georges C. Benjamin, secretary ofMaryland's Department of Health and Mental Hygiene, summed up the shortage this way: ‘They're not coming in; they're not staying in; and while they're here, they're not happy.’’’ San Francisco Chronicle, “Nationwide Shortage of Nurses Forecast Over Next 20 Years”,February 14, 2001

14. Focus on Patient Safety Institute of Medicine • November, 1999, To Err is Human: Building a Safer Health System – A call for action to make care safer • March 20, 2001, Crossing the Quality Chasm – A call for action to improve the American health care delivery system

15. Focus on Patient Safety con’t. Studies on Nursing • 1994, Nursing Care Report Card for Acute Care, ANA, in which 10 specific quality indicators of nursing were defined and developed • 1996, Shindal-Rothschild (et al) – Nurses reported factors of downsizing, restructuring, and increased use of unlicensed assistive personnel as dominant factors resulting in decreased quality of care

16. Focus on Patient Safety con’t. Studies on Nursing • 1998, Kovner and Gergen – Reported an inverse relationship between nurse staffing and adverse patient events • 2000, Aiken and Patricia – Reported that the higher the job satisfaction scores for nurses, the higher the quality of care

17. Focus on Patient Safety con’t. Studies on Nursing • 2002, Needleman, Buerhaus et al – Reported that a higher proportion of hours of nursing care provided by registered nurses per day are associated with better care for hospitalized patients

18. Concern for Care: Trends in Nursing Practice Concerns in Minnesota Minnesota Nurses Association Made possible by a grant from American Nurses Association

19. Purpose • To explore RNs’ concerns for effective, safe professional nursing practice in acute care facilities. • To identify a potential system for handling data on the issues of nursing practice and staffing.

20. Background • Changes in nursing as a career choice • Valuing of “caring” work • Restructuring of the health care system • Changing demography

21. Summary of Methods • Quantitative Methods • Concern for Safe Staffing and Concern for Practice Forms available from 1/95 - 3/99 (1321 forms) • Categorized into 6 most repetitive, salient concerns ( Figure 1) • Established inter-rater reliability • Compiled and summarized the data using the program ACCESS

22. Summary of Methods con’t. • Qualitative Methods • 2 focus group meetings • 3 regular meetings in facilities • 78 staff nurse interviews • 18 nursing administrator interviews • Reviewed notes from meetings and interviews - content analysis used to identify themes

23. Study Outcomes • Compromises in patient care result from inadequate staffing. (Figure 1) • Lack of supportive working environments for nurses affects the quality of care. • Description and documentation of staffing variables is inadequate. • Concern for practice standards is heightened where staffing is considered inadequate.

24. Study Outcomes con’t. • Compromises in patient care result from inadequate staffing. (Figure 1) • Inability to perform basic care - 52% • Inability to do basic assessment and monitoring - 70% • Inability to give medications on time or at all - 22% • Lack of time to provide emotional support or teaching - 14.5% • Concerns regarding personal safely and health and licensure - 15%

25. Study Outcomes con’t. • Lack of supportive working environments for nurses affects the quality of care • Effective communication, feeling of belonging, and sense of respect/dignity decreased • Nurse managers less visible and available • Mandatory overtime, cross training, chronic sick time, and seniority increase stress

26. Study Outcomes con’t. • Description and documentation of staffing variables is inadequate. • Acuity not regularly considered - 59% (Figure 1) • Admissions/discharges not often included in volume of patients • Type of nursing staff mix available should be considered • Structure and environment of the unit should be considered

27. Study Outcomes con’t. • Concern for practice standards is heightened where staffing is considered inadequate. • Hospital-mandated procedures may be unsafe for patients and a risk for nurses • Increase in part-time nurses because of increased demands and requirements of practice • Language minimizing the professional judgment of the nurse may affect practice standards

28. Figure 1 - Summary Reason for concern 28 Not oriented to unit 52 Not trained or experienced in area assigned 74 Given an assignment which posed a serious threat to my health or safety 704 Case load assignment is excessive and interferes with delivery of adequate patient care 285 Transferred, discharged, or admitted new patient(s) to unit without adequate staff Not given adequate staff for acuity (check appropriate descriptions) 37 Staffed with inappropriate number of temporary pool personnel 44 Staffed with inappropriate number of unlicensed personnel 883 Short staffed 92 Not provided with unit clerk

29. Figure 1 - Summary con’t. Staffing information on shift of objection Is staffing based on acuity?314 Yes 442 No Did staff provided match acuity?31 Yes 66 No

30. Needed staff to provide patient care 136 Short 1 Ancillary 25 Short 2 Ancillary 5 Short 3 Ancillary Figure 1 - Summary con’t. 434 Short 1 RN 190 Short 2 RNs 61 Short 3 RNs 106 Short 1 LPN 17 Short 2 LPNs 2 Short 3 LPNs

31. Figure 1 - Summary con’t. Float/casual/temporary staff used:513 Yes 494 No Maximum staffing but acuity high:39 Yes 6 No Acuity:837 High 178 Average 2 Low

32. Figure 1 - Summary con’t. Compromises in patient care resulting from lack of staff? 651 (52%) Basic hygiene, feeding, ADLs not done on time or at all. 856 (70%) Assessment, observation, not done as scheduled jeopardizing patient safety. 268 (22%) Medications, orders, not done on time or at all. 53 (4.3%) Special procedures, treatments, tests not done on time or at all. 180 (14.5%) Emotional support or teaching not done. 188 (15%) Nurse safety or license at risk, no breaks.

