Best Practices for Staffing: Acuity vs. Census BACKGROUND • Patient Classification Systems have been utilized since the 1960’s without standardization or consensus (Harper & McCully, 2007). • With a combination of increasing health costs, decreasing nurse satisfaction, a lack of communication tools, and staffing shortages; acuity tools can appropriately coordinate staff with patient needs (Twigg, Duffield, Bremner, Rapley, & Finn 2011). • Low nurse-to-patient ratios are related to lower rates of adverse patient outcomes (Harper & McCully, 2007). • “Patient classification systems and acuity tools allow managers and Lauren Bachman, Heath Chrisianson, Sylvia Davis, Heidi Kidd, Eric Stuemke SEARCHABLE QUESTION What are the best practices for staffing adult inpatient acute care units regarding patient census and patient acuity? Databases Searched CINAL & PUBMED CONCLUSIONS Nurse leadership should pay careful attention to seeking buy in from staff nurses and other interdisciplinary members (Harper and McCully, Each unit should seek out workable acuity tools, and implement them within their specific environment (Heede, Diya, Lesaffre, Vleugels, & Sermeus, 2008). RESULTS Evidence Answers Original Question •Research was inconclusive related to our original question. At this time there is a continued need for establishing a universal acuity rating tool. Additional experimentation, and possibly a meta-analysis of previous research is needed. Not Found in Evidence •There was no universal tool for patient acuity measurement found in the literature search.  For addition information please contact: University of Anchorage School of Nursing (907) 786-4550 Suggestions for Future Research •Meta-analysis of all currently available acuity tools. •Unit specific measures of acuity should be considered in development of future acuity staffing tools. •A patient acuity tool should be developed, and measured against patient Summary of Evidence What does it all mean? •Nurse tracking call light systems are an underutilized tool that can be used to effectively communicate patient needs among the interdisciplinary team, (Lucero, Ji, Cordova, & Stone, 2011) •There is a need to have a universal acuity tool, (Harper & McCully, 2007). •There is an association between acuity based staffing and improvements in patient safety, (Twigg, Duffield, Bremner, Rapley, & Finn, 2011). •Nursing satisfaction is related to patient acuity, nursing workload, and understaffing (McGillis & Kiesners, 2005). •Universal system for collection of nurses involved in patient care (Mark & Harless, 2011). •A standardized acuity system needs to be developed, tested, and implemented widely in hospitals and adopted by researchers (Mark & Harless, 2011) •Patient satisfaction is related to nurse staffing and the availability of hospital support services. (Bacon & Mark, 2009) •High acuity increases workload due to understaffing. Fixing staffing would decrease the workload per patient (Acar, 2010). •Patient acuity scoring systems and distance scoring systems can be used to estimate total workload of nurses, (Acar, 2010). •Units cannot use a minimum nurse patient ratio alone, a number of factors must be incorporated to determine an appropriate patient to nurse ratio, including patient acuity, skill mix, nurse competence, nursing process variables, technological sophistication (Lang, Hodge, Olson, Romano, & Kravitz, 2004). •There is a lack of support offered in the literature for specific minimum nurse patient ratios ,(Lang, Hodge, Olson, Romano, Kravitz, 2004). •The use of acuity tools alone is not sufficient to determine adequate staffing requirements, (Hayes & Ball, 2012) Level of Evidence/ Citation Key Measures Settings and sample Research Design Key Strengths/Weaknesses Results Level IV Evidence Lucero, R.J., Ji, H., de Cordova, P.B., & Stone, P. (2011). Information technology, nurse staffing, and patient needs. Nursing Economics, 29(4), 189-194. IV: DV: Orthopedic surgical unit Sample, n=34: -FTE RNs Retrospective Exploratory - Convenience, non- randomised sample Strengths: -Readily available data & use of existing technology - Application to clinical practice Weaknesses: -Admissions increased response times more than discharges. -Tracking call light study demonstrated the busiest times of the day. -Nurse staffing was adjusted accordingly. Level VI Evidence Harper & McCully. (2007). Acuity systems dialogue and patient classification system essentials. Nursing Administration Quarterly, 31(4), 284-299 IV: DV: Medical-surgical unit Sample, n=15: -RNs -5 Criteria of patient classification: medications, complicated procedures, education, psychosocial issues, complicated IV medications. -Yielded: 1-4 patient acuity rating Descriptive Strengths: -Use of staff nurses input to develop PCS tool. -5 rating concepts evaluate time and frequency required for interventions -Includes education and psychosocial considerations Weaknesses: -Small sample size -No clear The PCS tool was well received by nurses with 77% rating it as an effective voice for nurses in communicating about their patients. Level IV Evidence Twigg, D.I., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (2011). The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: A retrospective analysis of patient and staffing data. International Journal of Nursing Studies, 48(5), 540- 548. IV: Mandatory staffing levels: Nursing hours per patient day (NHPPD) DV: Patient outcomes Western Australian hospitals. Sample, n= 235,454: -patient records Sample, n=150,925: -staffing records Interrupted time series, retrospective analysis of patient and staffing data throughout the implementation of the mandated staffing level. Strengths: Extensive patient and nurse staffing records. Weaknesses: California hospitals did not have similar findings following mandatory staffing ratio implementation. This study found an association between implementing the NHPPD staffing method and improvements in patient safety. Specifically, there have been significant reductions in the rates of nine nursing-sensitive patient outcome indicators following the