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1 Staffing Unleashed Kathy Douglas Ratios If It Were Only That Easy EXECUTIVE SUMMARY Health care staffing is a complicated arena, and nurses are in the best position to assure a good match between the problems being addressed and the solutions being adopted. Why would nurses want to hand over their power to make staffing decisions to the government? Perhaps what got us into the situation of asking government to intervene in the world of health care staffing is the inability of management and staff to work together effectively to design the most effective approach to staffing. The business side and the quality/safety side of health care must work in harmony. Collaboration between nursing and finance is perhaps the most important formula for success. The challenges before us in health care staffing are big, but they will never be solved by the application of symptom-level solutions. THE CONTROVERSY OVER man - datory staffing ratios is widespread with passion fueling both sides of the debate. The topic has gotten so tangled up in politics, it has become difficult to sort through the rhetoric and separate facts from positioning. But no matter how difficult, it is essential nurses are well informed and become Kathy Douglas active participants in shaping the future of health care staffing. The direction nursing allows this topic to take has far-reaching implications for the role of the professional nurse and the management of patient care. At the center of the debate on mandatory staffing ratio legislation sits the question: Is government involvement the right answer to the problems we face in health care staffing? A national random survey of registered nurses suggests that 60% feel that mini- KATHY DOUGLAS, MHA, RN, is Founder and President, Institute for Staffing Excellence and Innovation, Sedona, AZ. For comments and suggestions regarding this column, contact Kathy at kathy@staffingexcellence.org NOTE: Share your ideas for this column and the world of staffing. Join the conversation. Visit mum staffing ratios should be mandated (Buerhaus, 2009). There are currently 24 states actively considering staffing legislation (see Table 1), 12 of which are considering mandatory staffing ratios (Chapman, Spetz, Seago, Kaiser, Dower, & Herrera, 2009). Alternatives to ratios being considered by legislators include staffing committees with strong staff RN representation, acuity systems, and disclosure of staffing plans to the public (Domrose, 2009). Outside of the legislative arena, many are working on alternative answers, for example Dall s work on the economic value of professional nursing and the work out of Kaiser looking at how nurses spend their time (Dall, Chen, Seifert, & Hogan, 2009; Hendrich, Chow, Skierczynski, & Lu, 2008). With so much activity around staffing regulations and considering the potential implications, there is some urgency to be sure we are headed in the right direction with full awareness of the overall impact. This calls for a thorough investigation into proposed solutions, identifying the difference between treating symptoms and underlying cause, having a solid understanding of the intended and unintended consequences, and consideration of long-term impact. Health care staffing is a complicated arena, and nurses are in the best position to assure a good match between the problems being addressed and the solutions being adopted. In this article I do not present the thorough investigation that is called for with this issue, but rather I attempt to inspire investigation and encourage new ways to think about staffing. Taking a step back, it seems reasonable to ask the question: What got us into this situation (government involvement in health care staffing)? What does the government know about running an ICU or an oncology unit? Answering these questions could be the key to uncovering the real problem and choosing the right solution. To find the answer requires sorting through a lot of data, information, interpretations, generalizations, attitudes, and belief systems. It also means looking beyond the concept of staffing to the whole of health care and the many ways staffing impacts the overall system. It is easy to get caught up in the stories, research findings, financial pressures, economy, variations on how professional nurse roles are defined in hospitals, opinions on safety and quality, budget tug-of-wars, issues with staffing metrics, individual and group agendas, etc. But what is needed now are different ideas. Remember, ratios represent one way to approach the challenges of health care staffing. Putting the ratio agenda forward has been one way to give voice to the concerns and needs in health care staffing. The real issue is how to deliver safe, quality, 119

