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10/31/2019
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New Jersey Workforce Initiative — an Alternative to Staffing Ratios
Maria Brennan, DNP, MSN, RN, CPHQ
Nurse Consultant
NWESC Commission Leader
Immediate Past President, ONL NJ
© 2019 ONL NJ
Staffing Ratio Legislation
Federal Regulation 42CFR 482.23(b)
Conditions of ParticipationRequires hospitals certified to participate in Medicare reimbursement to provide adequate numbers of licensed registered nurses and licensed
practical nurses and others to provide patient care as needed.
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Staffing Ratio Legislation
Registered Nurse Staffing Act“S‐1132 — 114th Congress: Registered Nurse Safe Staffing Act of 2015.”
www.GovTrack.us. 2015Amendment to Title XVIII Social Security Act
Proposed by Senator Jeff Merkley (D‐ OR) and introduced to the Senate Finance Committee on April 29, 2015
Staffing Ratio LegislationRegistered Nurse Staffing Act required:
Medicare participating hospitals to develop a staffing plan that would provide:
Staffing appropriate to the unique characteristics of the patient and unit
Maintain quality and safety
Establish a staffing committee
Died in Congress at the end of session
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ANA Position on Staffing
Supports legislative model in which nurses create staffing plans specific to each unit, considering intensity of patient needs, patient turnover, level of knowledge and experience of staff and other resources available.
State Positions on Staffing
Staffing Laws or Regulations in 14 statesCA, CT, IL, MA, MN, NV, NJ, NY, OH, OR, RI, TX, VT, WA
Staffing Committees in 7 statesCT, IL,NV, OH, OR, TX, WA
MN requires the CNO to develop a staffing plan in conjunction with others (similar to TJC standards)
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State Positions on Staffing
CA is the only state to mandate nurse to patient ratios to be maintained at all times on all units
MA enacted legislation mandating staffing ratios in critical care. 2018 attempts to broaden requirements failed
NJ has minimal staffing ratios in DOH regulations
Five states mandate reporting/ public disclosure IL, NJ, NY, RI, VT
State Positions on Staffing
NM in 2012 charged stakeholder groups to collect data and make recommendations to the legislature
NC in 2009 requested a study of mandatory OT as a tool. No further action
DC and ME passed legislation and then amended to remove staffing mandate
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New Jersey Efforts Staffing
13 year legislative history2018‐2019 A‐1470/S989 Sen. Vitale/Assemblyman Benson2016‐2017
A750/S1280 Sen Vitale/Sen Weinberg) Pulled, lack of support
2014‐ 2015 A647/S‐1183 Hearing, cleared the Assembly but insufficient support for a vote
2012‐2013 A2428/S1257 Sen Vitale/Sen Weinberg/ Sen Turner
2010‐2011 A660/S963 Sen Vitale/ Sen Weinberg/ Sen Greenstein
2008‐ 2009 A1531/S1233 Sen Vitale/ Sen Weinberg
2006‐ 2007 A754/S810 Sen Vitale/ Assemblywoman Weinberg
2004‐ 2005 A2004/S555 Assemblywoman Weinberg/Assembly Gordon/ Sen Vitale
New Jersey DOH Requirements
NJDOH Hospital Patient Care Staffing Report
• Nurse to patient ratios for each type of unit
• Daily number of patients and staff in the ED
• Daily number of Respiratory Care Practitioners
• Based on monthly average of staffing ratios
• Not reflective of patient need, staff competency or hospital variation
• Not reflective of other care provided
• Self reported by hospitals
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Ratios Legislative Activity Nov. 2018 voters in Massachusetts rejected ballot question that asked for state‐mandated nurse‐patient ratios
NJ A‐382/S‐1612 Establishes minimum certified nurse aid‐to‐resident ratios in nursing homes voted out of the full Senate
pending in the Assembly Appropriations Committee
You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.
R. Buckminster Fuller
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Coalition of Stakeholders
In response to legislative action to mandate nurse staffing ratios, ONL NJ wanted to take a proactive approach Under the leadership of ONL NJ, a coalition was established in July 2016:
NJ State Nurses Association NJ Council of Magnet Organizations New Jersey Hospital Association NJ Council of Deans and Directors NJ Nursing Leadership Council ONL NJ
Goals of the Staffing Ratios Task Force Conduct a review of the literature focused on:
Impact of the California law Impact of the Massachusetts law Initiatives in other states Relationship of staffing ratios to nursing satisfaction and
patient outcomes
Come up with an alternative approach to mandated ratios, and
Draft a message for legislators
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Ah‐Ha Moment
So focused on staffing ratios… but it was something more!
