Keeping Patients Safe Transforming the Work Environment of Nurses (2004) / Chapter Skim
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5 Maximizing Workforce Capability
5 Maximizing Workforce Capability
Pages 162-225
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From page 162... ...
The committee finds strong evidence that nurse staffing levels, the knowledge and skill levels of nursing staff, and the extent to which workers collaborate in sharing their knowIedge and skills affect patient outcomes and safety. The committee also finds that staffing levels in hospitals and long-term care facilities are uneven, posing risks to patient safety.
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From page 163... ...
Although there have been no experimental controlled studies of interventions that increased or decreased nurse staffing levels and measured the subsequent effect on patients, substantial evidence on the relationship between nurse staffing levels and patient outcomes has been produced by observational studies. This research has been conducted separately for acute care hospital and nursing home care.
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From page 164... ...
A problem with hospital-level aggregation is that heterogeneous nursing units, such as pediatric units, labor and delivery units, adult medical and surgical units, and ICUs, are combined. As a result, data on hospital-wide staffing levels may not well represent the staffing levels experienced by patients in a given nursing unit or of interest to poteniDiscussions of nurse-to-patient ratios can often be confusing.
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From page 165... ...
This issue is less significant in nursing homes, where heterogeneous nursing units are much less likely to exist, the resident population is more homogeneous, and variation in patients can be addressed for research studies as needed through case-mix adjustment. A number of studies of the effect of nurse staffing levels on patient outcomes have attempted to use patient mortality as an outcome measure.
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From page 166... ...
Nursing Homes The relationship between nurse staffing levels and patient outcomes in nursing homes has also been shown in numerous studies (Gustafson et al., 1990; Kayser-Tones et al., 1989; Nyman, 19881. Higher levels of registered nurse (RN)
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From page 167... ...
The Phase I report provides a discussion of relevant policy issues, including trends in payment and staffing levels in nursing homes; a discussion of how current federal regulatory staffing requirements are implemented; stakeholder perspectives; a literature review; and an analysis of different staffing data sources. The report also includes two other approaches to determining staffing needs: a time-motion study and use of operations research models.
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From page 168... ...
This sample included all residents with two MDS assessments 90 days apart. Outcome measures relevant to patient safety included incidents of pressure ulcers, skin trauma, and weight loss, which were then aggregated to the nursing home level.
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From page 169... ...
However, retention of less than 51 percent was associated with a high risk of adverse events, such as hospitalizations for UTIs and pressure ulcers. Explanations for the Causal Relationship Between Staffing Levels and Patient Outcomes Several studies have attempted to explain the relationship between higher levels of nurse staffing and improved patient outcomes.
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From page 170... ...
In nursing homes, the processes of care include a range of nursing activities, such as assistance with ADLs and monitoring of health status; therapeutic services, such as dressing changes and administration of medications; and other nursing activities, such as the management of incontinence. The outcomes of care can be measured as weight loss, pressure ulcers, incontinence, or other markers of physical decline (Zimmerman et al.,19951.
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From page 171... ...
reports staffing levels by type of patient care unit; (2) distinguishes directcare nursing staff from nursing staff in administrative, managerial, educational, or other non-direct patient care positions; or (3)
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From page 172... ...
As discussed in Chapter 3, data from a fiscal year 2002 national convenience sample survey of hospitals on staffing, scheduling, and workforce management of nursing department employees show similar variation. The 135 hospitals responding varied in nurse staffing levels even with the shift and type of patient care unit being held constant.
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From page 173... ...
Some studies specific to ICU staffing have been conducted; information on staffing levels in other hospital units, including medical-surgical units, is sparse. Overall hospital staffing As stated above, a problem with hospital-level aggregation is that when heterogeneous nursing units, such as pediatric units, labor and delivery units, adult medical-surgical units, and ICUs, are combined, hospital-wide staffing levels may not well represent the levels experienced by patients in a given nursing unit, and the findings of research can be clouded.
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From page 174... ...
Better understanding of actual nurse staffing levels is provided by studies that have examined staffing levels within specific types of patient care units. 5OSHPD's survey of hospitals is considered to be the most comprehensive in the United States and is held up as a model for other states.
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From page 175... ...
Hospitals falling one standard deviation below the mean had staffing ratios of one nurse for every 2.1 patients (Shortell et al., 1994~. This average of 1.5 patients ner nurse is identical to average ICU staffing levels 1 1 .
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From page 176... ...
This study estimated staffing levels using two methods: (1) computing a nurse staffing ratio based on the hospital-reported number of hours in a shift and the RN hours per patient for the shift, and (2)
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From page 177... ...
than those computed. These two methods yielded the average nurse-to-patient ratios and ranges of staffing levels by shift and rural/urban hospital status shown in Tables 5-4 and 5-5, respectively.
