Importance of Safe Staffing Ratios

Importance of Safe Nurse Staffing

Goal:

To raise awareness of the need of safe staffing for patients, nursing staff, and its effects on the medical facility.

Presented by Jennifer Nguyen, SN, BBCC

As the advancements in healthcare and technology continue to change

More people are living longer with more chronic health conditions

It is now more important than ever to ensure safe staffing levels to prevent complications, continue a good facility reputation where patients and nurses would want to be at.

Impact on:

the patient

To conclude

7%

According to Agency for Healthcare Research and Quality (AHRQ):

Patient mortality is increased by

for every additional patient added onto a nurse's workload.

Objectives

A number of studies

within the last 10 years

have shown strong

associations between

patient mortality and low staffing levels.

1. The patient: Low nurse staffing has a higher rate of poor patient rehabilitation/care, patient mortality, and patient dissatisfaction.

2. Nursing staff: Increase nurse-patient ratios lead to nurse burnout, increase medical errors, decrease nurse retention and job satisfaction.

3. Medical facility: Understaffing causes unnecessary costs r/t patient outcomes as well as high turnover rates, and poor reputation and credibility.

Fatigue cont...

Fatigue can also cause anger when compounded by the need for rest, necessity to work and lack of understanding from others.

Hospitals that are understaffed, with overworked nurses give out the impression that they do not care for their patients’ wellbeing.

Nursing Staff

Nurse Retention

Several interventions to combat nurse fatigue/ boost moral:

• Workshops
• Staff retreats and counseling
• Longevity Awards
• Uniform allowances (FT,PT,PD)
• Quality of life initiatives - varying shifts, lengths, *staggered start times to give flexibility for personal obligations

Such programs may only become more important as demands increase on a shrinking supply of nurses, who shoulder the heaviest burden of patient care.

Nurses and Compassion Fatigue

Similar to burnout, compassion fatigue is a combination of physical, emotional, and spiritual strain associated with traumatic and difficult situations related to patient conditions on a daily basis.

Fatigue

Slows reaction time

Decreases energy

Diminishes attention to detail

Contributes to errors

Leading to medical errors, unsafe practice, accidents, decrease in team morality, and patient satisfaction.

As recent as June of 2011,

• More than 121,000 new job ads were posted by employers and staffing agencies seeking RNs.
• The need for nurses to fill these positions is only on the rise.

As of February 2012,

• the Bureau of Labor Statistics predicted that employment in nursing would reach 3.4 million by the year 2020.

A perception is that time to complete patient care duties competes with time needed for hand washing.

Nosocomial Infections

Understaffing & hand hygiene

Time demands...

During the highest workload demands, staff washed their hands before contacting devices only 25% of the time

Hospitals with low nurse staffing levels lead to poor adherence to hand hygiene.

• Hand washing increased to 70% after the end of the understaffing and overcrowding period.

Ongoing surveillance determined that being hospitalized during this period was associated with a fourfold increased risk of acquiring an HAI. These studies demonstrates an association between staffing workload, infections, and microbial transmission from poor adherence to hand hygiene policies.

Nurse staffing affects job satisfaction

High workload and poor staffing ratios are associated with:

• Compassion fatigue
• Unsafe practice
• Unintentional negligence
• Medical errors
• Decrease job satisfaction
• Nurse burnout
• High turnover rate

OT Associated with Higher Rates of Infection

The Centers for Disease Control & Prevention (CDC) states over two million hospital infections occur each year.

Higher levels of overtime hours are associated with increased rates of infection such as pneumonia, skin ulcers and catheter-associated urinary tract infections.

Feeling understaffed, overworked, stressed, and unappreciated...

• Decrease in morale
• Burn out occurs
• Find more appealling places to work

Of nearly 13,500 nurses surveyed in Pennsylvania, 40% were dissatisfied with their career!

To put this into perspective, the average job dissatisfaction rates for other professions range from 10 to 15%.

Short-staffing, burnout and increased patient levels cause many nurses to leave the profession.

New nurses don’t fare any better: the Associated

Press reports that one in five new nurses quit

within 12 months.

Job Dissatisfaction

Effects on the

Medical Facility

Relationship between FTR and understaffed nursing?

• Miscommunication
• Incomplete assessments >> inadequate treatment
• Failure to recogonize s/sx of early deterioration in patient condition

• Data-driven staffing: shows whether depts need extra staffing and also indicates why a dept's dependency has increased.
• "Float" nursing staff can be employed to move from different dept to help out during busy periods.
• Identifying non-clinical tasks that can be delegated to non nursing staff (e.g. ward clerks, UAPs)
• Set nurse-patient ratios
• Nursing internship programs
• Hire more nurses - Cost of additional staff can be offset against savings from improved patient outcomes.

