Safe staffing in a just culture: REALLY?

1. Safe staffing in a just culture: REALLY?

2. Alice Dupler, JD, APRN-BC Neva Crogan, PhD, ARNP, FAAN

3. DEFINING SAFE STAFFING IN A JUST CULTURE IS RISKY!

4. Safe Staffing • What it is? • Defined traditionally 8 hour shifts, 5 on/ 2 off • Defined by nurse to patient ratios • Defined by nurse staffing committees • What it is not? • 12 hour shifts • ↑ n/workload by 1 pt → ↑ + 7% likelihood mortality • At 1:4 stable patients no significant difference noted • ↑10% BSN nurse staffing → ↓ 7% pt likelihood mortality

5. Safe staffing impacts • Medication accuracy • Client complications • Mortality • Patient satisfaction • Nurse fatigue • Burnout • Retention and jo satisfaction

6. Key Findings Research Annotated Bib – Safe Staffing Lit Review www.nursingworld.org Tellez, M., & Seago, J. (2013). California nurse staffing law and RN workforce changes. Nursing Economics, 31(1) 18-26. - links ratios to satisfaction to intent to stay

7. More Findings Dreya, L. Vanden Heede, K., Sermeus, W., & Lesaffre, E. (2013). The relationship between in-hospital mortality, readmission into the intensive care unit, and/or operating theatre and nurse staffing levels. Journal of Advanced Nursing, XXX, 1073-1081 - readmit into post-op ICU and/or OR = composite measure for adverse event - recommended change to staff by pt acuity

8. Safe staffing 3. And then…the rest of the story…. • Patient Safety Advocate Sorrel King https://www.youtube.com/watch?v=JeVcXhvPvbU 4. Federal response - AHRQ Ctr for QI and Patient Safety Agency for Healthcare Research and Quality • Genesis of Patient Safety Work Groups

9. AHRQ Collaborations for Safety • National Quality Forum • Retained to provide Patient Safety Work Group public comment & expert opinion on Common Formats • AHRQ TeamSTEPPS: AHRQ + DoD • PSOs – AHRQ publishes availability of formats in Federal Register • Partnerships for Patients

10. Staffing Impact - relationship between • # RNs : # patients • # years RN education : Patient mortality, 30 readmission & failure to rescue • Nurse satisfaction & burnout • Client satisfaction & outcomes data

11. State Staffing Law: • Nurse: Patient Staffing Ratios (1) • California • Staffing Committees (8) • CT, IL, NV, OH, OR, TX, WA • Disclosure and/or Public reporting of Staffing (5) • IL, NJ, NY, RI, VT • Traditional Staffing

12. Federal Staffing Law 42 CFR 482.23(b) Medicare certified hospitals must ‘have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed”

13. RN Safe Staffing Act • Require Medicare participating hospitals to have establish & publicly report unit staffing plans • Plans must: • ID minimum of RNS that may be adjustable • Include input from direct care RNs or their representatives • Be based on patient number and acuity needs • RN education, training and experience • Ancillary staff/services provided • Specialty organization guidelines • Facility\unit staffing, quality, client outcome & benchmark data • Assure RNs do not work on units for which not trained

14. Staffing in a Just Culture Similar to a culture of safety that encourages safer behaviors and enables a safer workplace, a culture of health provides a supportive work leadership with a favorable work environment and health-related policies that promote employee health and result in substantial decrease in employee health risks and medical costs.

15. A Fair & Just Culture is (TJC): • learns and improves by openly identifying and examining its own weaknesses. • is as willing to expose areas of weakness as to display areas of excellence. • is providing critical support of caregivers who feel safe when voicing concerns. • assures individual accountability for maintaining an outstanding care environment but will not be blamed for system faults beyond their control.

16. Audience…. Just Culture – what is that? • Two components….

17. Just Culture Strategic Vision Plan Development Ultimately, a Just Culture is about: • a fair, enlightened, and reasonable assessment of behavior and • produces a work environment that supports high reliability.

18. Unsafe Acts Algorithm…Just Culture To determine individual v system individual accountability: • Did the employee intend to cause harm? • Did the employee come to work drunk or equally impaired? • Did the employee knowingly and unreasonably increase risk? • Would another similarly trained and skilled employee in the same situation act in a similar manner (Reason's substitution test)? • If the first three answers are “No” and the last “Yes” the origin of the unsafe act lies in organization, not individual.

19. Just Culture…Good Citizenship • Just Culture = open commitment to good citizenship. • Employees and all care providers understand responsibility to support transparency and open communication.

20. Educate in Safety Concepts • human factors, • system complexity, • high reliability, • effective communication and • teamwork.

21. Clinical Findings…Research Parmeli, E., Flodgren, G., Fraser, S.G., Williams, N., Rubin, G. & Eccles, M. (2012). Interventions to increase clinical incident reporting in health care. Cochrane Collaboration DOI: 10.100/14651858.CD005609.pub2.

22. Regional Cases • Nursing ratios: California • Staffing committees: Washington • Quass v CHS • Use of non evidence based bed alarms • Introductions of MC l$170,000 potential lien against estate • Jury award • XXXXX v CHS • RN failure to awaken pt snoring at 3am; expired 3:20am • Anesthesiology issue / Miscommunication 12 post op

23. Lessons Learned • Applicable, reliable, credible evidence is the foundation upon which we practice • Moral distress is real / Application of a just culture framework is essential • Fostering nursing ownership of safe staffing is essential

24. Lessons Learned….(TJC) This is not utopian; it boils down to the comment, “I feel respected by everyone in each work interaction I have.” This state is achievable when outstanding leadership ensures that every employee clearly understands his own accountability and models such.

25. Malpractice/Profession Licensure Recommendations • Utilize ANA standards of nursing practice to define RN scope of practice • Link safe staffing to just culture framework • Educate RNs to staffing role • Integrate principles of ‘evidence based practice’ into legal arguments

26. Safe Staffing in a Just Culture Recommendations • Statutory change: own nursing practice • Staffing committees AND ratios • All settings vs isolated settings • Culture change: moral distress • Transparency • Post daily #RNs/Pts/Shift/Unit • Report data to HHS • Whistle blower protection Societal change • Nursing change

27. Phone: 509-385-7423 Email: dupler@gonzaga.edu Alice E. Dupler, JD, APRN-BC

28. THANK-YOU AND ENJOY YOUR STAY IN VEGAS!