2 State Status Summary Arizona Legislation introduced Prescribed minimum nurse-to-patient ratios by specialty Bill includes mandatory overtime prohibitions California Legislation passed Mandates specific minimum staffing. Staffing should be based on patient care needs, severity of condition, services needed Make staffing plans available Colorado Legislation introduced Staffing committees Make staffing plans available Whistle-blower protection Connecticut Legislation passed Staffing committees Plan to include the minimum professional skill mix for each patient care unit Sets level of administrative staffing that ensures direct care staff are not utilized for administrative functions Establish a process review of the staffing plan Florida Legislation introduced Prescribes nurse-to-patient ratios Includes mandatory overtime prohibitions Georgia Legislation introduced Introduced and supporting ANA s Safe Staffing Principals in place of staffing ratios Illinois Legislation passed Amendment legislation introduced Table 1. Staffing Legislation by State Staffing Pan 2007 Acuity model for adjusting the staffing plan Required to consider complexity of care and clinical judgment Amendment 2009 Minimum direct care registered nurse-to-patient ratios Development/re-evaluation requirements for the staffing plan Whistle-blower protection Maine Legislation passed Removed staffing ratios (per report from Quality Forum Advisory Council; their findings stated no reliable evidence that ratios guarantee quality of care) Adjustable to accommodate for change in acuity Standardization of staffing plans and acuity tools Massachusetts Legislation introduced Patient Safety Act Hospitals publicly accountable for staffing plans Plans developed with the input of nurses Hospitals required to monitor/collect patient outcome data based on nurse-sensitive measures and report for patient safety Michigan Legislation introduced Requires written staffing plan Requires an acuity assessment tool Staffing committee developed to oversee staffing plan Minnesota Legislation introduced Includes provisions similar to Michigan s bill plus a provision for Daily posting of staffing levels Request study of ways to achieve reimbursement for nursing services Missouri Legislation introduced Nursing advisory board committee Board managed by department of health and senior services Standardized acuity-based patient classification system Staffing plan includes a minimum nurse-to-patient ratio 120

3 Nevada State Status Summary Legislation passed (overriding the governor s veto) Table 1. (continued) Staffing Legislation by State Establish staffing committee Flexible enough to accommodate for changes in patients, staff, unit design, technology New Hampshire Legislation introduced Seeks the creation of staffing plans New Jersey Legislation introduced Original Legislation Daily staffing evaluation per unit/per shift Amendment Establishes minimum RN staffing ratios New York Legislation introduced Prescribes nurse-to-patient ratios Requires submission of staffing plans Prohibits most mandatory overtime Ohio Legislation passed CNO must establish mechanism for obtaining input from nurses in all patient care units Nursing care committee Committee must provide staffing plan that is evidenced based Staffing plan shall be available to all nursing staff and public Oregon Legislation passed, strengthens 2002 legislation Committee developed hospital-wide staffing plan for nursing services Requires that staffing plans be consistent with nationally recognized evidence-based specialty standards and guidelines Whistle-blower protection Random audits by Oregon Department of Human Services Pennsylvania Legislation introduced Staffing plans with minimum ratios Acuity system Public disclosure of staffing requirements Rhode Island Legislation passed Requires hospital to submit core nurse staffing plans to department of health Staffing plan specifies per patient care unit/per shift the number of RN/LPN/CAN assigned per average number of patients Texas Legislation passed Create staffing committee CNO to oversee with committee development of staffing plan Ensure a sufficient number and skill mix of nurses available to meet patients needs by unit and shift Provides whistle-blower protections Vermont Legislation passed Report nurse staffing information with comparisons to industry benchmarks for safety System-centered measures, such as skill mix, nursing care hours per patient day Required public access to information relating nurse staffing ratios Virginia Legislation introduced Minimum direct care RN-to-patient ratios Acuity-based patient classification system Washington Legislation passed Must establish a nurse staffing committee Must have CEO support; if plan developed is not implemented, CEO must submit reasons to staffing committee NOTE: Every effort has been made to assure accuracy of this list including review of Web sites for each state. Please refer to specific states for updated or full information. 121