Strategies for improvement

California RN to Patient Staffing Ratios

Type of Care RN to Patients

Intensive/Critical Care 1:2

Neo-natal Intensive Care 1:2

Operating Room 1:1

Post-anesthesia Recovery 1:2

Labor and Delivery 1:2

Antepartum 1:4

Postpartum couplets 1:4

Postpartum women only 1:6

Pediatrics 1:4

Emergency Room 1:4

ICU Patients in the ER 1:2

Trauma Patients in the ER 1:1

Step Down, Initial 1:4

Step Down, 2008 1:3

Telemetry, Initial 1:5

Telemetry, 2008 1:4

Medical/Surgical, Initial 1:6

Medical/Surgical, 2008 1:5

Other Specialty Care, Initial 1:5

Other Specialty Care, 2008 1:4

Psychiatric 1:6

The committee will produce the hospital's annual nurse staffing plan. If this staffing plan is not adopted by the hospital, the chief executive officer shall provide a written explanation of the reasons why to the committee

Since September 1, 2008, each hospital must have established a nurse staffing committee

At least one-half of the members of the nurse staffing committee must be registered nurses currently providing direct patient care and up to one-half of the members are determined by the hospital administration.

Each hospital must post, in a public area on each patient care unit, the nurse staffing plan and the nurse staffing schedule for that shift on that unit, as well as the relevant clinical staffing for that shift.

The staffing plan and current staffing levels must also be made available to patients and visitors upon request.

• Reduce overtime
• make this happen by creating a culture change from overtime being the "rule" to overtime being the exception.
• If hospitals implement measures to reduce shift and workweek length, and set guidelines for what is an acceptable amount of overtime, nurses will not feel obligated to tack on extra hours.

Strategies for improvement cont.

What is Failure to Rescue?

Pneumonia

Developing and overseeing annual patient care unit and shift-based nurse staffing plans, based on the needs of patients, to be used as the primary component of the staffing budget.

When nurses have a patient-to-nurse ratio of 4.95 or less, they had more time for patient teaching and to prepare the patient to transition home.

More patient and teaching demonstration

More time for mobility assistance

Reduction of "bed-bound" patients

This reduced:

• heart failure readmissions by 7%
• acute myocardial infarction readmissions by 6%
• and pneumonia readmissions by 10%.

Hospital administrators are reluctant to hire more nurses because it is not seen as cost-effective.

• Instead, it would appear to save more labor cost by making everyone do more work.

However, due to inadequate care r/t inadequate staffing, it is costing the facility more because of the excess costs incurred from poor outcomes.

• such as patients who return, postsurgical infections and other consequences of short staffing.

Responsibilities of the nurse staffing committee include:

RCW 70.41.420

Safe Nurse-to-Patient Staffing

Failure to rescue (FTR) refers to a death after a treatable complication.

It is a "failure to recognize changes in a patient's condition until major complications, including death, have occured."

This phrase is not intended to imply negligence or wrongdoing.

• Adding 10% more RNs to staff:
• decrease in lung collapse by 1.5%
• decrease in pressure ulcers by 2%
• decrease in patient deaths by 3%

This leads to increase in time with patients...

• Decrease risk of pneumonia:
• + 30 minutes with RN/ day
• Decrease risk by 4%
• + 1 hour with RN/ day
• Decrease risk by 8.9%

Costs

For every 1 percent increase of annual nurse turnover, hospitals lose $300,000.

According to the Journal of Nursing Administration, it costs roughly $82,000 to replace a nurse. This covers vacancy, orientation and training, the lowered productivity of a newly hired nurse, and advertising and recruiting.

Example 1: People who developed sepsis after surgery stayed in the hospital 11 days longer and the infections cost an extra $33,000 to treat per person.

• Even worse, nearly 20% of people died as a result of the infection.

Example 2: People who developed pneumonia stayed in the hospital an extra 14 days after surgery. Such cases cost an extra $46,000 per person to treat.

• In 11 % of the cases, the patient died as a result of the pneumonia infection.

Thank You!

Researchers looked at infections that developed after hospitalization.

Focus was on infections that are often preventable,

they discovered that the cost of such infections can be quite high...

The Numbers...

Negligence towards patients and responsibilities may not be intentional.

In the event of understaffing, negligence occurs as a side effect.

When mistakes made by nurses due to negligence occur, patients suffer in injuries or death, this opens the door for malpractice lawsuit(s).

Higher staffing at all levels of nursing (RNs, LPNs, CNAs) is associated with a 25% reduction in negative outcomes owing to nurse errors and inattention.

Negligence Caused Due To Understaffed Nurses

Patient Complications r/t understaffing

Research suggests that improved nurse staffing has beneficial effects on patient outcomes such as decreases in:

• Accidental death/Failure to rescue
• Cardiac arrest
• Medication errors
• Nosocomial infections (e.g. MRSA)
• Pneumonia
• Pressure ulcers
• Readmission rates
• Shock
• Thrombus complications in surgical patients
• Urinary tract infections

*According to research funded by the Agency for Healthcare Research and Quality (AHRQ) and others.