The Plan
Prepare a proactive response to pending legislative activity
Develop a better alternative
Secure partnerships and build a coalition
Educate and gain support of legislators and stakeholders
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Innovation: NWESC
The Nursing Workplace Environment and Staffing Council (NWESC) was established as a steering committee for the state
Nov. 4, 2016 The Chief Nursing Officers Constituency Group at New Jersey Hospital Association endorsed the concept of the NWESC
NWESC Purpose
Give a respected voice to staff nurses in the establishment of a healthy nursing work environments
Create a forum for participative leadership
Give direct care nurses a voice in human resource allocation through a formal process
Support equal participation of nurse staff in collaboration with management
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The PilotONL NJ recruited nine hospitals throughout the state to participate in a pilot program that would establish NWESC’s in each of the hospitals
Hospitals represented all types of organizations: Magnet®, non‐Magnet®, union, non‐union, urban and rural
A charter was developed with a vision and mission statement
Mission and Vision
Mission Statement – To promote and sustain a healthy workplace environment for the nurses of New Jersey
Vision Statement – New Jersey will be recognized as the leader in creating and sustaining a healthy work environment for its nurses
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Organizational NWESC StructureCo‐chairs: A Direct Care Nurse and the CNO
Membership: 51% bedside RNs with at least 50% of their work time spent in direct patient care
Number of staff nurses on the council is sufficient to provide adequate representation of all nursing care in the hospital/organization
Council participates in developing a plan for nurse staffing and creating a positive work environment and forwards the plan to the CNO for budget planning
Ad hoc members – Human Resources, Finance, Union ‐ no vote
Conceptual Framework
The NWESC program is based on the American Association of Critical Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments
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NWESC Education Sessions
Required for all NWESC members
Mandatory three‐session education series
Importance of Understanding the Model
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NWESC Education Sessions Session 1
Overview NWESC Program Legislation on Mandated Staffing
Research on Healthy Work Environment (HWE)
HWE Framework Model NWESC StructureNWESC Leaders Panel Discussion
Binders distributed
NWESC Education Sessions Session 2
Co‐chair ReportsElements of the Model Part 1:Skilled Communication and Effective Listening – nurses must be as proficient in communication skills as they are in clinical skillsTrue Collaboration – nurses must be relentless in pursuing and fostering true collaborationAuthentic Leadership – nurse leaders must fully embrace the imperative of a healthy work environment; authentically live it and engage others in its achievement
Binders updated
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Co‐Chair Reports
Given by staff nurse co‐chairExample of report for Session 2: How did the first meeting(s) go?
What is your council working on?
Has the council established a charter or bylaws?
Feedback from education NWESC Session #1
NWESC Education Sessions Session 3
Co‐chair ReportsAppropriate Staffing and Budgeting – staffing must ensure the effective match between patients needs and nurse competencies
Effective Decision Making – nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations
Meaningful Recognition – nurses must be recognized and must recognize others for the value each brings to the work of the organization
Binders updated
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NWESC Education Sessions Other Activities
Co‐chair ReportsInteractive – sharing of informationTable Top ExercisesReview and discussion of challenges at organizational Councils
Research Partners
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Research Related to the Pilot
To understand more about how nurses, including clinical nurses, and nurse managers/leaders, think about the HWE as well as staffing To gain further understanding from the perspective of nurses, which can be used to inform both hospital and healthcare policy implications
Qualitative Research Methods
Focus groups with volunteers from the NWESC participating organizations were interviewed prior to the implementation of the NWESC model to understand clinical/direct care nurses’ and nurse manager/nurse leaders’ perceptions of what is a HWE.
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Quantitative Research Methods
Clinical nurses and nurse managers/leaders of the NWESC organizations were invited to complete the AACN Healthy Work Environment Assessment Tool survey
The survey tool was administered prior to implementation of the NWESC model, and again 12 months after implementation, to measure the change from pre to post implementation
Quantitative Research Methods
The AACN Assessment tool to measure progress on achieving the six essential standards. It provides an overall healthy work environment score and scores for each of the six standards
www.aacn.org/nursing‐excellence/healthy‐work‐environment
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Research Results
Focus group and survey results were analyzed and reported back to ONL NJ for the pilot NWESC’s and future cohorts
Findings were presented at state and national conferences such as Sigma Theta Tau and AONE
Peer reviewed journals
Qualitative ResultsOverarching Theme: HWE
Sufficient resources at their hands Shared by both clinical/direct care
nurses and nurse manager/leaders
Agreement that appropriate staffing is paramount and having appropriate supplies and equipment is equally as important
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Quantitative Results
1. Overall, nurses perceive their work environments are healthier post‐implementation of the NWESC Councils
2. True Collaboration, Effective Decision Making, Appropriate Staffing, Meaningful Recognition and Authentic Leadership experienced an increase in excellent scores from pre to post‐implementation
3. Skilled Communication percentages of excellent scores pre and post‐implementation are equal
NWESC Toolkit
A how‐to guide for CNOs
Developed as a resource guide for the Councils
Distributed to all NWESC Council Members
Copyrighted
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NWESC’s Tally to Date
There are 37 hospitals in the program 35 Acute Care Hospitals (> 49% of all NJ hospitals)
One Specialty Hospital
One Acute Inpatient Rehabilitation Hospital
Includes urban, rural, Magnet® and non‐Magnet® union and non‐union Hospitals
These hospitals represent over 20,000 nurses
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NWESC Hospitals’ Work to Date
Established charter, bylaws and goals
Educated staff on staffing budget process and sharing all staffing and workforce data in monthly meetings
Established a Shift Work Safety Subcommittee and contracted with a vendor to provide staff education on shift work safety
NWESC Hospitals’ Work to Date (cont.)
