And bullying causes harm to more than just the victim. A December study in the Journal of Occupational and Environmental Medicinefound workplace bullying increases employees' psychological distress and intent to leave their job—even for workers who aren't personally being bullied.
More than 3,000 Japanese civil servants completed a questionnaire to assess bullying at work, rating the frequency of items such as "spreading of gossip and rumors" or "persistent criticism of your work." The researchers, including Kanami Tsuno, PhD, MPH, of Wakayama Medical University in Japan, gathered baseline and one-year follow-up responses from the participants.
At the one-year follow-up, individual reports of being bullied at work were linked to increased psychological distress such as depression. Bullied workers also had higher ratings on a scale assessing their intention to leave their job.
After the results were adjusted for bullying on the division and department levels, researchers found division-level bullying had a greater impact on both psychological distress and intention to leave, compared to individual exposure to bullying.
"[This] suggests that the presence of bullying in the workplace can be a strong indicator of mental health problems and intention to leave among work members, regardless of individual experiences or witnessing of bullying," Tsuno and coauthors write. "Bullying is not simply an interpersonal issue but is an organizational dynamic that impacts on all workers, even those who are not personally victimized."
A study published in the journal's February 2018 issue also found that bullying had far reaching effects in a work unit. The researchers found that non-bullied coworkers in work units where bullying was reported, had 15% to 22% more long-term sickness absence than employees in work units without bullying.
For healthcare organizations, it would pay—literally—to stop tolerating bullying. Nurse absenteeism and turnover are costly. A 2013 Gallup-Healthways Well-Being Index survey found the annual cost of lost productivity because of nurse absenteeism was $3.6 billion. The cost of turnover for a bedside nurse is estimated between $38,000 to $61,100. This results in an estimated per-hospital cost of between $4.4 million and $7 million per year.
Standardized cleaning method decreases contamination better than practitioner-preferred methods.
Stethoscopes are a symbol of healthcare. But a newstudy in the journal Infection Control & Hospital Epidemiology finds they also carry bacteria that can cause healthcare-associated infections.
The effectiveness of cleaning methods was also reviewed, and researchers found a standardized approach to be more effective at removing bacteria than healthcare practitioners' various approaches to cleaning.
"This study underscores the importance of adhering to rigorous infection control procedures, including fully adhering to CDC-recommended decontamination procedures between patients, or using single-patient-use stethoscopes kept in each patient's room," Ronald Collman, MD, a professor of medicine, pulmonary, allergy and critical care at the University of Pennsylvania Perelman School of Medicine and senior author of the study, says in a news release.
HAIs compromise patient safety and increase healthcare costs, according to the Agency for Healthcare Research and Quality. The organization reports one million HAIs occur in the U.S. healthcare system annually, "leading to the loss of tens of thousands of lives and adding billions of dollars to health care costs."
Researchers analyzed bacteria present on various types of stethoscopes used in an intensive care unit including:
20 traditional reusable stethoscopes used by physicians, nurses and respiratory therapists
20 single-patient-use disposable stethoscopes used in patient rooms
10 unused single-use disposable stethoscopes as a control
All of the 40 stethoscopes in use were significantly contaminated with multiple types of bacteria, including those that cause common HAIs. Staphylococcus, the bacteria responsible for Staph infections, was found on all stethoscopes, and more than half were contaminated with S. aureus. Other bacteria that can cause HAIs were also widely present in small quantities.
The Most Effective Cleaning Method
To compare the effect of cleaning on contamination, researchers sampled 10 additional practitioner stethoscopes before and after 60 seconds of cleaning with a hydrogen peroxide wipe, and 20 more practitioner stethoscopes before and after cleaning by the practitioner according to their usual methods.
Practitioner methods included using alcohol swabs, hydrogen peroxide wipes, or bleach wipes for various durations. While all cleaning methods reduced the number of bacteria, they failed to consistently bring contamination to the level of clean, new stethoscopes. The standardized cleaning method reduced bacteria to the "clean" level on half of the stethoscopes. The practitioner-preferred methods only achieved the clean level on 10% of the stethoscopes.
The study was not able to differentiate live bacteria from dead bacteria thus additional research is required to determine if stethoscopes are responsible for transmitting infections.
Collman says future research should identify improved cleaning methods and study bacteria present on multi-patient medical devices and in the healthcare environment.
Here is one chief nursing officer's take on the issues nurse leaders should focus on this year.
The Magic 8 Ball was recently inducted into the National Toy Hall of Fame. As I sat down to write about the top issues nurse leaders need to pay attention to in 2019, I was tempted to think about how easy it would be if nurses could consult this iconic fortune-telling game for answers.