4 Table 2. What Goes into a Staffing Decision 1. Number of patients 2. Range of conditions 3. Intensity of situation 4. Severity of illness 5. Stage of illness (pending death) 6. Family situation/needs 7. Safety 8. Quality 9. Education requirements 10. Treatment requirements 11. Observation and intervention requirements 12. Admissions, discharges, and transfers 13. Number of RNs 14. Number and skill mix of staff 15. Experience level of staff 16. Special credential requirements 17. Continuity of care 18. Role and skill competencies 19. Fatigue considerations 20. Setting, environments 21. Physical plant 22. Working conditions 23. Culture influences 24. Team dynamics 25. Individual nurse (staff dynamics) 26. Patient satisfaction 27. Nurse satisfaction 28. Ancillary and support staff availability 29. Physician preferences 30. Variations in technology 31. Policies and procedure requirements 32. Legislative and regulatory requirements 33. Safety considerations 34. Quality considerations 35. Budget considerations 36. Performance pressures (scorecards, benchmarks, and justifying variances) and cost-effective care. This is a challenge we all face and no mater what side of the debate you are on, there is no easy answer. If it were as simple as number of nurses to number of patients, we could all breathe a sigh of relief. But it is not. Why Is this So Hard? Health care by its very nature is constantly in motion and there is simply no easy way to account for all of the variables at play. This fact wreaks havoc with operations and our ability to plan, manage, and measure staffing. Table 2, while likely not comprehensive, paints a picture of what goes into staffing decisions. Using this as a backdrop can be helpful during an investigation into staffing ratios and in considering alternatives. The complexity of staffing is compounded by the fact that for any unit, on any given day, any one or multiple of these items can change minute-byminute, hour-by-hour, shift-by-shift. Add to this, each of the items in Table 2 could have its own detailed list of similar complexity as staffing decisions, and the challenge that staffing presents is further revealed. With a comprehensive picture of what goes into staffing, it is hard to imagine any formula, ratio, or other algorithm that could address the labyrinth of staffing in health care effectively. What Can We Learn from California? Mandatory minimum staffing ratios is the path California chose when in 1999 legislation was passed, making California the first, and to date the only, state where mandatory RN staffing ratios are defined by law. The ratios were implemented in Similar to the topic of ratios in general, understanding what the impact has been in California is not easy. This can be demonstrated by typing staffing ratios in California, into Google, where you will find many perspectives as well as many resources. California s situation, going on 6 years, with mandatory minimum ratios is unique in that it is the only place where the impact of mandatory staffing ratios can be fully studied. So far, the studies that have been conducted in California do not support the primary position of the pro-ratio movement, that ratios will improve quality. Three studies on the situation in California found no significant impact on quality of care, safety, or length of stay (Bolton et al., 2007; Donaldson, Bolton, Aydin, Brown, Elashoff, & Sandhu, 2005; Greenberg 2006). An insightful survey of hospital administrators in California highlights some of the response to the ratio mandate and the compromises made to comply with requirements. Respondents site a variety of methods used to accommodate the ratio laws including laying off ancillary staff to accommodate RN ratios by shifting non-rn work to the professional nurse, and holding patients longer in emergency departments while adjusting staffing to meet ratios. One of the biggest challenges sighted in the survey is meeting the at all times requirement. This requirement has many issues; it requires float RNs to cover breaks. These brief inserts into care situations raise a variety of concerns increased handover communications requirements with potential for error, variations in skills and competencies, variations in continuity all safety issues. In some cases the necessity to cover all areas places rigidity on coverage patterns that may not match workflow, nurse preference, and removes the ability for nurses to use their judgment in determining appropriateness and flexibility of the timing breaks. While most nurse leaders oppose ratios (not to be confused with opposition to safe and effective staffing), some indicate they have gained priority in 122

