Carl Brown, PhD, RN, AOCN, FAAN Director, Professional Services Oregon Nurses Association David Cadiz, MBA, PhD Director, WorkHealthy Oregon

Transcription

1 Staffing Request and Documentation Form (SRDF) Summary Report May May 2014 Carl Brown, PhD, RN, AOCN, FAAN Director, Professional Services Oregon Nurses Association David Cadiz, MBA, PhD Director, WorkHealthy Oregon

2 Executive Summary Staffing Request and Documentation Forms (SRDF) are filled out by staff nurses or charge nurses at 30 acute care facilities represented by the Oregon Nurses Association (ONA), to document the occurrence of an inappropriate staffing event on a specific shift and unit. We report on an analysis of 1,780 SRDFs submitted over a two-year period ranging from May 1, 2012 to April 30, There was a 5.3% year-over-year increase of total SRDFs submitted for the two-year reporting period. We highlight several key observations from the analysis below. Research Findings Summary of factors related to SRDF submissions: 84% of the SRDFs were submitted from an eight hour shift 46% were submitted from a day shift and 35% were submitted from night shifts Nearly 33% of the SRDFs were submitted from the ICU (12.5%), General Medical (11.0%) and Emergency Room (9.2%) units Summary of identified reasons for requesting additional staff: 89% note that not having enough staff was a reason for submitting the SRDF 59% indicate patient acuity and 44% indicate that patient intensity being too high were reasons for submitting the SRDF Summary of consequences of the insufficient staffing event on care tasks: 82% of pain management, 90% of medication and 91% of medical orders and treatments were reported as being delayed or omitted due to insufficient staffing on the unit Not enough staff, patient intensity and patient acuity were significantly related to the delay or omission of almost all of the measured care tasks Summary of patient safety consequences of insufficient staffing: 71% report that the staffing event compromised patient safety and 30% indicated that continuity of care was impacted There was a 1.5 to 2 times greater likelihood that compromised patient safety was reported when not enough staff, patient acuity being too high, and inappropriate staff mix were identified as a reason for submitting the SRDF Summary of self-care consequences of insufficient staffing event: 78% reported missed rest breaks, 55% reported missed meal breaks, and 31% indicated voluntary overtime When patient intensity was indicated, there was at least a 1.7 times greater likelihood that nurses reported voluntary overtime, missing meal breaks and missing rest breaks The results from our analyses support the adverse effect of insufficient staffing on delaying or omitting patient care tasks, compromised patient safety, and missed RN self-care activities. 2

3 Background The negative effects of insufficient staffing in nursing are becoming increasingly apparent. Research supports the negative outcomes of insufficient staffing on lower quality of patient care (Aiken et al., 2002), increased medical errors, infections and patient injury (Hall et al., 2004), and higher patient mortality (Clarke & Aiken, 2003). Moreover, insufficient staffing adversely affects nurses by placing greater demands on them. Those demands lead to increased self-expectations to shoulder a greater patient load (Wicker & August, 1995), work at a faster rate (Beglinger, 2006), and work overtime (Hall et al., 2004). Research also shows that insufficient staffing negatively affects nurse wellbeing by increasing job strain, emotional exhaustion (i.e., burnout) and depression (Aiken et al., 2002; Greenglass et al., 2003; Jamal & Baba, 1992; Leiter & Laschinger, 2006). Process: A Staffing Request and Documentation Form (SRDF) is submitted after a request for additional staffing resources is communicated up through the chain of command at an acute care facility. SRDFs are filled out by staff nurses or charge nurses to document the occurrence of an insufficient staffing event. Copies of the SRDF are distributed to the appropriate management personnel at the facility and the Oregon Nurses Association (ONA). The individual or group of individuals who submit the form also keep a copy. The next steps require ONA staff to follow specific protocol to transfer the information from the report into a database. First, quantitative data is extracted and transferred to a coding sheet by a trained coder. The data are then transferred from the coding sheet into a statistical database for analysis. Information written in the additional comments section of the form is also transcribed into a separate database for further analysis. The data from this process are what are analyzed and reported in this document. The analysis includes 1,780 SRDFs submitted by nurses from 30 different facilities from May 1, 2012 to April 30, We would like to acknowledge that more SRDFs may be submitted than are actually analyzed in this report. There are two reasons why a SRDF may not qualify for inclusion in this report. First, sometimes several SRDFs are submitted for the same insufficient staffing event. In this case, we examine the different reports to verify that the event being reported is truly the same. This step ensures that the event is only reported once. Second, SRDFs that are missing significant data regarding who was notified in the reporting chain about the insufficient staffing event are removed from the analysis. We have instituted these two controls as a way to increase the validity of the information being reported. Once ONA staff receive the form, it is logged into a spreadsheet and an acknowledgement is sent to each of the individuals who sign the form. 3

