1. Achieving Excellence in Nurse Staffing: Leveraging the Evidence
A Presentation of the Wisconsin Organization of Nurse Executives for Health Care Boards, Administrators and Medical Staff Leaders
© WONE – June, 2015

2. Objectives
Examine the evidence that links professional nurse staffing, professional practice environments and level of education to patient outcomes.
Describe initiatives at the national and state level that address professional nurse staffing.
Discuss implications for staffing decisions within organizations.

3. A Historical Perspective…
Decision making concerning staffing in health care organizations has been largely opinion-based due to a paucity of evidence.
“Benchmarking” has consisted of comparing the staffing decisions in one organization with those in another.
Results of staffing decisions frequently include unintended downstream consequences and are not sustainable.
In health care, in the absence of evidence on which to base our decisions, we go with practice wisdom. We have seen significant shifts in the clinical care of patients, as emerging evidence confirmed there are best ways to do things. Examples include the use of the VAP Bundle to prevent ventilator associated pneumonia and the use of the CLABSI Bundle to prevent central line associated blood stream infections.
We recognize the obligation to practice consistent with best evidence in clinical care, but this concept has been less well developed in management decision making. Until the past decade, there has been insufficient evidence on which to base staffing decisions. Now, however, the evidence that has emerged on nurse staffing, and its relationship to patient outcomes, has crossed the threshold that requires a change in practice.
Our approach to benchmarking has become outdated, as it reflects opinion-based decision making and is linear, meaning it does not take into account the downstream effects and sustainability of staffing decisions. Benchmarking, to be meaningful, must include an understanding of the outcomes being produced by a given staffing level, including clinical outcomes, patient satisfaction, and employee and physician engagement.

4. Emerging Evidence
Nurse staffing and the professional practice environment directly impact patient outcomes – mortality, “failure to rescue”, readmission rates, preventable complications and patient experience.
Organizations with the best staffing and positive practice environments have been demonstrated to produce the best outcomes.
The Affordable Care Act has identified improved outcomes (clinical and patient experience) as a priority goal. Through the use of rewards and penalties, we will be paid based on the outcomes we produce. Understanding the links between nurse staffing, the practice environment and patient outcomes will be essential to our effectively positioning ourselves to be successful in this transformational era.

5. What We Know…
Nurses who work in well-staffed hospitals have the time and resources to effectively execute the care processes that influence readmission. They are better equipped to monitor for complications and adverse events.
Nurses’ constant presence enables them to prepare patients and families for discharge throughout hospitalization. This preparation and teaching supports seamless transition to other settings.
Nurses are sentinels in identifying early warning signs and addressing complications and adverse events that increase readmission risk.
Nurses at the point of care play an integral role in preventing complications and preparing patients to successfully engage in self care once discharged from the hospital.

6. Extensive Research has Produced New Knowledge
Numerous, robust studies have equipped us with the evidence to drive decision-making. They have withstood the rigorous peer review processes of Health Affairs, Medical Care, The New England Journal of Medicine, The Journal of the American Medical Association and the major Nursing Journals.
The research studies have been conducted on a large scale. For example:
665 hospitals in 4 large states
1,262,120 hospital discharge abstracts
39,038 registered nurse participants
American Hospital Association data
As you can see from this slide, the research on nurse staffing has been extensive and widely published in the medical and health care literature, as well as the nursing literature.
The scope of the research has been extensive as illustrated by this example of a single study.

7. The Evidence…
In a study evaluating mortality and “failure to rescue” in surgical patients in Magnet (56) and non-Magnet (508) hospitals in 4 states:
Magnet hospitals had a 14% lower odds of mortality and 12% lower odds of “failure to rescue” than non-Magnet hospitals
Magnet hospitals had significantly better work environments than Non- Magnet hospitals.
The literature tells us that the hallmarks of successful organizations are flat organizational structures with accessible, informed managers, decentralized decision-making and empowered frontline workers to make decisions.
The next few slides summarize the findings of several major research studies that have been conducted in recent years to understand the impact of staffing and work environments on patient outcomes.
Professional Practice environment is measured using the Nursing Work Index-Revised (NWI-R)
It measures – nurse participation in hospital affairs, control over practice, nurse-physician relationships, nurse manager ability, staffing adequacy and organizational support.
The nursing care environment is an attractive target for organizational intervention because all hospitalized patients are exposed to direct care nurses throughout their hospital stay.

