Take California’s word: Nurse staffing levels do impact quality of care
To be sure your hospital has a problem, you’ll need to gather data
Editor’s Note: This is the second of a three-part series looking at how effective definition of provider roles can enhance patient, physician, and staff satisfaction. In the first article, we looked at some recent research on job role complexity. This month, experts will share their thoughts on why proper role definition is important; signs that you may not have the mix right; a way that you can better gauge nurse staffing needs in ICU settings; and cross-training to maximize nurse flexibility for improved patient care. In January, Patient Focused Care and Satisfaction will look at organizations that have had a problem in the area of role definition and how they solved it.
If you needed proof that nurse staffing is a hot topic, all you had to do was watch a mid-October legislation signing ceremony in Sacramento. There, Governor Gray Davis signed into law a regulation requiring the State Department of Health Services to adopt minimum nurse-to-patient ratios by nurse classification and hospital unit for all licensed hospitals.
California is the first state to react with legislation to an increasing number of consumer and caregiver complaints that managed care organizations and hospitals are keeping costs down by cutting nurses — something the complainants contend has a negative impact on patient care.
Beverly Malone, RN, FAAN, PhD, president of the American Nurses Association (ANA) in Washington, DC, says after the signing that a number of studies have proven the link between adequate nurse staffing and positive patient outcomes. (For a list of articles on the subject of staffing levels and quality of care, see box, p. 136.)
"Presently, the system works to keep patients out of the hospital as long as possible, and discharge them as soon as possible," she says. "Patients are sicker, and care is more complex. Cutting the numbers of RNs, substituting unlicensed aides for registered nurses, and preventing RNs from speaking out about patient care concerns are exactly the wrong moves."
"This isn’t a new problem," says Katherine Bradley, MN, RN, a researcher at Midwest Research Institute in Kansas City, MO. "It’s a longstanding one."
She is working on the ANA’s National Database of Nursing Quality Indicators, a report card program that looks at 10 quality indicators that relate to nursing roles. (See list of the ANA’s quality indicators, right.)
| ANA’s 10 Quality Indicators |
| 1. Skill mix of RNs, LPNs/LVNs, and unlicensed staff |
| 2. Total nursing care hours provided per patient day |
| 3. Maintenance of skin integrity (pressure ulcers) |
| 4. Patient injury rate (falls) |
| 5. Patient satisfaction with pain management |
| 6. Patient satisfaction with educational information |
| 7. Patient satisfaction with overall care |
| 8. Patient satisfaction with nursing care |
| 9. Nosocomial infections (under development) |
| 10. Nursing staff satisfaction |
| Definitions for these indicators are available at http://www.mriresearch.org/health/ndnqi.html, the Web site for the NDNQI project of the American Nurses Association. |
| Source: American Nurses Association, Washington, DC. |
The ANA research won’t be ready for publication for another year yet, but, after four years of study there is a sense that a link between staffing levels and quality of care will become even more evident. The question is whether hospitals should wait for their own states to legislate nurse- to-patient ratios, or if they should first determine appropriate staffing levels on their own.
Track your adverse indicators
There is a big leap, however, between saying you are concerned about staffing levels and figuring out how to tell if you have a problem. Mary Blegen, RN, PhD, a professor at the University of Colorado Health Sciences School of Nursing in Denver, has done a lot of the most current research on how staffing levels influence adverse outcomes, such as falls and medication errors. She says that most hospitals keep some data that can help them see if there is a problem.
"Although it would be nice to use some positive indicator of quality of care, adverse indicators are the most widely available," Blegen explains. "You could look at patient satisfaction, but surveys have a low return rate and they don’t usually identify the unit the patient was discharged from."
Blegen says that nursing administrators already have to have some idea about indicators such as pressure ulcers, falls, and medication errors for accreditation reports. "Track them. If they get too high, you may have a staffing problem," she says.
Another indicator you should look at is your staff and skill mix. "Some folks think you should never get below 70% RNs," Blegen says. "But, with sicker patients who are there for a shorter amount of time, I think that’s really what’s pushing it. And it should be higher for a critical care unit."
One of the hospitals that has participated in the ANA study is Hartford (CT) Hospital. Laura Caramanica, RN, PhD, is co-director of the women’s and cancer programs at the facility, and has been instrumental in creating an internal report card program that looks at 15 quality indicators that relate to nursing care. (See Hartford Hospital’s list of indicators, above.)
| Hartford Hospital’s 15 Nursing Quality Indicators |
| Clinical |
| • Primary bacteremias |
| • IV site infection |
| • Urinary tract infections |
| • Patient falls |
| • Decubitus ulcers |
| Functional |
| • Discharge teaching |
| • Hartford Hospital/VNA health care communication |
| Financial |
| • Mix of licensed and unlicensed staff (direct caregivers) |
| • Total staff hours per day |
| • RN total hours per care day |
| Satisfaction |
| • Patient satisfaction for nursing care, excluding behavioral health |
| • Pain control management: patient perception |
| • Overall satisfaction with care |
| • Would recommend Hartford Hospital |
| • Perception of quality care |
| Source: Hartford (CT) Hospital. |
Four years ago, the hospital was in the midst of a patient-focused redesign and needed to have some knowledge about the quality of nursing care. At the same time, the ANA was starting its nursing report card program, and Hartford Hospital’s chief operating officer was on the task force designing the program, says Caramanica. "We were able to put a team together and develop a data set to use internally that was based on the ANA data set," she says. "We wanted to create a balanced score card that looked at clinical, functional, finance, and satisfaction indicators."
