Nurse fatigue (sometimes called burnout) can be described by a number of symptoms, including irritability, insomnia, headaches, back pain, weight gain, depression, and high blood pressure. nurses 8600 Rockville Pike However, had we identified material that demonstrated a significant methodological advance or other insight we were open to including it for illustrative purposes. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. The establishment, once set, implies that care needs are then met by a fixed nurse-to-patient ratio or number of hours per day, although these ratios may differ between wards. diagnosis-related groups (Fasoli and Haddock, 2010), or bespoke categorisations, e.g. Indeed, a prototype classification system, such as the Safer Nursing Care Tool, resembles a volume-based mandatory minimum staffing policy supplemented by assessment of variation above the base requirement, such as that implemented in California, because there is an implied absolute minimum staffing level per patient, associated with the prototype with the lowest staffing requirement. While professional judgement remains the nearest to a gold standard, the desire to use a tool or other formal system to support and indeed justify such a judgement has remained a constant theme that can be traced back to Telford's work in the 1970s in the UK, and no doubt beyond. Subsequent reviews have had to embrace an ever-growing body of research and an increasing number of systems. Although the reports were focussed on demonstrating the precision of the mean time estimates they derived, the degree of variation associated with a particular task is well illustrated. Larson E.L., Cohen B., Liu J., Zachariah P., Yao D., Shang J. Assessing intensity of nursing care needs using electronically available data. Whereas volume-based approaches measure variation in workload determined by patient counts, other approaches recognise that patients in a given type of ward may have different care requirements. Finally, tools can be used retrospectively to review the success of staffing plans (how well the plan met needs) or as a measure of resource use for pricing, budgeting or billing purposes (Kolakowski, 2016). There is evidence that some systems are reliable, that workload measured by a system correlates with other (largely subjective) measures, that low staffing relative to a measured requirement is associated with worse patient outcomes and that increased staffing levels associated with use of a system is associated with improved patient outcomes. Flexible nurse staffing based on hourly bed census predictions. According to a study in the Journal of Hurst also identified regression-based approaches, which model the relationship between patient-, ward- and hospital-related variables, and the establishment in adequately-staffed wards (Hurst, 2002). WebCalifornia HealthCare Foundation, 20091 Overly simplistic. FOIA Although characterised by Hurst (2002) as a distinct method, like professional judgement, benchmarking does not involve any formal assessment of patient requirements for nursing care. Medicare.gov The results of several workload measurement systems correlate with the professional judgement of practicing nurses, but the correspondence is not perfect and the significance of any discrepancies in estimated staffing requirements is unclear. Determination of appropriate nurse staffing levels and measurement of workload have been studied since the earliest days of research into nursing (e.g. Jenkins-Clarke, 1992; O'Brien-Pallas etal., 1991, 1992, 1989). While it seems important to recognise that (for example) less experienced staff may be less able to meet a given level of demand and thus require some additional support, setting a lower staffing level based on the relative efficiency of a team may appear to be punishing success. Review of the literature. However, as we primarily aim to map the literature, identifying recent developments, key features and areas of relative strength and weakness, without necessarily giving each study an in-depth critical appraisal, we consider this a scoping review, serving to summarise findings and identify gaps in the knowledge (Arksey and O'Malley, 2005). The Oulu Patient Classification, part of the RAFAELA system, is one such example. van Oostveen C.J., Ubbink D.T., Mens M.A., Pompe E.A., Vermeulen H. Pre-implementation studies of a workforce planning tool for nurse staffing and human resource management in university hospitals. The https:// ensures that you are connecting to the Audit Commission; London: 2001. Two Democrats voted against the bill, while 19 Republicans voted in favor of House Bill 106, which now goes to the state Senate for consideration. The much-anticipated bill to address hospital staffing shortages and create nurse The literature describes the use of both empirical observations and expert opinion to determine the average time associated with tasks or patient classifications (De Cordova etal., 2010; Myny etal., 2014; Myny etal., 2010). Thus, approaches which seek to determine staffing requirements accounting for individual patient variation in need or other factors driving workload can be used as alternatives to, or in conjunction with, minimum staffing levels based purely on patient volumes. Nonetheless recent years have seen the appearance of some evidence linking a mismatch between staff deployed and a calculated staffing requirement to adverse outcomes. Sources of variation in demand for and supply of nursing care. Junttila J.K., Koivu