4 Total Number of SRDFs Submitted by Site Analysis: There were a total of 1,780 SRDFs coded between May 1, 2012 and April 30, For the two-year reporting period, the top 5 sites for total submissions accounted for 73% of the SRDFs submitted. There was a 5.3% year-over-year increase of total SRDFs submitted for the two-year reporting period. May 1, April 30, 2013 May 1, April 30, 2014 Total % of Total % Change Year over Year Sacred Heart (SH) % 5.9% Oregon Health & Science Univ (OHSU) % -17.6% Rogue Regional (RR) % 95.3% St. Charles Bend (STC-B) % -40.8% Providence Medford (PMMC) % -36.4% Providence Portland Medical Ctr (PPMC) % -8.1% Sky Lakes (SKY) % 42.9% Pacific Communities (SPCH) % 40.0% Providence St V (APRN) (STV) % 47.4% Bay Area (BA) % 90.9% Providence Willamette Falls (PWFH) % 200.0% Columbia Memorial (CMH) % -52.4% McKenzie-Willamette (MCW) % 400.0% Tuality (TCH) % 28.6% Coquille (CVH) % -81.8% Albany Samaritan (AGH) % 800.0% Providence Milwaukie (PMIL) % -33.3% Good Shepherd (GSH) % 100.0% SAMCO (SAO) % 33.3% St. Alphonsus (SAB) % 0.0% Mid-Columbia (MC) % % Blue Mountain (BMRC) % % Peace Harbor (PH) % 100.0% St. Charles Redmond (STC-R) % % Grande Ronde (GRH) % 0.0% Providence Seaside (PSH) % % St. Anthony (STA) % % Harney (HAC) % % Multnomah County (MUC) % % Samaritan Lebanon Comm Hosp (SLCH) % 100.0% Total % % 4

5 Top Five Sites for SRDF Submissions Total Submissions May May Sacred Heart (SH) Oregon Health & Science Univ (OHSU) Rogue Regional (RR) St. Charles Bend (STC-B) Providence Medford (PMMC) Series SRDF Submissions May May 2014 % Change at Site Over Prior Year Sacred Heart (SH) Oregon Health & Science Univ (OHSU) Rogue Regional (RR) St. Charles Bend (STC-B) Providence Medford (PMMC) 5

6 Analysis of Potential Factors Related to the Number of SRDFs Submitted Analysis: We examined several potential factors that could be related to the number of SRDFs submitted including shift length (eight versus twelve hours), time of day of the shift (day, evening or night), day of the week, month of the year and unit type. We observed that 84% of the SRDFs were submitted on eight hour shifts. We also found that 46% of the SRDFs were submitted during the day shift, followed by 35% on the night shift and 19% on the evening shift. Additionally, a greater percentage of SRDFs were submitted on Fridays (17%) and Saturdays (17.9%) compared to the rest of the week. Finally, nearly one third of the SRDFs submitted were from the ICU (12.5%), General Medical (11.0%) and Emergency Room (9.2%) units. % SRDFs Submitted by Day of Week % SRDFs Submitted by Time of Shift Sun 12% Mon 15% Sat 18% Tues 14% Night 35% Day 46% Fri 17% Thurs 12% Wed 12% Evening 19% % SRDFs Submitted by Shift Length 12 hour 16% 8 hour 84% 6

7 Percent of SRDFs Submitted by Unit Type Unit % of Total SRDFs Submitted ICU/CCU/CMICU/NICU 12.5% General Medical 11.0% Emergency Room 9.2% Other 9.2% General Surgical 8.7% Oncology 8.6% Inpatient Psychiatry/Behavioral Health Unit 5.2% Combined Medical Surgical 4.8% Mother/Baby, Family Birth Center, Nursery 3.7% Neourology 3.4% Short Stay 2.8% Orthopedics 2.5% Post-cardiac/Step Down/Telemetry 2.5% Operating Room/Surgery 2.4% Temporary Care/Unit Overflow 2.4% Rehabilitation/Longterm Care 2.1% Recovery Room/PACU 1.8% IV Therapy 1.7% Labor and Delivery 1.7% Combined Orthopedics/urology 0.9% Emergency/Pscyhiatric 0.8% Pediatrics 0.8% Outpatient Infusion 0.6% Diabetes/Renal 0.2% Home Health 0.2% Endoscopy Lab 0.1% Jail/prison 0.1% Special Procedures 0.1% 7

8 Analysis of Reasons for Reporting Analysis: 89% of the SRDFs indicated that not having enough staff was a reason for reporting. Patient acuity being too high for the current staffing level was identified on 59% of the SRDFs and 44% of the SRDFs reported that patient intensity was too high for the amount of staff on shift. We examined the written responses for reports where other was selected as the reason for reporting. Lack of functioning medical tools/resources (i.e., computers down, broken equipment, new equipment/technology where no training was given) could be an additional characteristic triggering insufficient staffing. Additionally, there were several responses that should have been categorized as inappropriate staff mix because the issue was inexperienced staff (orientation, monitoring and teaching were required), staff who did not have the skill set to perform the appropriate tasks, or float staff who did not know the particular process, policies or practices specific to the unit or facility. Reason For Submitting SRDF 89% 59% 44% 34% 28% Not Enough Staff Patient Acuity too High Patient Intensity too High Inappropriate Staff Mix Other 8

