Concerns About Staffing Levels and Patient Care in Acute Care Settings
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Transcript of Concerns About Staffing Levels and Patient Care in Acute Care Settings
Concerns About Staffing Levels and Patient Care in Acute Care Settings
Carol Diemert, RN, MSN
Minnesota Nurses Association
August 1, 2002
Causative Factors
Nursing shortageRestructuring of health care delivery systemIncreased demand for nursing services (and health care in general)Workplace issues, e.g., excessive workloads, stressful job, increases in illness and injury, low levels of morale and job satisfactionFocus on patient safety
Critical Public Health Issue
“I believe this [nursing shortage] is the issue in health care for the next 10 years. It will supercede other issues, as more and more of the public find themselves unable to access care when they need it.”
-Daniel Sisto, President, Healthcare Association of New York State
“Shortage of Nurses Worsens: ‘Doorstep of a crisis’ reached as demand outpaces supply.” Newsday, February 26, 2001
Fundamentally Different RN Shortage
Steep demand growth will continue while supply growth will slow and then decline significantly after 2010
Two decades of decline in younger RNs
Less status perceived in nursing career
Years of dwindling RN graduations
Lower real and relative RN wages
Unremitting cost pressures
Economy-wide workforce shortages
RN Supply-Demand Relationship
Slow but steady growth in supply of RNs, but peak & decline on horizon
Rapid and steep increase in demand
Diverging supply & demand curves
Shortage generally considered “demand-driven” for now
Both supply and demand will fuel RN shortage in the near future
1. Demand curve, American Health Care Association, February, 2001
2. March, 2000 RN FTEs = 1.9 million, National Sample Survey of Registered Nurses: Preliminary Findings, February, 2001
3. 2000 supply = 2020 supply, Buerhaus, et. al., “Implications of An Aging Registered Nurse Workforce”, JAMA, June 14, 2000
Restructuring of the Health Care Delivery System
The focus on cost containment driven largely by managed care has included a marked and often unsafe, decrease in the utilization of registered nurses. American Nurses Association, 1999
The downsizing, structuring of jobs and increased use of unlicensed assistive personnel were dominant factors resulting in decreased quality of care. Schindul-Rothschild, 1996. Where Have All The Nurses Gone, AJN
Demand for Nursing Services
54% increase projected for All Settings 41% increase projected for Short Term
Hospitals 66% increase projected for Nursing Homes 270% increase projected for Home Health
Agencies
Estimated U.S. increases in demand for nursing services, 1991 - 2020
Source: American Health Care Association, February, 2001
Demand for Patient Services
38% increase in outpatient surgeries19% increase in preventative care visits11% increase in inpatient hospital admissions 5% increase in office visits
Increases per 1000 Minnesota health plan members, 1995 - 1999:
Source: Minnesota Council of Health Plans
Pharmaceutical costs and greater service volumes are driving healthcare spending
Workplace Issues2001 ANA Staffing Survey75% of RNs feel quality of nursing care declined
over past 2 years at their facilities54% of RNs would not recommend the nursing
profession to their children or friends40% of RNs would not feel comfortable having a
family member or someone close to them cared for in the facility in which they work
American Nurses Association, February 6, 2001
Workplace Issues
2001 ANA Staffing Survey con’t78% of RNs indicated they are skipping meals
and breaks to care for patients
58% of RNs stated they are pressured to workvoluntary overtime
52% of RNs stated they suffer from increasedstress-related illness
American Nurses Association, February 6, 2001
Workplace Issues
“Not Enough Nurses”, Virginian Pilot ( Norfolk, VA) Jan. 14, 2001
RN Illnesses & Injuries Hospitals report more non-fatal workplace injuries than any other private sector industry according to the Bureau of Labor Statistics.90 percent of intensive care unit nurses have symptoms of post-traumatic stress disorder. The disorder is more common among ICU nurses than in any other segment of the population studied – including Israeli soldiers, Vietnam War veterans, rescue workers and medical students.
Workplace Issues
They came, they saw, they went
“Dr. Georges C. Benjamin, secretary ofMaryland's Department of Health and Mental Hygiene, summed up the shortage this way: ‘They're not coming in; they're not staying in; and while they're here, they're not happy.’’’
San Francisco Chronicle, “Nationwide Shortage of Nurses Forecast Over Next 20 Years”, February 14, 2001
Focus on Patient Safety
Institute of MedicineNovember, 1999, To Err is Human: Building a Safer Health System – A call for action to make care safer
March 20, 2001, Crossing the Quality Chasm – A call for action to improve the American health care delivery system
Focus on Patient Safety con’t.
Studies on Nursing1994, Nursing Care Report Card for Acute Care, ANA, in which 10 specific quality indicators of nursing were defined and developed1996, Shindal-Rothschild (et al) – Nurses reported factors of downsizing, restructuring, and increased use of unlicensed assistive personnel as dominant factors resulting in decreased quality of care
Focus on Patient Safety con’t.
Studies on Nursing1998, Kovner and Gergen – Reported an inverse relationship between nurse staffing and adverse patient events2000, Aiken and Patricia – Reported that the higher the job satisfaction scores for nurses, the higher the quality of care
Focus on Patient Safety con’t.
