Patient Safety and Nurse Staffing Does it really make a difference?

Objectives Discuss research on the relationship between staffing and quality of care Analyze data on hospital staffing in the United States Explore staffing-related policy options for ensuring quality of care

Objectives Discuss research on the relationship between staffing and quality of care Analyze data on hospital staffing in the United States Explore staffing-related policy options for ensuring quality of care

What Do We Mean by Staffing? Staffing of licensed personnel Staffing of assistive and ancillary personnel Staffing in hospitals Staffing in long-term care facilities

Research on Nurse Staffing has Changed in Recent Years In the 1990s: IOM said there was insufficient evidence to determine whether nurse staffing changes were detrimental (Crossing the Quality Chasm, 1996) ANA said there was insufficient scientific evidence to establish ratios (1999)

The newest research shows that nurse staffing is important Evidence suggests that an increase in nurse staffing is related to decreases in: risk-adjusted mortality nosocomial infection rates thrombosis and pulmonary complications in surgical patients pressure ulcers readmission rates failure to rescue Evidence that higher ratios of RNs to residents in long-term care has positive effects

The Most Influential Studies Report for Health Resources and Services Administration Use of administrative hospital data from states Key outcomes associated with nurse staffing: Urinary tract infections Pneumonia Length of stay Upper gastrointestinal bleeding Shock Failure to rescue Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346, 1715-1722.

The Most Influential Studies Survey of nurses about staffing and work environment in Pennsylvania, surveys linked to discharge data For every patient added to the average hospital-wide nurse workload 7% increase in mortality for every patient added to the 7% increase in failure-to-rescue patients with complications Patients in hospitals with 8:1 patient to nurse ratios have more than a 30% greater risk of death following common surgical procedures than patients in hospitals with 4:1 ratio Some 4 million surgical procedures like the ones studied are performed annually in US hospitals. If all patients were cared for in hospitals with 4 patients per nurse, up to 20,000 fewer deaths might be expected. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfactions. Journal of the American Medical Association, 288, 1987-1993.

The Most Influential Studies Cross-sectional analyses of outcomes data for 232,342 general, orthopedic, and vascular surgery patients discharged from 168 nonfederal adult general Pennsylvania hospitals Hospitals with more baccalaureate-educated RNs had lower: 30-day mortality Failure to rescue Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloan, D.M., & Silber J.H. (2003). Educational levels of hospital nurses and surgical patient mortality. . Journal of the American Medical Association, 290, 1617-1623.

The Most Influential Studies Data for patients aged 18 years and older who were discharged between 1990 and 1996 were used to create hospital-level adverse event indicators. Examined relationship between nurse staffing and four postsurgical adverse events: venous thrombosis/pulmonary embolism pulmonary compromise after surgery urinary tract infection pneumonia Poor nurse staffing increased pneumonia rates Kovner, C., Jones, C., Zahn, C., Gergen, P.J., & Basu, J. (2002). Nurse staffing and postsurgical adverse events: An analysis of administrative data from a sample of U.S. hospitals, 1990-1996. Health Serves Research, 37, 611-629.

Nurse staffing also affects job satisfaction High workload and poor staffing ratios are associated with: Nurse burnout Low job satisfaction Increased nurse stress Nurse stress is related to: Adverse patient events Nurse injuries Quality of care Patient satisfaction

Importance of Work Environment Every blue ribbon commission report on solutions to cyclical nursing shortages since 1980 has recommended changes in nurses’ work environments Recent reports: JCAHO, AHA, RWJF However, on the whole nurses work environments have deteriorated over the past 2 decades

Nurses Highly Dissatisfied with Hospital Practice Job dissatisfaction 41% High job burnout 43% Intend to leave within year 23% Under 30 leaving in year 33%

Sources of Dissatisfaction Too few RNs for quality care 66% Increased patient assignment 83% Inadequate support services 57% Quality care deteriorating 45% Not confident patients can 66% manage at discharge

Another Aiken Study Aiken, L.H. et al. (2001). Nurses' reports on hospital care in five countries. Health Affairs, 20(3), 43-53. Reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999 Core problems in work design and workforce management threaten the provision of care

Percent of Nurses Leaving Essential Nursing Care Undone Last Shift U.S. Canada Germany Comforting patients 40 44 54 Skin care 31 35 31 Oral hygiene 20 22 10 Teaching patients/families 30 26 30 Discharge planning 13 14 13 Care planning 41 47 34

Percent of Nurses Performing Non- Nursing Tasks on Last Shift U.S. Canada Germany Food trays 43 40 72 Housekeeping 34 43 na Transport 46 33 54 Ancillary services 69 72 28

RNs Reporting Adverse Events as “Not Infrequent” Wrong medication or dose 16% •Nosocomial infection 35% •Falls with injuries 20% •Patient/Family Complaints 49% •Verbal Abuse of Nurses 53%

Patient to Nurse Ratios Important in Nurse Retention Higher burnout and greater job dissatisfaction are strongly related to patient-to-nurse ratios. An increase of 1 patient per nurse increases the probability of high levels of burnout by 23% job dissatisfaction by 15% Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber J.H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfactions. Journal of the American Medical Association, 288, 1987-1993.

