Transcript Nurse Staffing Policy - Virginia Nurses Association

Nurse Staffing: National Policy Perspective
Pamela F. Cipriano, PhD, RN, FAAN, NEA-BC
Chief Clinical Officer and Chief Nursing Officer
The Impacts of Nurse Staffing
Patient Safety
Patient Satisfaction
Nurse Satisfaction
and Retention
Financial Outcomes
Patient Safety
• Research shows an association between higher levels of RN staffing
and fewer adverse events, such as:
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Increased complications
Shock
Urinary tract infections
Increased LOS
Failure to rescue
Pressure ulcers
Mortality
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Hospital-acquired infections
Pneumonia
Cardiac arrest
Upper GI bleeds
Medication error rates
Falls
Central line infections
• Every additional patient assigned to an RN is associated with a:
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53% increase in respiratory failure
17% increase in medical complications
7% increase in the likelihood of failure to rescue
7% increase in the risk of hospital-acquired pneumonia
Patient Safety
• Results from Alberta, Canada
• Nearly 1/3 of the variation in hospital death rates in Alberta were
associated with hospital nursing characteristics
• Four hospital nursing characteristics significantly associated with
lower mortality rates:
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Employment status
Education
Skill mix
Nurse/physician relationships
• Education Correlation
• A 10% increase in the proportion of nurses holding a BSN was
associated with a 5% decrease in both likelihood of patients dying
within 30 days of admission and the odds of failure to rescue.
• With higher proportions of nurses educated at the
baccalaureate level or higher, surgical patients
experienced lower mortality and failure-to-rescue
rates.
Patient Safety
• If a nurse has 8 patients instead of 4, the risk of death for
all those patients increases by 31%
• Adding one full-time RN per patient day eliminated 16% of
hospital-related deaths
• There is a 3% to 6% shorter length of stay for patients in
hospitals with a high percentage of RNs
• Caring for >2 ICU patients led to 49% increase in LOS and
increased risk of medical complications
• Excessive nurse workload is a key factor in safety in ICUs
• There are 17 errors per patient day in ICUs
• For every patient >4 assigned in acute care
areas, risk of mortality could rise 7%
Patient Safety
• Heavy workload leads to:
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Decreased patient supervision
Incorrect ventilator/equipment set-up
Drug administration problems
Insufficient time for clinical procedures to be done properly
Inadequate training or supervision
Errors
Patient Safety
Option
Outcome
Raise the proportion of hours
provided by RNs to 75% of total
nursing care hours
Reduce LOS by 1.5 million days
Increase the number of licensed
(RN & LPN) hours per day to
75% percent (without changing
the proportion)
Reduce LOS by 2.6 million days
Raise both staffing hours and
percentage of nursing care
provided by RNs to 75%
nationwide
Reduce LOS by 4.1 Million days
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Reduce adverse outcomes by
70,000
All options reduce hospital days and
patient mortality
Patient Satisfaction
• “Nursing care should receive universal recognition as the
principal factor in determining the inpatient acute care
experience” (Clark, Leddy, Drain, & Kaldenberg, 2007, p. 124).
• Greater patient satisfaction is associated with more total
nurse hours of care per patient day and with more RNs in
the staffing mix
• Patients’ perception of nurse staffing influences patients’
perception of nursing care, which influences their overall
satisfaction with the entire hospital experience
Patient Satisfaction
• When the ratio of working
RNs to state population
increases, perceived nursing
care quality increases, and
vice versa. (e.g. California
and Texas report lower than
average patient satisfaction
while also having the lowest
RN supply per patient.)
Improved Nurse
Staffing
Greater Nurse
Satisfaction
Improved Quality of
Care
Higher
Patient
Satisfaction
Nurse Satisfaction and Retention
• Inadequate nurse staffing leads to job dissatisfaction,
burnout, injury and illness, as well as high job turnover
• Results of an ongoing ANA survey:
• 40% report job dissatisfaction, and more than 43%
demonstrated high levels of burnout
• 23% plan to quit their current jobs within the next year; for
nurses under 30 years of age, that figure rose to 33%
• 60% said they knew of someone who left direct care nursing
due to concerns about safe staffing
• 73% don’t believe the staffing on their unit of shift is sufficient
• 52% said they thought the quality of nursing on their unit has
declined in the past year
Nurse Satisfaction and Retention
• “If you overburden nurses with too many patients who are as sick
as they are in hospitals today, patients will become a problem, an
undesirable, and not a challenge to them…and challenge is the
reason why they became nurses in the first place. Nurses will want
to flee their patients and their workplaces, not embrace patient
care and their work” (Suzanne Gordon, quoted in Massachusetts
Nurse, 2008).
Nurse Satisfaction and Retention
• The average age of an RN is increasing more than twice as fast as all
other occupations in the workforce (average age of a clinical nurse is
46.8)
• By 2020, 44 states are expected to have RN shortages
• 50% of the workforce will reach retirement age by 2015
National Projections
Virginia Projections
Year
Demand
Shortage
%
Shortage
2005
52,777
-7,698
15%
2010
57,643
-11,927
21%
2015
63,157
-18,446
29%
2020
68,945
-25,111
36%
Financial Outcomes
• Cost-effectiveness: Based on value patients and payers
assign to avoided death and complications
• Does improving quality increase or decrease the cost to
patients, hospitals and payers?
