nurse staffing: key to good patient, nurse, and financial outcomes nurse alliance of seiu healthcare...
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Nurse staffing: Key to good patient, nurse, and financial outcomes
Nurse Alliance of SEIU Healthcare
Train the Trainer Meeting
Change that Works: A Prescription for Quality Affordable Healthcare
March 12 – 13, 2009Lynn Unruh, PhD, RN, LHRM
Current healthcare climate Nursing shortage
Tight reimbursements to providers
Focus on capital & technology improvements: may be more costly then improving staffing may not improve quality and safety as intended
Presentation topics Conceptual framework Discuss the evidence on the
importance of nurse staffing for: Patient quality and safety Staff satisfaction and health Financial performance
Recommendations
Definition of nurse staffing
Number of nurses or nursing hrs/ the number of patients or patient days
Skill mix of nurses Little scientific evidence of exact
nurse-to-patient-ratios needed Staffing adequacy is related to
workload
Definition of workload The amount and intensity of work a nurse
encounters in a given period of time. Affected by all of the following:
# of patients patient acuity patient throughput unit design technologies resources amount of administrative tasks skills and education of nurses
Patient outcomes:
o Dissatisfaction
o Adverse events
o Mortality
o Failure to rescue
o Education deficits
o Readmission
Patient charac-teris-tics
Inadequate Staffing, Excessive workload
Org. climate & other work environment issues
Difficult working conditions
Poor nursingperformance
Pathways of inadequate nurse staffing
Nurse skills and characteristics
Nursing outcomes:
o Dissatisfaction
o Burnout, stress
o Injury/Illness
o Absenteeism
o Turnover
o Vacancy
Financial Outcomes:
--Unproductive workforce expenditures:
o Lower productivity
o Turnover costs
o Agency costs
o Absenteeism costs
o Worker’s comp claims
--Unnecessary patient care costs:
o Longer LOS
o Higher tx cost
o Malpractice claims
--Lower patient care revenue:
o Bed closures
o ER backup/bypass
o Loss of market share
Pathways of inadequate staffing
Inadequate staffing/heavy workload create a difficult work environment: Time constraints Inadequate knowledge or experience Inadequate supervision of support staff Inadequate communication Generally chaotic or stressful
environment
Difficult work environment
A difficult work environment can lead to poor performance Inadequate monitoring Missed care Wrong care
Other factors influencing performance
Other factors influencing performance Degree of control over nursing practice Nurse managers Nurse-physicians relationships Skills, competencies, and reactions of the
individual nurses Culture
Hypothesized impacts of understaffing
Negative patient outcomes patient dissatisfaction adverse events failure to rescue (FTR) Mortality
Negative nursing outcomes dissatisfaction burnout injury or ill-health turnover
Higher costs and lost revenues due to: lower productivity higher turnover use of agency nurses more workers’ compensation claims longer patient lengths of stay higher treatment costs
Evidence base for impact on outcomes Comprehensive literature review Several article databases 1980 - 2006: Multiple search terms Articles selected if they were original
empirical literature Existing reviews discussed when
evaluating the evidence
Impact on patients: studies 1980-2006 >= 45 original studies in the U.S. >= 20 studies outside the U.S. Vast majority of studies find a significant relationship
between nurse staffing and patient outcomes such as: Failure to rescueFailure to rescue FallsFalls Medication errorsMedication errors MortalityMortality PneumoniaPneumonia Pulmonary compromisePulmonary compromise Surgical or treatment complicationsSurgical or treatment complications
RN staffing impact on patients, 2002-2006 (20 studies, 112 findings)
Blood stream infections
Compli-cations Falls
Failure to rescue
RN, LN / pt, pt day, apd
1 = NS 2 = (- ) 3 = (-)
1 = NS
3 = (-)
2 = NS
1 = (+)
RN, LN
skill mix
1 = NS 1 = (-)
2 = NS
1 = (+)
1 = (-)
1 = NS
RN ed
level
1 = (-)
RN staffing impact on patients, 2002-2006 (20 studies, 112 findings)
Med errors
Mortal-ity
Pneu-monia
Post-op infec-tions
Pt satis-faction
Pulmon- ary compro-mise
RN, LN / pt, pt day, apd
1 = (- )
1 = NS
5 = (- )
3 = NS
2 = (- )
1 = NS
1 = (+)
2 = NS 1 = NS
1 = (+)
1 = (- )
1 = NS
RN, LN skill mix
1 = (- )
1 = NS
2 = (- ) 2 = (- ) 1 = (- )
2 = NS
1 = (+) 1 = NS
RN ed level
2 = (- )
Nurse/ pt 1 = (- )
