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Christan mulder is a Registered Nurse at western washington university. Mulder: I love my job and am motivated to continue my education. A controversial issue is presented with mandated RN-patient SAFE HOSPITAL STAFFING 3 ratio assignments.
Christan mulder is a Registered Nurse at western washington university. Mulder: I love my job and am motivated to continue my education. A controversial issue is presented with mandated RN-patient SAFE HOSPITAL STAFFING 3 ratio assignments.
Christan mulder is a Registered Nurse at western washington university. Mulder: I love my job and am motivated to continue my education. A controversial issue is presented with mandated RN-patient SAFE HOSPITAL STAFFING 3 ratio assignments.
2 Safe Hospital Staffing As my first year of employment as a Registered Nurse comes to an end, I have begun to question whether this is something that I can continue doing for another thirty years. There is no doubt in my mind that I love my job and I am motivated to continue my education to advance further into the field of nursing. I start to get frustrated reflecting on how little time I have available during my shift to be at the patients bedside in comparison with the time spent at the computer charting. As I reflect on these thoughts, I questioned whether its just me as a new nurse and in time I would feel confident in my ability to provide safe care without rushing out of patient rooms, or is there something else missing? Many evenings I often feel that if I had just one less patient assignment I could get everything done. Various groups and organizations such as the American Nurses Association and the Institute of Medicine have expressed concerns regarding hospital staffing. The Institute of medicine (IOM) has conducted research on hospital staffing concerns over the past 20 years and has set forth guidelines for hospitals to begin to model in hopes of improving staffing systems. Staggs and Dunton (2013) We know a great deal about patient safety measures within the hospital and I am always hearing about patient satisfaction but nearly nothing regarding nurse retention rates or registered nursing job satisfaction. After spending many long nights past my scheduled shift I started to realize I wasnt the only one who believed a change in staffing models was needed. I have watched nurses who have been hospital RNs for decades retire due to the stress of the job and dissatisfaction. I have come to the conclusion that many of these nurses were retiring due to increase in job demand and when patient safety was questioned due to staffing levels. I began researching to find out what the current staffing model was for other hospitals and how this has changed within the past 20 years. A controversial issue is presented with mandated RN-patient
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3 ratio assignments. While some might argue that staffing with a set number of patients per RN is beneficial, others may contend that this would not be an appropriate solution. As the patient acuity levels rise in the hospital, staffing models will continue to be questioned. Some evenings are smooth sailing and I clock out on time, other nights I may stay late and chart up to 2 hours past my scheduled shift. It isnt uncommon for one patient to take up the majority of a shift while the others I have hardly spent an hour with. High patient to RN ratios have a negative impact on patient safety, as evidenced by poor patient outcomes, missed nursing care, and RN dissatisfaction within the job. The Research Process I began researching the topic Safe hospital staffing as I questioned safety above all other things in regards to staffing. The articles link patient mortality to hours of provided care and examined if these mandated RN to patient ratios were indeed the best staffing model. Most scholars in the field recognize the need for a staffing model change but are uncertain of an adequate solution. Authors Staggs and Dunton explain an analysis study performed on nursing units through the National Database of Nursing Quality Indicators to promote an understanding of how RN staffing is directly related to unassisted falls in the hospital. The primary focus point for this study was to equip hospital managers with evidence that demonstrated an association between falls and RN staffing. The hope was that this could serve as an improvement strategy in safety. Staggs and Dunton (2013) revealed that the majority of units that were staffed with higher RNs had a lesser amount of unassisted falls. They concluded that the nurses with higher experience levels and had been employed on a particular unit contributed to a decrease in fall
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4 rates. As these authors explain the correlation between education level and fall rates, those unfamiliar with this school of thought may be interested to know that it basically boils down to the amount of RNs present on the unit. Although this article argues that an increase in RN staffing has shown a decrease in multiple adverse patient outcome events its information is limited in regards to proving that increased RN staffing would actually decrease the amount of falls. Staggs & Dunton (2013) Falls are costly, both in dollars and in human suffering, primarily because they cause injuries (Staggs and Dunton, 2013). As these authors attempt to explain the association between patient falls and RN staffing, its important to remember that this will vary depending on unit type and patient condition. Staggs and Duntons (2013) article explains the importance of changing the way in which units are staffed in order to decrease unassisted fall rates and concludes that an increase in nonRN staff may have little or no impact on the decrease in