Financial Outcomes
• Hospitals with better staffing are more profitable and have
a lower cost-per-patient discharge than understaffed
hospitals.
• Reports show that minimum RN staffing levels are more
cost-effective than common lifesaving practices such as
clot-busting medications for heart attack and stroke, and
cancer screenings.
• Nurses prevent adverse events
• Increased nurse hours = decreased complications
• Pneumonia adds 5.1-5.4 days and $23,000-28,000
• Adverse drug reaction adds 1.74-2.2 days and $2,000-3,500
Financial Outcomes
• Complications connected to higher nurse-to-patient ratios
increase the unreimbursed hospital costs by an average of
$1,248 per patient.
• The cost for advertising, training and loss in productivity
associated with recruiting new nurses to a facility is a
minimum of $37,000 per nurse.
Financial Outcomes
• Mortality is most affected (72,000 lives can be saved per
year with 1:4 ratio)
• Moving from 1:7 to 1:6 staffing saves 1.4 additional lives at
$64,000 per life
• Moving from 1:5 to 1:4 saves additional lives at $136,000
per life saved
Legislation
What’s going on around the country?
Federal Legislation - Pending
• The Registered Nurse Safe Staffing Act (S. 73/H.R. 4138)
• Sponsored by:
• Sen. Daniel Inouye (D-HI)
• Rep. Ginny Brown-Waite (R-FL)
• Rep. Lois Capps (D-CA)
• Proposes:
• Hospital staffing plans, developed in coordination with direct care
registered nurses
• Public reporting of staffing information
• No specified staffing ratios
State Legislation Overview
WA
ME
MT
ND
MN
OR
ID
WY
NV
CA
VT
NY
WI
SD
PA
IL
UT
CO
KS
RI
MI
IA
NE
MO
IN
OH
NM
OK
wv
VA
DE
DC
KY
NC
SC
AR
MS
TX
NJ
MD
TN
AZ
NH
MA
AL
GA
LA
FL
HI
Enacted legislation to date: CT, IL, OH, OR, WA, TX, RI, CA, FL, NJ, VT,
NV, NY, PA
Defeated/reversed legislation to date: AK, CO, FL, MA, NM, ME, DC
As of October 21, 2008
Pending legislation: AZ, HI, IL, IA, MI, MN, NY, OR, WV
State Legislation - Adopted
• Staffing Plans - Every hospital must have a committee who
will develop, oversee and evaluate a nurse staffing plan
• Hospital staffing committee must include direct care staff nurses
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Connecticut (50%)
Illinois (50%)
Ohio (50%)
Oregon (50%)
Washington (50%)
Texas (% not specified)
• Involvement of direct care nurses not specified
• Rhode Island – Hospitals must annually submit a core-staffing plan to
the Department of Health
State Legislation – Adopted
• Staffing Ratios – State-mandated unit-specific nurse-topatient ratios
• California - Defines the same minimum unit-specific nurse-topatient ratios to be utilized in all nursing units in all hospitals. The
nurse-to-patient ratio may be adjusted based upon patient acuity
and is enhanced by the continuation of the mandated use of a
patient classification system.
• Florida - Minimum staffing requirements for nursing homes.
State Legislation – Adopted
• Public Reporting of Nurse Staffing
• Illinois - Instituted a Hospital Report Card, which in addition to
reporting patient outcomes reports on nurse staffing plans,
orientation & training.
• New Jersey - Hospital must complete and post daily staffing
information for each unit and each shift. Made available to the
public on a quarterly basis.
• Vermont - Requires public access to information related to nurse
staffing ratios.
Other Actions Taken
• Nevada – In 2003, required the Legislative Committee on
Health to appoint a subcommittee to conduct an interim
study on nurse staffing
• New York – Ban on mandatory overtime
• Pennsylvania – Ban on mandatory overtime
State Legislation/Regulations Defeated or Reversed
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Alaska – Limits on mandatory overtime
Colorado – Staffing plan legislation
Florida – Public reporting and staffing ratio legislation
Massachusetts – Staffing ratio legislation
New Mexico – Public reporting legislation
• Reversed
• Maine - Removed established staffing systems consisting of
required minimum nurse-to-patient staffing ratios. Maine Quality
Forum Advisory Council recommended standardization of staffing
plans and acuity tools instead of mandated ratios.
• Washington DC - Waived enactment of staffing ratios previously
legislated in 2002
State Legislation - Pending
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Arizona – Staffing ratios
Hawaii – Staffing ratios
Illinois – Staffing ratios
Iowa – Hospital staffing committee (50% direct care RNs)
Michigan – Hospital staffing committee (50% direct care
RNs), staffing ratios
Minnesota – Hospital staffing committee and staffing ratios
Missouri – Public reporting
New York – Staffing ratios
Oregon – Staffing ratios
Pennsylvania – Limits on mandatory overtime
West Virginia – Staffing ratios