SEMINAR PRESENTATION ANGELA DUSHANE FERRIS STATE UNIVERSITY NURS

SEMINAR PRESENTATION ANGELA DUSHANE FERRIS STATE UNIVERSITY NURS 450 Capstone Course

Topic: Staffing Ratios � Question at Issue: Do mandatory staffing ratios positively affect nurse and patient outcomes?

Learning Objectives 1. 2. 3. 4. 5. Identify state mandated minimum nurse-topatient staffing ratios in California. Compare California’s mandated staffing ratios to those in other states. Assess current data on staffing ratios and their effect on patient outcomes. Assess current data on staffing ratios and their effect on nurse outcomes. Identify other work environment factors that can contribute to quality patient care.

Background on Mandated Staffing Ratios � � � California became the first state to implement minimum nurse-to-patient staffing ratios in 2004 Fourteen states and the District of Columbia have endorsed nurse staffing legislation or approved regulations addressing staffing as of 2009 Another 17 states have introduced legislation regarding staffing ratios Aiken, et al. (2010)

Adequate Staffing Levels � � According to the American Nurses Association (ANA) there is a correlation between staffing ratios and patient outcomes. Adequate staffing helps to: � reduce patient complications � improve patient satisfaction � reduce medical errors � decrease mortality � reduce nurse fatigue and nurse burnout � increase job satisfaction and nurse retention http: //nursingworld. org/Main. Menu. Categories/The. Practiceof. Professional. Nursing/Nurse. Staffing

California’s Current Minimum Staffing Ratios Critical Care 1: 2 Pediatric 1: 4 Step-down 1: 3 Telemetry 1: 4 Medical/Surgical 1: 5 Specialty Care 1: 4 Psychiatric 1: 6 Serratt (2013)

Staffing Ratios and Patient Outcomes � � � There is a seven percent increase in mortality with each patient added to a nurse's assignment More RN hours per patient day are linked to lower mortality rates for patients with acute myocardial infarctions California hospitals had 13. 9% fewer surgical deaths than New Jersey and 10. 6% fewer surgical deaths than Pennsylvania It is estimated that there are between one and five fewer patient deaths per 1000 inpatient days with increased staffing per patient. An increase in one RN per patient day was associated with a 9% reduction in mortality for an ICU patient, a 16% reduction for a surgical patient, and a 6% reduction for a medical patient. Not all patient outcomes showed improvement with increased staffing, including falls, pressure ulcers, and urinary tract infections. Aiken et. al (2010) Shekelle (2013)

Staffing Ratios and Nurse Outcomes � � � California nurses with fewer patients reported that their assignments were reasonable, there were enough nurses to get their work done, and 30 minute breaks were a regular part of their workdays. These nurses also reported a lesser chance of missing important changes in a patient’s condition. Nurses in California are more likely to stay in their jobs due to the mandated staffing ratios. Twenty-nine percent of nurses in California report high job burnout compared to 34% in New Jersey and 36% in Pennsylvania. Nurses are less likely to report poor work environments or an intent to leave their jobs if staffing ratios are adequate. Adequate staffing reduces the incidence of patient complaints, poor quality of care, and lack of confidence that patients can manage their care after discharge. Aiken, et. al (2010)

Staffing Ratios and Hospital Level Outcomes � � � Leaders in California hospitals stated that there were increased costs pertaining to recruitment bonuses, training new staff, and use of temporary staff to accommodate the new staffing ratios. Hospitals indicated that they had to cut support staff, programs, and services because of increased costs related to the new ratios. Nurses working in California hospitals had a 7. 8% wage increase after the implementation of the new staffing ratios. Serratt (2013)

Root Cause Analysis � � � Problem: Poor patient outcome Causes: � People: Inadequate nurse-to-patient ratios � Processes: Inadequate orientation and education for nursing staff � Environment: Lack of teamwork or collaboration on the unit Solution: Monitor patient’s immediately following surgery for changes � People: Adequate nurse-to-patient ratios � Processes: Adequate orientation and education for nursing staff � Environment: Collaboration between all hospital staff

Hildegard Peplau’s Theory of Interpersonal Relations � � � What is the ultimate goal of the nursing profession? How do we attain this goal? Mandated minimum nurse-to-patient staffing ratios can help nurses to achieve this goal The main idea of Peplau’s theory is the nurseclient relationship There are four phases in the interpersonal relationship: orientation, identification, exploitation, and resolution http: //nursing-theory. org/theories-and-models/peplau-theory-of-interpersonal-relations. php

Everett Rogers’ Diffusion of Innovation Theory � � � Reference to plan and guide organizational change processes Relative advantage Compatibility with existing values and practices Simplicity and ease of use Trialability Observable results Robinson (2009)

ANA Standards of Professional Performance: Ethics � � � Requires Registered Nurses (RN) to practice ethically Requires that nurses protect the patient’s values, rights, dignity, beliefs, and autonomy when providing care How does this pertain to the question at issue? American Nurses Association, 2010

