The Staffing for Patient Safety Challenges Core Concept and Patient Classification In Nursing. Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies, and environments in healthcare settings that consistently and sustainably reduce risks and the occurrence of preventable harm, minimize the likelihood of errors, and minimize their impact when they occur.
What is Staffing for Patient Safety Challenges Core Concept and Patient Classification In Nursing
Effective patient safety requires adequate nursing staffing and patient triage systems to ensure safe, high-quality care. Patient triage systems help determine each patient’s care needs, while adequate staffing ensures those needs are met. Insufficient staffing can create challenges, which can lead to missed care and adverse patient outcomes.
Staffing for Patient Safety
Appropriate staffing is critical to the delivery of quality care. “Appropriate staffing is 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” (ANA, 2012, p. 6). Nurse leaders and managers are responsible for making sure to have the appropriate number and mix of nursing staff at all times. Because staffing affects the ability of a nurse to deliver safe and effective care at every practice level and in all settings, staffing is a complex process (ANA, 2012).
Nurse leaders and managers must understand and follow federal, state, and local regulations related to staffing and scheduling; uphold nurse practice acts; verify and track licensure of nursing staff; respect nurses’ rights; ensure staff competencies; and substantiate staff compliance with regulatory and professional standards (ANA, 2015c). Safe staffing results in fewer hospital-acquired infections, reduces nurse fatigue, decreases nurse turnover, reduces hospital costs, improves patient satisfaction, and increases nurse productivity (ANA, 2015a).
Research in the United States specifically indicates that when units are staffed with more RNs, patients experience fewer complications, fewer urinary tract infections and cases of pneumonia, shorter lengths of stay, and decreased mortality rates (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; ANA 2015a, 2015b; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Knudson, 2013; Needleman et al., 2011; Unruh, 2008).
On an international scale, a Registered Nurse Forecasting (RN4CAST) study reflected similar findings: “Improved patient-to-nurse staffing ratios, sound nursing work environments, and a better educated nurse workforce are associated with improved nurse wellbeing and better patient outcomes, including higher patient satisfaction and lower patient mortality rates” (European Commission, 2016, para. 1).
Inadequate nurse staffing is often cited as a contributing factor when unanticipated events happen that result in patient injury, disability, or death. In addition, inadequate nurse staffing can cause nurses to experience job dissatisfaction, burnout, high “intent to quit” levels, and injury or illness (Unruh, 2008). Safe staffing fosters a positive environment for nursing practice by allowing nurses to apply the knowledge they have gained through education and practice experiences efficiently and effectively when caring for patients.
Staffing must be effective to achieve positive outcomes for patients and the health-care organization. Ensuring safe staffing is not an easy task for nurse leaders and managers, but it can be achieved by dynamic, multifaceted decision-making processes that consider a wide range of variables (ANA, 2012). The greatest challenge faced by nurse leaders and managers in maintaining safe staffing is the nursing shortage.
Challenges for Nurse Staffing
Shortage of Nurses
The nursing shortage is widespread globally (Knudson, 2013), and it affects all areas of nursing. This shortage is occurring at the same time the U.S. Department of Labor is suggesting that the need for nurses in outpatient settings, ambulatory care centers, outpatient surgery centers, and urgent care centers is rapidly increasing. The key to an ample supply of nurses in the future is the nation’s ability to produce new nurses.
The number of nurses passing the NCLEX-RN licensure examination increased from 68,561 in 2001 to 142,390 in 2011; although this represents substantial growth in the nursing workforce, this growth is concentrated at the younger and older ends of the age spectrum, with the fewest RNs between the ages of 36 and 45 years old (Health Resources and Services Administration [HRSA], 2013).
As of 2013, approximately one-third of the nursing workforce was older than 50 years, and the average age of an RN was 46.6 years old. Close to 1 million RNs will be retiring in the next 10 to 15 years, and this change will dramatically impact the number of nurses, as well as lead to a loss of experience, knowledge, and leadership of seasoned RNs (HRSA, 2013). It is anticipated that the nursing shortage will reach 1.2 million by 2020. Besides the high number of RNs expected to retire in the near future, there are several additional contributing factors (AACN, 2014, pp. 2–4):
- Nursing school enrollment is not growing fast enough to meet the projected demand for RN and advanced practice RN services. Although there has been an increase in enrollments in entry-level baccalaureate programs over the past few years, it will not provide enough RNs to meet the need. The passage of the Affordable Care Act has increased the need for RNs and advanced practice RNs as more than 32 million Americans have gained access to health-care services
- A shortage of nursing school faculty is restricting nursing program enrollments. Nursing schools have been forced to turn away qualified applicants because of insufficient numbers of faculty, clinical sites, classroom spaces, and clinical preceptors, as well as budget constraints, with faculty shortages noted as the major reason for not accepting qualified applicants into programs.