Continue to develop the charter to include attendance requirements and 2019 goals
ED staff nurses cross trained to critical care to increase their comfort with critical care patients held in the ED and ability to float to CC at times
Developed unique logo for the council
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NWESC Hospitals’ Work to Date (cont.)
Established NWESC as a major nursing council with cross membership from Professional Practice and Nurse Engagement
Completed nursing survey and data analysis
Video production in progress for four vignettes on incivility
Utilized the AACN Assessment tool to identify gaps
Produced video on Crucial Conversations Skills
NWESC Communication Plan
Messaging Campaign: Objective to increase the general awareness of the innovative work
of the NWESC program and the outcomes of these efforts Target Audiences include all RNs in NJ, legislators and the general
public Elements of campaign: Video content through social media/Facebook using micro‐videos
E‐mail Marketing
Press release campaign
Website
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NWESC Legislative Plan
Coordinate messaging campaign with ONL NJ Lobbyist
Meetings with key legislators
Prepare strategy for testimony
Direct care/staff nurse participation is critical to this campaign
NWESC Presentations• Chief Nursing Officers Constituency Group, New Jersey Hospital Association (NJHA) – Nov. 4, 2016
• Board of Trustees, NJHA – June 21, 2017
• Government Relations Officers Constituency Group, NJHA Feb. 2, 2018
Nov. 2, 2018
• American Organization of Nurse Executives – Affiliates meeting Washington, DC – Sept. 6, 2018
• NYONEL & HANYS Seminar on Safe Staffing – Sept. 12, 2018
•Magnet Recognition and Pathways to Excellence Program – Sept. 21, 2018
• Nassau‐Suffolk Hospital Council Nurse Executive Committee – Jan. 29, 2019
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NWESC Presentations• Sigma Theta Tau conference “Creating Healthy Work Environments,” New Orleans, LA Feb. 22‐24, 2019
• AONL Annual Conference, San Diego, CA April 10‐13, 2019
• Clemson University School of Nursing International Nursing Conference, Greenville, SC Aug. 14‐17, 2019
•NYONEL Advocacy Conference, Oct. 20‐21, Saratoga Springs, NY
ONL NJ Authors' PublicationsKowalski, MO, Basile C, Bersick E, Cole D, McClure D, Weaver S. What Do Nurses Need to Practice Effectively in the Hospital Environment? An Integrative Review With Implications for Nurse Leaders, Worldviews on Evidence‐Based Nursing, 2019; 1‐11.
Caruso JT, Smith R, Steingall P, Cholewka S, Borenstein K. Call to Action Implementing Nurse Workplace Environment and Staffing Councils in New Jersey Hospitals. NurseLeader, 2019; 17(4): 299‐302.
Johansen MI, de Cordova PB, Weaver SH. Nurse Workforce Environment Staffing Councils: An Innovative Approach. Nurse Leader, 2019; 17(2): 141‐146.
Burns H, Zedreck Gonzalez JF, Hoffman R, Fulginiti S. The CNO’s Role in a Healthy Work Environment. Nursing Management, October 2018.
Accessible from the ONL NJ website ‐http://www.njha.com/onlnj/advocacy‐policy/nwesc/research‐publications/
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NWESC Commission
June 2019, ONL NJ Board of Directors approved the establishment of the NWESC Commission to meet the need for a formal body to disseminate and sustain the NWESC work.
NWESC Commission Committees Communications Education Research & Data
NWESC Webpagehttp://www.njha.com/onlnj/advocacy‐policy/nwesc/
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Questions and Comments
Thank you!
Contact:Susan Cholewka, Executive Director, ONL NJ
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