2006 - ARNNL · Staffing for Quality Care in Institutional Settings rnRN

STAFFING FOR QUALITY CARE IN INSTITUTIONAL SETTINGS

2006

This Position Statement was approved

by ARNNL Council in 2006.

Staffing for Quality Care in Institutional Settings

55 Military Road | St. John’s | NL | Canada | A1C2C5 | Tel: (709) 753-6040 | 1 (800) 563-3200 | Fax: (709) 753-4940 | [email protected] ARNNL.CA

Acknowledgements This document was developed for the Association of Registered Nurses of Newfoundland and Labrador with significant input from: Karen Ballard Rosemary Barrington Madonna Chaulk Gail Downing Frances Dwyer Sylvia Francis Sheila Hynes Bonnie Keel Patricia Pilgrim Arleen Quann Eva Tucker Christine Way Pamela Elliott, ARNNL Project Consultant Betty Lundrigan, ARNNL Nursing Consultant

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ARNNL.CA 55 Military Road | St. John’s | NL | Canada | A1C2C5 | Tel: (709) 753-6040 | 1 (800) 563-3200 | Fax: (709) 753-4940 | [email protected]

Association of Registered Nurses of Newfoundland and Labrador

Table of Contents

Acknowledgements ................................................................................................................................. i

Introduction ............................................................................................................................................ 1

Background ............................................................................................................................................ 1

Guiding Principles .................................................................................................................................. 3

Factors Affecting Staffing ....................................................................................................................... 4

Accountabilities of Nurses in Staffing Decisions .................................................................................... 5

Conclusion ............................................................................................................................................. 6

References ............................................................................................................................................. 7

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Introduction Staffing decisions impact the quality, safety, and outcome of client care in all health care settings. At all levels in health care organizations, nurses are faced with the challenges of ensuring quality client care within the constraints of available fiscal resources. Nurse managers are challenged, individually and collectively, to make decisions about resource allocation, skill mix, and patient care assignment models, as well as the level of guidance and supervision necessary for various categories and skill levels of staff. Direct care registered nurses are challenged to provide quality client care and direction to other care providers, participate in decisions affecting staffing, and, when necessary, advocate for altered staffing levels to meet the needs of the client population. The Association of Registered Nurses of Newfoundland and Labrador (ARNNL) represents approximately 6,300 registered nurses in the province. ARNNL’s vision of Healthy People in Newfoundland and Labrador includes excellence in nursing, public protection, quality health care, and healthy public policy. Excellence in nursing is interpreted to include registered nurses are supported in their efforts to ensure that staffing levels support reasonable workloads and safe, client care. The purpose of this position statement is to provide support and direction to registered nurses in direct care and management roles when making staffing decisions. The directions provided are applicable to the acute care, and long term care sectors. It is not intended to replace collective agreement processes, to prescribe specific staffing levels or patterns for individual clinical settings, or to advocate for one group of nursing care providers over another. In addition to developing this position statement ARNNL has compiled a Staffing Resource Kit to support policy makers, employers, and registered nurses at all levels where staffing issues and decisions are being addressed. The Kit includes a range of resource material, including The Evaluation Framework to Determine the Impact of Nursing Staff Mix Decisions (CNA, 2005), summaries of various research articles demonstrating the impact of staffing decisions on client, nurse, and system outcomes, a tool for staffing decision making, and other resource material. Together the position statement and the ARNNL Resource Kit provides a comprehensive approach to staffing for quality care and contributes to achieving ARNNL’s vision for excellence in nursing and quality health care.

Background The importance of a comprehensive approach to staffing decisions resulting in appropriate staffing levels, skill mix, and staffing patterns has far reaching consequences for key goals of the health services sector and the nursing profession. These goals include quality patient care, achieving quality professional practice environments, addressing the patient safety agenda, and recruiting and retaining an adequate nursing work force. There is an accumulating body of research providing evidence to inform the effective use of nursing resources. The following evidence highlights the impact of various staffing factors on client, nurse and system outcomes:

A higher proportion of regulated nursing staff (RN and LPN) has a positive impact on patient health and satisfaction outcomes (McGillis Hall et al., 2003).

