Ashley borowiak, rn Nursing 450 Ferris state university Staffing Ratios Ashley borowiak, rn Nursing 450 Ferris state university

Introduction Nurse ratios are determined by working hours per patient per day. Nursing ratios are the number of patients assigned to a staff member. Nurse staffing can have effects on the quality of care patient’s receive, patient safety, and adverse outcomes from the plan of care.

Objectives Identify if a correlation exists between nurse to patient ratios and patient outcomes. Recognize mandated staffing ratios and the consistency across health care locations. Identify nursing implications of high and low nurse to patient ratios. Identify systems used to determine staffing numbers. Discuss theories related to the subject.

Theories Related to Nurse Staffing Nursing Services Delivery Theory Recognizes that many different factors affect the work demands in the health care system and nurse staffing. Input, throughput, and output interact to determine staffing needs and work demands. Staffing research has shown a correlation with key nurse staffing indicators and patient outcomes. Meyer & O’Brien Pallas, 2010

Theories Related to Nurse Staffing Maslow’s Hierarchy of Needs Nurses need to feel safe in the environment they practice, have a sense of belonging to their organization, and to feel empowered. This is achieved through Maslow’s Hierarchy of Needs. Inadequate staffing raises a nurses stress level, causing job dissatisfaction. These stressors can threaten patient safety and negatively affect the environment in which they practice in. Nurses are advised to address their basic needs to provide safe and quality care. Groff Paris & Terhaar, 2011

Achieving Self Actualization

Assessment of Health Care Environment Outpatient Environment-Hospice Guidelines have been in place since 1994. Varying acuity depending on home care patients or short length of service patients Often times family present to assist with cares. Uses an assessment process to estimate staffing levels such as characteristics of the patient population, level of care, length of service (LOS), and the environment. National Hospice and Palliative Care Organization [NHPCO], 2013

Assessment of Health Care Environment Higher percentage of short LOS which means acuity could be higher in the first week or two of care, and the patient ‘s needs are more resource intensive. Lower percentage of routine patients who partake in home care, which indicates a higher number of inpatients receiving continuous care. Issues for nurses to consider when determining staffing: Psychosocial issues of the complexity of the patient’s needs Safety issues for the nurse High intensity of services NHPCO, 2013

Assessment of Health Care Environment Inpatient Environment-Acute and Long Term Care Different levels of acuity of patients Confusion, frequent repositioning and toileting, frequent prn medications Severity of diagnosis and level of stability Staffing policies vary between facilities and states Delegation is often an underutilized tool that can ease the workload of nurses and CNAs. Ability to pull staff from other units to assist if needed Census changes throughout the day Discharges, Admissions

Management and Education Services for Healthcare (MESH) MESH is a patient centered acuity system designed to determine staffing by identifying patient’s distinctive needs. The Patient Classification and Staffing System Module (PCSS) is one of four modules used within MESH to assist with proper staffing. Prior to staffing for the next shift, a projected census is formulated to determine staffing needs and patients are categorized into acuity levels. University of Wisconsin, 2014

MESH System Taking census and acuity information, the system calculates the number of staff needed. The system will notify the person making staff assignments if the unit will overstaffed or understaffed depending on the data entered. University of Wisconsin, 2014

MESH System Nurses making staff assignments are able to and encouraged to documents notes regarding projected and actual decisions made in regards to staffing. All0ws for nurse explanation as why staff decisions were made to allow for better decision making in the future. University of Wisconsin, 2014

Census Grids Staff is determined solely by number of patients on the unit. Acuity is normally not a factor in census grids. Black and white-Nurses do not have ability to make judgments on staffing decisions Staffing adjustments are made according to the census grid

Root Cause Analysis

California Assembly Bill 394 In 1994, law was passed that requires acute care hospitals to maintain a minimum nurse to patient ratio. First state to initiate Facilities are required to use an acuity classification system Mandated staffing ratios are unit specific Facilities required to record and report staffing numbers to ensure compliance with the law. Agency for Healthcare Research and Quality [AHRQ], 2014

California Assembly Bill 394 What were the outcomes of the new legislation? Higher staffing levels Nurse hours per patient day increased from 6.03 to 7.11 Reduced Nurse Workload Average patients per shift decreased to 4.1 Fewer patient deaths In California, the death rate was 10-13 percent lower than 2 other states which do not have staffing mandates Decrease in nurse burnout and high job satisfaction 66 percent of nurses in California agreed they are more likely to remain in their jobs as a result of the legislation AHRQ, 2014

Michigan’s Safe Patient Care Act Proposed by State Representative Jon Switalski and State Senator Rebekah Warren Would implement a staffing plan which would have a minimum nurse to patient ratio. Facilities would create their own staffing plan Facilities would be banned from using mandatory overtime to compensate for poor staffing planning Studies show that facilities would benefit due to shorter lengths of stay, a decrease in readmissions, decreased legal liability for all complications that are associated with nurse staffing, and less nurse turnover. Michigan Nurses Association, 2014

Mandated Staffing Ratios Positives Ensure safe care if provided Increased job satisfaction Increased patient outcomes Nurse recruitment Negatives Reduction in hospital services Increased emergency room diversions Increased unit closures Increased expenses Nurses in Minnesota from facilities speak out on why staffing mandates would have a negative affect on the care their patients receive. https://www.youtube.com/watch?v=fY-fQ4ewPMM American Organization of Nurse Executives, 2014

Inferences and Implications Adequate staffing has been proven to: Reduce medication errors Decrease complications relating to patient diagnosis Decrease patient mortality Increase patient satisfaction Reduce nurse fatigue Decrease nurse burnout Increase job satisfaction ANA, 2014