A., Fagerstrom L., Haatainen K., Nykanen P. Hospital mortality and optimality of nursing workload: a study on the predictive validity of the RAFAELA Nursing Intensity and Staffing system. GUID:7BDA7B10-BF5B-443D-AC30-C22FCEC94572. For example, wards contributing to the database from which the multipliers for the Safer Nursing Care Tool are derived must meet a predefined standard for care quality (Smith etal., 2009). Griffiths P., Ball J., Bloor K., Bhning D., Briggs J., Dall'Ora C., Iongh A.D., Jones J., Kovacs C., Maruotti A., Meredith P., Prytherch D., Saucedo A.R., Redfern O., Schmidt P., Sinden N., Smith G. Nurse staffing levels, missed vital signs observations and mortality in hospital wards: retrospective longitudinal observational study using routinely collected data. Conversely, this method can be used to infer the daily staffing plan from the whole time equivalent staff employed by a ward, as illustrated by Hurst (2002). Rather it occurs in clusters, with clear seasonal patterns and variation by day of the week (Barham and Begum, 2005). Mandated nurse staffing ratios are a static and ineffective tool that do not ensure quality care, optimal patient experience, and staff well-being. Hurst K. Nuffield Institute for Health; 2002. Knowledge of this variability would help determine whether a fixed staffing plan is liable to meet patient need on a regular basis. These two studies again demonstrate the myriad of sources of variation in demand, and the challenge of matching supply of nursing care to that demand, particularly with an establishment based on the average demand, while providing little insight into how demand for nursing care should be measured in the first place. We draw selectively on older authoritative sources and reviews to give a general overview and background to the evidence (including the reviews already cited), using the results of our comprehensive searches and review of reviews undertaken for the National Institute for Health and Care Excellence, NICE (Griffiths etal., 2014) as a key source. Nurse staffing under demand uncertainty to reduce costs and enhance patient safety. Brennan etal., 2012; Hurst etal., 2008; Larson etal., 2017; Morales-Asencio etal., 2015; Smith etal., 2009). Patient-to-nurse staffing ratios are a static and ineffective tool that cannot guarantee a safe heath care environment, writes Mary Ann Fuchs, president of AHAs American Organization for Nursing Leadership affiliate, responding to a recent op-ed in the New York Times. Taylor B., Yankey N., Robinson C., Annis A., Haddock K.S., Alt-White A., Krein S.L., Sales A. By Elizabeth Hayes. We also included descriptive papers that might not merit the label study, provided that they included some data. The centrality of professional judgement as a criterion is demonstrated by the RAFAELA system, in which the Oulu Patient Classification (OPC) weighting that is associated with nurses judgements that staffing is optimal is used to set target staffing (Fagerstrm etal., 2014). The apparently simple assumption, that staffing to meet average need is the optimal response to varying demand, is also untested empirically, although research reviewed here suggests this assumption is likely to be incorrect. Yet, no evidence-based best practices, standards, or research exists to This research was funded by the National Institute for Health Researchs Health Services & Delivery Research programme (grant number 14/194/21). Nurses can make reliable assessments using a number of systems (Brennan etal., 2012; Liljamo etal., 2017; Perroca, 2013), although achieving inter-rater agreement is not always straightforward and the reliability of ratings in a new setting should not be assumed, even for tools where reliability has been established previously (van Oostveen etal., 2016). Taylor and colleagues describe the substantial challenges faced in implementing a professional judgement-based system for the US Veteran's Administration (Taylor etal., 2015). Furthermore, the OPC workload measure was not clearly superior to a simple patient per nurse measure based on analysis of decision curves (Fagerstrom etal., 2018). Beswick S., Hill P.D., Anderson M.A. Each staffing method makes an underlying assumption about what constitutes adequate, safe or quality staffing, although these are often implicit. These sources compared workload as assessed by different approaches. HARRISBURG Members of the state House of Representatives approved a bill that would mandate minimum nurse-to-patient ratios in Pennsylvania hospitals, Aug 20, 2021 - 11:01 AM. The bill passed 119-84 over strong objections from hospitals and many Republicans. A top concern for the union is lower guaranteed nurse-to-patient staffing ratios. Maenhout B., Vanhoucke M. An integrated nurse staffing and scheduling analysis for longer-term nursing staff allocation problems. Seventy-two percent of the 900-person nursing staff voted to form a union last fall. An examination of the comparability of workload measurement systems. Nurse Staffing Methodology, A Review and Critique of Selected Literature. Operational research studies seeking to optimise staffing in the face of varying supply/demand including simulations/mathematical models of different approaches to staff deployment. Aiken L.H., Sloane D., Griffiths P., Rafferty A.M., Bruyneel L., McHugh M., Maier C.B., Moreno-Casbas T., Ball J.E., Ausserhofer D., Sermeus W., Consortium R.C. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Griffiths P., Maruotti A., Recio Saucedo A., Redfern O.C., Ball J.E., Briggs J., Dall'Ora C., Schmidt P.E., Smith G.B., Missed Care Study Group Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. de Cordova P.B., Lucero R.J., Hyun S., Quinlan P., Price K., Stone P.W. The Safer Nursing Care Study Group comprises: Jane Ball (University of Southampton), Rosemary Chable (University Hospital Southampton National Health Service Foundation Trust), Andrew Dimech (Royal Marsden National Health Service Foundation Trust), Peter Griffiths (University of Southampton), Yvonne Jeffrey (Poole Hospital National Health Service Foundation Trust), Jeremy Jones (University of Southampton), Thomas Monks (University of Southampton), Natalie Pattison (University of Hertfordshire/East & North Herts NHS Trust), Alexandra Recio Saucedo (University of Southampton), Christina Saville (University of Southampton) and Nicky Sinden (Portsmouth Hospitals National Health Service Trust). Careers, Unable to load your collection due to an error. In task (or timed-task) approaches, a detailed care plan, consisting of specific tasks, is constructed for each new patient and used to determine the required staffing (Hurst, 2002). Using the nursing interventions classification as a potential measure of nurse workload. Major approaches for determining nurse staffing requirements. Nurse Staffing Standards for Patient Safety and Quality Care Act of 2021. While some systems such as RAFAELA are explicit about an acceptable degree of variation from the mean (Fagerstrm etal., 2014), this is rare, and the impact on safety of small deviations has not been widely researched. Given the significant body of evidence that emphasises the specific association between registered nurse staffing levels or skill mix and outcomes (e.g. nurse staffing Modelling the size and skill-mix of hospital nursing teams. D.C. Div. Few systems formally consider non-patient factors that may influence workload. The estimated standard time for partial help with hygienic care in bed had a 95% confidence interval from 7.6 to 21.2min. One early review of nurse staffing methodologies, published in 1973, included a bibliography of over 1000 studies (Aydelotte, 1973). Overall nursing workload is likely linked to patient An acuity- and dependency-based indicator system identified an additional six hours of care per day compared to a standard (fixed) hours per patient day method (Rivera, 2017). This lack of direct quantification is an important limitation given that tools are used to guide fixed staffing plans. Approaches that appear to set minimum staffing levels per patient, an example of a volume-based approach, are sometimes explicit in stating that additional staffing may be required to meet peaks in demand. Jenkins-Clarke S. Centre for Health Economics, University of York; 1992. After implementing a Nursing Hours per Patient Day methodology in three hospitals in Australia, there were increases in staffing levels and improvements in several patient outcomes over time, including mortality (Twigg etal., 2011). In one study, the five systems tested provided estimates that correlated highly. Fagerstrom L., Kinnunen M., Saarela J. Brennan etal., 2013; Griffiths etal., 2016, 2018b; Kane etal., 2007; Shekelle, 2013). WebNurse Staffing Measures. Nurses at the hospital say they are assigned too many patients at a time, Nurses Prototype or Patient Classification Systems group patients according to their nursing care needs and assign a required staffing level for each (Fasoli and Haddock, 2010; Hurst, 2002). Ball J., Barker H., Griffiths P., Jones J., Lawless J., Burton C.R., Couch R., Rycroft-Malone J. Nurse to patient ratios/standards. The .gov means its official. Other than the project funding, the authors declare no competing interests that might be perceived as influencing the results of this paper. So although professional judgement remains central and no system has been shown to be superior, it too may be systematically biased. However, nursing workload below the optimal level (higher staffing) was associated with improvements in outcomes (Fagerstrom etal., 2018; Junttila etal., 2016), challenging the notion of this staffing level as optimal. Variation is often systematic and just as demand is variable, so is the supply of staff to meet that demand (see Table 3). Report of the Mid Staffordshire NHS Foundation Inquiry. While this question arises in relation to the RAFAELA tool, because it explicitly identifies an optimum staffing level, the issue applies to all systems. In these more tailored approaches, the method for determining the required times for patient groups or tasks varies. Jun 23, 2023. Hurst K. UK ward design: patient dependency, nursing workload, staffing and quality: an observational study. These studies give some further indication of the validity of some tools as workload measures, but do not, in general, support conclusions that the tools give optimal staffing levels, in the sense of identifying a level at which adverse outcomes are minimised or there are diminishing returns from further increase. A tool to calculate safe nurse staffing levels. 