The Research Has Limits Data on hospitals do not recognize different staffing on different units Studies at the nursing unit level involve primary data collection and are costly Single-year studies cannot prove a causal relationships No study identifies the “ideal” staffing ratio

Objectives Review research on the relationship between staffing and quality of care Present data on staffing in the United States Explore staffing-related policy options for ensuring quality of care

There are many sources for nurse staffing data American Hospital Association State data Original surveys

There are many ways to measure nurse staffing Nurse-to-patient ratios 1:4, 1:8, 1:12 Hours per patient day (HPPD) Full-time equivalent employment (FTEE) Someone who does 100% patient care = 1 FTEE Someone who does 50% administration and 50% patient care = 0.5 FTEE Skill mix (how many RNs, LPNs, BSNs, PCTs??)

There is Wide Variation in HPPD Nationally 10th Percentile 20th Percentile Median 80th Percentile 90th Percentile RNs 4.28 4.66 5.26 6.05 6.63 LPNs 0.66 0.74 1.03 1.49 2.01 Source: AHA

What is Staffing in “Best Practices” Hospitals? Best practices hospitals identified by: American Nurses Association Magnet Hospitals JCAHO Commendation of CA hospitals US News rankings – national honor roll USA Today Top 100

Average HPPD in Best Practices Hospitals RN HPPD LPN HPPD ANA Magnet 20 7.35 0.69 JCAHO 13 7.22 0.82 US News honor roll 7.45 0.45 USA Today 100 6.13 0.93 US average 5127 5.75 1.42 Source: AHA

Objectives Review research on the relationship between staffing and quality of care Present data on hospital staffing in the United States Explore staffing-related policy options for ensuring quality of care

Rules and Regulations

Some States Have Adopted Some Rules California Hospitals must have a patient acuity system to determine staffing (1995) Kentucky and Virginia (1998) Hospitals must establish appropriate staffing methodology Nevada (1999) Hospitals must have a staffing methodology based on acuity

Some States Have Adopted Some Rules Oregon (2001) Hospitals must develop and implement staffing plans Provisions for inspections and penalties established Texas (2002) Hospitals must adopt, implement, and enforce a written staffing plan California Hospitals must meet specific minimum nurse-to-patient ratios (1999, implemented 2004)

Florida 2005 HB 1117 proposed the creation of the Safe Staffing for Quality Care Act, which would require ratio limits on nursing units Critical care units 1:2 nurse-to-patient ratio Labor and delivery units 1:2 Emergency departments 1:3 Step-down units 1:3 General medical/surgical 1:4 Died in the Health Care Regulation Committee 05/06/05

Florida 2005 Senate Bill 1176 also referred to the Safe Staffing for Quality Care Act and aimed to prescribe staffing standards for health care facilities. Died in Committee on Health Care 05/06/05

Florida 2005 Both Bills were Supported by the Nurse Alliance of Florida, a labor union in south Florida “Staffing ratios are crucial to patient safety, nurse satisfaction and hospital costs.” Maria Sanchez, member of the Alliance Opposed by the Florida Nurses Association “First of all, it is a nursing judgment to decide what care patients need. Second, ratios make all nurses the same. Every nurse, no matter how much experience or schooling she has, becomes a number. It’s demeaning to the profession, and when you put numbers on units, there’s no flexibility. It ties the hands of the nurses themselves.” Barbara Lumpkin, Associate Executive Director, FNA

Approaches to Staffing Standards Patient acuity/patient classification systems Fixed ratios Formula-based ratios Skill-mix requirements

Patient Acuity/Patient Classification Systems Input: # of patients, acuity of illness Output: appropriate staffing levels Widely marketed systems and home-grown systems Problems: Systems best for long-term, not short-term, prediction Difficulty of staffing up if necessary Enforcement – hard to monitor

Fixed Ratios Fixed, specific nurse-to-patient ratios are mandated Problems: Minimum staffing could become average staffing Hospitals could eliminate ancillary and support staff Enforcement – do you close hospitals? Loss of flexibility and innovation

Formula-based Ratios Nurse workload = function of: Problems: RN staff expertise Patient acuity, work intensity Support staff, MD availability Unit physical layout Problems: Defining the function Establishing new staffing ratios every week/month/year Enforcement

Skill-mix Requirements Hospitals must have a minimum fixed ratio of licensed staff relative to all staff Problems: What is the appropriate ratio? Minimum ratio could become average (like speed limit) Total staffing may not be adequate Loss of flexibility and innovation Enforcement

An Overriding Question How much are we willing to spend to increase quality of care? Do we take money from schools? Do we take money from salaries? Do we increased the number of uninsured?

What Next? More nurses lead to better patient outcomes Legislative approaches have potential pitfalls To improve nurse staffing: Hospitals need money to pay more staff More nurses are needed in the labor market

Responses to Hospital Nursing Shortages Responding to a nursing shortage in the early 1980s, the American Academy of Nursing embarked on the “magnet hospital” project Identify hospitals that attract and retain nurses. 1993 - the "magnet" concept by was formalized by the ANCC by establishing the Magnet Hospital Recognition Program for Excellence in Nursing Services McClure, M.L., & Hinshaw, A.S. (Eds.). (2002). Magnet hospitals revisited. Silver Spring, MD: American Nurses Association.