RN staffing impact on patients, 2002-2006 (20 studies, 112 findings)
Restraint use
Skin break- down
Throm-bosis
Urinary tract infec-tions
RN, LN / pt, pt day, apd
1 = (- ) 1 =(- )
3 = NS
1 = NS 2 = (- )
4 = NS
RN, LN
skill mix
1 = (- )
1 = NS
1 = (1)
2 = NS
Impact on patients: selected studies 2002-2003
Each additional patient in the RN patient load r/t 7% increase in FTR
(Aiken et al., 2002)
Impact on patients: selected studies 2002-2003
Higher numbers of RNs/adjusted patient days r/t lower rates of pneumonia
(Kovner et al., 2002) Higher ICU RN/patient ratios r/t
fewer patient complications
(Dang et al., 2002) An increase in RN HPPD or proportion r/t
a decrease in the odds of pneumonia
(Cho et al., 2003)
Impact on patients: selected studies 2002-2003
In surgical patients: Higher RN proportion
r/t fewer UTIs
Higher RN HPPD fewer UTIs FTR
(Needleman et al, 2002)
Impact on patients: selected studies 2002-2003
In medical patients: Higher RNs proportion r/t fewer:
UTIs Pneumonia Shock Upper GI bleed FTR
Higher RN HPPD r/t fewer UTIs Upper GI bleeds
(Needleman et al, 2002)
Impact on patients: selected studies 2002-2003
Higher levels of licensed nurses (LNs) r/t fewer: Atelectases Pressure sores Falls UTIs (Unruh, 2003)
Higher proportion of LNs r/t fewer Pressure sores Pneumonia (Unruh, 2003)
Impact on patients: reviews Lang et al., 2004, review 43 studies 1981–2003:
positive effect of nurse staffing with FTR and mortality
Haberfelde et al., 2005: evidence is mixed
Lankshear et al.,2005: accumulating evidence of a relationship between nurse
staffing & patient outcomes.
Lake & Cheung, 2006: studies of falls and pressure sores 1998-2005 methodologies vary and the evidence is inconclusive.
AHRQ, 2007 (Kane, et al., 2007): large meta-analysis of studies1990-2006 higher nurse staffing is r/t lower pt mortality, FTR
Impact on patients: summary Most studies find at least one positive
relationship between staffing and patient outcomes.
Counting the number of statistically significant relationships, the following are related to nurse staffing: FallsFalls
FTRFTR
MortalityMortality
PneumoniaPneumonia
Impact on patients: research needs Stronger, consistent methodology Consistent results Stronger clinical significance More valid and reliable unit level data Studies of changes over time Rigorous meta-analysis in which the results
are scored on: Statistical significance Methodology Clinical significance (effect size)
Impact on patients: conclusion
Although more research is needed, there appears to be sufficient evidence to indicate that staffing is a key factor in promoting patient quality and safety.
Impact on nurses: methods Studies assess responses of surveyed
nurses regarding adequacy of staffing amount of workload work pressures work demands, stress
AND emotional & physical health intent to stay at their job turnover
RN staffing & workload impact on nurses (22 studies, 36 findings)
Burn- out
Disengage- ment & intent to quit
Exhaus-tion
Health status
Job dissatis-faction
Job satis-faction
Under-staffing
1 = (+)
1 = (+) 4 = (+) 1 = (-)
High workload
1 = (+) 2 = (+) 2 = (+) 2 = (-)
1 = NS
High job demands, stress
1 = (+)
1 = NS
2 = (+)
1= (+) 1 (-) 2 = (+) 1 = (- )
RN staffing & workload impact on nurses (22 studies, 36 findings)
Life satisfac-tion & quality
Injury: assault
Injury: musculoskeletal
Injury: needlestick Stress
Turn-over
Under-staffing
1 = (+) 1 = (+)
High workload
1 = (- )
1 = (+)
1 = (+) 1 = (+) 1 = (+)
High job demands, stress
2 = (- ) 1 = (+) 1= (+)
Impact on nurses: emotional Emotional exhaustion and/or job
dissatisfaction are r/t: insufficient nurse staffing high work or job demands/pressure high patient acuity lack of time to do the job too many things happening at once exhaustion at the end of a shift a sense of poor quality fear of making or actually making a mistake
Impact on nurses: emotional Burnout and job dissatisfaction reported by
surveyed nurses (linked to archival staffing data) r/t lower staffed hospitals (Aiken, et al., 2002)
Impact on nurses: physical Higher probability of a
needle-stick injury r/t understaffing high workloads
(Clark, et al. 2002a,b)
Impact on nurses: physical Physical work demands are r/t
neck injuries shoulder injuries back injuries (Trinkoff, et al., 2003)
Imbalance between effort & reward is r/t poor self-rated health (Weyers, et al.,2006)
Work pressure is r/t the health status of nurses (Landeweerd & Boumans,1994)
Impact on nurses: retention Reasons for nurse dissatisfaction
psychological stress stressful work
(Gardulf, et al., 2005) Reasons for intending to quit