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From page 178... ...
OSHPD data also revealed that rural hospitals had higher staffing levels than urban hospitals (Spetz et al., 20001. Nursing Home Staffing Nurse staffing levels in nursing homes also are typically reported in terms of hprd.
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From page 179... ...
Federal nursing home regulations require that each facility receiving Medicare or Medicaid payments (the majority of nursing homes) have "sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care."8 These regulations also require all Medicare- or Medicaidcertified nursing homes to have an RN who is the director of nursing; at 842 Code of Federal Regulations (CFR)
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From page 180... ...
The committee believes the appropriate and coordinated use of all three approaches would have a synergistic effect and be most conducive to achieving safe staffing levels. Regulatory Approaches A number of labor, nursing, and consumer advocacy organizations recommend that quantitative ratios of the numbers of nursing staff or nursing hours per patient be mandated, in some form, for nursing homes and/or hospitals to promote safer patient care (Massachusetts Nurses Association, 2003; National Citizens Coalition for Nursing Home Reform, 1998; SEIU, 20011.
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From page 181... ...
In contrast, with the exception of studies of ICU staffing, the committee identified only one hospital staffing study that measured the effects of different staffing levels within a specific type of hospital patient care unit (i.e., medical-surgical unit ESochalski, 200111. In this study, the frequency of adverse events was subjectively reported by nursing staff using a Likert scale, rather than being counted using clinical data sets.
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From page 182... ...
Second, federal and state governments already regulate nursing home staffing levels, as described previously. Although a few states regulate hospital nurse staffing levels for specific types of patient care units (e.g., ICUs and labor and delivery units)
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From page 183... ...
With respect to the recommendation that DHHS specify staffing standards in regulations that would increase with the number of patients and be based on the findings and recommendations of the Phase II DHHS report to Congress on the appropriateness of minimum staffing ratios in nursing homes (CMS, 2001) , the committee notes that the thresholds identified in that study above which no further benefit from staffing ratios could be identified are above the staffing levels of 75-90 percent of facilities, depending on the type of staff.
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From page 184... ...
Thus, while staffing ratios can help protect against the most egregious staffing deficiencies, HCOs will need to employ more sensitive approaches internally to fine-tune staffing levels. More-Effective Internal Staffing Practices by HCOs Problems in the application of widely used tools to predict hospital staffing Many hospitals determine the amount of nursing staff they need to provide care on individual patient care units and shifts through the use of staffing tools collectively referred to as patient classification systems (PCSs)
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From page 185... ...
To the extent that these external work estimates were derived from work samplings for patient care units that differ from those of the institution using the PCS in terms of the experience level or skill mix of nursing staff, the availability of support staff, the way patient care is organized and delivered across units, and/or the physical layout of the nursing units and hospitalor are rationally derived using educated "best estimates," they will likely be inaccurate and unreliable estimates of how long it takes nursing staff within that particular institution to perform certain activities or care for a given level of patients. There is no "one size fits all" set of standard times that can be used across hospitals (Bayiz, 2003; DeGroot, 19941.
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From page 186... ...
This study found significant differences in the average prospective and retrospective classification scores in two of the three nursing units in which the study was conducted. For all three units, the retrospective PSC scores were higher than the prospective scores.
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From page 187... ...
Some urge the development of a formula approach to determining nurse staffing levels that would take into account multiple variables in addition to patient acuity, including RN staff expertise; work intensity; unit physical layout; and availability of NAs, other support staff, and physicians (Seago, 2002~. Failure of methods for predicting patient volume to keep pace with changes in hospital admission practices Compounding the above problems with predicting workload on the basis of patient acuity are problems in predicting daily and hourly patient volume.
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From page 188... ...
to a unit is not predictable, PCS predictions will be less accurate (Seago, 20021. Historically, hospitals have predicted patient volume and thereby staffing levels based on a daily census, typically taken at midnight.
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From page 189... ...
and nurse staffing levels are likely to continue to be made using some variant of PCSs. Estimates thus derived ideally should rely on work sampling studies conducted on the unit to which they will be applied, thereby better reflecting variations in the expertise and skill mix of nursing staff, the availability of support staff, the way patient care is organized and delivered across units, and the physical layout of the nursing unit and hospital (Bayiz, 2003; Malloch and Conovaloff, 19991.
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From page 190... ...
