Achieving Excellence in Nurse Staffing: Leveraging the Evidence

A Presentation of the Wisconsin Organization of Nurse Executives for Health Care Boards, Administrators and Medical Staff Leaders

© WONE – June, 2015

Objectives•Examine the evidence that links professional nurse staffing, professional practice environments and level of education to patient outcomes.

•Describe initiatives at the national and state level that address professional nurse staffing.

•Discuss implications for staffing decisions within organizations.

A Historical Perspective…•Decision making concerning staffing in health care organizations has been largely opinion-based due to a paucity of evidence.

•“Benchmarking” has consisted of comparing the staffing decisions in one organization with those in another.

•Results of staffing decisions frequently include unintended downstream consequences and are not sustainable.

Emerging Evidence•Nurse staffing and the professional practice environment directly impact patient outcomes – mortality, “failure to rescue”, readmission rates, preventable complications and patient experience.

•Organizations with the best staffing and positive practice environments have been demonstrated to produce the best outcomes.

What We Know…•Nurses who work in well-staffed hospitals have the time and resources to effectively execute the care processes that influence readmission. They are better equipped to monitor for complications and adverse events.

•Nurses’ constant presence enables them to prepare patients and families for discharge throughout hospitalization. This preparation and teaching supports seamless transition to other settings.

•Nurses are sentinels in identifying early warning signs and addressing complications and adverse events that increase readmission risk.

Extensive Research has Produced New Knowledge

•Numerous, robust studies have equipped us with the evidence to drive decision-making. They have withstood the rigorous peer review processes of Health Affairs, Medical Care, The New England Journal of Medicine, The Journal of the American Medical Association and the major Nursing Journals.

•The research studies have been conducted on a large scale. For example:•665 hospitals in 4 large states•1,262,120 hospital discharge abstracts•39,038 registered nurse participants•American Hospital Association data

The Evidence…In a study evaluating mortality and “failure to rescue” in surgical patients in Magnet (56) and non-Magnet (508) hospitals in 4 states:

•Magnet hospitals had a 14% lower odds of mortality and 12% lower odds of “failure to rescue” than non-Magnet hospitals•Magnet hospitals had significantly better work environments than Non-Magnet hospitals.

The literature tells us that the hallmarks of successful organizations are flat organizational structures with accessible, informed managers, decentralized decision-making and empowered frontline workers to make decisions.

The Evidence…In a study evaluating 30-Day readmissions among Medicare patients with Heart Failure, Acute Myocardial Infarction and

Pneumonia:

•Each additional patient per registered nurse above the average workload (4.9 patients) resulted in 7% higher odds of readmission for Heart Failure, 6% for Pneumonia and 9% for Myocardial Infarction.

•The odds of readmission in good versus poor work environments were 7% lower for Heart Failure, 6% lower for Myocardial Infarction and 10% lower for Pneumonia.

The Evidence…In a large study evaluating the effects of nurse staffing and work environment on inpatient mortality and failure to rescue on general, orthopedic and vascular surgery patients in 4 states:

•Best staffed hospitals with better work environments decrease the odds of mortality by 12% and failure to rescue by 14%.

•>25% of the hospitals had patient to RN ratios of 4 or less and 20% had ratios of 7 or more.

•BSN preparation was also evaluated and demonstrated that a 10% increase in BSN educated nurses decreases odds of mortality by 4% (the 5th major study to confirm this association).

In Summary, the Evidence Confirms…

•Linear strategies that assume decreasing the number of nurses at the point of care will improve the bottom line will have the opposite effect over the long haul.

•The ability to produce exceptional outcomes is dependent upon excellence in nurse staffing and positive practice environments.

•The downstream unintended consequences of the opinion-based staffing decisions, historically used in many organizations, are costly and include:

•Turnover, agency help, sign-on bonuses, extra shift premiums, employee disengagement, poor clinical outcomes, patient dissatisfaction, union organizing, legislated staffing ratios, consultant dependence.

Excellence and Evidence in Staffing: a Data Driven Model for Excellence in

Staffing (2014)

•A national organizing framework to lead the development of best practices for nurse staffing across the continuum through research and innovation.

•The 5 Core Concepts of the Model•Users and Patients of Health Care•Providers of Health Care•Environment of Care•Delivery of Care•Quality, Safety and Outcomes of Care

Agency for Health Care Research and Quality (AHRQ) Patient Safety Primer on Missed Nursing Care (updated 6/2015)

•Missed nursing care constitutes a form of medical error that may affect patient safety.

•A systematic review of 42 studies reveals 55% - 98% of nurses missed one or more items of care during their last shift worked.

•The most consistent predictors of missed nursing care are:•Staffing Levels•Work Environment•Team Work

Legislative Solutions Are Pursued With Increasing Frequency…

•“When health care employers fail to recognize the association between RN staffing and patient outcomes, laws and regulations become necessary.” The American Nurses Association (2015).

•14 states currently address nurse staffing in hospitals with laws or regulations.

•California mandates staffing ratios and, in June, 2014, Massachusetts passed a law mandating staffing ratios in ICU’s.

•In April, 2015, federal legislation was introduced that will require Medicare-participating hospitals to establish RN staffing plans using a committee, comprised of a majority of direct care nurses, to ensure patient safety, reduce readmissions and improve nurse retention. (“Registered Nurse Safe Staffing Act” H.R.2083/S.1132 - Endorsed by the ANA)

Guiding Principles in Achieving Excellence in Nurse Staffing: Standards

of Practice for the State of Wisconsin•WONE reviewed all of the published evidence on nurse staffing and, utilizing the framework of the Data Driven Model for Excellence in Staffing, established standards for Wisconsin (Available at W-ONE.org/Publications/WONE Positions – 2015)

• A tool Kit is in development, based on the identified needs of the WONE membership, to assist members in leading the transition from opinion-based staffing to evidence-based staffing in their organizations.