falls. Patients are scored when admitted to the hospital for risk of falling. This takes patient acuity back into consideration by recognizing this risk when the patient care assignment is being completed. In decreasing the amount of falls within the hospital this would promote patient safety and provide for positive patient outcomes. These conclusions, which Staggs and Dunton (2013) discuss in the research study performed, add weight to the argument that current staffing models need adjustment in order to provide safe care and decrease the amount of negative patient outcomes. Mandated patient to RN Ratios In addition to the study performed by Staggs and Dunton (203) multiple studies have focused on the direct correlation of mandated patient to RN ratios on safety. Author Shekelle evaluates whether the patient ratios should be utilized as a safety strategy in general. A small
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5 percentage of hospitalized patients die during or shortly after hospitalization. Evidence suggests that some proportion of these deaths could probably be prevented with more nursing care Shekelle (2013). The article claims that by simply increasing the ratio of RNs to patients we can decrease illness and death rates based on hospital admissions. This is due to the simple fact that its believed by improved attention to the patient the less of a risk they are at for negative outcomes. Shekelle (2013) during this study they found that several outcomes that were thought of as nurse sensitive had no consistent correlation with the nurse staffing levels. Examples included pressure ulcers, falls and urinary tract infections, both of which are considered poor patient outcomes. Shekelle (2013). After this study was performed, researchers discussed the possibility that patient mortality may not actually be reduced by increasing RN staffing but is directly affected by what the nurse actually does for the patient during hospitalization. Determining what this is and how it can best be facilitated should be the goal of an effective patient strategy (Shekelle, 2013). This study demonstrates that although most nursing professionals believe that an increase in the amount of RNs working and a decrease in the amount of assigned patients would promote positive patient outcomes it still comes down to how the nurse performs his or her job. In relationship to Staggs and Duntons (2013) study, additionally education levels must be taken into consideration. This study appears to have reveled opposing results as Staggs and Dunton in that there was no strong relationship between the staffing levels and nurse sensitive outcomes whereas Staggs and Dunton (2013) found a direct correlation between RN staffing and fall rates. With a primary focus on examining the patient to RN ratio as a safety strategy Shekelle concludes that much research is still necessary in order to implement the safest care possible.
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6 Multiple researchers have demonstrated the positive effects of mandated RN-patient ratios and prior to this evidence analysis search I also believed this was the best practice. By examining evidence and considering my recent work on a medical care unit I understand now that this indeed should not be the way hospitals are staffed. As discussed above, Shekelles (2013) research proves that ultimately what the nurse does for the patient should be at the forefront of staffing assignments which then brings acuity back to the top of staffing considerations. Missed Nursing Care The link between staffing levels and patient outcomes has been well established, few studies have focused on the process of nursing care that results in better outcomes when nurse staffing is richer (Hee Lee, Kalisch, Tschannen, 2011). A study conducted to examine whether nurse staffing levels could predict missed nursing care examined six significant care activities found frequently missed. Nurses must possess a skill set that encompasses many things including an ability to multitask and be flexible when completing job duties. Its well known that nurses must possess an ability to predict negative outcomes in patient condition and anticipate any adverse events. Frequent assessments and monitoring by the nurse is critical in the hospital setting. In a similar aspect, missed nursing care significantly increases the risk for negative patient outcomes and places the patient at a higher risk for adverse events. The six missed nursing care activities examined during the study were patient teaching, ambulation, mouth care, assessment of medication effectiveness, repositioning, and the timeliness of as needed medication administration. The focus of the study was to examine and relate missed care activities to nurse staffing. HPPD (hours per patient day), in this study was the strongest
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7 predictor of missed nursing care. It is possible that when staffing is less, a staff member may not be able to complete all care required (Hee Lee, Kalisch, Tschannen, 2011). Similarity is noted between this research study by Hee Lee, Kalish and Tschannen (2011) compared to Shekelles (2013) study on RN-patient ratios for safety strategy in that both studies address that patient outcomes are frequently positive with an increase in nurse staffing but more importantly outline the fact that the care actually provided by the nurse is most important in promoting positive patient outcomes. Understanding what care is being provided (or not) will assist in the development of focused interventions. Unless we understand what is actually occurring at the point of nursing care delivery, we will not be able to develop interventions to improve processes which lead to higher quality of nursing care and in turn, better