This principle of high involvement of nursing staff in selecting, modifying, and evaluating approaches to estimating nurse staffing is based on evidence presented in Chapter 4 describing the benefits of involving workers in work design and work flow decislon ma" ring. Provide for "on-time" staffing or demand elasticity to accommodate unpredicted variations in patient volume and/or acuity and respiting workioua[.
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From page 191... ...
However, staffing above projected need for each nursing unit will result in additional supply and higher labor costs. When staffing above predicted levels for each unit is not possible, additional staff will need to be obtained in other ways.
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From page 192... ...
Advocates of work sampling tools to reengineer nurses' work assert that achieving optimum nursing work distribution requires empowered nursing staff who are allowed to use their creativity and search for more efficient ways to delivery quality patient care (Upenieks, 19981. Allowing staff to regulate work flow will reduce the need for a float pool (Bayiz, 20031.
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From page 193... ...
Minimize staff turnover and use of nursing staff from external agencies. As discussed in Chapter 3, high turnover of nursing staff and the use of temporary staff from external agencies threaten patient safety by decreasing the continuity of patient care and introducing personnel with less knowIedge of nursing unit policies and practices.
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From page 194... ...
Hospitals and nursing homes should perform ongoing evaluation of the effectiveness of their nurse staffing practices with respect to patient safety, and increase internal oversight of their staffing methods, levels, and effects on patient safety whenever staffing falls below the following levels for a 24-hour day: · In hospital ICUs one licensed nurse for every 2 patients (12 hours of licensed nursing staff per patient day)
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From page 195... ...
With respect to the recommendation that hospitals and nursing homes perform ongoing evaluation of the effectiveness of their nurse staffing practices with respect to patient safety and increase their internal oversight of their staffing methods, levels, and effects on patient safety whenever staffing levels fall below the identified levels, we wish to offer the following clarification: these staffing levels are not intended to be rules that should never be violated, but to serve as yardsticks against which each hospital and nursing home can compare the results of the methods it uses to predict its staffing needs on a daily basis, across all shifts in the aggregate. Because of the very strong evidence linking staffing levels to patient safety, we believe that all hospitals and nursing homes should examine trends in their staffing levels and the daily patterns that emerge when their staffing levels are compared against these standards.
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From page 196... ...
This is the rationale behind the committee's recommendation that all HCOs provide for staffing elasticity or slack within each shift's scheduling to accommodate unpredicted variations in patient volume and acuity and resulting workload. Alternatively, if an HCO's staffing were consistently below these levels, it might want to pay particular attention to the recommendation to involve direct-care nursing staff in determining and evaluating approaches used to calculate appropriate unit staffing levels for each shift.
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From page 197... ...
Cainhs staffing indicators provide information on hprd for total nursing staff and by type of staff. Each nursing home is then rated based on its staffing levels.
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From page 198... ...
Establishing quantitative measures of nurse staffing levels for hospitals will be more difficult than for nursing homes. As discussed at the beginning of this chapter, hospitals have a large number of heterogeneous nursing units (e.g., labor and delivery, oncology, ICU, pediatrics)
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From page 199... ...
study on the appropriateness of minimum nurse staffing ratios in nursing homes states that a new staffing reporting and auditing system is needed for nursing facilities. During this phase of the study, payroll data were collected from nursing facilities in one state to assess the validity and reliability of staffing data from the Medicaid Cost Reports and OSCAR.
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From page 200... ...
Based on the importance of nurse staffing levels to patient safety, the role of the health care marketplace in promoting patient safety, and the current poor quality of nurse staffing data, the committee makes the following recommendation: Recommendation 5-4. DHHS should implement a nationwide, publicly accessible system for collecting and managing valid and reli
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From page 201... ...
. 201 The creation of such a system for collecting staffing data from hospitals and nursing homes should remedy the lack of a national database on hospital nurse staffing levels that, as previously cited, (1)
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From page 202... ...
, they frequently lack the resources to pursue continuing education on their own. Thus while the individual nurse is responsible for her or his own continuing education and training, all HCOs need to provide actively for their nursing staff's ongoing acquisition of new knowledge and skills, and to support the application of this knowledge and offer other decision support at the point of care delivery.
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From page 203... ...
This position is echoed by organizations employing nurses, organizations concerned with patient safety and quality of care, and nurses themselves. Likewise, in a statement before the Senate Committee on Health, Education, Labor and Pensions, TCAHO (2001)
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From page 204... ...
states and jurisdictions required RNs to engage in continuing education, and 4 required competency examinations (National Council of State Boards of Nursing,2001)
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From page 205... ...
The CMS (2001) Phase II final report on the appropriateness of minimum nurse staffing ratios in nursing homes includes a review of the training and education of NAs in nursing homes.
