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5 Staffing and Quality of Care in Hospitals
Pages 92-127

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From page 92...
... Reports of hiring freezes and layoffs of RNs in hospitals have led to increasing apprehension among them and their supporting organizations about the potential threat to the quality of patient care in hospitals as well as their physical and economic wellbeing. RNs have expressed concerns that hospitals are implementing a variety of nursing care delivery systems involving major staff substitutions, reducing the proportion of RNs to other nursing personnel by replacing them with lessertrained (and at times untrained)
From page 93...
... This chapter examines the relationship of staffing patterns of nursing personnel in hospitals and quality of patient care. The chapter begins with a discussion of the restructuring of hospital care and the changing roles of nursing personnel in hospitals.
From page 94...
... Staff reductions or changes in labor mix are at times implemented without attention to the organizational changes that might facilitate the possibility of better outcomes with fewer, more appropriately trained and used staff, while at the same time focusing on improved patient outcomes (VHA, 1995~. The labor intensity of nursing services in hospitals cannot be disputed when one considers the fact that the average nursing department's full-time-equivalent (FTE)
From page 95...
... It is not surprising, therefore, that the restructuring of hospitals and redesign of nursing services are among the most pressing issues for the nursing profession and ultimately for the future of health care delivery in hospitals. Staffing to provide safe, effective, and therapeutic patient care is a challenge for nurse administrators under any circumstances, and substantial changes are occurring in the organization and delivery of hospital care.
From page 96...
... Today's work redesign appears to be changing some of those schedules back to the more traditional 8-hour day and 40-hour week, reducing some costs in doing so and providing the potential for more stability in staffing systems that provide opportunity for some nursing staff to practice across the boundaries of inpatient and ambulatory or community nursing care. It is this latter challenge, along with the demands for increased efficiency within a standard of good quality of care that, in part, has led many hospitals to implement the concept of care teams.
From page 97...
... They also are responsible for the ongoing primary care of a group of healthy individuals. The value of such clinical nurse specialists, in terms of both patient care and economic factors have been studied over the past 20 to 25 years.
From page 98...
... Oncology clinical nurse specialists have also been shown to improve patient outcomes. McCorkle and colleagues (1989)
From page 99...
... RECOMMENDATION 5-1: The committee recommends that hospitals expand the use of registered nurses with advanced practice preparation and skills to provide clinical leadership and cost-effective patient care, particularly for patients with complex management problems. Advanced practice nurses are typically classified in at least one of four ways, and their educational training and duties differ accordingly.
From page 100...
... Clearly, well-trained advanced practice nurses can function in a number of different roles. They can work independently to solve patient care problems, serve as patient advocates, and be integral members of a health care team.
From page 101...
... The use of NAs and other ancillary nursing personnel to assist RNs with patient care is reported to have increased in recent years. In most instances, NAs and other ancillary nursing personnel are used in simple bedside care or as unit assistants (e.g., changing dressings, taking vital signs such as blood pressure and temperature)
From page 102...
... The committee is greatly concerned about this lack and the potential for adverse impact on patient care. RECOMMENDATION 5-2: The committee recommends that hospitals have documented evidence that ancillary nursing personnel are competent and that such personnel are tested and certified by an appropriate entity for this competence.
From page 103...
... Restructuring of inpatient services in hospitals, accompanied by a changing mix of nursing personnel, is an inevitable consequence of the demands by society, through the payers of care, to control the costs of health services. Downsizing of the patient care workforce in inpatient hospital settings will continue, at least in the near future.
From page 104...
... Furthermore, the health care sector is moving rapidly to adopt principles of continuous quality improvement and total quality management as means for addressing issues in quality of care, for advancing the state of the art of quality measurement and management, and for promoting continuous progress in health care processes and patient outcomes. These newer quality assurance and improvement techniques rely heavily on input from multiple segments of a health organization's personnel and departments; that is, they do not deal with quality issues that relate to only a single department, in part because most problems in health institutions and facilities are systemic rather than traceable to single events, people, or units.
From page 105...
... As stated earlier, throughout the period of the committee's study changes were occurring in hospitals in the use of RNs and in the ratio of RNs to other nursing personnel in the organization of the delivery of patient care. Many of them intimated that such changes potentially will diminish the quality of care provided but the committee was unable to find evidence of a decline in the quality of hospital care because of any changes in staffing.
From page 106...
... Among the many questions that warrant attention are the implications of restructuring for career choices, the structure of occupational ladders, and both entry and midcareer curriculum design. RECOMMENDATION 5-4: The committee recommends that hospital management monitor and evaluate the effects of changes in organizational redesign and reconfiguration of nursing personnel on patient outcomes, on patient satisfaction, and on nursing personnel themselves.
From page 107...
... Excluding resource constraints in the definition provides the opportunity for Quality assurance (QA) and Quality Improvement (QI)
From page 108...
... outcomes of care. Thus, the question of whether problems with the levels of nurse staffing or the mix of competencies within a nursing staff may be associated with poor care and risk of patient harms is a reasonable one, but the probable lack of explicit information on any association between such structural variables and the larger issues of interest must be clearly understood from the outset.
From page 109...