But, of course, the field of nursing is not easy, and the challenges within the healthcare industry that affect nursing require more insight than vague answers from a plastic toy. To get a real understanding for what the future holds for nursing, I spoke with Paula McKinney, DNP, RN, NE-BC, vice president, patient services at Woodlawn Hospital in Rochester, Indiana, who is knowledgeable about the challenges chief nursing officers are facing this year.
According to McKinney, here are five issues that will likely garner the attention of CNOs in 2019, ranging from recruitment and retention to employee engagement. The transcript has been lightly edited for clarity.
1. Recruitment and Retention
"I think the No. 1 issue is going to continue to be recruitment and retention and, over the next several years, [an area] where CNOs will be focusing. It's a multifaceted issue and there are so many reasons why we're not able to recruit and retain nurses."
"On the recruitment side, I think it's because there's a lot of competition. There are more areas for nurses to work like occupational health or informatics. More people are wanting to become nurse practitioners and they are moving out of that bedside role into a provider-type role."
"I think [healthcare executives] need to look at being more creative in recruitment activities to attract people to their facilities. But then, if they can attract them, they need to make sure they can retain them. Again, that's multifaceted. I think what hospital executives need to understand is that the generation of nurses that have been coming out [of nursing school] over the last five to seven years—and the ones that will be coming out over the next five to seven—they want something different than what the baby boomers wanted. They want flexible schedules. They want to feel appreciated. They want engagement. I think hospitals, as far as nursing in general, gear running nursing departments for the boomers. This new group of nurses wants something different."
"The boomers they 'lived-to-work,' whereas this next generation has a work-to-live mindset. The philosophy of nursing over the next several years needs to be focusing on what this [new] generation wants so that we can retain them. I think a lot of them are struggling with the 12-hour shifts. Over the past several years, I've spoken to many of these newer nurses, and as far as the 12-hour shifts go, these nurses want to get home and be with their friends and their families. But a lot of places only do 12-hour shifts."
2. Innovative Technology
"We need to be paying attention to innovation in technology. There are a lot of creative, innovative ways [to take] care of patients now. For example, there are glucometers that transmit [patient] information to the electronic health record. Those are time-savers for nurses. But if a hospital doesn't invest in a good system, it just creates more work for nurses as far as double documentation and things of that nature. Some hospitals are getting on that technology bandwagon, but some are not because of the price. They're looking at the financial impact and the bottom line more than they're looking at innovation."
"As CNOs, we need to stay abreast of new technology and how it will help us to better care for patients. And we need to be advocates for the technology that will help our nursing staff take care of patients better and quicker and make [nurses] more available to the bedside."
"This younger group of nurses, they're more technologically driven. When we [pair] them with new technology, it's going to be a benefit for the hospitals."
3. Culturally Aware Patient Care
"We need to pay close attention to people that speak other languages or are from other cultures. I don't think in nursing we've done a good job of that over the years. Yes, people do their computer-based learning to be culturally competent, but I think we've gotten lax regarding how we interpret [the term] competent and how we train nurses to provide that bedside care. But, with what's going on in society—migration and the #MeToo movement—our patient population is going to be made up of more people from different cultures."
"Along with that is we need to get out in our communities and make sure that we're hiring diverse nurses. Nurses that speak Spanish or Russian or Chinese. Many hospitals have a language line, but you miss the human connection. And the human connection is a huge part of caring. If we are able to pay attention to society, and the different cultures that are out there and encourage people of other cultures to get into nursing, then it's going to be a benefit to our whole profession and to patient care."
4. Employee Engagement
"You don't need to be a Magnet hospital to get bedside nurses involved in quality care, safe care, hospital projects, committees, and those things. For hospitals that can't afford Magnet certification, how do you engage your bedside nurses? We can still take some of those [Magnet] principles to help our bedside nurses be more engaged in safety and quality projects. I think the more engaged this next group of nurses is, the more likely we're going to retain them."
"We need to pay attention to recognizing people for their good work. CNOs need to be more visible and connect with that bedside nurse. I think this generation of nurses is going to require that of CNOs. We're going to have to make sure that we're [personally] engaging [nurses] by asking them to serve on committees and [having them get] involved in a project that we're working on instead of their manager or director asking them. I think it will be more meaningful from the CNO, and I think we'd have better participation and engagement; that helps our nurses become more autonomous and feel like they're part of the bigger team. It may even inspire some of them into nursing leadership."