8. The Evidence…
In a study evaluating 30-Day readmissions among Medicare patients with Heart Failure, Acute Myocardial Infarction and Pneumonia:
Each additional patient per registered nurse above the average workload (4.9 patients) resulted in 7% higher odds of readmission for Heart Failure, 6% for Pneumonia and 9% for Myocardial Infarction.
The odds of readmission in good versus poor work environments were 7% lower for Heart Failure, 6% lower for Myocardial Infarction and 10% lower for Pneumonia.

9. The Evidence…
In a large study evaluating the effects of nurse staffing and work environment on inpatient mortality and failure to rescue on general, orthopedic and vascular surgery patients in 4 states:
Best staffed hospitals with better work environments decrease the odds of mortality by 12% and failure to rescue by 14%.
>25% of the hospitals had patient to RN ratios of 4 or less and 20% had ratios of 7 or more.
BSN preparation was also evaluated and demonstrated that a 10% increase in BSN educated nurses decreases odds of mortality by 4% (the 5th major study to confirm this association).
Research has provided irrefutable evidence that both the professional practice environment and professional nurse staffing are integrally linked to patient outcomes.
Improving work environments is not expensive but requires changing inter-professional culture and devolving more authority for care management decisions to those closest to the patients.

10. In Summary, the Evidence Confirms…
Linear strategies that assume decreasing the number of nurses at the point of care will improve the bottom line will have the opposite effect over the long haul.
The ability to produce exceptional outcomes is dependent upon excellence in nurse staffing and positive practice environments.
The downstream unintended consequences of the opinion-based staffing decisions, historically used in many organizations, are costly and include:
Turnover, agency help, sign-on bonuses, extra shift premiums, employee disengagement, poor clinical outcomes, patient dissatisfaction, union organizing, legislated staffing ratios, consultant dependence.
The evidence linking nurse staffing and practice environments to patient outcomes requires a change in administrative practice. The history of staffing decision making in health care organizations suggests that there have been significant, unanticipated and unquantified costs associated with driving staffing to low levels in an effort to produce a stronger financial bottom line.
In the next few slides we will consider some of the efforts occurring nationally and at the state level to achieve excellence in nurse staffing.

11. Excellence and Evidence in Staffing: a Data Driven Model for Excellence in Staffing (2014)
A national organizing framework to lead the development of best practices for nurse staffing across the continuum through research and innovation.
The 5 Core Concepts of the Model
Users and Patients of Health Care
Providers of Health Care
Environment of Care
Delivery of Care
Quality, Safety and Outcomes of Care
A position paper entitled “Excellence and Evidence in Staffing: a Data Driven Model for Excellence in Staffing” was developed by a large number of nurse staffing experts from across the country, using best available evidence. The model was published in 2014 with a primary goal of generating research and innovative thinking about nurse staffing across all health care settings.
The 5 core concepts of the model move us from the linear thinking of the past, such as focusing on hours of nursing care per patient, to a holistic and comprehensive approach to understanding how the investment in staffing directly impacts the organization’s outcomes.

12. Agency for Health Care Research and Quality (AHRQ) Patient Safety Primer on Missed Nursing Care (updated 6/2015)
Missed nursing care constitutes a form of medical error that may affect patient safety.
A systematic review of 42 studies reveals 55% - 98% of nurses missed one or more items of care during their last shift worked.
The most consistent predictors of missed nursing care are:
Staffing Levels
Work Environment
Team Work
In a recently published Patient Safety Primer, the AHRQ identifies missed nursing care as an error of omission and describes the findings of 42 studies in which nurses identify missing at least one element of care. Missed nursing care, the primer states, is “primarily a problem of time pressure and competing demands and adequate nurse staffing is needed to prevent it. Evaluation of organizational nurse staffing plans should include, not just the average needs of nursing units, but also careful assessment of how frequently surges in demand or patient complexity affect the adequacy of staffing.”

