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

2. 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

3. 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

4. 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

6. 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)

7. 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

8. 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,

9. 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,

10. 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,

11. 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, Health Serves Research, 37,

13. 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

14. 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

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

17. 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

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

19. Percent of Nurses Leaving Essential Nursing Care Undone Last Shift
U.S. Canada Germany
Comforting patients
Skin care
Oral hygiene
Teaching patients/families
Discharge planning
Care planning

20. Percent of Nurses Performing Non- Nursing Tasks on Last Shift
U.S. Canada Germany
Food trays
Housekeeping na
Transport
Ancillary services

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

22. 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,

23. 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

24. 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

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

26. 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??)

27. 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

28. 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

29. 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

30. 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

31. Rules and Regulations

32. 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

33. 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)

34. 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

35. 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

36. 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

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

38. 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

39. 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

40. 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

41. 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

42. 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?

43. 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

44. 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.
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.