1) although the distinction between these approaches is less absolute than it may appear and terminology varies. There has been a repeated pattern whereby new tools are developed with little programmatic research addressed at existing tools, even when they are widely used. The new version of a patient classification instrument: assessment of psychometric properties. As with prototype approaches, indicator approaches ultimately assign patients to categories, in this case based upon ratings across a number of factors that are related to the time required to deliver patient care. We may have missed some recent studies or older studies about some of the tools featuring in the more recent research. Aiken etal., 2017) it is perhaps surprising that the mix of staff is rarely addressed directly in this literature. To truly commit to patient safety Nursing and Patient Safety | PSNet Davis A., Mehrotra S., Holl J., Daskin M.S. A number of different decisions can be made using staffing systems and tools, with decisions operating in different time frames (Table 1). Bruyneel L., Li B., Ausserhofer D., Lesaffre E., Dumitrescu I., Smith H.L., Sloane D.M., Aiken L.H., Sermeus W. Organization of hospital nursing, provision of nursing care, and patient experiences with care in Europe. nurse staffing Pa. House passes bill mandating nurse staffing ratios in hospitals Nursing workload, patient safety incidents and mortality: an observational study from Finland. Left (negatively) skewed ward occupancy distributions have been reported (Davis etal., 2014). While cause and effect cannot be directly inferred from observational studies, the case for a conclusion that low nurse staffing causes harm to patients is increasingly compelling. Telford's professional judgement method (Telford, 1979), first formally described in the UK in the 1970s, provides a way of converting the shift-level staffing plan, decided using expert opinion, into the number of staff to employ. Nursing services do not operate in isolation and the demand for nursing care and the required level of staff may also change as inputs from other staff groups vary. unstable), states (e.g. Mixed methods evaluation of the impact of 100% single-room accommodation on staff and patient experience, safety and costs. Benefits associated with tools appear to be based on increased staffing levels. For many years this approach was used by the audit commission in the UK (Audit Commission, 2001) to compare nursing establishments and expenditure between units across hospitals. By Elizabeth Hayes. Nurse Staffing The appropriate response to variation in the productivity of staff, related to factors such as experience or efficient deployment of a team, also makes any definition of an optimal staffing level a challenge. Some states already have minimum staffing standards in place, including Illinois, which has tied a portion of a $700 million boost to nursing home funding to improve staffing standards. Gabbay and Bukchin, 2009; Smith etal., 2009), arising from the number of patients, the numbers of admissions and discharges, individual patient characteristics and their specific needs (e.g. Staff costs and patient outcomes using different systems have rarely been compared. While some systems account for these factors to some extent, they rarely consider that the averages they use to determine staffing requirements, associated with a given factor, are also subject to variation. Brennan C.W., Daly B.J., Jones K.R. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews. More recently, a UK study found that registered nurse staffing below the level planned using the Safer Nursing Care Tool was associated with a 9% increase in the hazard of death in one English hospital trust, although low assistant staffing according to this criterion was not associated with mortality increases (Griffiths etal., 2018a). However, our approach of building on existing reviews and our extensive searches means that it is unlikely that we have missed substantial volumes of research that would lead to an overall different conclusion. Existing reviews present no such evidence (Arthur and James, 1994; Aydelotte, 1973; DHSS Operational Research Service, 1982; Fasoli and Haddock, 2010; Griffiths etal., 2016; Hurst, 2002; Twigg and Duffield, 2009). For example, the Safer Nursing Care Tool was designed to support decisions about the total nursing establishment required on a ward based on meeting the daily needs of a sample of patients (The Shelford Group, 2014). The commercial GRASP system, still widely used in the United States, is an example of such a system (Edwardson and Giovannetti, 1994). This evidence does not clearly point to any particular measurement system and instead tends to align with evidence showing the benefits of higher staffing levels. Each task is assigned an amount of time. Staffing The full Telford method provides a framework for wider deliberation, but the judgement of required staffing does not require the use of objective measures to determine need (Arthur and James, 1994), hence it is an example of a professional judgement-based approach. There are many studies showing adverse effects of low nurse staffing on patient outcomes. Maben J., Griffiths P., Penfold C., Simon M., Anderson J.E., Robert G., Pizzo E., Hughes J., Murrells T., Barlow J. Barham C., Begum N. Sickness absence from work in the UK. There are many methods for determining nurse staffing requirements described in the literature. WebFindings revealed that nurse staffing varied considerably across hospitals ranging from having 4.3 to 10.5 patients per nurse. Building on the extensive evidence from cross-sectional studies, recent studies have shown associations at a patient- rather than hospital- or unit-level (Griffiths etal., 2018a, 2019; Needleman etal., 2011b). Managing unnecessary variability in patient demand to reduce nursing stress and improve patient safety. O'Brien-Pallas L., Cockerill R., Leatt P. Different systems, different costs? Before Understanding Nursing Staff Ratios Perroca M.G. Minimum nurse-to-patient Ratios Improve Staffing, Patient The methods described in the literature generally match staffing levels to the average (mean) demand associated with a particular patient group, factor or aspect of care when attempting to estimate current or future staffing requirements. There are also examples of tools specifically to balance workload within a unit, which thus focussed primarily on immediate assignments for staff members (Brennan and Daly, 2015; Brennan etal., 2012). Received 2019 May 18; Revised 2019 Sep 10; Accepted 2019 Nov 18. Benchmarking approaches involve using expert judgements to identify suitable comparators, with the staffing levels compared between similar units to establish requirements. 