5 the budgeting process and are supporters of keeping ratios; however, these tend to be in places where there was poor staffing prior to the ratio law (Bolton, 2007; Chapman et al., 2009). Considering information to date, there is not enough research yet to draw definitive conclusions from the experience in California, and much like broader research on RN staffing, there is still much to be learned. Research Looking at the Evidence There is good reason to believe that more nurses means better outcomes on multiple fronts. Many studies over multiple years have associated increase RN staffing with patient safety, quality, LOS, patient satisfaction, workforce satisfaction, decreased burnout, and turnover (Aiken, Clark, & Sloane, 2002; Dall et al., 2009; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Both sides of the ratio debate use research to make their case, in some instances the same findings. But making generalizations based on these studies may not be such a good idea. Research results are inconsistent and not specific enough to recommend ideal nurse-to-patient ratios (New England Public Policy Center [NEPPC], 2005; Spetz, Chapman, & Herrera, 2009). This may be due to limits of the research, gaps in the research, and the dynamic nature of the items in Table 2. A close look at the research exposes some issues that must be addressed if we are going to rely on the research to guide us to an informed solution on staffing that can be applied to operations. Specifically defining what more nurses means needs to be fully understood, not just in terms of number of nurses described as an FTE. Nurses, after all, are not FTEs; they are individuals with different levels of skill, experience, and competency. We also need to ask what other variables were at play during the research period. Such questions as: How long has the team worked together? What are the skill mix and education levels? What was staffing prior to change? What was the volume of other unit activity (A/D/T)? Physical plant layout? Variations in patient populations? More basic questions should also be considered, such as: What was the size of the study? How well does it represent broader implications? Were there variations by unit, or area of service, over what period of time were the data collected, and on. We need to call upon our academic partners for more help as more rigorous research is needed that takes into account the many influences on staffing. Also standardization is needed so studies on staffing can be more easily compared and provide stronger guidance as research is translated into operations. Whatever steps are taken to govern staffing, it would be a mistake to have rigidity that did not allow for adjustments as new research uncovers more and more findings. It is through research that so much improvement has been made in health care; there is no reason to doubt that there is still much research will reveal. On the other hand, given the nature of care delivery, we also need to be prepared that the research may never provide the full-proof answers but only be part of the equation as we look to solve the challenges of staffing in health care. Beyond Research The Role of the Expert Nurse Every day in hospitals across the country staffing activities bring nurses and patients together for the delivery of care. In 2008, the number of people who were hospitalized for nursing care was 37,529,270 in 5,815 hospitals (American Hospital Association, 2008). If you take the number of patients who receive care and multiply them by the number of variables in staffing (see Table 2), it is hard not to be amazed at the burden that is carried by daily staffing decisions. If one considers hospital staffing over time, even before the support of technology and research, the constant has been and in most cases remains, the decisionmaking abilities of the professional nurse. This raises the question: What is the role of the expert nurse in predicting and managing staffing needs? This line of thinking gave rise to reflection on the work introduced by Patricia Benner and colleagues in It seems that there are parallels that can be drawn between the levels of proficiency a nurse passes through in the acquisition and development of patient care skills and those of staffing skills. Benner (1984) identified three general aspects of skilled performance. 1. One is a movement from reliance on abstract principles to the use of past concrete experience as paradigms. 2. The second is a change in the learner s perception of the demand situation, in which the situation is seen less as a compilation of equally relevant bits, and more as a complete whole in which only certain parts are relevant. 3. The third is a passage from detached observation to involved performer. The performer no longer stands outside the situation but is now engaged in the situation. It seems reasonable to think that if you asked an expert nurse about the staffing needs for a group of patients under their care, they could provide an instant response, with remarkable accuracy. It is conceivable and likely happens daily, that an expert nurse considers all of the items in Table 2, combines these with the knowledge of evidence, observations, and the wisdom that experience has developed, and quickly provides the most accurate accounting of staffing needs possible. This is not to say that opinion -based staffing is the answer; quite the opposite. This description assumes expert role competency, which includes highly developed communication 123