5. Promoting Self-Care
"For me, the thing I think we need to emphasize is getting nurses to take care of themselves. It starts with CNOs. What are we doing for stress relief? When we're struggling in the personal world, it's reflected in your professional world."
"As nurses, we do not typically take good care of ourselves. What are things we can encourage nurses to do right where they are? I would to encourage relaxation techniques. For example, a meditation room or somewhere staff could go for time to just reflect, do some deep breathing, and get away from the craziness to give them spiritual time or comfort time, whatever they might need."
"Maybe we can ask the chaplain to engage with the nurses and [notice or recognize] when someone seems like they need to take a deep breath—just anything that we can do towards self-care. Many places are starting wellness programs, but wellness isn't just physical. It's not just making sure you're getting the physical activity or that you're keeping your blood pressure and blood sugar down. We often forget about the psychological piece."
A federal bill calls for creation of mandatory workplace violence prevention standards for healthcare employers.
Workplace violence is a serious, and growing issue, in healthcare. According to the Occupational Safety and Health Administration, from 2002 to 2013, the rate of serious workplace violence incidents was, on average, over four times greater in healthcare than in private industry. Plus, according to the administration's website, "healthcare accounts for nearly as many serious violent injuries as all other industries combined."
The bill would mandate that OSHA establish a national standard requiring healthcare and social service employers to create and implement a comprehensive workplace violence prevention plan.
"We applaud Rep. Courtney for introducing a bill that is so critical, not just for nurses and other healthcare workers, but also for patients, families, and visitors, given that violence impacts everyone in the vicinity of healthcare and social service settings," said National Nurses United Executive Director Bonnie Castillo in a news release. NNU is a union and professional organization representing 150,000 registered nurses.
The bill:
Requires OSHA to create a federal workplace violence prevention standard that mandates employers develop comprehensive, workplace-specific plans to prevent violence before it occurs.
Encompasses a wide array of workplaces, beyond just acute care hospitals. This includes residential treatment facilities, non-residential treatment settings, psychiatric treatment facilities, and substance use disorder treatment centers. Community care settings, federal health care facilities, field work settings such as home care and emergency services, would be covered as well.
Establishes minimum requirements for the standard and for employers' workplace violence prevention plan. This includes unit-specific assessments and implementation of prevention measures, physical environmental changes, staffing for patient care and security, employee input in the plan, and hands on training. Record keeping requirements include a violent incident log and protections for employees to report workplace violence to their employers and law enforcement.
"Right now, healthcare and social service employers are not doing enough to prevent the violent incidents that nurses and other workers experience daily. Under the proposed federal standard, employers would need to assess and implement interventions that can reduce violence—for example, affixing furniture and lighting so they can't be used as weapons," Jean Ross, RN, NNU co-president says in a news release. "It's so important for nurses, doctors, and other healthcare and social service workers to be directly involved in the development and implementation of these plans, because employees know best the risks we face on the job."
To be effective in today's healthcare industry, nurse leaders' knowledge must extend beyond traditional nursing issues.
I often get asked, "What do nurse leaders care about?" My answer: "Everything." Modern nurse leaders don't have the luxury of remaining in a hospital-based bubble. Among population health initiatives, changing reimbursement models, and more diverse practice settings, nurse leaders must care about and understand everything from finance to ambulatory care to IT needs. In addition to dealing with traditional nursing issues such as staffing and nursing skill mix, they must grasp the bigger picture of business strategy, organizational goals and outcomes, and healthcare system mergers to be effective leaders.
There is so much information of which nurse leaders need to be aware, and HealthLeaders can help. Here are five stories from HealthLeaders editors on business topics that nurse leaders should read to stay up-to-date on industry developments.
Hospitals across the country have seen the effects of drug shortages and sky-high medication prices and have struggled with access to inpatient medications as a result. So how can hospital executives and clinicians address growing costs and spotty medication supply? HealthLeaders editor John Commins spoke with pharmacy directors at three health systems grappling with these issues.
Commins writes that successful systems communicate the extent and cost of the problem with clinical and administrative stakeholders and monitor medication usage daily on a patient-by-patient, dosage-by-dosage basis.
Outpatient payment policy changes set to take effect in January 2018 have spurred two national hospital groups and three individual hospitals to sue the Trump administration. The changes, which the Centers for Medicare & Medicaid Services finalized last month, will result in a significant reimbursement reduction for hospital-owned outpatient departments.
HealthLeaders editor Steven Porter writes: "Central to the suit is the difference between 'excepted' and 'non-excepted' off-campus hospital provider-based departments. The final rule for 2019 'effectively abolishes any distinction' between the two groups, resulting in hundreds of millions of dollars in payment reductions for hospital-owned departments that would otherwise be grandfathered into a higher reimbursement tier."