higher work tempo work-related exhaustion lower quality of care
(Gardulf, et al., 2005)
Impact on nurses: retention
Why nurses left their last job: poor staffing poor work environment work stress (Strachota, et al., 2003)
Impact on nurses: summary Nearly all studies find that lower staffing
or higher workload are related to negative emotional and physical health lower retention (directly or indirectly)
More studies of physical impacts need to be conducted
3 out of 4 reviews of the literature have summaries that correspond to these findings
Impact on hospital finances
Small number of studies Difficulty in making the linkage because benefits
of better staffing are difficult to monetize Four approaches
1) Efficiencies r/t impact on personnel and operating costs
2) Cost savings r/t impact on patient LOS
3) Cost savings r/t impact on patient adverse events
4) Costs savings of reduced nurse turnover (thought to be affected by staffing)
RN staffing impact on finances (20 studies, 35 findings)
Costs, gen-eral
Costs from pt. complic.
Costs: operat- ing
Costs: person- nel
Costs: net
RN hours 1 = (- ) 1 = (+)
RN/pt, pt days
2 = (- )
2 = (+)
1 = (- ) 1 = (+)
RN skill mix 1 = (- ) 1 = (+)
1 = NS
1 = (- )
1 = NS
2 = (+)
1 = (- )
RN turnover 3 = (- )
RN other* 2 = ( - )
1 = (+)
2 = ( - )
1 = NS
* actual hrs/recommended hrs, tenure, part-time, temporary, hppd below median
RN staffing impact on finances (20 studies, 35 findings)
LOSPerfor-mance Profits
RN hours 3 = (- ) 1 = NS
RN/ pt, pt days
2 = (- )
RN skill mix 1 = (- ) 1 = (- )
RN turnover
RN other* 1 = (- )
* actual hrs/recommended hrs, tenure, part-time, temporary, hppd below median
Impact on finances: costs
Older studies of the impact of RN skill mix on personnel & operating costs have mixed results.
A newer study of both personnel and operating costs finds that: Greater RN skill mix is cost-neutral for both
types of costs Greater use of temp RNs leads to higher
operating costs (Bloom, Alexander, & Nuchols, 1997)
Impact on finances: patient LOS
Lower LOS r/t greater RN hours (Brown, et al., 2002; Shamian, et al., 1994)
higher nurse/patient ratios (Provonost, et al., 1999)
lower nurse workload (Behner, et al., 1990)
Impact on finances: patient adverse events
An increase in RN hours or proportion is r/t a decrease in the odds of pneumonia significantly lower lengths of stay decreased medical cost (Cho, et al., 2003)
An increase in RN hours significantly increases operating expenses but has no
significant effect on profits (McCue et al., 2003)
An increase in RN skill mix increases operating expenses and lowers profits (McCue
et al., 2003)
Impact on finances: patient adverse events
Decreasing patients/nurse lowers mortality and decreases costs but cost savings
never completely offset the labor costs. the cost effectiveness declines as the pt/nurse ratio
declines is more cost effective than other patient safety
interventions (Rothberg et al., 2005)
Raising the proportion of RNs without changing licensed hrs is the least costly of several staffing improvement
strategies would result in a small average net benefit (negative net
cost) (Needleman, et al., 2006)
Impact on finances: nurse turnover For each nurse replaced,
turnover costs include: lower productivity of nurse
leaving termination costs training costs lower productivity of nurse
hiring on other common expenses
Impact on finances: nurse turnover
Turnover is estimated in 2002 dollars to cost around (Jones, 2005): $62,100 for a medical surgical nurse $67,100 for a specialized nurse This is 119-128% of the average 2002 RN salary Depending on the cost categories and other
factors other research shows these costs to be: More: $104,089 - $161,139 (Colosi, 2002) Less: $48,258 - $73,538 (Strachota, et al., 2003)
Impact of nurse staffing on outcomes: conclusions
It is becoming clear that adequate nurse staffing and balanced workload are key factors in achieving: Safe, quality patient
care Satisfied and healthy
nurses Healthy bottom line
Recommendations ensure good staffing levels maintain reasonable workload make improvements in work environment consider the opportunity costs of choices be careful with innovations evaluate interventions promote staffing research promote adequate supply of nurses
Ensure good staffing levels
As ways are explored to make nursing
care safer and better, to recruit and
retain nurses, and to maintain healthy
financial performance, it should be kept
in mind that ensuring reasonable
staffing levels and nursing workloads
are important interventions.