•This presentation, intended to inform administrators, boards and medical staff leaders on the state of the evidence on staffing, is one of the first tools.

Standards of Practice for the State of Wisconsin…

•Core Concept: Users and Patients of Health Care•The user/patient must be a full partner.•The plan of care is owned by the user and systems must be designed to enable full access to information and participation by the user/patient and family.

•Core Concept: Providers of Health Care•Authority and accountability for all nurse staffing decisions must rest with the nurse executive who will work in collaboration with the direct care nurses.•Professional standards developed by nationally recognized specialty nursing associations must be considered.•The IOM goal of 80% BSN preparation by 2020 must be embraced in all settings.•Certification in specialty practice should become the standard in nursing as it is in medicine.

Standards of Practice for the State of Wisconsin…

•Core Concept: Environment of Care•Authentic Shared Governance, the structure through which the profession fulfills its societal mandate of self-regulation, should be implemented in every setting in which nursing is practiced.•Direct care nurses must recognize that meaningful voice requires awareness of fiscal realities and a willingness to engage in ensuring effective and efficient approaches to care.•All organizations should actively work to achieve the principles of Magnet Recognition or Pathways to Excellence Recognition from the American Nurses Credentialing Center, as these environments produce best outcomes.•Focus in every setting should be on effective interprofessional teams.•Nurses must be actively involved in the design of the environments in which they practice.

Standards of Practice for the State of Wisconsin

•Core Concept: Delivery of Care•Effective systems of staffing match patient care requirements with nursing resources each shift, each day.

•The determination of appropriate staffing requires both objective information and expert clinical judgment. Mechanisms to increase and decrease staffing in response to fluctuating demand are essential.

•Direct Care Nurses must be active participants in the design and integration of technology to ensure that it supports, rather than impedes, practice.

•Pursuit of evidence-based practice is an obligation of the profession. Benchmarking is useful in determining appropriate staffing only when it is a comprehensive process that includes downstream outcomes of staffing decisions. Comparisons of single variables such as “hours of care” are not useful.

Standards of Practice for the State of Wisconsin…

•Core Concept: Quality, Safety and Outcomes of Care•Ongoing evaluation of outcomes is a necessary element of excellence in staffing. A minimum data set of nurse sensitive outcomes must be continually analyzed, as well as, the impact of quality of work-life on quality of care.•National Safety Standards must be adopted in every practice setting, with strategies to protect nurses as well as patients.

Implications – A Call to Action•The evidence on nurse staffing has crossed a critical threshold that requires a transition, in every practice setting, from opinion- based to evidence-based staffing decisions.

Linear thinking must give way to holistic, systemic thinking that encompasses downstream consequences and sustainability of staffing decisions.

Every organization must implement a process to systematically evaluate its current practice and plan for any changes that may be indicated.

Proposed Next StepsThis slide, and any subsequent slides, are intended to be customized by the nurse leader in each organization to his/her setting.

Suggested Next Slide Topics:

•Compare/contrast the information from the presentation with current practice within your organization.

•Suggest a strategy to engage administration, nursing, finance and other appropriate stakeholders, in a systematic approach to analyzing organization specific data and ensuring evidence-based decision making with respect to nurse staffing.

• Provide current organization specific data on nurse sensitive outcomes, such as:•Incidence pressure ulcers, VAP, CLABSI, catheter associate UTI

• Readmission rates

•RN turnover,

•Cost of agency nurses

•HCAHPs Scores that are nurse driven

•Nurse Engagement

•Physician engagement and perceptions of nursing care

Add as many additional slides as desired to customize and complete

this presentation.

Useful Sources are included as the final slides of this presentation.

Useful SourcesAiken, L.H. (2014). Baccalaureate nurses and hospital outcomes: More evidence. Medical Care, 52(10), 861-3.

Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L. & Neff, D.F. (2011). Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care, 49(12), 1047-53.

Baggett, Margarita et. al. Excellence and Evidence in Staffing: A Data-Driven Model for Excellence in Staffing (2nd Edition). Nursing Economics Supp. (May-June, 2014), 5-35.

Beglinger, Joan Ellis. " Designing Tomorrow: Changing Our Practice in Response to Evidence" JONA Volume 44, No. 4. April, 2014. Pgs. 194-195.

Federal Legislation to Protect Patients, Nurses. The American Nurse, (May-June, 2015), 15.

McHugh, M.D., Berez, J. & Small, D.S. (2013). Hospitals with higher nurse staffing had lower odds of readmissions penalties. Health Affairs, 32(10, 1740-47.

McHugh, M.D., Kelly, L.A., Smith, H.L., Wu, E.S., Vanak, J.M. & Aiken, L.H. (2013). Lower mortality in Magnet hospitals. Medical Care, 51(5), 382-8.

 

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Useful Sources

McHugh, M.D. & Ma, C. (2013). Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Medical Care, 51(1), 52-9.

Needleman, J., Buerhaus, P., Pankratz, V.S., Leibson, C.L., Stevens, S.R. & Harris, M. (2011). Nurse staffing and inpatient hospital mortality. New England Journal of Medicine, 364(11), 1037-45.

Nurse Staffing Plans and Ratios. ANA Nursing World. Accessed on June 29, 2015 at http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/State/Legislative-Agenda

Patient Safety Primer - Missed Nursing Care. AHRQ Patient Safety Network (PSNet). Accessed on June 22, 2015 at http://psnet.ahrq.gov/glossary.aspx.