Nurse Staffing Guidelines must exist in order to ensure optimal patient safety in every setting nursing exists. Nursing administration must look at best practice strategies in order to set an appropriate budget to establish an optimal workforce.
Click on the above picture to be re-directed to the Safe Staffing is an Emergency Campaign in New York State. With up to 12 plus patients at a time, New York Nurses and their patients are at risk. Research has proven the risk for patient mortality increases by 7% each time a nurse resumes care of another patient. This is why guidelines must be established to ensure optimal volume is correct with a plan on to flex when volume increases. The plan simply can't be to just take more patients.
I want to just reflect back on my 20 plus years, mainly as a clinical bedside nurse, charge nurse often with a full assignment, and supervisor with patient assignments, and reflect some of my thoughts on how to ensure the best patient assignments for the nurses on duty.
To begin, I do look at numbers and I understand that a very stable patient can go bad quickly. I have experienced this many times in my personal career. Not fun when your stable patients suddenly goes into flash pulmonary edema when your other 4 or 5 patients need you. In order to have a good staffing plan and ability to respond to patient surges, we must also look at patient acuity.
Patient acuity is more than the number of IV medications, ventilators, and critical drips. Patient acuity is the entire picture and time it takes for the registered nurse to perform good care for a patient. Acuity means answering questions from the patient or family, trying to contact physicians, filling out discharge paperwork, securing patient belongings, going into the room fifty times a night to keep a confused patient in bed.
In addition to acuity, systems must be in place to make things as safe, simple, and efficient as possible. Systems on how to know who is on call and how to reach that provider can help ensure quick answers or responses to patient conditions can make a huge difference. Having supplies in the right places where they can be easily found reduces time away from the patient.
Before we examine nurse staffing guidelines, these variables must be considered as those pose different advantages, risks, and threats to each organization.
We as nurses know that the best systems can be place and yet nurses still feel they can't give the best care. Even when the five patients they care for are routine, it can still be very overwhelming for the nurse.
Guideline #1 - Think of each patient as how much time they will need from the nurse in a given shift. SO if a patient needs 3 hours of care in an 8 hour shift, then the nurse can't possibly care for 5 patients who require 3 hours of care as the math simply does not add up. Pretty simple! Use this little trick in your business case for safe staffing when looking for more nursing positions in your area.
SO how do you determine how many hours of care a patient requires? Of course fancy firms out there can figure it out for you, although they have no clue of what acuity is or what it even means to be a nurse caring for people. Many electronic medical record companies are implementing acuity tools to help determine this.
As a supervisor I relied on an accurate and honest view of how each patient was doing in order to respond and make the assignments possible. I would review patients to see how often staff are in the room or certainly observe this because we all know it is impossible to chart everything!
Some days it made sense giving one nurse 3 patients while another 4 to five based on different acuity factors. With that said, if the reason for 3 patient assignment was due to 1 particular patient, re-evaluating the setting for this patient is very important. We must make sure patient's are in the best setting based on their clinical picture. Advocate for an ICU bed when the nurse is providing a majority of their time with a particular patient. Acuity and patient placement boils down to nursing care.
Guideline #2 - Level of care is based on Nursing care and nursing care only. Think about this. The physician can see the patient anywhere in the hospital as can every other discipline. Now think of nursing care in order to get the patient better. If the nurse simply can't give the patient the care they want due to competing priorities, that patient requires a higher level of care. The same goes for the stable patient in a setting where high patient care is present that does not need it. I feel these variables do not get the attention they deserve when we look at safe staffing in general.
This goes for all settings of the hospital. Emergency room nurses can only provide so much care. As the patient stabilizes, they must leave to a setting where the nurse can continue that same care. This leads to the next guideline.
Guideline #3 - Organizations need good thru-put initiatives and systems in place to help ensure patients are in the right setting at the right time. Easier said than done, however after working on a patient-centered thru-put initiative and presenting this at the ANA staffing conference 2014, I have grown to first hand see how this can impact safe staffing. The emergency room nurse who is taking on more patients while the medical patients hang out in the department must be able to move those patients out of the department to focus on the sicker patients as they arrive. The nurses on the floor must be able to accept another patient and so on. This is a domino affect that be fully looked at. Many organizations have admission nurses or circulating nurses to help patient flow while reducing the demand on the nurses with patient assignments.
Guideline #4 - Advocate fro resources!
Research and work by Dr. Jack Needleman et. al, identifies the business case for nurse staffing in terms of best patient outcomes. View their work here!The costs of increasing the nursing force is far less than the costs acquired thru negative patient outcomes. A strong business case can advocate for increased nursing numbers. Arm yourself with power and data at your organization to determine how many patient deaths, falls, pressure ulcers, medication errors, and nosocomial infections happen and then place a price tag on it. Believe me it can add up to millions! Now add the cost of another 10 new registered nurses at $65,000 a year. You do the math, the increase in nurses wins every time. Plus the organization can have better outcomes and be viewed more positive in the public eye.
If you owned a store and lost customers because you only had one person on the register, don't you think you would hire more people to run more registers? Makes sense. Except we are talking about human life and that is so much more important than people walking out of a store because of lines. We see people walk out of emergency rooms because of time to be seen. Sad!
As Nurse Manager and prior supervisor, the one thing you should never do is make staffing the nurses problem. What do I mean? Mandating overtime or forced staying. This only leads to keeping an already fatigued nurse at the bedside where their attention is critical caring for a sick person. Now that doesn't make much sense!
Bugging a nurse 15 times during their shift to stay because the next shift is short is not fair. That nurse also has a life outside of work. If you find yourself in these situations you need to project ahead and work on each shift to try an avoid this as much as possible. While doing so advocate for more positions or deal wit the actual problems. Is a certain nurse calling off frequently causing holes that put the other nurses in bad situations.
Have a proactive back-up plan that works!
Ensure your budget includes 25% more staffing to avoid staffing to the ceiling. When you need to flex due to higher volumes, vacation time, or sick-call and your staffed to the ceiling, well there is nowhere else to go. SO what do you do? Increase the rate of mortality another 7% by placing the patient on the unit, keep them in the emergency room where the same risk resides, or send them to another hospital trying to avoid EMTALA laws.
I worked where all the nurses took turns on a call-schedule where we were paid a fraction of our pay to be able to come into work due to call-ins or patient surges. It worked fairly well. It was a solution to when things happened, but was not the norm. Why? Because this organization overstaffed to begin with, which really meant we were perfectly staffed for the most part.
Staff must be able to take their vacations to refresh the batteries. Denying because staffing is always short will lead to, yup you guessed it more turn-over.
I do not want to make this a retention post at that is a whole different story. Of course hospitals that staff better have better retention!
When organizations begin to follow the above guidelines the cycle may slow down. It may not stop, but slowing down is a good thing. What do I mean?
Hiring a nurse because a nurse resigns, to have another nurse leave because of the stress the vacancy creates. The new nurse is trained, just to make it how it was before the hire. This process repeats and repeats and repeats. Instead, hire 2 nurses when the one nurse leaves and start over hiring to account for patient acuity. Nurses are smart and we see how this can be fixed. Unfortunately nursing must receive the credit it deserves from the business model in order to excel.
Do the research and make a plan to visit your CNO and CFO today to advocate for resources.