3.6 hprd minimum weekly average (includes 2.5 hprd by CNA) RN (inc.DON @.06) 0.06 LPN 0.94 Total LN 1.00 CNA 2.50 DC 3.60 Total Nursing Staff 3.66 Hospital nurse staffing and staffpatient interactions: an observational study. Patient Safety Act setting nurse-to-patient ratio passes Despite correlations, different systems can give dramatically different results and so it is clear that there can be no single answer to the questions of whether workload measurement systems result in improvements in the utilisation of nursing personnel. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect. Nurse Staffing Crisis Rauhala A., Fagerstrm L. Determining optimal nursing intensity: the RAFAELA method. Questions that remain unanswered about many tools include the extent to which they truly identify a level of staffing sufficient to meet the needs of a ward of patients, and the number of observations required to get an accurate baseline to estimate average need. Determining nurse staffing needs: the workload intensity measurement system. Nurse-patient ratios as a patient safety strategy: a systematic review. Controlled trials comparing outcomes of staffing guided by tools with other approaches may be challenging to undertake, but are by no means impossible to conceive. Hurst also describes three main types: Patient Classification Systems, timed-task and regression-based (Hurst etal., 2002). Nurse Staffing Ratios: The Crucible of Money, Policy, Research There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. WebA 2009 study estimated that adding 133,000 RNs (the number of RNs needed to increase nursing staff to the 75th percentile) to the U.S. hospital workforce would result in medical savings of $6.1 billion on health care spending, not including the value of increased productivitywhen RNs help patients recover more quickly.11 Baernholdt M., Cox K., Scully K. Using clinical data to capture nurse workload: implications for staffing and safety. The impact of the nursing hours per patient day (NHPPD) staffing method on patient outcomes: a retrospective analysis of patient and staffing data. While limitations in tools have continually motivated the development of new approaches, limited evidence means it is hard to determine if existing approaches may be good enough or if new approaches are any better in practice. It seems highly unlikely that there are no adverse outcomes caused by low nurse staffing levels. Kolakowski D. Constructing a nursing budget using a patient classification system. Allocate software, 2017. Correlations between measures of staffing requirement or workload have been used to establish validity (e.g. Reliability of assessment in real life may be considerably lower than that achieved under controlled conditions and there are potential adverse effects on engagement when items that end users consider to be important aspects of care are omitted because of less desirable psychometric properties (Brennan and Daly, 2015). non ambulatory), specific activities (e.g. The problem is not a simple lack of published literature. The question of how best to identify the required nurse staffing level remains unanswered. Bill to mandate nurse staffing levels at hospitals moves Results Most nurses reported that the AWHONN nurse staffing guidelines were frequently or always followed in all aspects of care surveyed. As is clear from Myny etal. A top concern for the union is lower guaranteed nurse-to-patient staffing ratios. Writing in 1994, Edwardson and Giovanetti noted the absence of published scientific evidence for a number of systems, such as GRASP or Medicus, which were in widespread use in North America (Edwardson and Giovannetti, 1994). The Patient Safety Act, which specifies the number of patients per-nurse required in different hospital settings, passed with a 119-84 vote. Lewinski-Corwin E.H. Assuming some degree of flexibility in the work capacity of a given group of staff, most patients needs might be safely accommodated most of the time. Nurse leaders and nurses are best qualified to determine appropriate staffing for the needs of their patients. Ferguson-Par M., Bandurchin A. Allowing a small percentage of additional staff based on the average percentage of time lost does not mean that sufficient staff are available to cover days or weeks when staff are actually absent. The following ratios would be established. Specifically, the law requires: One CNA to every eight residents for the day shift; Establishment setting: employment and base deployment decisions (long term). The underlying sample of observations could not be easily determined but the wide confidence intervals appear to result from intrinsic variability rather than simply a small sample.