The suit claims that rather than making the changes in budget-neutral fashion as required, CMS instead finalized changes that would result in a $380 million reduction next year followed by a $760 million reduction in 2020.
3. Healthcare IT Investment is Overvalued, But Will Increase Next Year
Healthcare professionals' love-hate relationship with technology continues.
HealthLeaders editor Jack O'Brien writes about a new survey released by KPMG-Leavitt Partners that found while more than 60% of healthcare professionals view healthcare IT asset prices as overvalued, they also expect the subsector to grow faster than the overall healthcare market
"Thirty-four percent of respondents favored investing in healthcare IT, leading the way over subsectors such as care management, home health services and retail-centric medical groups, among others," he writes.
Driving forces behind healthcare IT investment include increased consumerism, increases in patients receiving care in ambulatory and outpatient settings, shifting payment models, and corporate disruptors.
No one likes medical bills. Westmed Medical Group, which is managed by Westmed Practice Partners and has locations in New York and Connecticut, had proof of that based on its patient relations hotline. Westmed’s hotline was tracking many complaints and questions about the organization's billing process.
To improve patients' billing experience, Westmed invested in technology that allows for simple, user-friendly bill pay.
"In an era where patient satisfaction is prioritized for everything from the clinical experience to the cleanliness of the waiting room, the billing experience has largely been left behind," writes HealthLeaders editor Alexandra Wilson Pecci.
Since Westmed Medical Group introduced a new patient payment and engagement platform, which has provided a process for streamlining the billing process, it has experienced a 36% increase in dollars collected, a 59% reduction in time to collect, and a 23% increase in patient satisfaction to reach 97% overall patient satisfaction.
In an ever-evolving healthcare environment, organizations are finding they need to become more efficient in all areas of the business.
"Quality improvement project management has become an essential capability in operational areas ranging from clinical care to finance to innovation," writes HealthLeaders editor Christopher Cheney.
To help health systems and other healthcare organizations implement quality improvement initiatives, The Institute for Healthcare Improvement has developed a QI Project Management Tool.
The QI Project Management Tool consists of five elements: frontload the work, build the project team, set the pace, make the project easy, and start with the end in mind. It also includes strategies to manage quality improvement projects and ideas to try within each strategy.
Here's a roundup of our most popular nursing stories of the year.
Life can get hectic, especially at this time of year as both the flu and holiday seasons ramp up. With that in mind, I have compiled a list of HealthLeaders' most read stories on topics affecting the nursing profession in 2018, so that busy nurse leaders can catch up on articles they might have missed.
This year education preparation, patient experience, and nurse stressors were among the most popular topics that piqued readers' interest. Here is the list of HealthLeaders' top 10 nursing stories ranked by popularity.
While patient volume and acuity play a role in a nurse's ability to provide optimal care, so does "subjective workload," say researchers at The Ohio State University. Subjective workload includes everything from the mental pressures of the job to time constraints and affects a nurse's ability to deliver quality care, regardless of the number of patients.
A difficult experience with the healthcare industry inspired Sharon Quinlan, MSN, MBA, RN, NEA-BC, vice president/chief nursing officer of ambulatory at Advocate Aurora Health, to improve patient experience through patient- and family-centered care. She shares some of her insights on enhancing patient experience.
Understanding national trends in nurse staffing is necessary, but overlooking the finer details, such as what's occurring in specific geographic areas or specialties, ignores the complexities of nurse supply and demand. Heidi Sanborn, DNP, RN, CNE, clinical assistant professor and interim director of the RN-BSN, and concurrent enrollment program in the College of Nursing and Health Innovation at Arizona State University in Phoenixshares five observations on the nursing shortage that should be considered in the workforce forecasts.
The American Medical Association crafted a resolution to create a strategic campaign to oppose legislation that supports APRN independent practice, despite evidence that advanced practice registered nurses improve outcomes and access to care. The campaign also takes aim at the National Council of State Boards of Nursing's APRN Compact model. Many nursing groups, including the American Association of Nurse Anesthetists, were not pleased with the move, which was driven by the American Society of Anesthesiologists.
At AONE 2018, Chip Heath, an expert in organizational behavior at Stanford Graduate School of Business, spoke about creating nurse-patient moments that can positively influence patient experience. According to Heath, positive moments between nurses and patients involve four specific qualities—elevation, insight, pride, and connection. By focusing on those elements, nurses can improve a patient's healthcare experience.