... Recent years have seen important advances in measuring quality of patient care at the individual patient and population levels,3 involving both process and outcome measures. From the vantage point of this study, however, existing work has not typically focused on isolating the contribution of nursing care in measuring the quality of patient care in hospitals.
From page 110...
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From page 111...
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From page 112...
... suggests, in particular, that complication rates will not be related significantly to mortality rates. Those problems notwithstanding, it should be clear that for the purposes of this study, such information tells little, if anything, about the precise role of nurse staffing levels or mix in promoting higher-quality patient care.
From page 113...
... Moreover, as with the earlier generic screen approach, these types of measures tell little about nursing care per se. Status of Hospital Quality of Care Quality of patient care is central to the delivery of health care services in hospitals.
From page 114...
... Quality was measured by both outcome measures 30- and 180-day mortality rates after admission and an indicator of whether the patient was discharged from the hospital in an unstable condition and measures of implicit and explicit process. The implicit process indicators were summary measures of process of care giving the physician reviewers' overall assessment of the quality of the care process for a particular hospitalization.
From page 115...
... Although the quality of nursing care was measured, details about performance of RNs have not been provided in the reports published to dated Inferentially, however, the levels of quality of nursing care must have been well within acceptable limits, given the overall findings of acceptable quality of care and the fact that decisions to discharge patients (unlike the planning for discharge and for care postdischarge) are not made by nurses.
From page 116...
... RELATIONSHIP OF NURSING STAFF TO QUALITY OF PATIENT CARE The issues surrounding the relationship of staffing levels and staffing patterns of nursing personnel and outcomes have taken on added importance since the committee was established. Hospitals are restructuring and redesigning the organization and delivery of patient care, and the committee heard many reports of reduction of nursing staff and its adverse effects on quality of care.
From page 117...
... Literature on RNs' impact on hospital mortality rates is considerable. Prescott (1993J provides a comprehensive review of empirical evidence of the impact of nursing staff levels and mix on quality of patient care in hospitals.
From page 118...
... in a demonstration project to document fiscal costs and patient care effectiveness of critical care nursing in a unit characterized by valued organizational attributes, reported findings similar to those of Knaus and colleagues. Units characterized by a high perceived level of nurse-physician collaboration, highly rated objective nursing performance, and significantly more positive organizational climate were associated with desirable clinical outcomes such as low mortality ratio, no new complications, and high patient satisfaction.
From page 119...
... When institutional attributes or characteristics are the focus of hospital mortality studies, many organizational correlates are examined, of which nursing often is one (Shortell and Hughes, 1988; Hartz et al., 1989~. Nurse-to-patient ratios or nurses as a percentage of total nursing personnel are sometimes found to be significant correlates of patient mortality rates, but usually these studies give little consideration to the mechanisms by which staffing ratios might affect patient outcomes.
From page 120...
... Furthermore, these two studies confirm that the same factors that lead hospitals to be identified as effective from the standpoint of the organization of nursing care are associated with lower mortality among Medicare patients. Aiken and colleagues concluded that although RN-rich staffing ratios are sometimes associated with improved outcomes, the results of their research indicate that such staffing ratios are essentially a proxy measure for other organizational attributes of hospitals that grant nurses autonomy over their own practice and control of the resources necessary to deliver patient care and create good relationships with physicians.
From page 121...
... The committee supports efforts to improve systems for planning appropriate nursing care as well as monitoring the outcomes of that care. The committee believes that high priority should be given to obtaining empirical evidence that permits one to draw conclusions about the relationships of quality of inpatient care and staffing levels and mix.
From page 122...
... A major part of any such research agenda might call for elaboration of the actual variables in terms of structure, process, and outcome that warrant high priority attention in studies of the relationship of nursing care, staffing patterns for nursing, to patient outcomes. As discussed below, for example, the American Nurses Association (ANA)
From page 123...
... no measures reflect nursing care as distinct from hospital care, and (2) the information provided by only mortality and length-of-stay data is insufficient to understand the quality of patient care processes or outcomes other than death.
From page 124...
... assessment of patient care requirements (Telephone communications with Janet Heinrich, Director, American Academy of Nursing)
From page 125...
... Furthermore, JCAHO standards for nursing care place a new emphasis on the role, responsibility, qualifications, and accountability of the nurse executive, including the authority and responsibility for ensuring that standards of nursing practice are in place and meet JCAHO's patient care standards (JCAHO, 19941. The hospital organization must provide "a sufficient number of qualified nursing staff members to assess the patient's nursing care needs; plan and provide nursing care interventions; prevent complications and promote improvement in the patient's comfort and wellness; and alert other care professionals to the patient's condition as appropriate" (JCAHO, 1994, p.
From page 126...
... not accredited. Given the continued reliance of the federal government on this approach to certification for hospital reimbursement through federal health programs, the committee is encouraged by the evolution of JCAHO methods and standards in the past few years and by the more sophisticated attention being paid to the role of nursing care in those standards.
From page 127...
... The committee concludes that a clear need exists for a system for monitoring and evaluating the impact of the rapidly changing delivery system on the quality of patient care and the well-being of nursing staff. For this reason, it has advanced several recommendations intended to provide better information on hospital restructuring and to help in delineating those factors that affect patient outcomes.


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