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From page 206... ...
As noted in Chapter 3, unlike NAs working in nursing homes, there are no federal requirements for the amount of training NAs working in hospitals must receive. Benchmark Training Practices in Other Industries and Health Care Worker training is not an issue unique to the health care industry.
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From page 207... ...
. Strategies to Support Nursing Staff In Ongoing Acquisition of Knowledge and Skills Continuing and in-service education using formal and informal classroom-style group lectures traditionally has been used to provide ongoing knowledge and skill acquisition in health care.
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From page 208... ...
CD-ROM-based and individualized text-based programs can be used to provide this individualized learning (Rauen, 20011. Peer support groups also are helpful to NAs in nursing homes in internalizing new knowledge (CMS, 20001.
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From page 209... ...
At a Tune 2002 invitational conference on Using Innovative Technology to Enhance Patient Care Delivery, sponsored by the American Academy of Nursing, attendees representing national health care associations, health care provider organizations, clinicians, and health care technology vendors identified minimal decision support for nurses within HCOs as a deficiency in their work environments (Bolton, 20021. Such supports can be both low-tech and high-tech.
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From page 210... ...
The AHRQ evidence-based report Making Health Care Safer: A Critical Analysis of Patient Safety Practices cites conflicting evidence on the efficacy of clinical pathways in influencing provider behavior and patient safety (Trowbridge and Weingarten, 2001a)
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From page 211... ...
HCOs should dedicate budgetary resources equal to a defined percentage of nursing payroll to support nursing staff in their ongoing acquisition and maintenance of knowledge and skills. These resources should be sufficient for and used to implement policies and practices that:
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From page 212... ...
FOSTERING INTERDISCIPLINARY COLLABORATION Because of the increasing acuity of their health care needs, individual patients are often attended to by an array of different health care providers with whom nursing staff must interact, including physicians, pharmacists, allied health providers, social workers, and unlicensed health care technicians. Sometime nurses interact with these providers as members of a formal interdisciplinary team of health care providers, such as in the OR or emergency department.
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From page 213... ...
Clinical competence as a component of effective interaction and coordination of medical and nursing staff has been associated with lower risk-adjusted length of stay (Shortell et al., 1994) , lower nurse turnover, higher professionally evaluated technical quality of care (Mitchell et al., 1996; Shortell et al., 1994)
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From page 214... ...
Shared understanding of goals and roles Collaboration is enhanced by shared unclerstancling of an agreeci-upon collective goal (Gittell et al., 2000~. Role confusion and role conflict are a frequent barrier to interdisciplinary collaboration (Rice, 2000~.
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From page 215... ...
. Of the 674 RN respondents to this survey who were currently employed as full-time hospital or nursing home general-duty staff, 82.4 percent agreed or agreed strongly with the statement, "In my job, doctors and nurses have i3These states were selected because they have large ethnic diversity in their RN populations and because they renew RN licenses annually, providing up-to-date mailing lists.
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From page 216... ...
· Commitment of resources to build nurse expertise The strong evidence cited above that individual clinical competency is an essential precursor to collaborative practice is further reinforcement for recommendation 5.5 regarding the actions HCOs should take to support nursing staff in their ongoing acquisition and maintenance of knowledge and skills. · Design of work and workspace to facilitate collaboration Collaboration is facilitated by providing workspaces that encourage physical proximity among those performing the work and by ensuring that staff have the time to participate in collaborative activities, such as conducting interdisciplinary patient rounds (Baggs and Schmitt, 19971.
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From page 217... ...
HCOs can act on this information to build and nurture collaboration across health care providers. Many strategies to this end have already been addressed in the committee's recommendations pertaining to evidence-based management, staffing, and the acquisition of new knowledge and skills by nursing staff.
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From page 218... ...
1998. The relationship between nursing staffing levels and nursing home outcomes.
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From page 219... ...
2000. Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase I Report.
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From page 220... ...
1996. The effect of Medicaid reimbursement on quality of care in nursing homes.
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From page 221... ...
Nursing Staff in Hospitals and Nursing Homes: Is It Adequate? Washington, DC: National Academy Press.
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From page 222... ...
1998. Nurse staffing levels and adverse events following surgery in U.S.
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From page 223... ...
Stewart M, Zelevinsky K.2002. Nurse-staffing levels and the quality of care in hospitals.
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From page 224... ...
Nursing Home Staffing Information: Does It Reflect Differences in Quality of Care? Los Angeles, CA: California HealthCare Foundation.
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From page 225... ...
2002. Nursing staff reductions in Pennsylvania hospitals: Exploring the discrepancy between perceptions and data.
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