Nurse Staffing: National Policy Perspective Pamela F. Cipriano, PhD, RN, FAAN, NEA-BC Chief Clinical Officer and Chief Nursing Officer.

Nurse Staffing: National Policy Perspective

Pamela F. Cipriano, PhD, RN, FAAN, NEA-BCChief Clinical Officer and Chief Nursing Officer

The Impacts of Nurse Staffing

Financial Outcomes

Nurse Satisfaction and Retention

Patient Safety Patient Satisfaction

• Research shows an association between higher levels of RN staffing and fewer adverse events, such as:• Increased complications

• Shock

• Urinary tract infections

• Increased LOS

• Failure to rescue

• Pressure ulcers

• Mortality

• Every additional patient assigned to an RN is associated with a:• 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

• Hospital-acquired infections

• Pneumonia

• Cardiac arrest

• Upper GI bleeds

• Medication error rates

• Falls

• Central line infections

• 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:• 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:• 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

Raise the proportion of hours provided by RNs to 75% of total nursing care hours

Outcome

Reduce LOS by 1.5 million days

Patient Safety

All options reduce hospital days and patient mortality

Increase the number of licensed (RN & LPN) hours per day to 75% percent (without changing the proportion)

Raise both staffing hours and percentage of nursing care provided by RNs to 75% nationwide

Reduce LOS by 2.6 million days

Reduce LOS by 4.1 Million days• Reduce adverse outcomes by

70,000

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

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%

National ProjectionsVirginia Projections

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

Enacted legislation to date: CT, IL, OH, OR, WA, TX, RI, CA, FL, NJ, VT, NV, NY, PA

Pending legislation: AZ, HI, IL, IA, MI, MN, NY, OR, WV

SC

VA

NM

CO

TX

OK

WA

OR

CA

ID

NVUT

MT

WY

NDMN

KS

NE

MO

IA

ARMS

IL INOH

KY

TN

wv

WIMI

PA NJ

NY

AK

HI

MD DE

MACT

NHVT

RI

NC

GAAL

FLLA

ME

SD

AZ

DC

State Legislation Overview

Defeated/reversed legislation to date: AK, CO, FL, MA, NM, ME, DC

As of October 21, 2008

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

• 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-to-patient ratios• California - Defines the same minimum unit-specific nurse-to-

patient 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

• Defeated• 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

• 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