Transcript Nurse staffing: Key to good patient, nurse, and financial

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, 2009
Lynn Unruh, PhD, RN, LHRM
[email protected]
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
Pathways of inadequate nurse staffing
Financial Outcomes:
Org. climate &
other work
environment
issues
Inadequate
Staffing,
Excessive
workload
Patient
characteristics
Difficult
working
conditions
Poor nursing
performance
Nurse skills and
characteristics
Patient outcomes:
--Unproductive workforce
expenditures:
o Dissatisfaction
o Lower productivity
o Adverse events
o Turnover costs
o Mortality
o Agency costs
o Failure to rescue
o Absenteeism costs
o Education deficits
o Worker’s comp claims
o Readmission
--Unnecessary patient care
costs:
Nursing outcomes:
o Longer LOS
o Dissatisfaction
o Higher tx cost
o Burnout, stress
o Malpractice claims
o Injury/Illness
--Lower patient care
revenue:
o Absenteeism
o Turnover
o Vacancy
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




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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
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
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
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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:


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
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
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Failure to rescue
Falls
Medication errors
Mortality
Pneumonia
Pulmonary compromise
Surgical or treatment complications
RN staffing impact on patients, 2002-2006
(20 studies, 112 findings)
Blood
stream
Compliinfections cations
RN, LN / pt, 1 = NS
pt day, apd
RN, LN
skill mix
RN ed
level
1 = NS
2 = (- )
Falls
Failure
to
rescue
3 = (-) 3 = (-)
1 = NS 2 = NS
1 = (+)
1 = (-) 1 = (-)
2 = NS 1 = NS
1 = (+)
1 = (-)
RN staffing impact on patients, 2002-2006
(20 studies, 112 findings)
Med
errors
Mortal- Pneuity
monia
PulmonPost-op Pt
ary
infec- satis- comprotions
faction mise
RN, LN / 1 = (- )
pt, pt day, 1 = NS
apd
5 = (- )
3 = NS
2 = (- )
1 = NS
1 = (+)
2 = NS
1 = NS 1 = (- )
1 = (+) 1 = NS
1 = (- )
1 = NS
2 = (- )
2 = (- )
1 = (- )
2 = NS
1 = (+) 1 = NS
RN, LN
skill mix
RN ed
level
2 = (- )
Nurse/ pt
1 = (- )
RN staffing impact on patients, 2002-2006
(20 studies, 112 findings)
Skin
Restraint breakuse
down
RN, LN / pt, 1 = (- )
pt day, apd
RN, LN
skill mix
1 =(- )
3 = NS
1 = (- )
1 = NS
Urinary
tract
Throm- infecbosis
tions
1 = NS
2 = (- )
4 = 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


Higher ICU RN/patient ratios r/t


lower rates of pneumonia
(Kovner et al., 2002)
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:




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
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:

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Atelectases
Pressure sores
Falls
UTIs
(Unruh, 2003)

Higher proportion of LNs r/t
fewer


Pressure sores
Pneumonia
(Unruh, 2003)
Impact on patients: reviews
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Lang et al., 2004, review 43 studies 1981–2003:
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Haberfelde et al., 2005:
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accumulating evidence of a relationship between nurse
staffing & patient outcomes.
Lake & Cheung, 2006:
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evidence is mixed
Lankshear et al.,2005:
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positive effect of nurse staffing with FTR and mortality
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:

Falls

FTR

Mortality

Pneumonia
Impact on patients: research needs
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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





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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)
Disengagement &
Job
Job
Burn- intent to
Exhaus- Health dissatis- satisout
quit
tion
status faction faction
1 = (+)
4 = (+)
1 = (-)
1 = (+)
2 = (+)
2 = (+)
2 = (-)
1 = NS
High job 1 = (+) 1 = NS
2 = (+)
demands,
stress
1= (+)
2 = (+)
1 = (- )
Understaffing
High
workload
1 = (+)
1 (-)
RN staffing & workload impact on nurses
(22 studies, 36 findings)
Life
satisfaction &
Injury:
quality assault
Understaffing
High
workload
High job 2 = (- )
demands,
stress
1 = (- )
1 = (+)
Injury: Injury:
musculo needle
skeletal stick
Stress
Turnover
1 = (+)
1 = (+)
1 = (+)
1 = (+)
1 = (+) 1 = (+)
1= (+)
Impact on nurses: emotional

Emotional exhaustion and/or job
dissatisfaction are r/t:







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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



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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)
2)
3)
4)
Efficiencies r/t impact on personnel and operating costs
Cost savings r/t impact on patient LOS
Cost savings r/t impact on patient adverse events
Costs savings of reduced nurse turnover (thought to be
affected by staffing)
RN staffing impact on finances (20 studies,
35 findings)
Costs, Costs
Costs: Costs:
genfrom pt. operat- person- Costs:
eral
complic. ing
nel
net
RN hours
RN/pt, pt
days
1 = (- )
1 = (+)
2 = (- ) 1 = (- )
2 = (+)
RN skill mix
1 = (- )
1 = (+)
1 = (+)
1 = NS
1 = (- )
1 = NS
2 = (+)
2=(-)
1 = (+)
2=(-)
1 = NS
1 = (- )
RN turnover 3 = (- )
RN other*
* actual hrs/recommended hrs, tenure, part-time, temporary,
hppd below median
RN staffing impact on finances (20 studies,
35 findings)
LOS
RN hours
3 = (- )
RN/ pt, pt
days
RN skill mix
2 = (- )
Performance
Profits
1 = NS
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




An increase in RN hours


a decrease in the odds of pneumonia
significantly lower lengths of stay
decreased medical cost (Cho, et al., 2003)
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):

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$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


Staffing plans/systems






California since 2004
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 Resources
Title/ URL
Description
AHRQ 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/pr
ess+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
JCAHO report on the
Executive Summary:
impact of understaffing on
http://www.jcaho.org/news+room/p patient safety (2002).
ress+kits/executive+summary.htm
Keeping Patients Safe:
Transforming the Work
Environment of Nurses:
http://www.iom.edu/CMS/3809/467
1/16173.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
Recognizes health care organizations
Program®:http://nurse that provide high quality nursing care
credentialing.org/mag
net/
Transforming Care
at the Bedside®:
http://www.ihi.org/IH
I/Programs/Strategic
Initiatives/Transform
ingCareAtTheBedsi
de.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/prode
v/ce_article.asp?tid=762475
The AJN article upon which this
presentation was based. The online version has detailed tables
(free) and offers CEUs (for a
charge).
Value Care, Value Nurses:
Postings of articles and blogs
http://www.valuecarevaluenurses.org regarding nursing care quality
and work environment, led by
the Nurse Alliance of the Service
Employees International Union.
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