ANA Standard: Collaboration � � � States “the registered nurse collaborates with healthcare consumer, family, and others in the conduct of nursing practice” (ANA, 2010, p. 57). Collaboration means working as a team to promote positive outcomes for patients. How does this standard relate to staffing ratios? American Nurses Association, 2010

ANA Standard: Resource Utilization � � � Registered nurses follow this standard by assessing “individual healthcare consumer needs and resources available to achieve desired outcomes” (ANA, 2010. p. 60). This standard includes advocating for resources that will help to improve practices (ANA, 2010). How does this standard relate to staffing ratios? American Nurses Association, 2010

Assessment of the Healthcare Environment � � The number of patients that a nurse can provide safe, high-quality care depends on many factors. Critics of staffing ratios state that mandated staffing ratios will “lead to a reduction in hospital services, increased emergency room diversions, increased unit closures, and increased expenses as hospitals pay additional labor costs for overtime and temporary agency nurses” (AONE, 2003, p. 1).

Ways to improve patient safety � Staffing based on the acuity level of patients, with increased staff when patient acuity is high. Regulated use of unlicensed staff Competency determination and orientation Accommodations in areas with RN shortages Records of staffing to ensure compliance � Work environment factors linked to patient care quality � � � Physical work environment � Work-group cohesion � Quantitative workload Organizational constraints Procedural justice Nurse-physician relations Personality traits Work motivation Positive affectivity Agency for Healthcare Research and Quality, 2012

Conclusions � � How do mandated staffing ratios affect patient outcomes? How do mandated staffing ratios affect nurse outcomes? How do mandated staffing ratios affect hospital outcomes? What can be done to improve the safety and quality of patient care?

References Aiken, L. H. , Sloane, D. M. , Cimiotti, J. P. , Clarke, S. P. , Flynn, L. , Seago, J. A. , Spetz, J. , & Smith, H. L. (2010, August). Implications of the California nurse staffing mandate for other states. Health Services Research, 45(4), 904 -921. doi: 10. 1111/j. 1475 -6773. 2010. 01114. x American Nurses Association [ANA]. (2010). Nursing: Scope and standards of practice (2 nd ed). Silver Spring, MD: Author. California Nurses Association. (2011, February 8). California nurses praise RN-to-patient ratios (Video file). Retrieved from http: //www. youtube. com/watch? v=-V 2 Vh. Hl 6 nco Djukic, M. , Kovner, C. T. , Brewer, C. S. , Fatehi, F. K. , & Cline, D. D. (2013, April-June). Work environment factors other than staffing associated with nurses’ ratings of patient care quality. Health Care Management Review, 38(2), 105 -114. doi: 10. 1097/HMR. 0 b 013 e 3182388 cc 3. Furillio, J. & Mc. Ewen, D. (2012). State-mandated staffing level alleviate workloads, leading to lower patient mortality and higher nurse satisfaction. Agency for Healthcare Research and Quality. Retrieved from http: //innovations. ahrq. gov/content. aspx? id=3708 Michigan Nurses Association. (2010). Key legislative issues. Retrieved from http: //www. minurses. org/legislation/safepatientcare Minnesota Nurses Association. (2013, August 21). Bedside nurses want to protect patients (Video file). Retrieved from http: //www. youtube. com/watch? v=u. YXZw 3 c 1 HAs Nursing Theory. (2013). Hildegard Peplau – Nursing Theorist. Retrieved from http: //nursing-theory. org/nursing-theorists/Hildegard-Peplau. php Robinson, L. (2009). A summary of diffusion of innovations. Retrieved from http: //enablingchange. com. au/Summary_Diffusion_Theory. pdf

References, cont. Serratt, T. (2013). California’s nurse-to-patient ratios, part 1: 8 years later, what do we know about nurse-level outcomes? The Journal of Nursing Administration, 43(9), 475 -480. doi: 10. 1097/NNA. 0 b 013 e 3182 a 23 d 6 f Serratt, T. (2013). California’s nurse-to-patient ratios, part 2: 8 years later, what do we know about hospital level outcomes? The Journal of Nursing Administration, 43(10), 549 -553. doi: 10. 1097/NNA. 0 b 013 e 3182 a 3 e 906 Serratt, T. (2013). California’s nurse-to-patient ratios, part 3: Eight years later, what do we know about patient level outcomes? The Journal of Nursing Administration, 43(11), 581 -585. doi: 10. 1097/01. NNA. 0000434505. 69428. eb Shekelle, P. G. (2013, March). Nurse-patient ratios as a patient safety strategy. Annals of Internal Medicine, 158(5), 404 -410. Retrieved from http: //annals. org/article. aspx? article. ID=1656445 The American Organization of Nurse Executives [AONE]. Policy statement on Mandated Staffing Ratios. Retrieved from http: //www. aone. org/resources/leadership%20 tools/staffingratios. shtml