Minding the Safety Gap: Nursing Staff Mix and Care Delivery

Minding the Safety Gap: Nursing Staff Mix and Care Delivery 34 th Department of Nursing Annual Symposium- Nursing, Health and Health Care Jewish General Hospital May 26, 2017

Declaration I, Irmajean Bajnok, declare I have no conflict of interest in making this presentation at the 34 th Annual Department of Nursing Symposium.

Overview and Goals Background of RNAO Historical approaches to staffing and patient, provider and organizational outcomes Minding the Safety Gap 70 years of RN effectiveness: A scoping review to build a comprehensive database of evidence Other Resources: Effective Staffing and Workload Practices Best Practice Guidelines

RNAO is the voice of Registered Nurses, Nurse Practitioners and Nursing Students in Ontario, Canada RNAO is leading the nursing profession to influence and promote healthy public policy, and clinical excellence The Best Practice Guidelines is a signature program of RNAO Influencing Healthy Public Policy is a Hallmark of RNAO RNAO is the Professional Association of Registered Nurses, Nurse Practitioners and Nursing Students in Ontario

Some Staffing Issues Over Time Increasing complexity of patients Shifting more care into community.. even more complex patients in hospital Staffing Cost Quality Equation Full time part time mix Continuity of Care Giver and Continuity of Care Scope of practice complex, unstable patients to RN In tertiary and quaternary care if have less than RN staffing means that care is inadequate or patients are in the wrong facility Satisfaction and safety- one patient one nurse Teams of staff and working with groups of patients... this is not a circus, serious care is being given

Mind the Safety Gap slides based on presentations and webinars related to the topic by Dr. Doris Grinspun, CEO, RNAO and other elected officers and staff 6

Model for Health System Effectiveness 7

Nursing Workforce Profile RN Workforce 96,000 More complex patient, with less predictability and less stable environment creates the need for RNs (CNO, 2014) RPN Workforce 39,100 Less complex patient, with predictability and a stable environment creates the need for RPNs (CNO, 2014) NP Workforce 2,400 Builds and expands upon RN competencies (CNO, 2016) Four specialities: Primary Health Care, Paediatrics, Adult and Anaesthesia (Ont. Regulation 275/94) 8

What We Know 9

Policy Agenda Re-designing health system around the needs of patients to optimize quality and outcomes and maximize return on investment Shift of service to the community complexity of patients in hospitals complexity of patients in community/ltc, as patients are being discharged sooner Enhancing RN scope of practice to include independent RN prescribing Need to enhance public health and primary care 10

Issue No provincial interprofessional health human resource plan Some organizations respond to budgetary constraints by replacing RNs with less qualified providers and/or re-arranging organizational models of nursing care delivery as a short-sighted attempt to drive efficiency We ve seen this before and nursing is erroneously regarded as low hanging fruit The issue is that budgetary constraints are driving decisionmaking and not evidence, quality, safety and optimal patient outcomes Disconnect with vision to put patient s first 11

What We ve Heard 12

What We ve Done Action Alerts to Stop RN Replacement and implement the recommendations from this report Over 21,500 respondents Called for an interprofessional HHR plan at QP Day 2016; moratorium on nursing skill mix changes and stop to fragmented care models Stop RN replacement QPOR priority Active media and social media presence Mind the Safety Gap Initiative 13

Model for Health System Effectiveness 14

Mind the Safety Gap in Health System Transformation: Reclaiming the Role of the RN Robust evidence-based report that analyzed and compared nursing HR trends, population health and health system priorities Nursing HR trends found inconsistent with population health and health system priorities Conclusion is an urgent call for an interprofessional HHR plan for Ontario that would follow a transparent, evidence-based, and engaged process 15

Policy Priorities Identified Re-orient the health system within community-based care; Increase public transparency; Provide co-ordinated and integrated services that match population health needs; and Monitor health system performance and improve accountability. 16

Nursing HHR Priorities 1. Appropriate nurse skill-mix utilization 2. Organizational models of nursing care delivery that advance care continuity 3. Maximize and expand scopes of practice 4. Evidence based-practice 17

Shift To Health Illness Health Shifting from an illness focused health-care system to a true health system also requires system planning that captures: Robust public health services Co-ordinated primary care Social and environmental determinants of health Health equity Effective nursing skill mix and organizational models of nursing care delivery are key! 18

