Evaluations, Recommendations, References, and Expert Panels
Evaluation
Adequate numbers of staff are necessary to reach a minimum level of quality patient care services. Ongoing evaluation and bench marking related to staffing are necessary elements in the provision of quality care. At a minimum, this should include collection and analysis of nursing-sensitive indicators (ANA/1997) and their correlation with other patient care trends. It has been shown that the quality of work life has an impact on the quality of care delivered. Therefore, on an ongoing basis, the following trends should be evaluated:
- work-related staff illness and injury rates (Shogren and Calkins/1995)
- turnover/vacancy rates
- overtime rates
- rate of use of supplemental staffing
- flexibility of human resource policies and benefit packages
- evidence of compliance with applicable federal, state and local regulations
- levels of nurse staff satisfaction
Staffing should be such that the quality of patient care is maintained, the quality of organizational outcomes are met and that the quality of nurses' worklife is acceptable. Changes in staffing levels, including changes in the overall number and/or mix of nursing staff, should be based on analysis of standardized, nursing-sensitive indicators. The effect of these changes should be evaluated using the same criteria. Caution must be exercised in the interpretation of data related to staffing levels and patterns and patient outcomes in the absence of consistent and meaningful definitions of the variables for which data are being gathered.
Recommendations
Shifting the nursing paradigm away from an industrial model to a professional model would move the industry and organizations away from the technical approach of measuring time and motion to one that examines myriad aspects of using knowledge workers to provide quality care. This shift would spell the end to the "nurse-is-a-nurse-is-a nurse" mentality by focusing on the complexity of unit activities and level(s) of nurse competency needed to provide quality patient care. To facilitate this shift, the ANA makes the following recommendations:
- A distinct standardized definition of unit intensity must be developed. Factors to be taken into consideration in the development of such a definition include
- Number of patients within the unit;
- Levels of intensity of all of the patients for whom care is being provided;
- Contextual issues including architecture and geography of the environment and available technology;
- Level of preparation and experience (i.e., competency) of those providing care.
- Data should be gathered to address the relationship between staffing and patient outcomes including but not limited to
- Improvement in health status;
- Achievement of appropriate self-care;
- Demonstration of health-promoting behaviors;
- Patient length of stay or visit;
- Health-related quality of life;
- Patient perception of being well cared for; and
- Symptom management based on guidelines (Mitchell, et al./1997).
References
Aiken, L.H., Smith, H.L. and Lake, E.T. (1994). "Lower Medicare mortality among a set of hospitals known for good nursing care." Medical Care. 32(8), 771-787.
American Nurses Association (1997). Implementing Nursing's Report Card: A Study of RN Staffing, Length of Stay and Patient Outcomes. Washington, DC: American Nurses Publishing.
Bridges, W. (1991). Managing Transitions: Making the Most of Change. Reading, MA: Addison-Wesley Publishing Company.
Joint Commission on the Accreditation of Healthcare Organizations. (1998, January). Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace: The Joint Commission on the Accreditation of Healthcare Organizations.
Leape, L. (1994). "Error in Medicine." Journal of the American Medical Association, 272,(23), 1851-1857.
McClure, M.L., Poulin, M.A., Sovie, M.D. and Wandelt, M.A. (1983). Magnet Hospitals: Attraction and Retention of Professional Nurses. Kansas City, MO: American Nurses Association.
McHugh, M., West, P., Assatly, C., Duprat, L., Howard, L, Niloff, J., Waldo, K., Wandel, J., Clifford, J. (April 1996). "Establishing an interdisciplinary patient care team." Journal of Nursing Administration. 26(4), 21-27.
Mitchell, P.H., Heinrich, J., Moritz, P. and Hinshaw, A.S. (1997). Outcome measures and care delivery systems: Introduction and purposes of conference. Medical Care Supplement. 35(11) NS1-NS5.
Prescott, P., Ryan, J.W., Soeken, K.L., Castorr, A.H., Thompson, K.O. and Phillips, C.Y. (1991). "The patient intensity for nursing index: A validity assessment." Research in Nursing and Health, 14, 213-21.
Shogren, B. and Calkins, A. (1995). Minnesota Nurses Association Research Project on Occupational Injury/illness in Minnesota Between 1990-1994. St. Paul, MN, The Minnesota Nurses Association.
Williams, T.. and Howe, R. (1994). W. Edwards Deming and total quality management: An interpretation for nursing practice. Journal for Healthcare Quality, 14(2). 36-39.
Wunderlich, G.S., Sloan, F.A. and Davis, C.K. (1996). Nursing Staff in Hospitals and Nursing Homes: Is it Adequate? Washington, DC: National Academy Press.
Expert Panels
Leah Curtin, ScD, RN, FAAN
Jacqueline Dinemann, PhD, RN, CNAA, FAAN
Christine Kovner, PhD, RN, FAAN
Mary Elizabeth Mancini, MSN, RN, CNA, FAAN
RADM Carolyn Beth Mazzella, Ms, MPA, RN
RADM Kathryn Lothscheutz Montgomery, PhD, RN, CNAA
Judith Shindul-Rothschild, PhD, RN,CS
Julie Sochalski, PhD, RN, FAAN
Margaret D. Sovie, PhD, RN, FAAN
Joyce Verran, PhD, RN, FAAN
Other Participants
Cathy Coles, MSN, RN
Denise Geolot, PhD, RN, FAAN
Judy Goldfarb, MA, RN
Cheryl Jones, PhD, RN, CNAA
Lorraine Tulman, DNSc, RN, FAAN