The ANA Principles for Safe Staffing Models and Implementing Plans. Staffing decisions should be made by nursing staff, especially direct care nurses, who are best equipped to meet patient needs.
What are ANA Principles for Safe Staffing Models and Implementing Plans
The American Nurses Association (ANA) advocates for safe staffing models that prioritize patient safety and optimal health outcomes. These models emphasize a balanced approach, including required nursing ratios, as well as flexible, evidence-based staffing tailored to different healthcare settings. The ANA also promotes a healthy work environment and the well-being of nursing staff. It recognizes that staffing decisions should include nursing staff and consider factors such as patient condition, nursing competencies, and the need for flexibility and teamwork.
American Association of Nurses Principles for Safe Staffing
The ANA document Principles for Nurse Staffing was initially developed in 1999 to “focus the health care industry on how complex nurse staffing decisions are and to identify major elements to consider when evaluating safety and appropriateness of nurse staffing” (ANA, 2012 p. 3). The ANA (2012) defines appropriate nurse staffing as “a match of registered nurse expertise with the needs of the recipient of nursing care services in the context of the practice setting and situation” (p. 6).
Evidence demonstrates that nursing care directly impacts the quality of services and that, when RN staffing is adequate, adverse events decrease and, overall, patient outcomes improve (ANA, 2012). The evidence linking adequate nurse staffing to improved patient outcomes has continued to grow. After systematically assessing the original principles for scientific relevance, applicability, and gaps, the ANA published the second edition of ANA’s Principles for Nurse Staffing in 2012.
The updated principles are focused on addressing the complexities of nurse staffing decisions and apply to all types of nurse staffing in all types of health-care settings. To take into account the various health-care settings and situations, the updated principles are organized into the following five categories (ANA, 2012, pp. 7–11):
- The characteristics and considerations of the health-care consumer: Staffing decisions are based on the number and needs of the individual, families, and populations served.
- The characteristics and considerations of RNs and other inter-professional team members and staff: The needs of the populations served determine the appropriate clinical competencies required of the RNs practicing in that clinical setting.
- The context of the entire organization in which the nursing services are delivered: Health-care organizations must create work environments that value RNs and other staff as strategic assets and budgeted positions are filled in a timely manner.
- The overall practice environment that influences delivery of care: Staffing is a structure and process that affects patient outcomes as well as nursing outcomes. Health care organizations must recognize that nurse staffing is integral to a culture of safety. 5. The evaluation of staffing plans: Health-care organizations must use flexible staffing plans that demonstrate logical methods for determining staffing levels and skill mix based on evaluation data.
Agency for Healthcare Research and Quality Nurse Staffing Model
The Agency for Healthcare Research and Quality (AHRQ) nurse staffing model evolved from meta-analysis conducted by investigators (Kane et al., 2007) under contract with the AHRQ. After reviewing 28 research studies related to the effects of nurse staffing on patient safety, the investigators found a positive correlation between adequate RN staffing levels and patient outcomes.
Based on the results, these investigators developed a conceptual framework to guide nurse staffing that considers the complexity of hospital care today and accounts for the following: patient, hospital, and organizational factors; nurse characteristics; nurse staffing; medical care; and the impact of these factors on patient outcomes and length of stay (Kane et al., 2007).
They also identified two key consequences of safe nurse staffing—patient outcomes and nurse outcomes—while recognizing that although patient outcomes are nurses’ ultimate concern, nurse outcomes can positively or negatively affect patient outcomes and therefore must also be considered.
The AHRQ model provides nurse leaders and managers a realistic frame work for staffing because it reflects the complex relationships among patient factors, nurse staffing, nurse characteristics, hospital and organizational factors, and patient outcomes.
National Database of Nursing Quality Indicators Staffing Benchmarks
In 1994, the ANA launched the Safety and Quality Initiative to explore the empirical link between nursing care and patient outcomes (Montalvo, 2007). The ANA’s findings highlighted strong links between nursing actions and patient outcomes. The focus of the initiative since the 1990s has been educating RNs about quality measurement, informing the public and policy makers about safe and quality health care, and investigating research methods and data sources to evaluate safety and quality patient care empirically (Montalvo, 2007).