Provincial Trends Complexity is increasing RPN share of nursing workforce rose from 21.5 to 28.4%in 10 years (2005-15) Over-reliance on illness based care Ontario has the lowest RN to population ratio ONT: 711:100,000 CAN: 841:100,000 19

Evidence Skill Mix Replacing RNs with less qualified providers results in: More mortality readmissions pressure ulcers pneumonia post-operative infections upper GI bleeds cardiac arrests medication errors lengths of stay transfers of care Less.. continuity of care quality safety satisfaction (Aiken et al., 2011; de Cordova et al., 2014; Ehsani et al., 2013; Estabrooks, et al., 2005; Frith et al., 2012; Glance et al., 2012; Hugonnet et al., 2007; Kane et al., 2007; Lee et al., 2014; Needleman et al., 2011; RNAO, 2010; Tourangeau et al., 2006; Tubbs-Cooley et al., 2013; Twigg et al., 2012) 20

Evidence Skill Mix Nursing Skill Mix in European Hospitals: Cross-sectional study of the association with mortality, patient findings, and quality of care (2016) Hospitals that employ more nursing assistants relative to the number of professionally qualified nurses have higher mortality rates, lower patient satisfaction, and poorer quality and safety of care In European hospitals, where an average of six nurses (four of whom are professional nurses) serve 25 patients, the replacement of a professional nurse by a less qualified nursing assistant was associated with a 21% increase in mortality and; a 10% increase in percentage of professional nurses among all bedside caregivers was associated with a 10% decrease in probability of patients giving low ratings to their hospital Giving professional nurses more clinical assistants does not improve patient outcomes or reduce nurse exhaustion, job dissatisfaction, and the intention to leave clinical care The key to improving care and retaining enough professional nurses by the bed is to maintain safe levels of professional nursing staff in hospitals Reference: Aiken LH, Sloane D, Griffiths P, et al. BMJ Qual Saf Published Online First: [16 November, 2016] doi:10.1136/bmjqs-2016-005567

Changing Models of Care Total Patient Care Team Models One nurse (RN or RPN) provides total care to a small group of patients based on stability, predictability and complexity. UCP supports nurse with delegated tasks under supervision. What is Lost? Continuity Efficiency Safety Quality Patient satisfaction Multiple providers (RN, RPN and/or UCP) parcel out tasks and care for a pool of patients 22

Primary Nursing Primary nursing: individual patients are assigned to the most appropriate nurse (RN or RPN) who acts as their primary nurse throughout the entire care process, providing all aspects of nursing care (Grinspun, 2010). The most effective means of ensuring continuity of care and continuity of careprovider. 23

Evidence Models of Care Functional (or team ) organization models of nursing care delivery result in: More hospital acquired infections time spent in administrative tasks instead of patient care fragmentation of units hierarchal care teams inequitable workloads liability risk adverse events Less psychosocial care, clarity of accountability continuity of care continuity of careprovider productivity (Duffield et al., 2010; Fairbrother, Jones and Rivas, 2010; Wells, Manuel, and Cunning, 2011; Grinspun, 2010; Rogowski et al., 2013; Tiedman and Lookinland, 2004; Wolf and Greenhouse, 2007) 24

Recommendations 1. The MOHLTC develop a provincial evidence-based interprofessional HHR plan to align population health needs and the full and expanded scopes of practice of all regulated health professions with system priorities 2. The MOHLTC and Local Health Integration Networks (LHIN) issue a moratorium on nursing skill mix changes until a comprehensive interprofessional HHR plan is completed 3. LHINs mandate the use of organizational models of nursing care delivery that advance care continuity and avoid fragmented care 4. The MOHLTC legislate an all-rn nursing workforce in acute care effective within two years for tertiary, quaternary and cancer centres (Group A and D) and within five years for large community hospitals (Group B) RNs working together with an increased number of NPs and clinical nurse specialists practising to their full scope 25