Maintain reasonable staffing & workload
As technological and workspace changes are made, one of the important goals should be to reduce workload
If changes in the workplace can maintain good workloads or reduce heavy workloads they should be implemented
If they can’t, they should not.
Maintain reasonable staffing & workload
Mandated ratios California since 2004
Staffing plans/systems RN Staffing Act of 2005 Quality Nursing Care Act of 2005 State laws
Public reporting of staffing Recruitment and retention strategies Support staff
Be careful with innovations
Need to understand all effects of innovations
Innovations made to improve patient safety, quality, or satisfaction could have a side effect of increased
nursing workload may counter-act the intended improvement
e.g. going to all private rooms Innovations made in order to increase
market share or reduce patient LOS could also increase nursing workload
Be careful with innovations
Innovations that increase patient volume or throughput…. expansions remodeling technology
….should be matched with additional nurses or with other interventions so that workload doesn’t increase computerized ordering and charting increased support staff
Consider the opportunity costs of choices
Capital & technological improvements are expensive remodeling expansion information technology
So are increases in nurses Consider the opportunity costs of spending
on capital & technology vs. nursing Consider which is most efficacious
Make other improvements in nursing work environment
Scheduling/work hours Leadership and management Organizational culture Professional Practice
Staff development & educational support Interdisciplinary collaboration Workspace and work process redesign Nursing process Nurse Competence
Evaluate interventions How all types of interventions impact
important patient, nurse, and organizational outcomes
How they interact with each other to do so Rigorous evaluations need to be made of
interventions and innovations in bedside patient care Explore the impact of technical and capital
changes on workload Define workload Should commercial patient acuity or staffing
systems be used?
Promote staffing research on: The relationship between
staffing, workload, & working conditions working conditions & performance performance and medical error situational conditions and working conditions
Impact of staffing, working conditions on patients, nurses, finances
System barriers to reducing staffing-related errors Rigorous meta-analysis of outcomes studies
Promote adequate supply of nurses Fund and support
nursing education Develop partnerships
between educators, employers, payers, consumers and regulatory bodies
Improve knowledge of nurses’ contributions to patient safety and quality
Internet ResourcesTitle/ URL DescriptionAHRQ Patient Safety Network: http://psnet.ahrq.gov/
Patient safety news, literature, tools, and resources complied by the Agency for Healthcare Research and Quality.
Health Care at the Crossroads Executive Summary:http://www.jcaho.org/news+room/press+kits/executive+summary.htm
JCAHO report on the impact of understaffing on patient safety (2002).
Keeping Patients Safe: Transforming the Work Environment of Nurses: http://www.iom.edu/CMS/3809/4671/16173.aspx
Book 3 (2003) of Institute of Medicine IOM series on quality. This book focuses on the nursing work environment.
Internet Resources
Title/ URL Description
Health Care at the Crossroads Executive Summary:http://www.jcaho.org/news+room/press+kits/executive+summary.htm
JCAHO report on the impact of understaffing on patient safety (2002).
Keeping Patients Safe: Transforming the Work Environment of Nurses: http://www.iom.edu/CMS/3809/4671/16173.aspx
Book 3 (2003) of Institute of Medicine IOM series on quality. This book focuses on the nursing work environment.
Internet Resources
Title/ URL Description
Magnet Recognition Program®:http://nursecredentialing.org/magnet/
Recognizes health care organizations that provide high quality nursing care
Transforming Care at the Bedside®: http://www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAtTheBedside.htm /
A Robert Wood Johnson Foundation/Institute for Healthcare Improvement collaboration to create, test and spread prototype hospital nursing unit-level strategies to improve the work environment and quality of care.
Internet Resources
Title/ URL Description
Lynn Unruh PhD RN, (2008). Nurse Staffing and Patient, Nurse, and Financial Outcomes, American Journal of Nursing, January 2008 (108)1, 62 - 71. Available at: http://www.nursingcenter.com/prodev/ce_article.asp?tid=762475
The AJN article upon which this presentation was based. The on-line version has detailed tables (free) and offers CEUs (for a charge).
Value Care, Value Nurses: http://www.valuecarevaluenurses.org
Postings of articles and blogs regarding nursing care quality and work environment, led by the Nurse Alliance of the Service Employees International Union.
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