ANA Principles for Nurse Staffing Ohio Nurses Association Convention 11 October 2013 Katherine A. Kany, MSN, BS, RN Assistant Director/AFT Healthcare

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The Most Amazing Feats of Daring; All done without a safety net! 3

Appropriate Nurse Staffing Appropriate nurse staffing is a match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation. The provision of appropriate nurse staffing is necessary to reach safe, quality outcomes; it is achieved by dynamic, multifaceted decision-making processes that must take into account a wide range of variables. (ANA, 2012) 4

How do we determine appropriate nurse staffing and what are the variables that need to be factored into that determination?

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Pathway to the Principles: Conception and Gestation Recognition of the problem. Identification of subject matter experts. Review and annotation of the literature. Convening of the expert panel. Deliberations and discussion of the state of the science. Consideration of nurse: patient ratios. Identification of the structure, process and outcome variables comprising the PNS. 7

I. Patient Care Unit Related Appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs. There is a critical need to either retire or seriously question the usefulness of the concept of nursing hours per patient day (HPPD). Unit functions necessary to support delivery of quality patient care must also be considered in determining staffing levels. 8

The specific needs of various patient populations should determine the appropriate clinical competencies required of the nurse practicing in that area. Registered nurses must have nursing management support and representation at both the operational level and the executive level. Clinical support from experienced RNs should be readily available to those RNs with less proficiency. 9 II. Staff Related

III. Institution/Organization Related Organizational policy should reflect an organizational climate that values registered nurses and other employees as strategic assets and exhibit a true commitment to filling budgeted positions in a timely manner. All institutions should have documented competencies for nursing staff, including agency or supplemental and traveling RNs, for those activities that they have been authorized to perform. Organizational policies should recognize the myriad needs of both patients and nursing staff. 10

ANA Principles for Nurse Staffing, 2 nd Edition (2012) Principles Related to the Healthcare Consumer Principles Related to Registered Nurses and Other Staff Principles Related to Organization and Workplace Culture Principles Related to the Practice Environment Principles Related to Staffing Evaluation 11

PNS Policy Statements Nurse staffing patterns and the level of care provided should not depend on the type of payor. Evaluation of any staffing system should include quality of worklife outcomes, as well as patient outcomes. Staffing should be based on achieving quality of patient care indices, meeting organizational outcomes and ensuring that the quality of the nurse's worklife is appropriate. 12

What Does This Do for the Problems We Face? 13

Framework for Appropriate Nurse Staffing 14

Weaving the PNS into a Valuable Framework Legislative language. Contract language. Assessing staffing systems. Information with which to educate policymakers and the public. 15

PNS as a Legislative Framework Staffing systems must: Be created with input from direct-care RNs. Be based on the number of patients and level and intensity of care to be provided, with consideration given to admissions, discharges and transfers that nurses must handle each shift. Reflect the level of preparation and experience of those providing care. 16

Legislative Framework (contd.) Account for architecture and geography of the environment and available technology. Reflect staffing levels recommended by specialty nursing organizations. Provide that a RN not be assigned to work on a particular unit without first having established the ability to provide professional care in such a unit. 17

Federal Staffing Bills H.R Registered Nurse Safe Staffing Act of 2013 (Capps/CA) Requires staffing plans to identify appropriate number of registered nurses provide direct patient care in each unit that: (1) address the unique characteristics of the patients and hospital units; and (2) result in the delivery of safe, quality patient care consistent with specified requirements. H.R Nurse Staffing Standards for Patient Safety and Quality Care Act of 2013 (Schakowsky/IL) Minimum direct care registered nurse-to-patient ratio by unit + adjustments above. HHS to develop a national acuity tool to establish nurse staffing requirements above minimum ratios. S National Nursing Shortage Reform and Patient Advocacy Act (Boxer/ CA)-same provisions as H.R Reference: 18

Using the PNS to Evaluate Staffing Does the staffing plan account for the myriad patient needs? Does the staffing plan factor the nurse staff characteristics? Does the staffing plan consider the practice environment? Does the staffing plan reflect the 19

PNS Used in Contract Language Hawaii Nurses Association (patient acuity system) Michigan Nurses Association (nursing- sensitive outcomes data review) Ohio Nurses Association … 20

Educating the Public and the Policy Makers Using the PNS as a framework, nurses can explain the complexity of staffing decision- making: Distinguishing the abilities of nurses from a range of perspectives (expertise, fatigue, orientation to unit). Quantifying the level of illness and requisite care needs of each patient. Clarifying the continuum of care. Highlighting the need for autonomy. Measuring the sufficiency of staffing. 21

Are Ratios Necessary; Are Ratios Enough? What everyone forgets about California; ratios are the fallback staffing method. A nurse is not a nurse; a patient is not a patient. Technology and implications for the care process; care can protracted rather than shortened with some of the HER requirements. Safety nets versus ceilings; what we miss when we rush to use ratios. 22

How Can You Use the PNS? Lobbying efforts Contract proposals Organizing tool Setting the standard for all staffing deliberations at the facility, state and federal level Contract committee resource or policy Patient classification system assessment Other ?? 23

References: American Nurses Association (ANA).(1999). Principles for nurse staffing.Washington,DC:Author. American Nurses Association (ANA).(2012). Principles for nurse staffing(2 nd ed.) Silver Spring, MD: Nursebooks.org. Needleman, J., Buerhaus, P., Pankratz, V., Leibson, C., Stevens, S., & Harris, M. (2011) Nurse staffing and inpatient mortality. New England Journal of Medicine, 364(11), Weston, M., Brewer, K., & Peterson, C. (2012). ANA Principles: The framework for nurse staffing to positively impact outcomes. 24