In 1999, the ANA joined with the University of Kansas School of Nursing and the Midwestern Research Institute to form the National Database of Nursing Quality Indicators (NDNQI), and together they work to establish definitions, data collection, and benchmarking criteria. The mission of the NDNQI is to aid RNs “in patient safety and quality improvement efforts by providing research based national comparative data on nursing care and the relationship to patient outcomes” (Montalvo, 2007,para. 7).
In addition, the NDNQI facilitates the standardization of information on nursing quality and patient outcomes across the nation. Hospitals report unit-level data quarterly, and feedback reports are provided to hospitals quarterly. The ANA developed nursing-sensitive quality indicators to measure patient outcomes most affected by nursing care (Montalvo, 2007): “Nursing sensitive indicators reflect the structure, process, and outcomes of nursing care. Structure is indicated by the supply, skill level, and education of nursing staff.
Process measures aspects of nursing care such as assessment, interventions, and RN job satisfaction. Patient outcomes are those that improve if there is a greater quantity or quality of nursing care (e.g., pressure ulcers, falls, and IV in filtrations)” (NDNQI, 2010, p. 3). The NDNQI measures characteristics of the nursing workforce related to quality of patient care, including staffing levels and turnover as well as other nursing sensitive quality indicators.
Although all the current nursing-sensitive quality indicators reflect safe staffing in some way, several indicators such as skill mix and NHPPD, which are discussed earlier in this post, are directly correlated to staffing (NDNQI, 2010). The national database provides benchmark data for specific unit types that nurse leaders and managers can use to establish safe staffing plans.
In 2014, Press Ganey Associates, Inc. acquired the NDNQI from the ANA. The NDNQI data program measures nursing quality, improves nurse satisfaction, strengthens the nursing work environment, assesses staffing levels, and improves reimbursement under current pay-for-performance policies. Currently, the NDNQI collects and evaluates unit-specific nursing-sensitive data from hospitals in the United States and other countries and provides benchmarking data to measure RN job satisfaction, compare nursing measures, and improve nursing and patient outcomes (Press Ganey, 2014).
Developing and Implementing a Staffing Plan
Nurse leaders and managers must ensure that appropriate staff members are scheduled during each shift each day to provide safe and quality nursing care. A staffing plan describes the number and type of nursing staff needed from shift to shift and from day to day. When considering a staffing plan, nurse leaders and managers must consider regulatory requirements (federal and state legislation, as well as state boards of nursing). Accrediting agencies such as The Joint Commission also have guidelines for effective staffing that must be considered.
Additionally, nurse leaders and managers are bound by standards of practice such as those outlined in the ANA Nursing Administration: Scope and Standards of Practice (2015c). The ANA (2015a) supports legislation to empower nurses to establish safe staffing levels that are unit specific and to account for changes in patient needs, patient flow (admissions, discharges, and transfers during a shift), staff experience level, staff education, unit layout, and available resources.
As of 2015, seven states had some type of legislation related to staffing that resembled the ANA recommendations (ANA, 2015b). The Registered Nurse Safe Staffing Act of 2015 (H.R. 2083/S. 1132) was introduced in Congress by an RN to empower RNs to drive staffing decisions in hospitals to improve quality of care (ANA, 2015b). Other requirements of the Registered Nurse Safe Staffing Act include the following (ANA, 2015b):
- Hospitals that participate in Medicare reimbursement must establish a committee, composed of at least 55% direct-care nurses, to create nurse staffing plans that are specific to each unit.
- The practice of “floating” nurses would be limited to ensure that RNs are not forced to work on units if they lack the education and experience in that specialty.
- Hospitals would be held accountable for safe nurse staffing by being required to ensure that RNs are not forced to work without orientation in units where they are not trained or experienced; develop procedures for receiving and investigating complaints; consider RN educational preparation, professional certifications, and level of clinical experience; consider the number and capacity of available health-care personnel, geography of a unit, and available technology; and consider the intensity, complexity, and stability of patients. In addition, the act includes whistleblower protections and requires public reporting of staffing information Nursing leaders and managers can also look to Benner’s novice-to-expert model for a framework for developing and implementing staffing plans. Benner’s model takes into account the tasks, competencies, and outcomes RNs can be expected to acquire based on five stages of experience (Benner, 1984):
Stage I—Novice: A novice is a nurse with no experience of situations in which they are expected to perform. Typically, the novice performs tasks from a rule based perspective or a checklist approach. Nursing students are in the novice stage, as are nurses who change their clinical area of work to one in which they do not have previous experience (pp. 20–21).