- Changing demographic factors signal a need for more nurses to care for our aging population. The demand for more nurses will increase as more baby boomers reach 60 years old and older. However, the current numbers indicate that as the older population increases, the number of nurses available to care for them will decrease.
- Insufficient staffing is raising the stress level of nurses, impacting job satisfaction, and driving many nurses to leave the profession. Research supports the notion that the nursing shortage increases personal stress, lowers patient care quality, and causes nurses to leave the profession.
- High nurse turnover and vacancy rates are affecting access to health care. Newly licensed RNs have a high rate of job change after only 1 year, and the overall RN turnover rates and vacancy rates remain close to 15%. The impact of the nursing shortage is surely felt by nurse leaders and managers as they attempt to staff their patient care areas safely.
To provide safe and quality care effectively, there are many factors that must be considered by nurse leaders and managers when establishing safe staffing plans.
Core Concepts of Staffing
Historically, staffing decisions were dictated by the number of patients on the unit and fixed nurse-to-patient ratios; this method did not consider the needs of the patients or the nurses’ levels of education, expertise, and work satisfaction. Staffing and work load are part of a complex process that can negatively impact patient and nurse out comes (Unruh, 2008).
For example, when nurses believe that they cannot deliver quality care, they become dissatisfied with the work, and this can negatively impact patient satisfaction and outcomes and becomes “a vicious cycle: inadequate staffing leads to reduced job performance and diminished patient and nurse satisfaction; the resulting burnout and high turnover rates worsen staffing levels” (Unruh, 2008, p. 64).
To ensure positive patient and nurse outcomes, nurse leaders and managers must consider critical factors, such as number of patients, intensity of care, contextual issues, and level of expertise when determining staffing needs. Although cost effectiveness is an important factor in the delivery of safe and quality care, the re imbursement structure should not influence the staffing plan. Rather, nurse leaders and managers must consider the staffing needs and staffing plan for the unit when developing the fiscal budget.
It is critical that health-care organizations consider the financial impact of patient outcomes when evaluating the cost of nurse staffing. To deal with staffing most effectively, understanding core concepts related to staffing is critical for nurse leaders and managers. Important concepts include full time equivalent, productive time, average daily census, staffing mix, workload, units of service, nursing hours per patient day (NHPPD), unit intensity, patient acuity, and skill mix.
Full-Time Equivalent
Full-time equivalent (FTE) is a unit that measures the work of one full-time employee for 1 year (or 52 weeks) based on a 40-hour work week, equating a total of 2,080 paid hours per year. An FTE may comprise one person working full-time or several people sharing the full-time hours. For example, two nurses working 20 hours/week equate to one FTE.
Productive Time
Productive time refers to the actual hours worked on the unit caring for patients. In contrast, nonproductive time refers to benefit time, such as vacation hours, holiday time, sick hours, education time, and jury duty. When determining staffing needs, the manager accounts for nurses who are using benefit time and who in turn need to be replaced by additional staff. To determine available productive time for each FTE, the manager must subtract nonproductive time from the total hours a full-time employee works.
Average Daily Census
Average daily census (ADC) is the average total number of patients when census is taken (at midnight) over a given period of time, such as weekly, monthly, or yearly. ADC helps nurse leaders and managers project staffing needs of the unit.
Staffing Mix
Staffing mix refers to the appropriate numbers of RNs, LPNs/LVNs, and UAPs needed on a unit, and it is based on the type of care required for specific patients and who is qualified to provide such care. Determining the staffing mix requires nurse leaders and managers to assess staff competency and make sure that all staff members have the necessary skills to carry out assigned and delegated tasks. A higher-RN staff mix provides more staffing flexibility.
Workload and Units of Service
Workload is the number of nursing staff members required to deliver care for a specific time period and is dependent on patient care needs. Units of service (UOS) reflect the basic measure of nursing workload based on different types of patient encounters. Staffing needs vary by clinical setting. UOS assist nurse leaders and managers in determining unit-specific needs for staffing. One example of workload is nursing hours per patient day (NHPPD), which rep resents the nursing care hours provided to patients by nursing personnel over a 24-hour period. NHPPD is usually.
Unit Intensity
Unit intensity takes into account the totality of the patients for whom care is provided and the responsibilities of nursing staff. Unit intensity is very valuable in deter mining staffing because it takes into consideration admissions, transfers, and discharges (ANA, 2012). However, unit intensity can be difficult to measure in view of the many factors that influence it, such as severity of illness, patient dependency for activities of daily living, complexity of care, and amount of time needed to deliver care (Beglinger, 2006).
