Nurse staffing law may herald benchmarks
Mandate now, numbers later aided by research
California became the first state to require all patient care units in hospitals to meet fixed minimum nurse-to-patient ratios when Gov. Gray Davis signed the legislation known as the "Patient Safety Act" in October. This legislation comes at a time when caregivers’ and consumers’ concerns have risen dramatically.
Many institutions have decreased the numbers of RNs caring for an increasingly acutely ill patient population, cutting corners by substituting unlicensed personnel for RNs, says Beverly L. Malone, PhD, RN, FAAN, president of the American Nurses Association (ANA).
Malone points out that a number of studies have proven the link between adequate nurse staffing and positive patient outcomes. "Presently, the system works to keep patients out of the hospital as long as possible, and to discharge them as soon as possible," she says. In a hospital environment where patients are sicker and care is more complex, "cutting the numbers of RNs and substituting unlicensed aides for registered nurses are exactly the wrong moves."
Making the right moves
ANA’s "Principles of Nurse Staffing" call for staffing decisions to be made on the basis of three sets of principles: those related to patient care, staff-related issues, and institution/organization concerns. "What the Principles boil down to," says Malone, "is what should be the obvious. Staffing decisions should be based on real patient conditions and real provider competencies, not on a cookie-cutter approach that treats both patients and their nurses as widgets on an assembly line."
Available on the ANA Web site (http//www/ ana.org), these principles are:
- Patient care unit
— Appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs.
— There is a critical need to either retire or question the usefulness of the concept of nursing hours per patient day (HPPD).
— Unit functions necessary to support delivery of quality patient care must also be considered in determining staffing levels.
- Staff
— The specific needs of various patient populations should determine the appropriate clinical competencies of the nurse practicing in that area.
— RNs must have nursing management support and representation at both the operational level and the executive level.
— Clinical support from experienced RNs should be readily available to those RNs with less proficiency.
- Institution/organization
Organizational policy should reflect an organizational climate that values RNs and other employees as strategic assets and should exhibit a true commitment to filling budgeted positions in a timely manner.
All institutions should have documented competencies for nursing staff, including agency or supplemental and traveling RNs for those activities they have been authorized to perform.
Organizational policies should recognize the myriad needs of both patients and nursing staff.
Determining quality indicators
The California legislation contains no specific numerical requirements. Instead, the California Department of Health Services has been charged with promulgating appropriate regulations by Jan. 1, 2001, with actual implementation to take place one year later, Jan. 1, 2002.
The process of coming up with specific nurse-to-patient ratios should be aided by ongoing ANA research being conducted by six state nursing associations (SNAs). These organizations are currently testing a series of nursing-sensitive quality indicators, laying the groundwork for the measures that can be used to generate benchmarks of nursing performance in the future.
These quality indicators are comprised of a series of measures, such as the number of nursing care hours per patient day, levels of patient and nurse satisfaction, and incidence of patient falls, pressure sores, and nosocomial infections, that represent the nursing community’s current conception of how nurse staffing levels impact patient care. (See "10 ANA quality indicators for acute care settings," at right.)
The indicators began with an ANA-commissioned 1995 study "Nursing Care Report Card for Acute Care," conducted by the Fairfax, VA-based Lewin-VHI Inc. consulting firm explains ANA spokesman Michael Stewart.
"Since then, we have widely disseminated the original indicators among state nursing associations, and several of them have been extensively field-testing them, resulting in some of the indicators being redefined." This testing is ongoing, adds Stewart, "and we will keep refining these indicators as necessary over time."
[For further information, contact:
• American Nurses Association (ANA), 600 Maryland Ave. S.W., Suite 100 West, Washington, DC 20024. Telephone: (202) 651-7000. Fax: (202) 651-7001. Web site: www.ana.org.
• ANA/California, 801 Portola Drive, Suite 108, San Francisco, CA 94127-1234. Telephone: (415) 664-3262. Fax: (415)664-3464. Web site: www.nursing world.org/snas/ca/.]
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