Nursing groups responded favorably to the U.S. House of Representatives' passage of the Title VIII Nursing Workforce Reauthorization Act (HR 959) in 2018. Last reauthorized in 2010, the act would reauthorize the nursing workforce development programs through fiscal year 2022.
The legislation will continue nursing workforce development programs, which support the recruitment, retention, and advanced education of skilled nursing professionals. It will also extend advanced education nursing grants to support clinical nurse specialists and clinical nurse leaders, define nurse-managed health clinics, add clinical nurse specialists to the National Advisory Council on Nurse Education, and reauthorize loan repayments, scholarships, and grants for education, practice, quality, and retention.
While there is a great deal of discussion about burnout and compassion fatigue among nurses, nurse suicide is a topic that is not often discussed. While national data on nurse suicide rates is lacking, that doesn't mean it's not an issue. Nurse leaders should recognize and respond to factors that contribute to nurse suicide and take specific actions to prevent it.
Over the past decade, both the number of and need for nurse practitioners has grown and, so too, have their salaries. In a 2018 study, NPs reported an average salary of $113,900, an increase of 6.6% over last year's average reported salary of $106,000. The survey also found that sign-on bonuses are becoming more common.
Healthcare leadership that is eager to tackle the many challenges of running a healthcare organization may be overlooking a large and effective group of change agents—nurses. RNs can improve quality and outcomes, enhance an organization's culture, and build relationships with patients, colleagues, and the community if given the opportunity. Three nurse leaders share their thoughts on how nurses can influence change in healthcare and drive innovation.
And the No. 1 most-popular HealthLeaders nursing story:
In 2018, New York became the first state to pass a law requiring new nurses to earn a bachelor's degree within 10 years of initial licensure. The legislation went into effect immediately but the requirement that nurses obtain a baccalaureate degree or higher within 10 years of licensure doesn't begin until 2021. The new education requirement does not affect nurses already in practice.
Just over a year ago, a man walked into New Hampshire's Dartmouth-Hitchcock Medical Center and shot his mother, who was a patient in the intensive care unit.
Don't wait for something bad to happen. Nurse leaders and other healthcare executives can act now to create a safe workplace though training, communication, and creating physical barriers.
In an article for Patient Safety & Quality Healthcare, contributing writer John Palmer shares some strategies to help healthcare organizations prevent and prepare for violent incidents. Below is an excerpt outlining ways to improve safety. It can be read in its entirety here.
1. Know your patients, and talk to coworkers.
People who commit violent acts against healthcare facilities are usually well-known to the people who work there. Offenders may be furious at a [healthcare provider] for being unable to save the life of a loved one, angry about a large bill, or upset at an estranged spouse who works there.
Whatever the case, know who is coming into the facility and communicate with them. If a patient or family member is known for having anger issues or makes threats against employees, communicate and document it. Hospital personnel and security officers should know who they are dealing with, and in extreme cases, the police should be notified. Consider banning the person from the facility, but remember that decision may also make the person angry.
2. Recognize the warning signs.
Experts on healthcare safety say nonverbal body language known as “behaviors of concern” can precede actual violence. If caught early, de-escalation tactics can be used to intervene and keep the situation from becoming violent.
Be on alert for the telltale signs of stress and anxiety, including raised voices or fast talking, clenched fists and teeth, glaring eyes, and fixed or darting stares. These behaviors of concern can usually be defused with simple tactics such as calming talk, offering a glass of water, or allowing the person to sit in a quiet area to relax.
3. Communicate "zero-tolerance."
Letting people know violence will not be tolerated is a deterrent in itself. Many facilities have a “zero-tolerance” approach to violence and have informed those working inside their walls. You should also let patients and visitors know that violent or aggressive acts will be taken seriously and reported to the police.
4. Install locks and barriers.
This sounds like a no-brainer, but many nurses' stations and intake areas are still very vulnerable because they do not have proper locks installed. Exterior doors should latch when closed. Install glass or plastic partitions (bulletproof is best) that enclose front-desk personnel and protect them from violent individuals. Lastly, instruct staff members to always keep exterior doors shut.
5. Secure furniture.
Many waiting areas and patient rooms have lightweight furniture, lamps, tables, and other items that could be wielded as weapons. Tie or clamp down waiting room furniture, or purchase weighted furniture that is harder to lift and does not contain glass or sharp edges.
6. Establish safe rooms.
If violence does break out, there should be a designated room where staff and patients can go to escape. Staff should be trained to run, look for a room in which to barricade themselves and their patients, and lock the door to keep out violent individuals. Also, designate an area outside the facility where employees can meet if necessary.