6 and decision-making skills and the use of evidence (Jones, White, & Smith, 2009; O Rourke, 2006). If there is agreement that the expert professional nurse has an essential role in staffing, then whatever solution we stand behind must give the nurse the power to make staffing decisions and to override models, including ratios, when they don t make sense and to have the authority to use their expertise in the best interest of patients, the care team, and the hospital. Addressing why we are facing, and in some cases living, the adopting of staffing practices that remove the voice of the expert nurse in the staffing decision is starting to get to the root of the matter. Why would nurses want to hand over their power to make staffing decisions to the government? Trust and Behavior A Hypothesis The hypothesis offered here is a simple one, that the barriers to having optimal staffing in health care are trust and behavior. Perhaps what got us into the situation of asking government to intervene in the world of health care staffing is the inability of management and staff to work together effectively to design the most effective approach to staffing. We have many resources to guide us to make informed decisions including research, data analysis, understanding trends, recommendations from professional organizations, and technology. All of this, combined with the experience and wisdom of the expert nurse and effective and efficient staffing, seems within reach for all hospitals. So if some are turning to government to intervene, something is clearly wrong and it might not be the bad guys some would have us think. One place to look for answers is the structures we rely on to inform staffing. Given Table 2 and the fact that staffing will never be static, it should not be surprising that putting effective metrics around these structures is hard. The disconnects between the realities of daily operations and commonly used numbers, formulas, and structures used to guide staffing plans, budgets, and daily staffing decisions are well known. Take, for example, the common use of midnight census as a representation of volume. Widely used in a variety of ways, including formulas for staffing, staffing benchmarks (averages of averages), staffing budgets, and staffing performance measures, midnight census is not an indication of how many patients were served in a 24-hour period and thus an inaccurate indicator of volume and predictor of workload. Similar issues exist with hours per patient day (HPPD) and other commonly used metrics. Trying to apply a static structure to a dynamic process creates problems and yet we need to have some structure to plan and manage care delivery. Perhaps this gets to the very core of what is driving the pro-ratio agenda the problem with metrics in health care staffing. If the formulas we use to understand, project, manage, and measure operational performance don t actually do that, the plans based on those numbers will never be right. If the numbers aren t right, there will be tension between those delivering care and their reality, and the people who set the numbers and their reality, causing frustration on both sides. This can blur the issues and distract from addressing underlying cause in favor of symptom-level interventions. It is the nature of things that when a system is broken or there are obstacles, work-arounds develop. So imagine the following scenario. Budgets are established and staffing levels set based on national benchmarks and volume/trend analysis, both of course using midnight census and HPPD as guides. On the operational side, nurses find their budgeted staffing out of sync with the workload requirements of the unit. Nurses figure out how to work the system to get the numbers they feel they need to deliver safe and quality care. Budgets are off, not good for finance and their ability to manage the cost of operations, and not good for the relationship between nursing and finance as work-arounds are uncovered and mistrust fed. Or staffing is so out of sync with needs nurses feel unsafe or frustrated they can not deliver the required care, so they seek employment elsewhere or leave hospital nursing entirely. This adds up to fertile ground for mistrust and elicits unwanted behaviors. Nursing thinks they have to fight or work-around finance to get what they need and finance thinks nursing is not capable of putting forth accurate needs. What s actually true is that the system is broken, not necessarily the individuals on both sides trying to do their jobs. Fixing the system requires close collaboration between nursing and finance. The starting point must be to understand the underlying issues, re-establish trust, and engage in behaviors that will leverage the best thinking on both sides. Tackling this will not be easy. Changing commonly used measures and links to reimbursement are a problem. However hard this may be, it should not stop us from getting it right. Moving Forward Much is riding on effective staffing decisions. Staffing decisions impact almost every aspect of the performance of a health care organization from quality and safety to operational and financial performance (Needleman, Buerhaus, Stewart, Zelevinsky, & Mattke, 2006). The work on excellence in staffing which proposed an evidence-based approach to staffing concluded that data, research, and mathematics, while essential influencers, will never be the full answer. The contribution of the frontline professional nurse and expert nursing judgment is an essential ingredient to staffing excellence (Douglas, 2008; Kerfoot & Douglas, 2010). The business side and the quality/safety side of 124

