50
Concerns About Staffing Levels and Patient Care in Acute Care Settings Carol Diemert, RN, MSN Minnesota Nurses Association August 1, 2002

Concerns About Staffing Levels and Patient Care in Acute Care Settings

  • Upload
    farhani

  • View
    72

  • Download
    0

Embed Size (px)

DESCRIPTION

Concerns About Staffing Levels and Patient Care in Acute Care Settings. Carol Diemert, RN, MSN Minnesota Nurses Association August 1, 2002. Causative Factors. Nursing shortage Restructuring of health care delivery system Increased demand for nursing services (and health care in general) - PowerPoint PPT Presentation

Citation preview

Page 1: 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

Page 2: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 3: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 4: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 5: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 6: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 7: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 8: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 9: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 10: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 11: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 12: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 13: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 14: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 15: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 16: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 17: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 18: Concerns About Staffing Levels and Patient Care in Acute Care Settings

Concern for Care: Trends in Nursing Practice Concerns in Minnesota

Minnesota Nurses Association

Made possible by a grant from

American Nurses Association

Page 19: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 20: Concerns About Staffing Levels and Patient Care in Acute Care Settings

BackgroundBackground

Changes in nursing as a career choice

Valuing of “caring” work

Restructuring of the health care system

Changing demography

Page 21: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 22: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 23: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 24: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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%

Page 25: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 26: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 27: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 28: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 29: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 30: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 31: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 32: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 33: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 34: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 35: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 36: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 37: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 38: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 39: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 40: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 41: Concerns About Staffing Levels and Patient Care in Acute Care Settings

Concern for Safe Staffing Form

The revised Concern for Safe Staffing

form is attached

Page 42: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 43: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 44: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 45: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 46: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 47: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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.

Page 48: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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

Page 49: Concerns About Staffing Levels and Patient Care in Acute Care Settings

Magnet Recognition Program

AAN Study 198341 hospitals

Attracted and retained qualified nurses (magnet concept)

Promotion of quality patient care through excellence in nursing services

Page 50: Concerns About Staffing Levels and Patient Care in Acute Care Settings

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