Studies on Nursing2002, Needleman, Buerhaus et al – Reported that a higher proportion of hours of nursing care provided by registered nurses per day are associated with better care for hospitalized patients
Concern for Care: Trends in Nursing Practice Concerns in Minnesota
Minnesota Nurses Association
Made possible by a grant from
American Nurses Association
PurposePurpose
To explore RNs’ concerns for effective, safe professional nursing practice in acute care facilities.
To identify a potential system for handling data on the issues of nursing practice and staffing.
BackgroundBackground
Changes in nursing as a career choice
Valuing of “caring” work
Restructuring of the health care system
Changing demography
Summary of MethodsSummary of Methods
Quantitative MethodsConcern for Safe Staffing and Concern for
Practice Forms available from 1/95 - 3/99 (1321 forms)
Categorized into 6 most repetitive, salient concerns ( Figure 1)
Established inter-rater reliabilityCompiled and summarized the data using
the program ACCESS
Summary of Methods con’t.Summary of Methods con’t.
Qualitative Methods2 focus group meetings3 regular meetings in facilities78 staff nurse interviews18 nursing administrator interviewsReviewed notes from meetings and
interviews - content analysis used to identify themes
Study OutcomesStudy Outcomes
Compromises in patient care result from inadequate staffing. (Figure 1)Lack of supportive working environments for nurses affects the quality of care.Description and documentation of staffing variables is inadequate.Concern for practice standards is heightened where staffing is considered inadequate.
Study Outcomes con’t.Study Outcomes con’t.
Compromises in patient care result from inadequate staffing. (Figure 1) Inability to perform basic care - 52% Inability to do basic assessment and monitoring -
70% Inability to give medications on time or at all -
22% Lack of time to provide emotional support or
teaching - 14.5% Concerns regarding personal safely and health
and licensure - 15%
Study Outcomes con’t.Study Outcomes con’t.
Lack of supportive working environments for nurses affects the quality of careEffective communication, feeling of
belonging, and sense of respect/dignity decreased
Nurse managers less visible and availableMandatory overtime, cross training, chronic
sick time, and seniority increase stress
Study Outcomes con’t.Study Outcomes con’t.
Description and documentation of staffing variables is inadequate.Acuity not regularly considered - 59%
(Figure 1)Admissions/discharges not often included in
volume of patientsType of nursing staff mix available should be
consideredStructure and environment of the unit should
be considered
Study Outcomes con’t.Study Outcomes con’t.
Concern for practice standards is heightened where staffing is considered inadequate. Hospital-mandated procedures may be unsafe for
patients and a risk for nurses Increase in part-time nurses because of increased
demands and requirements of practice Language minimizing the professional judgment of
the nurse may affect practice standards
Figure 1 - SummaryFigure 1 - Summary
Reason for concern 28 Not oriented to unit 52 Not trained or experienced in area assigned 74 Given an assignment which posed a serious threat to my health or safety704 Case load assignment is excessive and interferes with delivery of adequate patient care285 Transferred, discharged, or admitted new patient(s) to unit without adequate staff Not given adequate staff for acuity (check appropriate descriptions)
37 Staffed with inappropriate number of temporary pool personnel 44 Staffed with inappropriate number of unlicensed personnel883 Short staffed 92 Not provided with unit clerk
Figure 1 - Summary con’t.Figure 1 - Summary con’t.
Staffing information on shift of
objection
Is staffing based on acuity?314 Yes 442 No
Did staff provided match acuity? 31 Yes 66 No
Figure 1 - Summary con’t.Figure 1 - Summary con’t.
Needed staff to provide patient care
136 Short 1 Ancillary
25 Short 2 Ancillary
5 Short 3 Ancillary
434 Short 1 RN
190 Short 2 RNs
61 Short 3 RNs
106 Short 1 LPN
17 Short 2 LPNs
2 Short 3 LPNs
Figure 1 - Summary con’t.Figure 1 - Summary con’t.
Float/casual/temporary staff used: 513 Yes 494 No
Maximum staffing but acuity high: 39 Yes 6 No
Acuity:837 High 178 Average 2 Low
Figure 1 - Summary con’t.Figure 1 - Summary con’t.
Compromises in patient care resulting
from lack of staff?651 (52%) Basic hygiene, feeding, ADLs not done on time
or at all.
856 (70%) Assessment, observation, not done as scheduled jeopardizing patient safety.
268 (22%) Medications, orders, not done on time or at all.
53 (4.3%) Special procedures, treatments, tests not done on time or at all.
180 (14.5%) Emotional support or teaching not done.
188 (15%) Nurse safety or license at risk, no breaks.
Figure 2 - Interview Guide DataFigure 2 - Interview Guide Data
Position with bargaining unit:49 Chair 11 Rep 15 MemberIn your work environment, do you use theConcern for Safe Staffing form?
49 Yes 5 No 3 Have own formConcern for Practice form?
6 Yes 15 No 10 Never heard of itApproximate number of forms completed in one year span of time:26 Less than 10 53 10 to 50 11 More than 50
Figure 2 - Interview Guide Datacon’t.Figure 2 - Interview Guide Datacon’t.