A higher proportion of RN staffing has a positive impact on patient’s self-care ability, managing patient’s pain and patient satisfaction (Potter, Barr, McSweeney & Sledge, 2003).

A higher proportion of RN staffing is associated with a decrease in the rate of patient falls and an increase in patient satisfaction with pain management (Sovie & Jawad, 2001).

A higher proportion of RNs is associated with shorter lengths of stay, and lower rates of urinary tract infections, upper gastrointestinal bleeding and failure to rescue (Needleman, Buerhaus, Mattke, Stewart & Zelevinsky, 2000).

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Patients with acute myocardial infarction in hospitals with higher ratios of RNs were less likely to die in hospital than patients in hospitals with lower ratios of RNs to patients (Person et al., 2004).

A higher proportion of RNs and RN experience on the clinical unit were both positively associated with decreased 30-day mortality (Torangue, Giovannetti, Tu & Wood, 2002).

When nurses are required to work extra hours, the likelihood of them making an error increases (Rogers, Hwang, Scott, Aiken & Dinges, 2004).

A lower proportion of RN and LPN staffing results in negative system outcomes such as higher nursing costs overall, decreased patient safety, and low quality care (Mcgills Hall, Doran & Pink, 2004; Aiken, Clarke & Sloane, 2002; and Delledield, 2002).

Higher RN staffing results in shorter lengths of stay (Needleman, Buerhaus, Mattke, Stewart & Zelevin-sky, 2002).

Inadequate staffing has been shown to result in low staff morale, inability to get requested leave or to attend educational events, and higher soft tissue and needle stick injuries (Baumann et al., 2001). These research findings demonstrate that effective use of nursing resources will improve client, nurse, and system outcomes therefore contributing to improved safety, quality, and cost-effectiveness of care. However at this time there are very limited research sources prescribing a specific staffing mix and levels to be used in various clinical settings or effective staff mix decision making models to achieve these outcomes (CNA, 2004). Defining a specific minimum RN staffing level for a specific practice setting is proposed by some as the way to ensure safe patient care and acceptable nursing workload levels. In the United States a number of jurisdictions have or are considering the legislation of specific nurse to patient ratios (eg. 1 nurse to 6 medical surgical patients) and others are regulating criteria for the development of nurse staffing plans for specific practice. settings. In 2005 the Canadian Federation of Nurses Unions and Health Canada initiated the first formal examination of nurse-patient ratios as a potential staffing approach for Canada. Based on this work, a report titled Enhancement of Patient Safety through Formal Nurse-Patient Ratios: A Discussion Paper (Tomblin Murphy, 2005) recommends further examination, consultation, and applied research in a Canadian context to determine whether nurse-patient ratios would be an effective way to improve patient safety and well being of nurses. The concept of nurse-patient ratios is controversial. Proponents view them as an approach to promote and improve patient safety and to deal with heavy workloads, turnover and burnout of nurses. Opponents view it as a “one size fits all” approach and not reflective of patient needs, patient complexity, and the many other factors impacting staffing needs (ICN, 2003). Any adoption of a nurse-patient ratio or minimum staffing approach needs to be flexible and allow upward adjustment depending on patient requirements and other factors such as the experience and competency of the RN staff (Tomblin Murphy, 2005). In Canada established nurse staffing standards exist for a small number of specific client populations. The Operating Room Nurses Association of Canada (ORNAC) stipulates each case or surgical procedure must be staffed by a minimum of two perioperative RNs (ORNAC, 2003). Health Canada stipulates a series of minimal staffing standards for different categories of obstetrical and neonatal clients for example one to one registered nurse, or midwifery care, for women in active labour through the completion of fourth stage and one registered nurse to two infants for more acute or unstable babies; and one nurse to three infants for those babies requiring convalescent care. In the examples cited both organizations set these as minimal staffing and recom-mend that additional staff be added based on the needs of the client. Staffing for quality care in rural and remote NL communities poses some unique challenges. Kulig et al., (2003) identify five specific areas that require examination when analyzing the current state of rural and remote nursing practice. These are (1) advanced practice, (2) nursing practice issues in aboriginal communities, (3) educational preparation of RNs for rural and remote areas, (4) physician supply in rural and remote areas, and (5) health care organization and delivery in rural and remote areas. A recent survey of Canadian nurses in rural communities found 12% of respondents worked alone, 74% reported feeling physically safe during the work evening/night and 92% reported feeling safe during the workday (Stewart et al., 2005).