7. Check your phone lines.
Regularly update lists of emergency contact numbers and communication plans. If a violent incident occurs, who should staff call for help? Is there an alarm or code to alert others about the situation? Staff may know to call 911, but would they know what to say? Consider writing a short script for callers to follow when calling for help. Also, many police and fire departments will send representatives to a healthcare facility to talk about security.
8. Fight as a last resort.
Many facilities have turned to government agencies such as the FBI and the Department of Homeland Security to teach participants to run, hide, and fight during a violent incident. But in a healthcare setting, that sort of training won’t work, since most physicians and nurses would not leave a patient’s side during a shooting.
"Avoid, Deny, Defend, and Treat" is an alternative shooting response plan in use at Carolinas Medical Center in Charlotte, North Carolina, says David Callaway, MD, FACEP, director of operational and disaster medicine at the organization.
Here’s a breakdown of how it works:
Avoid. Hospital staff need to develop habits to help raise situational awareness and avoid a shooter situation in the first place. They should know their location’s access points and take time to check them (e.g., making sure doors are locked). They also need to engage people and observe whether visitors' hands are in their pockets, they are hiding something, or if they will exchange a handshake if one is offered. By engaging people, it may be possible to prevent a shooter incident from occurring.
Deny. Almost half of active shooter incidents end within five minutes, and victims are usually chosen at random. Staff members need to be trained to quickly recognize when an incident is about to get violent and to find a safe room where they can quietly hide with patients, barricading the entrance with things such as beds, chairs, or other objects.
Defend. Only as a last resort should a staff member in a healthcare setting fight back. Even then it’s a personal decision that should be made deliberately. Staff should always understand that it is never a job requirement to put their life in jeopardy.
Treat. This is where a hospital’s response plan differs from a typical shooting scene, Callaway says. Because the hospital is where shooting victims will be treated, staff members cannot flee after an incident.
9. Get rid of jewelry.
Necklaces can be a choking hazard, rings can be a hard weapon, and earrings can be used to stab at someone’s eyes. Instruct staff members to leave jewelry at home or keep it in a locker.
10. See something, say something.
One of the reasons accurate statistics on patient violence and worker injuries are not available is because most incidents go unreported. Recent campaigns from nurses’ associations and healthcare worker advocates encourage healthcare staff to report incidents to their supervisors and keep good paperwork. Incident reports should always be filled out and kept on file for accurate reporting.
Mandating nurse-to-patient ratios is one solution to nurse staffing, but some favor different approaches to the issue.
In 1999, California became the first state to pass a law mandating nurse-to-patient ratios in hospitals. The requirement went into full effect on January 1, 2004.
At the time, there was speculation in the nursing community that other states would quickly follow suit, and mandatory ratios would spread across the country. That has not been the case.
In fact, this November, Massachusetts voters rejected a law that would establish mandatory staffing ratios in the state. Almost 20 years later, California remains the only state to require nurse-to-patient ratios to such a broad extent.
But why?
Certainly, some of it is politics and how successfully those for or against ratios lobby lawmakers and the public to support their stance. Another reason is the idea that creating ratios based strictly on mandatory numbers is not enough to address the complexities of staffing and patient care.
For example, the American Nurses Association says numbers-only ratios are too rigid and don't allow nurses to make staffing decisions that address their individual unit's needs or to account for patient acuity.
According to the ANA's Principles for Nurse Staffing, the following concepts need to be considered to achieve optimal staffing and safe, high-quality care delivery:
Nurse staffing is more than numbers.
One size does not fit all.
Components such as nurses' experience, patient acuity, workflow, patient volume, and available resources in the delivery of care affect decisions on what is appropriate staffing at any given time.
Patient care needs are fluid and vary among hospitals, nursing units, and shifts.
Flexibility and teamwork are essential to effectively meet patients ever-changing needs.
Below are five HealthLeaders articles highlighting the spectrum of opinions and issues related to nurse staffing.
When Riverside Methodist Hospital in Columbus, Ohio, experienced a period of multiple changes and high nurse turnover in the 32-bed neurocritical care unit, two of the unit's nurses launched a workflow study to assess relationships between neurological assessment, documentation, traveling with patients for diagnostic tests, and the effects of patient acuity and nurse experience.
The study found that for nurses on neurocritical care units, accompanying patients for imaging scans and other procedures significantly impacted nurse-patient staffing ratios.