Patient Outcomes High Nurse Staffing Reduces UTIs Pneumonia Shock Upper GI Bleeding Longer Hospital Stay & Preventable Readmissions Decreases costs lost by facility for little to no CMS reimbursement Failure to Rescue Greater patient and family satisfaction Failures in the plan of care and meeting outcomes AHRQ, 2014

Nurse Burnout and Turnover Rates Decreased work conditions and stressful environments have been proven to have direct negative effects on a nurses satisfaction with their job. Patient satisfaction is much less in facilities where nurse burnout and turnover rates are higher. Nurses working in direct patient care areas (especially those which are short staffed) have the highest burnout rates. High burnout and turnover rates have direct negative affects on patient care. McHugh, Kutney-Lee, Cimiotti, Sloane, Aiken, 2011

Budgeting Hospital budgets are one of the main reasons for staffing issues at facilities. Hospitals spend a large amount of dollars in overtime pay and incentive pays for outside nurses. Many nurses do not see unit budgets or are aware the amount of funds paid out to employees

Centers for Medicare/Medicaid Services (CMS) Reimbursement Medicare spends $15 billion a year on preventable hospital readmissions. Hospital Readmissions Reduction Program Research has proven that hospitals with adequate staffing have a lower level of readmissions. Government can assist with decreasing readmissions by: Mandating minimum staffing levels Using benchmarks and payment incentives based on nurse staffing Public reporting of nurse to patient ratios Mitka, 2013

Recommendations for Quality and Safety Improvements Quality and Safety Education for Nurses (QSEN) Competencies Patient Centered Care Recognize the patient as a the main source for providing compassionate and coordinated care. Proper staffing ratios can deliver safe and quality care which the patient is entitled to. Evidence-Based Practice Integrate the best current evidence to deliver optimal care. Continue to study the positive affects that staffing mandates and increase staffing have on patient outcomes. QSEN Institute, 2014

Recommendations for Quality and Safety Improvements QSEN Competencies Quality Improvement Use improvement methods to design changes to improve the quality and safety of health systems. Discover and test new staffing grids to optimize patient care Seek out information and formulate a root cause analysis to determine the cause of staffing issues. QSEN Institute, 2014

American Nurses Association (ANA) Standards Standard Nine: Evidence Based Practice The nurse will incorporate research into everyday practice. With this, nurses can discover ways to improve upon staffing issues to deliver quality care and reduce nurse stress. Standard 10: Quality of Practice The nurse delivers quality care in his or her nursing practice. Regardless of staffing issues and/or patient ratios, nurses should deliver safe, quality care, without taking shortcuts to get tasks accomplished that could sacrifice the safety of the patient (i.e. leave catheters in too long, disregard dressing changes) Standard 16: Environmental Health The nurse practices in an environmentally safe and healthy manner. Nurses reach Maslow’s hierarchy of needs and promotes a health environment so patient care can be optimized. Ferris State University, 2014

Summary Nurse to patient ratios vary between environments Research and studies can improve the way facilities staff their units and improve patient care Staffing can have both positive and negative affects on patients and the facility Government mandates are not widely accepted by those in the health care field Using the standards set by the ANA and QSEN, nurses can continue to deliver optimal patient care.

References Agency for Healthcare Research and Quality (2014). Hospital nurse staffing and quality of care. Retrieved from http://www.ahrq.gov/research/findings/factsheets/services/nursestaffing/index.html#Staffing Agency for Healthcare Research and Quality (2014). State-mandated nurse staffing levels alleviate workloads, leading to lower patient mortality and high nurse satisfaction. Retrieved from http://innovations.ahrq.gov/content.aspx?id=3708 American Organization of Nurse Executives (2014). Mandated staffing ratios. Retrieved from http://www.aone.org/resources/leadership%20tools/staffingratios.shtml Barton, N. (2013). Acuity-based staffing: Balance cost, satisfaction, quality, and outcomes. Nurse Leader, 11(6), 47-50. Centers for Medicare and Medicaid Services (2012). Design for nursing home compare five-star quality rating system. Retrieved from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf Ferris State University (2014). Standards of professional nursing practice (ANA). Retrieved from http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/Standards-of-Professional-Nursing-Practice.htm Groff Paris, L., & Terhaar, M. (2011). Using Maslow’s pyramid and the national database of nursing quality indicators to attain a healthier work environment. The Online Journal of Issues in Nursing, 16(1).

References McHugh, M.D., Kutney-Lee, A., Cimiotti, J.P., Sloane, D.M., & Aiken, L.H. (2011). Nurses’ widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care. Health Affairs, 30(2), 202-210. doi: 10.1377/hlthaff.2010.0100 Meyer, R.M., & O’Brien-Pallas, L.L. (2010). Nursing services delivery theory. Journal of Advanced Nursing, 66(12), 2828-2838. doi: 10.1111/j.1365-2648.2010.05449.x Michigan Nurses Association (2014). MI needs a safe staffing law now! Retrieved from http://www.minurses.org/legislation/safepatientcare Mitka, M. (2013). Greater nurse staffing may lower hospital readmissions. The Journal of the American Medical Association, 310(18). National Hospice and Palliative Care Organization (2013). Staffing guidelines for Hospice home care teams. Retrieved from http://www.nhpco.org/sites/default/files/public/quality/Staffing_Guidelines.pdf QSEN Institute (2014). Pre-licensure KSAS. Retrieved from University of Wisconsin (2014). Management and education services for healthcare (MESH). Retreieved from http://www.uwhealth.org/misc/mesh/management-and-education-services-for-healthcare-mesh-patient-classification-and-staffing-system/35619