Recommendations (cont.) 5. LHINs require that all first home health-care visits be completed by an RN 6. The MOHLTC, LHINs and employers eliminate all barriers, and enable NPs to practise to full scope, including: prescribing controlled substances; acting as most responsible provider (MRP) in all sectors; implementing their legislated authority to admit, treat, transfer and discharge hospital in-patients; and utilizing fully the NP-anaesthesia role inclusive of intraoperative care 7. The MOHLTC legislate minimum staffing standards in LTC homes: one attending NP per 120 residents, 20 per cent RNs, 25 per cent RPNs and 55 per cent personal support workers 8. LHINs locate the 4,100 CCAC care co-ordinators within primary care to provide health system care co-ordination and navigation, which are core functions of interprofessional primary care 26

Progress on MTSG 27

Progress on MTSG Recognition RNAO was pleased to have been: Referenced in the Patients First Discussion Paper Recognized by Health Minister Hoskins at our 91st AGM in May 2016 that ECCO heavily informed the reform agenda MTSG recognized by Health Minister Hoskins at our 92nd AGM in May 2017 28

Progress on MTSG Recommendations 1. Develop a provincial evidence-based interprofessional HHR plan McMaster Health Forum. Topic Overview: Planning for the Future Health Workforce of Ontario. Hamilton, Canada: McMaster Health Forum, 28 September 2016. 29

Progress on MTSG Recommendations 2. Legislate an all-rn nursing workforce in acute care for tertiary, quaternary and cancer centres Deputy Minister Bob Bell committed at RNAO BOD meeting that patients classified as having tertiary or quaternary needs who are in acute care hospitals require RN care, as do most cancer patients in acute care hospitals. 30

Progress on MTSG Recommendations SCOPE of Practice: Independent RN Prescribing Steady progress toward RN Independent Prescribing, RNAO launched effective advocacy for this change in scope over past year; September, 2016, in mandate letter from Premier to Health Minister, included RN Independent prescribing; Announcement by Health Minister at Queen s Park Day, February, 2017; Budget Announcement, April, 2017, and announcement at RNAO AGM April 27, 2017; College of Nurses of Ontario directed to develop regulations IT WILL HAPPEN 31

Progress on MTSG Recommendations 3. LHINs mandate the use of organizational models of nursing care delivery that advance care continuity and avoid fragmented care 4. Eliminate all barriers, and enable NPs to practise to full scope 5. Legislate minimum staffing standards in LTC homes 6. LHINs locate the 4,100 CCAC care co-ordinators within primary care 32

Learn More and Contact www.rnao.ca/mindthesafetygap Doris Grinspun, RN, MSN, PhD, LLD(hon), O.ONT. Chief Executive Officer dgrinspun@rnao.ca CC: Josephine Mo, executive assistant, jmo@rnao.ca 33

Seventy (70) years of RN Effectiveness Scoping Review of evidence of RN staffing levels on nurse, patient, and organizational outcomes Data base of evidence available on web site Media event during nursing week (public on board) Press Release announcing media event Results of Scoping Review Results of Nursing week event 34

A Scoping Review to Build a Comprehensive Database of Evidence Zainab Lulat, RN, MN Anastasia Harripaul-Yhap, RN, MSc(A) Tasha Penney, RN, MN, CPMHN(C) Julie Blain-McLeod, RN, BScN, MA Michelle Rey, MSc, PhD Purpose of the Database Establish an electronic database of studies investigating the effectiveness of Registered Nurses (RNs) on clinical/patient outcomes, organizational/nurse outcomes, and financial outcomes.

Research Questions What is the effectiveness of Registered Nurses in improving Q1 Clinical/patient outcomes Q2 Organizational/nurse outcomes Q3 Financial outcomes compared to other health workers (regulated or non-regulated), other types of nurses, or the absence of nursing care?

Inclusion and Exclusion Criteria Inclusion Criteria Studies published within the last 70 years (1946 2016) Target: Registered Nurses Client population: All clients Primary area of focus: All health care disciplines Setting: All health care settings, sectors Published in English International literature All study designs/type (qualitative, quantitative, mixed methods, reviews) Presence of a comparator to RN: Other types of nurses Other health workers Absence of RN care Exclusion Criteria Articles that are not research studies (ex. commentaries, editorials, conference proceedings, etc.) Non-English titles and abstracts Animal studies Outside of year parameters Articles with minimal focus on RN effectiveness or did not focus on RN care/staffing Articles that were not retrievable electronically Articles in which the type of nurse was not specified after reviewing full-text