Based on these results, the authors recommended a new "circulator" nurse position to travel and assist with patients and to free primary nurses on the unit to stay with their patients. They also recommended three new "one-to-one" staff positions to allow high-acuity patients or those with multiple diagnostic tests scheduled to be assigned to a dedicated nurse.
Four years ago, Massachusetts passed a law requiring 1-to-1 or 2-to-1 patient-to-nurse staffing ratios in intensive care units, as guided by a tool that accounts for patient acuity and anticipated care intensity.
A recent study by physician-researchers at Beth Israel Deaconess Medical Center found Massachusetts' previous regulations regarding nurse-to-patient staffing ratios in ICUs were not associated with improved patient outcomes.
After comparing outcomes between academic ICUs nationwide and in Massachusetts, the authors found modest increases in ICU nurse staffing ratios—a change from 1.38 patients per nurse to 1.28 patients per nurse— before and after the mandate's implementation. These increases weren't significantly higher than staffing trends in states without state-mandated ICU staffing.
Additionally, the risk of mortality and risk of complications in Massachusetts' ICUs remained stable after the law's implementation, with no significant difference in trends compared to out-of-state hospitals.
In the November midterm elections, 70% of Massachusetts voters rejected a law seeking to implement nurse-to-patient ratios in hospitals and other healthcare settings.
For months, the law was hotly debated. Those in favor said it would improve patient safety and care. Those opposed said it didn't account for patient acuity and would create a financial burden on hospitals and healthcare systems.
Patricia A. Hickey, PhD, MBA, RN, NEA-BC, FAAN, vice president and associate chief nursing officer, cardiovascular and critical care patient services at Boston Children's Hospital and assistant professor of pediatrics at Harvard Medical School, is internationally known for her work in research and leadership development, care delivery innovation, patient safety, and bridging nursing practice and health policy.
She is a proponent of updating patient acuity instruments which have traditionally been time-based.
"For example, a tool may have allocated 5 minutes to suction a patient. But sometimes it takes 7 minutes," Hickey says.
At Boston Children's Hospital, the CAMEO nursing acuity instrument was developed "as a contemporary tool to measure the cognitive workload and complexity of nursing work. The CAMEO score for each patient is helpful to staffing decisions in combination with the judgment of frontline nurses," Hickey says.
Patient volume and acuity aren't the only factors affecting a nurse's ability to deliver high-quality care, finds a new study examining nurses' 'subjective workload.'
Researchers at The Ohio State University found that everything from mental pressures of the job to time constraints can influence whether a nurse can provide optimal care, regardless of how many patients they are assigned.
The study calls for developing broader workload strategies to ease nurses' stress and improve care quality.
The researchers evaluated the relationships between objective and subjective workload measures and quality of care and found the nurses' perceived workloads had a consistently strong influence on missed essential care.
One nurse leader shares her insights gained over an accomplished career.
Patricia A. Hickey, PhD, MBA, RN, NEA-BC, FAAN, is a pediatric nurse, yet the work she has done during her career transcends any single specialty. Hickey, vice president and associate chief nursing officer, cardiovascular and critical care patient services at Boston Children's Hospital and assistant professor of pediatrics at Harvard Medical School, is internationally known for her work in research and leadership development, care delivery innovation, patient safety, and bridging nursing practice and health policy.
Some of her research examines the nursing and organizational factors associated with pediatric patient outcomes and the health of the work environment.
True to her passion of supporting other nurses, Hickey is more than willing to impart her decades of research findings, knowledge, and wisdom to fellow nurse leaders.
In an interview with HealthLeaders, she shares six areas in nursing that are vital for nurse leaders to focus on to grow in their roles and to move nursing forward.
"Innovation in healthcare delivery, understanding employee well-being, and taking care of our teams across the continuum of care are key priorities for leaders."
"Creating and sustaining healthy work environments is an ongoing goal. We need to ensure the health of the work environment is considered in all our decisions, so that nurses and extended teams are enabled to do their best work, voice their opinions, and know that they are valued."
"A consistent passion, as a leader, has been to support and optimize care for pediatric patients and families while understanding that our most important asset is our staff. "
2. The Work Environment
"The health of the work environment includes authentic leadership, true collaboration, meaningful recognition, and effective decision-making. We all benefit when frontline nurses are involved in decision-making at every level. Nurses really do have the best questions. When leaders are working through problems, the frontline staff need to be involved."
"Our practice environments must be a place where leaders support each other and staff are supported in their delivery of the highest quality of care. Today’s practice areas are challenged by a multitude of competing demands and patient care complexities. At Boston Children's Hospital, we use AACN's Healthy Work Environment assessment tool and results as an important measurement to improve and sustain environments that empower staff and optimize experience for patients and families."