patient outcomes (Hee Lee, Kalisch, Tschannen, 2011). A New Staffing Model When it comes to the topic of hospital staffing, most people educated on this topic would readily agree that a change in the staffing model is necessary. Where this argument usually ends however, is on the question of the best possible way to make this change. Whereas many are convinced that by regulating the nurse to patient ratios we can solve the problem, others maintain that there are too many associated risks with regulating and mandating ratios. In Robin Hertels (2010) article both sides to this staffing dilemma are addressed. Nurses are dedicated to the safety of their patients, working diligently toward positive outcomes. In order to succeed, patient-staff ratios must be reasonable (Hertel, 2010). Its important to take into consideration financial implications on hospitals when making a major staffing change. In 2003 California became the first state to implement a mandated RN-to patient ratio. The results of change are
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8 variable and there is still not enough evidence to support that this should be an appropriate measure to be taken nationwide. Hertels article explains the proposed staffing plans that have been presented to both the United States House and Senate, both address different staffing models but share a requirement for Medicare participating hospitals. Hertel (2010) Establish nurse staffing committees to implement and oversee hospital-wide staffing plan for nursing services. Plan requires appropriate number of nurses provide direct patient care in each unit and on each shift to ensure staffing levels that address the unique characteristics of the patient and hospital unites and result in delivery of safe, quality patient care (Hertel, 2010). Nurse staffing committees have been implemented in hospitals around the country and have positively impacted most staffing models. By providing nurses with a chance to voice concerns and bring ideas to the table also encourages retention of currently employed nurses in addition to job satisfaction. Although there are multiple variables that come into play when attempting to develop a major staffing change, financial implications, hospitals current staffing model and we then cannot forget about the current nursing shortage. Hertel (2010) explains that if hospitals begin regulating staffing ratios it may place an increased financial burden on the hospital. In order to meet this increase in costs ancillary staff may be cut which in turn may increase the overall burden on the RN. In regards to the nursing shortage this ties back into nurse retention and job satisfaction. Hospitals need to continue to focus on improvement and implementation of residency programs to train new RNs and generally increase the amount of staff available for work. Nurses who feel overworked especially shorthanded are more likely to resign from practice then those who feel supported and that a change of action is in place. Its also important
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9 to consider the fact that if all states had a mandated RN-patient set ratio we may not have enough working nurses to meet this requirement. Alternatively to set RN-patient ratios is an idea Hertel (2010) explains is the model based on patient acuity. This staffing model is used in multiple hospitals around the United States but yet still yields inconclusive results of a measureable benefit. Hertel explains the model as based on a classification system to predict patient needs and requirements for staffing. Although reliability and validity is questioned with this model I believe it reflects a more true description of the way in which hospitals should be staffing. The use of a standardized staffing model does not produce accurate results (Hertel, 2010). These conclusions, which Hertel (2010) discusses in the article add weight to the argument that a new staffing model should incorporate current practicing RNs input into the new model. My own view is that with an acuity based staffing model, we could assume that although additional work on the hospitals part upfront may be require, in the long run patient safety and outcomes could be much better. Hertel (2010) concludes his article with expressing that the debate will simply continue on until an appropriate solution has been found. Nurse Job satisfaction and Retention Nurse staffing and the relationship to job satisfaction and retention mentioned briefly above in regards to the nursing shortage is an important consideration to be made on the topic of hospital staffing. An article written by a group of professors serves to explain the study performed to examine the relationship between nurse staffing, job satisfaction and retention rates within the acute care environment. The study reveals that work environment and dissatisfaction with work were the major contributors to turnover rates in the hospital. Hairr, Johannsson,