The hospital also wanted to get a picture of its staff profile — how many nurses there were, the staff mix, their specialties, certifications, and years of experience, as well as their roles and how they broke down.
It took four years to get the information systems and teams completely in place to define and begin measuring the various indicators. "We had to do a lot of convincing — of the health information department and risk management departments to collect this data," Caramanica says. "And of the staff, too. We had to help them understand we wanted them to fill out incident reports for the information only, not to use as some sort of judge of their work. That is still something we have to work on — to make sure those reports are getting filled out."
So far, there have been two outcomes reports, and a third one is due out in December. The latter will be the first where the information can be broken down by unit. Among the other changes discussed for later report cards are setting goals for existing indicators, adding comparison data, selecting additional quality indicators, and identifying areas for research.
Making use of the data
"Before we did this, we really had no idea of whether our nursing care was good, bad, or otherwise," says Caramanica. "We didn’t even know our staff mix. So here we were, getting ready to redesign patient care, and change processes and procedures, and we had no base line data. We were going to change based on what a consultant said a hospital was doing somewhere else. That made us sit up and realize that we couldn’t do this; we couldn’t potentially jeopardize patient care. And yet, we couldn’t tell our board and our staff that we wouldn’t be jeopardizing it if we didn’t have more information."
Having that information has pointed out some key areas for improvement. For instance, although the hospital was hitting 89% to 91% in patient satisfaction surveys, Hartford Hospital was not perceived as being as caring as other hospitals in the area. "[Patients] thought we were more technical than caring," Caramanica explains.
The hospital’s .3% rate for decubitus ulcers was not a bad number, but over time subsequent report cards showed it wasn’t improving. "We are an 879-bed tertiary hospital with a high acuity of patients. So that’s not a horrible rate. But in this day and age, it’s also not acceptable," says Caramanica.
The report card has resulted in four continuous quality improvement (CQI) projects — on fall risk and falls, on skin integrity, on patient satisfaction, and on discharge planning. "We just never would have known there were problems unless we looked at some of these nursing quality issues," she says.
Report card conveys quality goal
There is a growing sense among the nurses that administration is serious about maintaining nursing quality. "Every nurse gets a copy of the report card and it is discussed every month," Caramanica says.
While she admits that some nurses will always view any administration initiative with skepticism, Caramanica says that nurses who are close to the process and the CQI programs know they are a means to assist the hospital in providing the best quality patient care. An additional study of staffing levels and mix as they correlate to the 15 quality indicators should provide further information to ensure that Hartford Hospital changes its staffing levels appropriately.
But once you determine you have issues to address, your problems don’t end. Blegen says that there is no template or proven path for correcting a problem. "Sometimes hiring unlicensed providers can be helpful," she says. "That’s especially true in areas where nurses are hard to come by."
Some hospitals have had to close beds, at least temporarily, to ensure that quality of care doesn’t suffer, says Blegen. Sometimes, just instituting a CQI program to address individual issues, as Hartford Hospital has done, will work. But that takes time.
"Regardless of what you decide to do, you should bring nurses into the decision-making process," says Blegen. "Ask them to help decide about closures, about when to move people, and about finding more long-term solutions to the problems."
Blegen says input is something that nurses crave. "Some of the more recent strikes have focused on that issue," she says. "They want to be in that decision-making loop."
Caramanica and Hartford Hospital have opted to go the CQI route. Next month, PFC will look more closely at how Hartford Hospital solved some of its more pressing problems.
Sources
• Katherine Bradley, MN, RN, National Database of Nursing Quality Indicators, Midwest Research Institute, Kansas City, MO. Telephone: (816) 753-7600, ext. 1783.
• Mary Blegen, RN, PhD, Professor, University of Colorado Health Sciences School of Nursing, Denver. Telephone: (303) 315-4237.
• Laura Caramanica, RN, PhD, Co-Director, Women’s Health & Cancer Programs, Hartford (CT) Hospital. Telephone: (860) 545-2635.
Further reading
• Aiken JH, Sochalski J, Anderson GF.. Downsizing the hospital nursing workforce. Health Aff 1996; 15(4):88-92.
• Aiken L, Smith H, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. Med Care 1994; 32(8):771-787.
• American Nurses Association. Implementing Nursing’s Report Card: A Study of RN Staffing, Length of Stay and Patient Outcomes. Washington, DC: American Nurses Publishing; 1997.
• Anderson GF, Kohn LT. Employment trends in hospitals, 1981-1993. Inquiry 1996; 33:79-84.
• Blegen M, Vaugh T. A multisite study of nurse staffing and patient occurrences. Nursing Economics 1998; 16:196-203.
• Blegen MA, Goode CJ, Reed L. Nurse staffing and patient outcomes. Nurs Res 1998; 47(1):43-50.
• Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image J Nurs Sch 1998; 30(4):315-321.
• Reed L, Blegen MA, Goode CJ. Adverse patient occurrences as a measure of nursing care quality. J Nurs Adm 1998; 28(5):62-69.
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