Patient Acuity
Patient acuity represents how patients are categorized according to an assessment of their nursing care needs (Harper & McCully, 2007). It is a critical factor in deter mining safe staffing. Patient classification systems are tools used to determine staffing based on patient acuity. Typically, patients with more acute conditions or sicker patients receive higher classification scores to indicate that they need more direct nursing care.
Skill Mix
Skill mix refers to the varying levels of education, licensure, certifications, and experience of the staff. Skill mix can include a team made up of various numbers of RNs, LPNs, and UAPs. Determining the skill mix occurs on every shift and depends on many factors, such as the model of care delivery, patient population, patient acuity, competency requirements to care for a specific patient, levels of experience and education of staff, and licensure of staff. Nurse leaders and man agers must know their staff well and understand the scope of practice for each type of staff. Appropriate staffing and skill mix can have a positive impact on patient care (Dabney and Kalisch, 2015).
RN Scope of Practice
The RN scope of practice is fairly consistent nationally and globally and includes all aspects of the nursing process. RNs are licensed personnel who have completed a specific course of study at a state-approved school of nursing and passed the NCLEX-RN examination (National Council of State Boards of Nursing [NCSBN], 2016).
The responsibilities of RNs include assessment, diagnosis, planning, intervention, and evaluation. Patient teaching, discharge planning, evaluating and monitoring changes in patient status, and complex patient care that requires special knowledge and judgment are also within the scope of practice of the RN.
In addition, RNs are responsible for assigning, supervising, and delegating appropriately to other team members to ensure that safe and quality care is delivered. Teaching the theory and practice of nursing and participating in the development of health care policies, procedures, and systems are also components of the RN’s scope of practice (NCSBN, 2012).
LPN/LVN Scope of Practice
The LPN/LVN scope of practice includes physical care, taking vital signs, and ad ministering medication, and it can vary significantly from state to state. LPN/LVNs are licensed personnel who have completed a specific course of study of a state approved practical or vocational nursing program and passed the NCLEX-PN examination (NCSBN, 2016).
Regardless of their scope of practice, LPN/LVNs always work under the direction or supervision of an RN, advanced practice RN, physician, or other health-care provider designated by the state (NCSBN, 2012). Nurse leaders and managers must be cognizant of their state’s nurse practice act to ensure that LPN/LVNs are being assigned within their scope of practice.
UAP Scope of Practice
The UAP scope of practice typically includes activities of daily living, hygiene, and physical care. However, the scope of practice for UAPs also varies from state to state. UAPs are unlicensed personnel specifically trained to function in an assistive role to RNs and may or may not be regulated by a state board of nursing. UPAs perform tasks as delegated by an RN (NCSBN, 2016).
Staffing Approaches
Research on safe staffing has revealed that it is effective in reducing adverse events, improves quality of care received, and improves nurse satisfaction, which in turn reduces costly nurse turnover. Determining adequate staffing levels requires nurse leaders and managers to recognize unique patient care settings, patient flow (admissions, discharges, and transfers), patient acuity, and the skills, education, and experience of the available nursing staff. However, there is not a perfect method for determining staffing.
The AONE (2010) calls for nurse leaders and managers to develop core staffing models that support patient-centered care and allow staff members to function at the peak of their licensure. Nurse leaders and managers can use a variety of approaches to safe staffing, such as patient classification systems, ANA’s Principles for Nurse Staffing, the Agency for Healthcare and Research Quality nurse staffing model, and National Database of Nursing Quality Indicators staffing benchmarks.
Patient Classification Systems
A patient classification system (PCS) predicts patient needs and requirements for nursing care. A PCS groups patients according to acuity of illness and complexity of nursing activities necessary to care for the patients. Typically, patient acuity data are collected every shift by nursing staff and are analyzed to project nursing staff needs for the next shift. The advantage of using a PCS is that it is an objective approach to determining staffing based on patient care needs: a sicker patient requires more nursing care and therefore would have a higher acuity level.
How ever, there are numerous issues regarding use of PCSs, including lack of standardization, lack of credibility among nurse leaders and managers, and no consideration of patient flow (Hertel, 2012). Nurse leaders in informatics are investigating the use of information technology with PCSs to assist in effective nurse staffing (Harper, 2012). Information technology can potentially decrease costs, improve staffing efficiency, and improve quality of care and patient safety.
Information technology incorporated with a meaningful model for nurse staffing, such as the Clinical Demand Index, “can make staffing based on evidence a reality” (Harper, 2012, p. 267). Although there are commercial PCSs for purchase, many health-care organizations design their own. Regardless of the type of PCS used, it must be reliable and valid.
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