implementation of the NHPPD staffing method. Level VI Evidence McGillis Hall, L., & Kiesners, D. (2005). A narrative approach to understanding the nursing work environment in Canada. Social Science & Medicine, 61(12), 2482-2491. doi: 10.1016/j.socscimed.2005.05.002 8 acute care, publicly funded, Canadian hospitals (randomly selected) Sample, n=8: -nurses -selected by purposive Qualitative -Detailed analysis of transcripts Strengths: -Themes dominated conversations and were interrelated Weaknesses: -Group size was preselected -No mention of data saturation Detailed analysis of transcripts revealed three key themes: patient acuity, workload, and understaffing. Workload and understaffing dominated the narrative and showed a strong link to patient acuity. Level IV Evidence Mark, B. A., & Harless, D. W. (2011, March/April). Adjusting for patient acuity in measurement of nurse staffing. Nursing Research, 60(2), 107-113. Non-Experimental 13 states from 2000 - 2006 Sample, n=579: -Hospitals - Included were: three measures of nurse staffing and hospital characteristics (ownership, geographic location, teaching status, Non-Experimental - Cross-sectional - Longitudinal study Strengths: -Large sample size Weaknesses: - NIWs provide a true estimate of patient needs -CMI doesn’t reflect acuity -CMI only for Medicare patients The study used descriptive statistics and simple correlation analysis and found no statistically significant relationship between NIW-adjusted and CMI adjusted staffing. This study suggests one way to start addressing staffing based on patient acuity is to have a “standardized acuity system developed, tested, implemented widely in hospitals, and adopted by researchers”. Level IV Evidence Heede, K. V., Diya, L., Lesaffre, E., Vleugels, A., & Sermeus, W. (2008). Benchmarking nurse staffing levels: The development of a nationwide feedback tool. Journal of Advanced Nursing, 63, 607-618. Non-Experimental 1637 acute care nursing units in 115 hospitals Sample, n=690,258: -inpatient days for 298,691 patients Non-Experimental - Retrospective analysis of cross-sectional data Strengths: -Random selection of patients data Weaknesses: -Data assumes units within hospitals are correlated -Aim of study to report, not predict staffing -Feedback tool only available The study found that variability in nurse staffing levels occurs within a specific unit and not the whole hospital. Another finding was the feedback tool develops accurate reflection of staffing in the past, but “the figures generated do not indicate the optimal or evidence-based nurse staffing level.” Level IV Evidence Acar, I. (2010). A decision model for nurse-to-patient assignment. Western Michigan University. IV: Acuity; distance traveled by RN per shift (each based on detailed scoring system) DV: Total workload Single adult medical/oncology unit (general medical unit) Sample, n=40: -RNs -Approximately 100, 12- hour shifts were observed. Quantitative -After-only, comparative design, looking at two models developed to balance total workload of RN's. -Model(1): focused on acuity and distance - Model(2): considered total workload of nurses Strengths: -Measurement tools demonstrated validity and reliability, and may be useful for a future workload measurement system. Weaknesses: -The population of the study was hand-selected, lending to some possible internal bias. -A single-hospital study may have limited generalizability. -Scoring measures were designed Of the two models tested, the model with a focus on patient acuity and distance traveled by the RN resulted in a more balanced total workload, reducing the variability between the workload of all nurses on the unit per shift. Level IV Evidence Bacon, C.T. & Mark, B. (2009). Organizational effects on patient satisfaction in hospital medical surgical units. Journal of Nursing Administration, 39(5), 220-227. IV: Organizational characteristics, nursing unit characteristics, patient characteristics DV: Patient satisfaction 286 Medical-surgical units in 146 hospitals Sample, n=3718 RNs; 2720 patients: -Randomly selected Descriptive/correlational study -3 questionnaires, over 6- month period (RNs) -1 questionnaire (patients) Strengths: -Large sample size Weaknesses: -Sampling bias -Possible threat to internal validity -Questionnaires have Measures to reduce work complexity, such as regulation of nursing assignments based on patient acuity and improved support services, positively influence patient satisfaction. Level V Evidence Lang, T.A., Hodge, M., Olson, V., Romano, P.S., & Kravitz, R.L. (2004). A systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. JONA, 34(7/8), 326- 337. IV: Nurse staffing DV: Patient, nurse employee, and hospital outcomes Acute care, rehabilitation, or psychiatric hospitals Sample, n=43: -research studies Systematic review of descriptive/correlational studies -assessed relationship between some measure of nurse staffing and patient, nurse employee, or hospital outcomes. Strengths: -former nurse with 15 years experience as a medical reference librarian performed the literature search Weaknesses: -49% of studies analyzed hospital-level data, rather than nursing-unit-level data. -include data from ICUs, which have different staffing patterns and different patient characteristics A minimum nurse-patient ratio alone is likely not appropriate to ensure quality of care. Patient acuity, skill mix, nurse competence, nursing process variables, technological sophistication, and institutional support of nursing should also be taken into consideration when establishing minimum staffing requirements. Level VI Evidence Hayes, N. & Ball, J. (2012). Achieving safe staffing for older people in hospital. Nursing Older People 24(4), 20- IV: Nurse staffing levels NHS hospitals in the United Kingdom Sample, n=240: Descriptive -Mixed Methods -quantitative, yet from a 2 survey method Strengths: -Royal College of Nursing’s (2012) guidance and -The use of acuity tools alone is not sufficient to determine adequate staffing requirements. During periods of high patient acuity, charge nurses must have instant access