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10 Redfern-Vance, Salisbury (2014) As nursing turnover is costly researchers argue that with continued improvement in hospital practices promoting a healthy/happy work environment the retention of nurses should increase. The authors of this article argue that improvement of hospital staffing could be a feasible solution for patients and nurses in regards to outcomes, safety and job retention. A key strategy for retaining bedside nurses was identified as improving nurse patient ratios. Improving nurse staffing will likely improve nurses job satisfaction and in doing so will help in keeping needed nurses at the bedside and decrease the likelihood of a new nursing shortage (Hairr, Johannsson, Redfern-Vance, Salisbury,2014) The conclusion of the article explains that by improving job satisfaction hospitals will notice retention of experienced nurses. Hairr, Johannsson, Redfern-Vance, Salisbury (2014) claim that by simply decreasing the number of assigned patients to the RN during a shift will improve job satisfaction of the nurse rests upon the questionable assumption that many nurses may always have something to complain about. I am not arguing that lowering the number of patients assigned to the nurse is a bad idea, I am simply stating that it will not completely fix or solve the problem at hand. By focusing on a set number assignment, the authors overlook the deeper problem of not addressing patient acuity. As Hertel (2010) explained in his article, its vital that nurses participate in this change and aid in development of a practice change and staffing model. Consideration of unit characteristics must be acknowledged when a major staffing change is ready to be made. Childbirth centers, emergency departments and post operational care units all operate and serve a very different patient population group versus a medical unit. There is only one unit within my hospital that staffs strictly on patient acuity. Other units such as the
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11 medical care unit where I work will accommodate for patient acuity concerns if and when they arise and its all based on who is working during that particular shift. The progressive care unit treats a variety of patient populations including drug and alcohol withdraw, cardiovascular rehab and cerebral vascular accident monitoring. The problem with this unit being the only unit implementing an acuity based scoring system is that many of the patients on the unit are also placed on the medical care unit which does not score patients based on acuity. I began to wonder if the patients on the progressive unit were receiving better quality of care resus the medical unit based on more time with the RN. What Happens Next? In conclusion its been demonstrated through all of these articles that much work is to be made on development of the best staffing model to be implemented. As mentioned earlier, when I started this research project I had believed that by having a set ratio of patients per nurse would enable myself to provide the safest possible care. After researching the subject and experiencing a set ratio of patients on multiple occasions I have come to the conclusion that many other nursing units should be staffing based on acuity. Patient safety, outcomes, nurse retention and job satisfaction are all negatively impacted by the use of set RN-patient ratios. Conducting this research and comparing it to my current practice in an impatient acute care setting has enabled me to improve my critical reading skills and has given me the opportunity to change my opinion on staffing models. All of the authors of these articles share the same common belief that a change in the current staffing model needs to be addressed. In order for nurses who are currently working to feel satisfied with their work and to believe that patient safety and patient outcomes are at the forefront of the hospitals mission, a change in staffing models is absolutely necessary.
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12 Much research will still need to be conducted in order to implement a change and although I feel a complete change is a long way out, evidence has proven that its definitely a work in progress. What I Have Learned During the process of writing this paper I have learned a few different things not only about hospital staffing but in regards to the writing/research process and myself. Academic writing isnt a new concept for me but analyzing and synthesizing sources is. I found that once I had chosen a topic of interest my research all appeared to be one sided, it all pointed towards mandating patient to ratios. Since beginning this research study I have changed my point of view and definitely agree that a change in staffing model is necessary but I am learning more towards an acuity based approach. Finding and evaluating these sources was the difficult part of this paper. I wanted to agree with all the articles I read or I didnt feel they should be in my paper. As the process of writing this source analysis essay continued, I started recognizing the importance of really digging into the article and figuring out the authors key points. Overall I have improved in my ability to identify a good and accurate source of information and have developed a basic understanding for developing arguments and comparing them to another writers ideas.
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13 References Hairr, D.C., Johannsson, M., Salisbury, H. & Redfern-Vance, N. (2014). Nurse Staffing and the Relationship to Job Satisfaction and Retention. Nursing Economics, 32(4), 142-147. Retrieved from http://www.medscape.com/viewarticle/828494 Hee Lee, K., Kalisch, B.J., Tschannen, D (2011). Do staffing levels predict missed nursing care? International Journal for Quality in Health Care, 23(3), 302-308. Retrieved from http://intqhc.oxfordjournals.org/content/intqhc/23/3/302.full.pdf Hertel, Robin. (2010). Regulating patient staffing: A complex issue. Health Care Reform & Issues In Nursing, 21(1), 3-7. Retrieved from https://www.amsn.org/sites/default/files/documents/practice-resources/healthy-workenvironment/resources/MSM-Hertel-Jan12.pdf Shekelle, P. G. (2013). NursePatient ratios as a patient safety strategy a systematic review. Annals of Internal Medicine, 158(5_Part_2), 404409. http://doi.org/10.7326/0003-4819158-5-201303051-00007 Staggs, V. S., & Dunton, N. (2014). Associations between rates of unassisted inpatient falls and levels of registered and non-registered nurse staffing. International Journal for Quality in Health Care, 26(1), 8792. http://doi.org/10.1093/intqhc/mzt080