Overview of Methodology Purpose and Scope Inclusion/Exclusion Criteria Concept Tables For each research question Collaborate with Health Sciences Librarian to develop search strategy and perform test searches Conduct searches in electronic databases: CINAHL Medline Cochrane SR and CT Compilation of Database Full-Text Relevance Review Title and Abstract Screening Electronically screen for keywords (Registered Nurse, RN, Baccalaureate, BScN, etc.) and key authors

300 250 Number of Articles in Database by Outcome Measured 239 265 200 150 122 100 50 0 Clinical/Patient Organizational/Nurse Financial

70 years of RN Effectiveness: A scoping review to build a comprehensive database of evidence 40

Nursing Week 2017 Media Event 41

Clinical/ Patient Outcomes Quality of care and patient satisfaction (46) Patient safety (19) Pain management (16) Mortality (57) Ulcers (33) Infections (32) Length of stay (21) Complications (19) Falls (14) Medication errors (11) Readmissions (9) Morbidity (7) Other Organizational/Nurse Outcomes Organizational safety (39) Job satisfaction and team functioning (41) Retention (29) Efficiency (19) Continuity of care (3) Turnover (34) Adverse events (27) Errors and incidents (19) Overtime (14) Intention to leave (7) Absenteeism (7) Needlestick injuries (5) Deficiencies (4) Other Financial Outcomes Cost savings (10) Cost-effectiveness (8) Economic/cost benefit (2) Other *Number in brackets refers to frequency of articles relating to that outcome within the database Arrows represent direction for positive outcome

Outcome Positive Clinical/Patient Outcomes Decreased mortality Increased quality of care and patient satisfaction Decreased ulcers Decreased infections Decreased length of stay Increased patient safety Decreased complications Improved pain management Decreased falls Decreased medication errors Decreased readmissions Improved diabetes nursing care Decreased morbidity Improved vascular nursing care Frequency 0 10 20 30 40 50 60 Number of Articles in Database

Outcome Positive Organizational and Nurse Outcomes Increased job satisfaction and team functioning Increased organizational safety Decreased turnover Increased retention Decreased adverse events Decreased errors and incidents Increased efficiency Decreased overtime Decreased intention to leave Decreased absenteeism Decreased needlestick injuries Decreased deficiencies Improved continuity of care 0 5 10 15 20 25 30 35 40 45 Number of Articles in Database

Outcome Positive Financial Outcomes Cost savings Cost-effectiveness Economic/cost benefit 0 2 4 6 8 10 12 Number of Articles in Database

Number of Articles Conflicting/Neutral Outcomes 30 out of the total 626 articles demonstrated conflicting or neutral results which is less than 5% (4.8%) 60 50 40 Positive Outcomes Positive vs. Conflicting/Neutral Outcomes Conflicting or Neutral Outcomes 30 20 10 0 Outcome Measured

Number of Articles Published by Decade 300 265 250 247 200 150 100 76 50 0 7 31 1970-1979 1980-1989 1990-1999 2000-2009 2010-Present

Effective Staffing and Workload Practices RNAO BPG 2017, 2 nd Edition Structure Timelines Quality Evaluation DEVELOPMENT PROCESS Topic Selection Expert Panel identified Additional Scoping of BPG Systematic review in response to research questions Data extracted and data tables developed Based on evidence draft recommendations developed Modified Scope Delphi used to determine what recommendations to use and what new ones to develop Final daft for stakeholders Stakeholder review Revision Publication

Staffing and Workload Practices Best Practice Guideline (BPG) Part of Healthy Work Environment (HWE) BPG Series A Healthy Work Environment maximizes the health and wellbeing of nurses and other health care professionals, improves patient outcomes, increases organizational performance and benefits society. It is challenging to implement evidence-based practice in work environments that are not healthy. Effective workload and staffing practices are part of a Healthy Work Environment

What the Guideline Does This Guideline includes specific evidence based recommendations that address the following: how organizations can best engage in workload and staffing practices that are safe and effective; what knowledge, skills and supports individual nurses require in order to safely and effectively manage day to day staffing decisions for their units/teams; the kinds of organizational policies that need to be in place to support safe, effective staffing and workload practices, including processes for identifying, documenting and reporting unsafe staffing practices responsibilities of standard setting bodies and governments to measure and ensure safe and effective staffing and workload practices. future research focus

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THANK YOU!! QUESTIONS AND DISCUSSION www.rnao.ca/mindthesafetygap