33. Figure 2 - Interview Guide Data • Position with bargaining unit:49 Chair 11 Rep 15 Member • In your work environment, do you use the • Concern for Safe Staffing form?49 Yes 5 No 3 Have own form • Concern for Practice form?6 Yes 15 No 10 Never heard of it • Approximate number of forms completed in one year span of time:26 Less than 10 53 10 to 50 11 More than 50

34. Figure 2 - Interview Guide Datacon’t. • Does your workplace have a formal procedure for responding to the concerns expressed through the use of these forms?20 Yes 29 No 2 "Sort of" • Do you think the procedure in your workplace is effective?6 Yes 22 No 6 Sometimes • Is your perception that your workplace is currently experiencing a shortage of nurses?39 Yes 10 No

35. Conclusions(Secondary Purpose) • Use of Concern for Practice and Concern for Safe Staffing forms is episodic rather than systematic. • Data not regularly compiled or reported. • Practice and staffing issues are often interrelated, but are not systematically connected. • 57% of respondents stated no follow-up procedure in their facility. • 65% of respondents stated existing procedure not effective.

36. Sample Management Response • Example of Management Response to Concern for Safe Staffing • refer to page 23 of report • includes: • actions taken • effects on patient care • follow-up by nurse manager • conclusion

37. Sample Management Responsecon’t. Procedure for Follow-up to Concern for Safe Staffing Forms SAMPLE HOSPITAL SAFE STAFFING CONCERN LOG DATES / TOTAL

38. Sample Log SAMPLE HOSPITAL SUMMARY - SAFE STAFFING CONCERN LOG 1st2nd3rd 4th Quarter Quarter Quarter QuarterTotal Total Received 19 30 8 11 68 By Unit: 2E 0 0 0 0 0 3W 0 0 0 0 0 3E 3 0 1 2 6 ICU 1 1 3 2 7 4W/4E 6 0 0 3 9 2W 1 0 0 0 1 E.D. 7 22 4 0 33 SARS 1 0 0 0 1 PACU 0 0 0 0 0 5E 0 7 0 4 11

39. Follow-up Since Studyat Minnesota Nurses Association • Implemented, tracked and reported new Concern for Safe Staffing forms • Operationalized the patient flow policy contained in contract agreements between MNA and several metro hospitals following nurses strike June 2001 • Passed the mandatory overtime bill (MS181.275) in 2002 legislature

40. Follow-up Since Studyat Minnesota Nurses Association con’t • Promoted the ANA programs: • Nursing-Sensitive Quality Indicators for Acute Care • Magnet Nursing Service Recognition

41. Concern for Safe Staffing Form The revised Concern for Safe Staffing form is attached

42. Contract Language/Collective Bargaining Agreements All units will review staffing grids which cannot be changed downward unless evaluated by a team. Staffing grids will be based on acuity, experience level of RN staff, composition of skills/roles available, unit admissions, discharges, and transfers.

43. In the Twin Cities agreements, MNA won the right for RNs to close a unit to new patients when too few staff are available to care for more patients. This landmark innovation to deal with excessive workloads could set a new direction in collective bargaining. American Journal of Nursing, August 2001

44. In the area of health and safety, there is growing interest among frontline nurses to protect themselves and their livelihood from work-related injury and illness. This concern is likely to intensify and become a dominant issue at the bargaining table. American Journal of Nursing, August 2001

45. Mandatory Overtime Bill What does the new law accomplish? The new law clearly states that a hospital is prohibited from “taking any action against a nurse solely on the ground that the nurse fails to accept an assignment of additional consecutive hours at the facility in excess of a normal work period, if the nurse declines to work additional hours because doing so may, in the nurse’s judgment, jeopardize patient safety.” MS 181.275 Subd. 2

46. Mandatory Overtime Bill con’t The focus of the law is on the nurse being able to exercise his/her own judgment to decline the work if the nurse believes working the additional hours would jeopardize patient safety. The law clearly recognizes that the nurse, not the employer, must make this judgment call.

47. Nursing Sensitive Quality Indicators What is NDNQI? The National Database of Nursing Quality Indicators (NDNQI) is a project of the American Nurses Association’s (ANA) Safety & Quality Initiative, which addresses the issues of patient safety and quality of care arising from changes in health care delivery.

48. What kind of information is in NDNQI? NDNQI will contain information on nursing staff mix and nursing hours, as well as indicators that describe the structure, process, and outcomes of care. The following seven quality indicators form the core of NDNQI: • Patient Injury Rate (Falls) • Maintenance of Skin Integrity (Pressure ulcers) • Patient Satisfaction (Overall care, nursing care, patient education, and pain management) • Nursing Staff Satisfaction • Skill Mix of RNs, LPNs/LVNs, and Unlicensed Staff • Total Nursing Care Hours Provided per Patient Day • Nosocomial Infections

49. Magnet Recognition Program AAN Study 1983 • 41 hospitals • Attracted and retained qualified nurses (magnet concept) • Promotion of quality patient care through excellence in nursing services

50. Magnet Recognition Program Purpose Recognize excellence in: • Management philosophy and practices of nursing services • Adherence to standards for improving the quality of patient care • Leadership of the Chief Nurse Executive in supporting professional practice and continued competence • Attention to cultural and ethnic diversity in patient, family and staff