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Staffing decisions are complex with significant consequences for clients, nurses and the system. The ARNNL Staffing for Quality Care Position Statement outlines the guiding principles, factors to consider in staffing decisions and the RN’s responsibilities and accountabilities for staffing decisions. The framework described below is complementary to achieving quality professional practice environments for registered nurses and safe, competent, ethical nursing care for patients and clients in NL.

Guiding Principles ARNNL believes the determination of staffing levels is a complex process that requires consideration of various principles. The following principles are grounded in the CNA Code of Ethics and the ARNNL Standards for Nursing Practice in Newfoundland and Labrador, and should guide staffing decisions:

Organizations use an evidence-based approach to determine, implement and evaluate staffing levels, skill mix, and models for care delivery and the impact of these on client, nurse and system outcomes (CNA, 2003; CNA, 2005).

Multiple factors (outlined in the next section) are considered when establishing staffing levels, staffing patterns, and skill mix to support the delivery of quality care.

Staffing decisions require the input of nurses and nurse managers at all levels within the organization.

Accurate, comprehensive documentation of client care is critical to obtaining the information necessary for staffing decisions.

Workload measurement systems that account for the analytical nature of nursing assessment and planning, decision making, and critical thinking, and the characteristics of the practice setting, in addition

to the time required to perform the care, assist in effective staffing decisions.

Safety of clients is never compromised by substituting less qualified workers when the competencies of a registered nurse are required (CNA, 2003).

Staffing levels, skill mix, and staffing patterns are based on ongoing assessment of care needs in the clinical setting, current trends, and other information gathered in the practice setting.

Position descriptions that clearly outline the responsibilities and accountabilities of each employee group facilitate staffing decisions and maximize the scope of practice for each employee group.

Further, RNs must adhere to the following professional standards:

Nurses at all levels are responsible for providing safe, competent, and ethical care.

Individual registered nurses are accountable for ensuring they possess or seek out the knowledge, skills, and attributes required to competently care for the client population.

Also, it is ARNNL’s belief that:

Employers, ARNNL, nurse managers, and government must provide the necessary resources to ensure ethical and professional nursing practice standards are met in the delivery of quality care.

Employers must provide resources to facilitate the education of nurses in meeting the competency requirements of the position, especially as it relates to new techniques, treatments, and equipment.

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In situations where non nurse managers are responsible for staffing decisions, employers, registered nurses and the managers are responsible for ensuring the principles and factors outlined in this position statement guide staffing decisions.

Factors Affecting Staffing Identification of the nursing staff mix1 requires consideration of many factors that can be grouped into four main categories - the philosophical framework for nursing practice, the client group, personnel factors, and the environment (Dechant, 1999). Some of the most important factors that nurses should consider when making staffing decisions include the following:

Philosophical Framework for Practice

vision mission values goals and objectives standards policies and procedures care model used culture staff participation in teaching

Client Factors

number of clients average occupancy rates patterns and trends in client census admission rates average length of stay acuity of client conditions/illnesses complexity of care required demographics:

age education socio-economic factors physical needs psychological needs spiritual needs recreational needs cultural needs language

client (and sometimes family) service expectations family support needs

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1Nursing Staff Mix: the combination and number of regulated and unregulated persons providing direct and indi-rect nursing care to clients in all settings where regulated nursing groups (RNs, LPNs, RPNs) practice (CNA, 2003).