13. Legislative Solutions Are Pursued With Increasing Frequency…
“When health care employers fail to recognize the association between RN staffing and patient outcomes, laws and regulations become necessary.” The American Nurses Association (2015).
14 states currently address nurse staffing in hospitals with laws or regulations.
California mandates staffing ratios and, in June, 2014, Massachusetts passed a law mandating staffing ratios in ICU’s.
In April, 2015, federal legislation was introduced that will require Medicare- participating hospitals to establish RN staffing plans using a committee, comprised of a majority of direct care nurses, to ensure patient safety, reduce readmissions and improve nurse retention. (“Registered Nurse Safe Staffing Act” H.R.2083/S Endorsed by the ANA)
WONE does not promote legislative solutions and Nurse executives understand that the complex variables that must be considered in making effective staffing decisions do not lend themselves to ratios and the “black and white” approaches that often result from legislation. We also recognize, however, that legislative solutions are often pursued by those who feel powerless and voiceless, and we believe organizations must assign high priority to evidence-based decision making and collaboration with those who provide care at the point of service.

14. Guiding Principles in Achieving Excellence in Nurse Staffing: Standards of Practice for the State of Wisconsin
WONE reviewed all of the published evidence on nurse staffing and, utilizing the framework of the Data Driven Model for Excellence in Staffing, established standards for Wisconsin (Available at W-ONE.org/Publications/WONE Positions – 2015)
A tool Kit is in development, based on the identified needs of the WONE membership, to assist members in leading the transition from opinion-based staffing to evidence-based staffing in their organizations.
This presentation, intended to inform administrators, boards and medical staff leaders on the state of the evidence on staffing, is one of the first tools.
One of the strategic priorities of the Wisconsin Organization in 2014 and 2015 is to “broadly disseminate the evidence that links nurse staffing, practice environments and education levels to patient outcomes” This goal is being accomplished through the 2015 major revision of the staffing standards that were originally developed in By utilizing the core concepts of the Data Driven Model which was presented on an earlier slide, the standards are comprehensive and holistic and reflect the essential shift from linear thinking to systemic thinking.

15. Standards of Practice for the State of Wisconsin…
Core Concept: Users and Patients of Health Care
The user/patient must be a full partner.
The plan of care is owned by the user and systems must be designed to enable full access to information and participation by the user/patient and family.
Core Concept: Providers of Health Care
Authority and accountability for all nurse staffing decisions must rest with the nurse executive who will work in collaboration with the direct care nurses.
Professional standards developed by nationally recognized specialty nursing associations must be considered.
The IOM goal of 80% BSN preparation by 2020 must be embraced in all settings.
Certification in specialty practice should become the standard in nursing as it is in medicine.
On the next few slides we will review a summary of the guiding principles that have been developed using the Core Concepts described earlier.

16. Standards of Practice for the State of Wisconsin…
Core Concept: Environment of Care
Authentic Shared Governance, the structure through which the profession fulfills its societal mandate of self-regulation, should be implemented in every setting in which nursing is practiced.
Direct care nurses must recognize that meaningful voice requires awareness of fiscal realities and a willingness to engage in ensuring effective and efficient approaches to care.
All organizations should actively work to achieve the principles of Magnet Recognition or Pathways to Excellence Recognition from the American Nurses Credentialing Center, as these environments produce best outcomes.
Focus in every setting should be on effective interprofessional teams.
Nurses must be actively involved in the design of the environments in which they practice.