Does your workplace have a formal procedure for responding to the concerns expressed through the use of these forms?20 Yes 29 No 2 "Sort of"
Do you think the procedure in your workplace is effective? 6 Yes 22 No 6 Sometimes
Is your perception that your workplace is currently experiencing a shortage of nurses?39 Yes 10 No
Conclusions (Secondary Purpose)Conclusions (Secondary Purpose)Use of Concern for Practice and Concern for Safe Staffing forms is episodic rather than systematic.Data not regularly compiled or reported.Practice and staffing issues are often interrelated, but are not systematically connected.57% of respondents stated no follow-up procedure in their facility.65% of respondents stated existing procedure not effective.
Sample Management ResponseSample Management Response
Example of Management Response to Concern for Safe Staffing refer to page 23 of report includes:
actions takeneffects on patient care follow-up by nurse managerconclusion
Sample Management Response con’t.Sample Management Response con’t.
Procedure for Follow-up to Concern for Safe Staffing FormsSAMPLE HOSPITAL SAFE STAFFING CONCERN LOGDATES / TOTAL
DATE/SHIFT
PATIENTCARE AREA
ISSUE ACTION TAKENTHAT SHIFT
MANAGERFOLLOW-UP
Sample LogSample LogSAMPLE HOSPITAL SUMMARY - SAFE STAFFING CONCERN LOG
1st 2nd 3rd 4thQuarter Quarter Quarter Quarter Total
Total Received 19 30 8 11 68
By Unit: 2E 0 0 0 0 0
3W 0 0 0 0 0
3E 3 0 1 2 6
ICU 1 1 3 2 7
4W/4E 6 0 0 3 92W 1 0 0 0 1E.D. 7 22 4 0 33SARS 1 0 0 0 1PACU 0 0 0 0 05E 0 7 0 4 11
Follow-up Since Studyat Minnesota Nurses
Association1. Implemented, tracked and reported new
Concern for Safe Staffing forms
2. Operationalized the patient flow policy contained in contract agreements between MNA and several metro hospitals following nurses strike June 2001
3. Passed the mandatory overtime bill (MS181.275) in 2002 legislature
Follow-up Since Studyat Minnesota Nurses Association con’t
4. Promoted the ANA programs: Nursing-Sensitive Quality
Indicators for Acute Care Magnet Nursing Service
Recognition
Concern for Safe Staffing Form
The revised Concern for Safe Staffing
form is attached
Contract Language/Collective Bargaining Agreements
All units will review staffing grids which cannot be changed downward unless evaluated by a team. Staffing grids will be based on acuity, experience level of RN staff, composition of skills/roles available, unit admissions, discharges, and transfers.
In the Twin Cities agreements, MNA won the right for RNs to close a unit to new patients when too few staff are available to care for more patients. This landmark innovation to deal with excessive workloads could set a new direction in collective bargaining.
American Journal of Nursing, August 2001
In the area of health and safety, there is growing interest among frontline nurses to protect themselves and their livelihood from work-related injury and illness. This concern is likely to intensify and become a dominant issue at the bargaining table.
American Journal of Nursing, August 2001
Mandatory Overtime BillWhat does the new law accomplish?The new law clearly states that a hospital is prohibited from “taking any action against a nurse solely on the ground that the nurse fails to accept an assignment of additional consecutive hours at the facility in excess of a normal work period, if the nurse declines to work additional hours because doing so may, in the nurse’s judgment, jeopardize patient safety.” MS 181.275 Subd. 2
Mandatory Overtime Bill con’tThe focus of the law is on the nurse being able to
exercise his/her own judgment to decline the work
if the nurse believes working the additional hours
would jeopardize patient safety. The law clearly
recognizes that the nurse, not the employer, must
make this judgment call.
Nursing Sensitive Quality Indicators
What is NDNQI?
The National Database of Nursing Quality
Indicators (NDNQI) is a project of the American
Nurses Association’s (ANA) Safety & Quality
Initiative, which addresses the issues of patient
safety and quality of care arising from changes
in health care delivery.
What kind of information is in NDNQI?NDNQI will contain information on nursing staff mix and nursing hours, as well as indicators that describe the structure, process, and outcomes of care. The following seven quality indicators form the core of NDNQI:
Patient Injury Rate (Falls)Maintenance of Skin Integrity (Pressure ulcers)Patient Satisfaction (Overall care, nursing care, patient education, and pain management)Nursing Staff SatisfactionSkill Mix of RNs, LPNs/LVNs, and Unlicensed StaffTotal Nursing Care Hours Provided per Patient DayNosocomial Infections
Magnet Recognition Program
AAN Study 198341 hospitals
Attracted and retained qualified nurses (magnet concept)
Promotion of quality patient care through excellence in nursing services
Magnet Recognition ProgramPurpose
Recognize excellence in:Management philosophy and practices of nursing servicesAdherence to standards for improving the quality of patient careLeadership of the Chief Nurse Executive in supporting professional practice and continued competenceAttention to cultural and ethnic diversity in patient, family and staff