9 Analysis of Patient Care Task Consequences Due to Insufficient Staffing Analysis: An example of what is meant by the impact of insufficient staffing on patient care tasks is captured in the following comment from a submitted SRDF, Meds given up to 2-3 hours late, AM assessments not completed until afternoon, no breaks or lunches for some nurses, orders completed late. When an insufficient staffing event occurred, nurses reported between 82% to 94% of the time that a patient care task was either delayed or omitted. Pain management was the least delayed or omitted task, but it was only fully completed 22% of the time within the expected time frame. The least completed task was documentation, which was completed only 6% of the time within the expected time frame. The insufficient staffing characteristics of not enough staff, patient intensity and patient acuity were significantly related to the delay or omission of almost all of the measured patient care tasks. In fact, when it was indicated that there were not enough staff, there was over 3.1 times greater likelihood that patients and/or their families did not receive, or received delayed psychosocial support, information or support. Additionally, when patient intensity was noted as the reason for the insufficient staffing event, there was a 2.2 times greater likelihood that medical orders and medications were delayed or omitted. When it was reported that patient acuity was too high, there as a 2.0 times greater likelihood that medical orders and hygiene were delayed or omitted. Finally, when inappropriate staff mix was indicated, there as a 1.4 times greater likelihood that pain management was delayed or omitted. Type and Percentage of Delayed or Omitted Patient Care Tasks 94% 90% 90% 88% 87% 91% 89% 88% 89% 82% 9

10 Analysis of Patient Safety Consequences of Insufficient Staffing Analysis: An example of what is meant by the impact of insufficient staffing on patient safety is captured in the following comment from a submitted SRDF, I feel that this weekend we knowingly put patients in a potentially unsafe situation. I am putting my license in jeopardy. I will not work in a situation like this again and I m having serious thoughts about looking elsewhere for employment. We found that 71% of the nurses indicated that patient safety was compromised due to the insufficient staffing event and 30% reported that it affected continuity of care. Not enough staff, inappropriate staff mix and patient acuity were significantly related to reports of compromised patient safety. Patient acuity being too high, inappropriate skill mix and patient intensity being too high were significantly related to reported issues with continuity of care. When not enough staff, inappropriate staff mix and patient acuity being too high were indicated, there was between a 1.5 to 2 times greater likelihood that compromised patient safety was reported. Indications of patient acuity being too high, inappropriate skill mix and patient intensity being too high were related to at least a 1.6 times greater likelihood of continuity of care being compromised. Patient Safety Consequences 71% 30% Compromised Safety Continuity of Care 10

11 Analysis of RN s Self-Care Consequences of Insufficient Staffing Analysis: An example of what is meant by the impact of insufficient staffing on RN self-care is captured in the following comment from a submitted SRDF, No one got breaks except the CNA. I had to call the Director of Shift Operations to come to the floor so that we could retrieve food from the cafeteria - for safety. RNs didn t get 15min breaks legally allotted to Q4hrs. Forced to eat at nurses station while charting. Nurses reported missing rest breaks 78% of the time and missing meal breaks 55% of the time on the submitted SRDFs. Patient intensity had the strongest relationship with RN self-care outcomes. When patient intensity was indicated, there was at least a 1.7 times greater likelihood that nurses reported voluntary overtime, missing meal breaks and missing rest breaks. When not enough staff, patient acuity being too high, and patient intensity being too high were reported, nurses had at least a 1.6 times greater likelihood of missing their rest breaks. Type and Percentage of Delayed or Omitted Self-Care Tasks 79% 55% 31% 11% No Rest Break No Meal Break Voluntary Overtime Mandatory Overtime 11

12 References Aiken, L., Clarke, S., & Sloane, D. (2002). Hospital staffing, organization, and quality of care: Cross-national findings. International Journal for Quality in Healthcare, 14, 1. Beglinger, J.E. (2006). Quantifying patient care intensity: An evidence-based approach to determining staffing requirements. Nurse Administration Quarterly, 30, Clarke, S., & Aiken, L. (2003). Failure to rescue: Needless deaths are prime examples of the need for more nurses at the bedside. American Journal of Nursing, 103, Greenglass, E., Burke, R., & Moore, K. (2003). Reactions to increased workload: Effects on professional efficacy of nurses. Applied Psychology: An International Review, 52, Hall, L., Doran, D., & Pink, G. (2004). Nurse staffing models, nursing hours, and patient safety outcomes. The Journal of Nursing Administration, 34, Jamal, M., & Baba, V. (1992). Shiftwork and department-type related to job stress, work attitudes and behavioral intentions: A study of nurses. Journal of Organizational Behavior, 13, Leiter, M., & Laschinger, H. (2006). Relationships of work and practice environment to professional burnout: Testing a causal model. Nursing Research, 55(2), Wicker, A., & August, R. (1995). How far should we generalize?: The case of a workload model. Psychological Science, 6,