Stage II—Advanced beginner: An advanced beginner can demonstrate marginally acceptable performance of tasks with enough experience to grasp some meaningful aspects of the situation at hand. Newly graduated nurses are considered advanced beginners and need support in the clinical setting (pp. 22–25).
Stage III—Competent: Competent nurses have 2 or 3 years of experience. The competent nurse can establish a plan of care and can determine which aspects of a situation are important and which aspects are not priorities (pp. 25–27).
Stage IV—Proficient: Proficient nurses have 3 or more years of experience. They perceive the situation as a whole rather than as aspects and use maxims, or subtle changes nurses recognize based on previous experience, as guides (pp. 27–31).
Stage V—Expert: Expert nurses operate from a deep understanding of the total situation and do not rely on analytical principles to understand the situation (pp. 31–36). They use intuitive and reflective thinking in their practice.
Nurses transition from one stage to the next as they gain more knowledge and experience, and their performance becomes fluid and flexible depending on the situation. Understanding what stage each member of the nursing staff is in can help nurse leaders and managers when developing effective staffing plans. Novice and advanced beginner nurses need more direction and coaching than competent and proficient nurses, whereas expert nurses are able to function independently and are great resources for the less experienced nurses.
Benner’s model has been used over the years as a framework for teaching, as clinical ladders in health-care organizations, and for developing staffing plans. The model warns against using nurses interchangeably; rather, nurse leaders and man agers should use staffing strategies that foster staffing stability and maximize expert clinical performance. Further, staffing should be such that expert nurses are avail able to advanced beginner nurses, competent nurses, and proficient nurses at all times for consultation to ensure safe and quality care.
Monitoring Productivity
Staffing plans can have a positive or negative effect on staff morale, turnover, and retention, as well as the quality of nursing care delivered. Nurse leaders and managers can find themselves constantly balancing the care requirements of the patients with the needs of nursing staff and the economic and productivity expectations of the organization (Roussel, 2013).
Productivity is related to the efficiency of a nursing staff in delivering nursing care and the effectiveness of the care delivered relative to its quality and appropriateness (Roussel, 2013). These factors can be very difficult to quantify because they depend on the educational level, competence, and critical thinking skills of the nursing staff. Productivity can be measured using the following formula:
Required staff hours / Provided staff hours × 100 = Productivity
Nurse leaders and managers have a major challenge today balancing safe and quality care with meeting organizational productivity requirements. They must monitor staff productivity and evaluate staffing effectiveness on a regular basis. Productivity can be improved by decreasing provided staff hours and maintaining or increasing required staff hours. Productivity is discussed further.
Evaluating Staffing Effectiveness
Ensuring positive patient outcomes requires nurse leaders and managers to evaluate staffing effectiveness daily, weekly, and monthly. When evaluating staffing effectiveness, nurse leaders and managers must consider many of the elements already discussed, including patient acuity trends, staffing overtime, staffing mix, patient satisfaction, and patient outcomes. Variance reports are used to evaluate staffing effectiveness by comparing planned staffing with budgeted staffing.
These reports assist in identifying trends in key areas. All nurses have a role in evaluating staffing effectiveness. Nurses are responsible for reporting to nurse leaders and managers any concerns they have related to safe staffing. In return, nurse leaders and managers have a responsibility to investigate staffing concerns identified by nursing staff and to act immediately on any issues that could negatively impact patient or nurse outcomes.
Conclusion
Organizing patient care to deliver safe and quality nursing care is a critical role for all nurse leaders and managers, whether organizing care for an individual patient in the hospital or at his or her home or whether organizing care for a group of patients in a community setting such as a skilled nursing facility. Nurse leaders and managers must anticipate patient volume, complexity of patient care needed, admissions, discharges, and transfers when establishing staffing plans to provide safe and quality nursing.
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