Personnel Factors

available skill mix roles and scope of practice availability education (including continuing education) experience expertise position classification individual aspirations, goals, and objectives length of service age gender social and ethnic background support service resources teamwork

Environmental Factors

design of the setting – size, layout, number of beds/clinic spaces unit intensity physician practices equipment and technology used union contracts service boundaries and geography supplies available hours of operation access to other services

Accountabilities of Nurses in Staffing Decisions Nurses in various positions throughout the organization are responsible for and contribute to staffing decisions. The nature of the nurse’s role in staffing decisions will vary depending on the organization and the position held, however, a number of accountabilities are consistent and are outlined as follows:

Executive/Senior Nurse Managers

engage, in an informed and meaningful way, in decision making affecting nursing resources;

ensure there are adequate resources to staff at safe levels;

ensure there are valid and reliable workload measurement systems and that results are factored into decision making;

promote the implementation of the electronic health record with workload measurement as a by-product;

promote the development of evidence-based guidelines and policies for assisting managers in staffing decisions;

ensure there are accessible qualified nurse experts to support the professional practice of nurses in the clinical setting;

ensure there are professional development programs in place to address the competency needs of nurses in the provision of safe client care;

implement measures to maximize the scope of practice of all care providers.

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Frontline and Middle Nurse Managers

collaborate with direct care nurses in staffing decision making;

inform nurses of the guidelines and principles used to develop staffing levels;

utilize evidence in making staffing decisions;

monitor and evaluate client outcomes, effectiveness of staffing decisions, and the performance of nurses;

demonstrate leadership in promoting teamwork and unit cohesion, and facilitating/resolving staffing issues;

advocate for the resources required to support safe staffing levels;

implement measures to maximize the scope of practice of all care providers.

Direct Care Nurses

become knowledgeable about the factors affecting staffing levels;

identify staffing concerns to nurse manager based on practice standards, code of ethics, and the factors involved;

work collaboratively with nurse managers and other disciplines to resolve staffing issues;

use appropriate decision-making processes in the assignment and delegation of care to registered nurses and other categories of nursing personnel, including unregulated workers;

be knowledgeable of, and advocate to maximize, the scope of practice of all care providers;

initiate action to attain and maintain the competencies required to meet the needs of clients in their care;

promote teamwork and unit cohesiveness;

ensure accurate, comprehensive documentation of factors impacting on workload and staffing decisions. Those responsible for staffing in rural and remote communities must consider:

the safety of nurses working in isolated communities and alone,

the impact of the provision of expanded nursing services and first point of contact care on staffing needs, and

the provision of formalized peer support programs and accessible continuing education opportunities.

Conclusion ARNNL acknowledges the many complexities affecting staffing decisions. This position statement, along with the ARNNL Staffing Resource Kit, provide guidance in addressing staffing decisions, recognizing that the health care system will continue to evolve and develop new approaches to deal with the challenges associated with ensuring quality client care.

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References Aiken, L.H., Clarke, S.P., Sloane, D.M. (2002). Hospital staffing, organization, and quality of care:

Cross-national findings. International Journal for Quality in Health Care, 14(1), 5-13.

Association of Registered Nurses of Newfoundland and Labrador (1995). Standards for Nursing Practice in

Newfoundland and Labrador. St. John’s: Author. Baumann, A., O’Brien – Pallas, L., Armstrong – Stassen, M., Blythe, J., Bourbonnais, R., Cameron, S., Foran,

D. J., Kear, M., McGillis Hall, L., Vezina, M., Butt, M., & Ryan, L. (2001). Commitment and Care: The Benefits of a Healthy Workplace for Nurses, their Patients, and the System. Ottawa: Canadian Health Services Research Foundation.