7 health care must work in harmony. Collaboration between nursing and finance is perhaps the most important formula for success. If the ratio issue has brought this fact front and center, we should all be grateful. The challenges before us in health care staffing are big, but they will never be solved by the application of symptom-level solutions. Call for Actions 1. Fix measures to better reflect realities of hospital operations. 2. Build trust and strong collaboration between finance and nursing. 3. More research with standards that allow cross study comparisons. 4. Grow understanding of the economic value of nursing. 5. Work together to close the gap between reimbursement and the cost of operations. 6. Choose not to fight battles, but build bridges. Any solution must strengthen our ability to adjust to the many variables that make up health care staffing and strengthen the use of professional nurses; their knowledge, experience, and wisdom are essential ingredients in staffing excellence. The call for unity comes from many quarters (Buerhaus 2009; Buerhaus, 1997; NEPPC 2005). Within health care we have the talent, experience, and goodwill to find a solution that is fair and can be embraced by all. $ REFERENCES Aiken, L., Clark, S., & Sloane, D. (2002). Hospital staffing, organization, and quality of care: Cross-national findings. Nursing Outlook, 50(5), American Hospital Association (AHA). (2008). Fast facts on US hospitals. Retrieved from Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA: Addison-Wesley. Retrieved from n312/benner.htm Bolton, L.B., Aydin, C.E., Donaldson, N., Brown, D.S., Sandhu, M., Fridman, M., & Aronow, H.U. (2007). Mandated nurse staffing ratios in California: A comparison of staffing and nursing-sensitive outcomes pre- and post-regulation. Policy, Politics and Nursing Practice, 8(4), Buerhaus, P. (2009). Avoiding mandatory hospital nurse staffing ratios: An economic commentary. Nursing Outlook, 57(2), Buerhaus, P. (1997). What is the harm in imposing mandatory hospital nurse staffing regulations? Nursing Economic$, 15(2), Chapman, S.A., Spetz, J.A., Seago, J.A., Kaiser, J., Dower, C., & Herrera, C. (2009). How have mandated nurse staffing ratios affected hospitals? Perspectives from CA hospital leaders. Journal of Healthcare Management, 54(5), Dall, T., Chen, Y.J., Seifert, R., Maddox, P., & Hogan, P. (2009). The economic value of professional nursing. Medical Care, 47(1), Domrose, C. (2009). Personal choice: States consider the pros and cons of mandating rn staffing levels. Nurse.com: The Magazine. Retrieved from nxtbooks/gannetthg/nursecom_200912/#/2 Donaldson, N., Bolton, L.B., Aydin, C., Brown, D., Elashoff, J., & Sandhu, M. (2005). Impact of California s licensed nursepatient ratios on unit-level nurse staffing and patient outcomes. Policy, Politics and Nursing Practice, 6(3), Douglas, K. (2008). Excellence and evidence in staffing: Essential links to staffing strategies, design and solutions for healthcare. Retrieved from resources/whitepaper Greenberg, P.B. (2006). Nurse-to-patient ratios: What do we know? Policy, Politics and Nursing Practice, 7(1), Hendrich, A., Chow, M., Skierczynski, B., & Lu, Z. (2008). A 36 hospital time and motion study: How do medical-surgical nurses spend their time? Permanente Journal, 12(3), Retrieved from time-study.pdf Jones, B., White, C., & Smith, A.S. (2009). Data-driven systems for RN autonomy. Nurse Leader, 7(5), Kane, R., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007). The association of registered nurse staffing levels and patient outcomes. Medical Care, 45(12), Kerfoot, K., & Douglas, K. (2010). Evidence-based staffing and communityship as the key to success. Nursing Clinics of North America, 45(1), O Rourke, M.W. (2006). Beyond rhetoric to role accountability: A practical and professional model of practice. Nurse Leader, 4(3), Needleman, J., Buerhaus, P., Stewart, M., Zelevinsky, K., & Mattke, S. (2006). Nurse staffing in hospitals: Is there a business case for quality? Health Affairs, 25(1), New England Public Policy Center (NEPPC) & Massachusetts Health Policy Forum. (2005). Nurse-to-patient ratios: Research and reality. Concert report series 05-1, July Retrieved from conreports/2005/conreport051.pdf Spetz, J., Chapman, S., & Herrera, C. (2009). Assessing the impact of California s nurse staffing ratios on hospitals and patient care. California Healthcare Foundation. Retrieved from NurseStaffingRatios.pdf 125