17. Standards of Practice for the State of Wisconsin
Core Concept: Delivery of Care
Effective systems of staffing match patient care requirements with nursing resources each shift, each day.
The determination of appropriate staffing requires both objective information and expert clinical judgment. Mechanisms to increase and decrease staffing in response to fluctuating demand are essential.
Direct Care Nurses must be active participants in the design and integration of technology to ensure that it supports, rather than impedes, practice.
Pursuit of evidence-based practice is an obligation of the profession. Benchmarking is useful in determining appropriate staffing only when it is a comprehensive process that includes downstream outcomes of staffing decisions. Comparisons of single variables such as “hours of care” are not useful.

18. Standards of Practice for the State of Wisconsin…
Core Concept: Quality, Safety and Outcomes of Care
Ongoing evaluation of outcomes is a necessary element of excellence in staffing. A minimum data set of nurse sensitive outcomes must be continually analyzed, as well as, the impact of quality of work-life on quality of care.
National Safety Standards must be adopted in every practice setting, with strategies to protect nurses as well as patients.

19. Implications – A Call to Action
The evidence on nurse staffing has crossed a critical threshold that requires a transition, in every practice setting, from opinion- based to evidence-based staffing decisions.
Linear thinking must give way to holistic, systemic thinking that encompasses downstream consequences and sustainability of staffing decisions.
Every organization must implement a process to systematically evaluate its current practice and plan for any changes that may be indicated.
Every leader in health care expects clinicians to utilize the best available evidence, in pursuit of exceptional outcomes, for those who are served. The resource decisions that are made within organizations create the conditions that facilitate, or impede, exceptional clinical practice. The evidence that is now available to us creates the ethical imperative to apply the evidence in our staffing decisions. Since this is new for us, it will require our deliberate attention and collaboration.

20. Proposed Next Steps
This slide, and any subsequent slides, are intended to be customized by the nurse leader in each organization to his/her setting.
Suggested Next Slide Topics:
Compare/contrast the information from the presentation with current practice within your organization.
Suggest a strategy to engage administration, nursing, finance and other appropriate stakeholders, in a systematic approach to analyzing organization specific data and ensuring evidence-based decision making with respect to nurse staffing.
Provide current organization specific data on nurse sensitive outcomes, such as:
Incidence pressure ulcers, VAP, CLABSI, catheter associate UTI
Readmission rates
RN turnover,
Cost of agency nurses
HCAHPs Scores that are nurse driven
Nurse Engagement
Physician engagement and perceptions of nursing care

21. Useful Sources are included as the final slides of this presentation.
Add as many additional slides as desired to customize and complete this presentation.
Useful Sources are included as the final slides of this presentation.

22. Useful Sources
Aiken, L.H. (2014). Baccalaureate nurses and hospital outcomes: More evidence. Medical Care, 52(10),
Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L. & Neff, D.F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12),
Baggett, Margarita et. al. Excellence and Evidence in Staffing: A Data-Driven Model for Excellence in Staffing (2nd Edition). Nursing Economics Supp. (May-June, 2014), 5-35.
Beglinger, Joan Ellis. " Designing Tomorrow: Changing Our Practice in Response to Evidence" JONA Volume 44, No. 4. April, Pgs
Federal Legislation to Protect Patients, Nurses. The American Nurse, (May-June, 2015), 15.
McHugh, M.D., Berez, J. & Small, D.S. (2013). Hospitals with higher nurse staffing had lower odds of readmissions penalties. Health Affairs, 32(10,
McHugh, M.D., Kelly, L.A., Smith, H.L., Wu, E.S., Vanak, J.M. & Aiken, L.H. (2013). Lower mortality in Magnet hospitals. Medical Care, 51(5),
ry.aspx.

23. Useful Sources
McHugh, M.D. & Ma, C. (2013). Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Medical Care, 51(1), 52-9.
Needleman, J., Buerhaus, P., Pankratz, V.S., Leibson, C.L., Stevens, S.R. & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11),
Nurse Staffing Plans and Ratios. ANA Nursing World. Accessed on June 29, 2015 at Agenda
Patient Safety Primer - Missed Nursing Care. AHRQ Patient Safety Network (PSNet). Accessed on June 22, 2015 at