Canadian Nurses Association. (2002). Code of Ethics for Registered Nurses. Ottawa: Author. Canadian Nurse Association. (2004). Nursing Staff Mix: A Literature Review. Ottawa: Author. Canadian Nurses Association. (2003). Position Statement–Staffing Decisions For the Delivery of Safe Nursing

Care. Ottawa: Author. Canadian Nurses Association. (2005). Evaluation Framework to Determine the Impact of Nursing Staff Mix

Decisions. Ottawa: Author. Dechant, Germaine. (1999). Human resource allocation: Staffing and scheduling, Nursing Management in

Canada. Winnipeg: WB Saunders Company. Dellefield, M.E. (2002). The relationship between nurse staffing in nursing home and quality indicators: A

literature review. Journal of Gerontological Nursing, June, 15-28. Health Canada. (2000). Family-Centered Maternity and Newborn Care: National Guidelines, Chapter 2. Ottawa:

Minister of Public Works and Government Services. International Council of Nurses. (2003). Nurse:Patient Ratios. ICN Nursing Matters Fact Sheet. Geneva: Author. Kulig, J. C., Thomlinson, E., Curran, F., Nahachewsky, D., Macleod, M., Stewart, N., Pitblado, R. (2003). Rural

and Remote Nursing Practice: An Analysis of Policy Documents. Ottawa: Canadian Health Services Research Foundation.

McGillis Hall, L., Doran, D., Baker, G.R., Pink, G.H., Sidani, S., O’Brien-Pallas, L., & Donner, G.J. (2003).

Nurse staffing models as predictors of patient outcomes. Medical Care, 41(9), 1096-1109.

McGillis Hall, L., Doran, D., Pink, G.H. (2004). Nursing staffing mix models, nursing hours and patients safety outcomes. Journal of Nursing Administration, 34(1), 41-45.

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levels and the quality of care in hospitals. New England Journal of Medicine, 346 (22), 1715-1722.

Operating Room Nurse Association of Canada, (2003). ORNAC Position Statements. Staffing the Surgical Suite. Location unknown: Author.

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Person, S.D., Allison, J.J., Kiefe, C.I., Weaver, M.T., Williams, O.D., Centor, R.M., & Weissman, N.W. (2004).

Nurse staffing and mortality for medical patients with acute myocardial infarction. Medical Care, 42(1), 4-12.

Potter, P., Barr, N., McSweeney, M., & Sledge, J. (2003). Identifying nurse staffing and patient outcome relationships: A guide for change in care delivery. Nursing Economics, 21(4), 158-166.

Rogers, A. E., Hwang, W. T., Scott, L. D., Aitken, L. H., & Dinges, D. F. (2004). The Working hours of hospital staff nurses and patient safety. Health Affairs, 23 (4), 202-212.

Sovie, M.D., & Jawad, A.F. (2001). Hospital restructuring and its impact on outcomes: Nursing staff regulations are premature. Journal of Nursing Administration, 31(12), 588-600.

Stewart, N., D’Arcy, C., Pitblado, R., Forbes, D., Morgan, D., Remus, G., Smith, B., Kosteniuk, J. (2005). Report of the National Survey of Nursing Practice in Rural and Remote Canada. Saskatoon, Saskatchewan : University of Saskatchewan, Applied Research/Psychiatry and College of Nursing.

Tomblin Murphy, G. (2005). Nurse – Patient Ratios and Patient Safety : A Review of the Literature. Ottawa : The Canadian Federation of Nurses Unions & The Office of Nursing Policy, Health Canada.

Tourangeau, A.E., Giovannetti, P., Tu, J.V., & Wood, M. (2002). Nursing-related determinants of 30-day

mortality for hospitalized patients. Canadian Journal of Nursing Research, 33(4), 71-88.

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55 Military Road

St. John's

NL | Canada

A1C 2C5

Tel (709) 753-6040

1 (800) 563-3200 (NL only)

Fax (709) 753-4940

[email protected]

arnnl.ca

2006 - ARNNL · Staffing for Quality Care in Institutional Settings rnRN

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