Chapter 10 Flashcards
Staffing Ratios
Economics: primary driver for changes in RN skill mix in hospitals
Trend over past decade: reduce RNs, replace with less expensive alternatives
Research shows number of RNs in staffing mix directly impacts quality of care, especially patient outcomes
Increasing demand for adequate staffing ratios of RNs in acute-care settings
National movement already begun to mandate minimum staffing ratios
Staffing Ratios and Patient Outcomes
Suggested link between increased RNs in staffing mix, improved patient outcomes
Association between staffing levels and patient mortality, hospital outcome; relationship not causal
Failure to find anticipated significant improvements in fall incidence, prevalence of hospital-acquired pressure ulcers after implementing mandated staffing ratios (in CA; see Table 10.1)
Study by Aiken et al. as seminal work in support of establishing minimum staffing ratio legislation
True or False: Research has demonstrated a direct causal link between staffing levels and patient outcomes.
False: Although research has identified an associated link between staffing levels and patient outcomes, this relationship has not be identified as causal.
Need for Mandatory Minimum Staffing Ratios?
Proponents
Mandated minimum staffing ratios essential to promote patient safety, achieve outcomes
Standardized ratios as more consistent approach
Appealing to nurses due to protection from overburdening assignments
Critics
Overall cost of care increasing exponentially with mandated ratios nationally; no guarantee of quality improvement or positive outcomes
Lack of reimbursement for increased cost of more RNs leading to unfunded mandates
Predetermined ratios overlook level of experience/knowledge of nurse
Difficulty translating for medical/surgical units than for specialty units due to variability in patient population
No scientific evidence to support nurse-patient ratios in all settingsCost (most often cited as deterrent); resources away from patient care, into compliance
Health care professionals as best qualified to determine staffing needs
Reduction in hospital services, increased emergency room diversions, unit closures, expenses (payment of additional labor costs for overtime, temporary agency nurses)
California as the Prototype
Minimum licensed nurse-to-patient ratio requirement for ICU and CCU for over 30 yrs
California: 1st state to implement mandatory minimum staffing ratios
Maximum number of patients RN could be assigned to care for under any circumstance
Prohibition of unlicensed personnel from performing procedures Medication administration Venipuncture Parenteral or tube feedings Inserting nasogastric tubes, catheters Prohibition of unlicensed personnel from performing procedures Tracheal suctioning Assessment of patient conditions Patient education Moderately complex lab tests
Struggle to Determine Appropriate Ratios
Lack of readily accessible data about distribution of nurse staffing in California hospitals, number of hospitals likely to be affected or expected costs
Ratios to supplement valid, reliable patient classification systems
No standardization, little guidance about what was valid or what criteria to use
Initial costs unknown
Proposals suggest wide ranges of minimum ratios with differing cost estimates
True or False: California has had mandatory minimum staffing ratios for general medical-surgical units for over three decades.
False: California has had minimum nurse-to-patient ratios for intensive-care and coronary-care units for the past three decades.
But it wasn’t until 1999 that a bill was passed to establish minimum staffing ratios for other care areas.
Delays in Implementation: Challenges
Interpreting meaning, intent of language constituting “licensed nurse” — RNs or LVNs/LPNs meeting requirement
Controversy with labor unions for LVNs
Questions about hospitals eliminating/reducing nonlicensed staff to save costs
New legislation to delay implementation of 1:5 ratio
Bill failed
Emergency regulation by Governor to overturn emergency room ratios, improve med/surg ratios due to financial crisis
Ruled illegal
Accusations of hospitals undermining ratios; unions threatening to close down units
Struggle to Implement the Ratios
Staffing mandate becoming effective Jan 1, 2004
Question about hospitals being ready, willing to implement changes
Bigger hospitals ready to meet mandate; smaller hospitals seeking waivers due to existing budget deficits
“At-All-Times” Clause
Legal clarification necessary after implementation related to ratio coverage “at all times”
Strict interpretation by CDHS that ratios maintained at all times including breaks, lunches
Lawsuit in 2003 challenged ruling, argued “at all times” was impossible to implement
Judges ruled that not adhering to “at-all-times” clause would make ratios meaningless
Assuring Compliance
CDHS charged with compliance oversight of mandatory minimum staffing ratios Procedures for Compliance verification Responding to complaints Addressing compliance violations
Bottom Line: Improvement in Staffing?
Compliance: nurse staffing ratios increased significantly 1999-2004
Highest increase in 2004
Hospitals most likely below minimum ratios with high Medicaid/uninsured patient population
Government owned, nonteaching, urban, more competitive markets
California Hospital Association: although numbers increased, many nurses now traveler nurses
True or False: The “at-all-times” clause of California legislation did not apply to break and lunch times.
False: The “at-all-times” clause strictly interpreted required institutions to maintain the staffing ratios at all times, including breaks and mealtimes.
Similar Initiatives in Other States
Several attempts to address, enact hospital staffing laws
None close to fruition
42 Code of Federal Regulations for Medicare-certified hospitals
Prediction: within 5 years, staffing legislation will have been at least introduced in all 50 states
With significant number having passed some type
Various states have passed safe nurse staffing or hospital-wide staffing plans legislation
Passage of “patient safety” bill
Other Alternatives
Staffing plans
No support by ANA for legislated minimum staffing ratios
Advocating for workload system that takes into account variables to ensure safe staffing
View that staffing ratios too inflexible, potentially inefficient if calibrated incorrectly
Joint Commission: reluctant to endorse nationally mandated minimum staffing ratios
Advocating Staffing Effectiveness and Continuous Quality Improvement
Another alternative: market-based incentives to optimize nurse staffing levels using revenue code data as benchmark
And evaluate inpatient nursing care performance by case mix across hospitals