"Patient and staff outcomes are inextricably linked, so I hold those front and center."
3. Patient Acuity Measurement
"In the 1970s and 1980s, the majority of the acuity instruments were based on time. For example, a tool may have allocated 5 minutes to suction a patient. But sometimes it takes 7 minutes."
"At Boston Children's Hospital, we’ve developed the CAMEO nursing acuity instrument as a contemporary tool to measure the cognitive workload and complexity of nursing work. The CAMEO score for each patient is helpful to staffing decisions in combination with the judgment of frontline nurses. "
4. Specialty Certification
"Through serial studies over the last 12 years, we have examined nursing and organizational characteristics and their impact on patient outcomes, including mortality and complications for pediatric patients. The most recent findings show, for the first time in adult or pediatric research, that AACN Specialty Certification is correlated with reduced complications for postoperative surgical patients. Our research findings over the last decade have also revealed that levels of nursing education and experience are significantly associated with improved patient outcomes across critical care units in the United States."
5. Empathic Teams
"It’s important to understand the attributes of 'empathic and empowered teams'. Nurses work within teams and that interdisciplinary collaboration is so critical to effective decision-making. How we support those teams to do their best work is a big responsibility of leaders. For example, we have used evidence that was generated from frontline clinical nurses to develop a path for moral resiliency in nurses caring for acute and critically ill patients. We know the topic of moral distress is prolific in articles, but there are very few unit-based interventions in the literature."
"At Boston Children's Hospital, we developed a nurse education and support team to empower critical care nurses when they feel challenged with an ethical or complex dilemma. They can receive support, mentorship, and practical tools from an experienced cardiovascular or critical care nurse. The key component of the approach is when a nurse is feeling challenged at the bedside, he or she can call a number, and an experienced critical care nurse will come to the bedside and offer real-time coaching. It is peer-to-peer support. They know the coach has walked in their shoes."
"There are a number of options for employee support in healthcare organizations including offices of clinician support. Staff can call psychosocial specialists and get an appointment [later]. However, we also need to better understand and support staff in the moment when they are dealing with challenges. Staff have evaluated this support program positively."
6. Leadership Qualities
"Leaders should be able to articulate the value of nursing and help nurses articulate professional practice, whether that be with each other or even to influence public policy. Nurses are key to helping patients, families, and the general public understand and navigate what is becoming an increasingly complex healthcare system. Sharing and effectively communicating a collective vision for the future and supporting staff in achieving personal and professional goals is always important."
Bay State residents reject a law requiring mandatory staffing ratios, but proponents and opponents of the measure vow to continue to address the issue.
Last night, Massachusetts voters had their say on ballot Question 1, which sought to implement nurse- to-patient ratios in hospitals and other healthcare settings.
It was met with a resounding 'no' from the electorate, with about 70% voting against the measure and almost 30% voting for it.
For months, the law has been hotly debated. Those in favor said it would improve patient safety and care. Those opposed said it didn't account for patient acuity and would create a financial burden on hospitals and healthcare systems.
Had the law passed, Massachusetts would have joined California as the only other state to require that level of mandatory ratios.
The Massachusetts Nurses Association, the union which represents nurses in over 70% of acute care hospitals in the state, supported of the law.
Donna Kelly-Williams, RN, president of the MNA, provided a statement after the measure failed to pass. She thanked frontline nurses for their advocacy of patient safety and high-quality care.
"We are all disappointed by tonight's results and the impact this will have on the patients we care for every day. We know that right now – as I speak to you here – there are nurses caring for too many patients, and those patients are unnecessarily being put in harm's way," she said. "The problem continues to grow every year. The status quo is not a solution here. "
"What we won tonight was the ability to continue providing the best possible care for patients throughout Massachusetts," he said. "This is the beginning of a conversation, not the end. Question 1 forced some difficult and necessary discussions about the future of health care and the future of our workforce going forward. These conversations with our care teams and in our communities have been critically important and will continue in bargaining sessions, legislative debates, board rooms, and newspapers. These are conversations we owe to the voters. Most importantly, these are conversations we owe to our patients."
Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN, president of the American Nurses Association, which opposed the mandatory ratio law because the organization felt it was too rigid and did not account for issues like patient acuity, weighed in with a statement encouraging discussions about patient safety and nurse staffing to continue at a national level.
"ANA has long been a strong advocate for appropriate nurse staffing in all healthcare settings. We know that providing the right nursing resources makes a critical difference for patients and the quality of their care. Many factors affect the number of patients for whom each nurse may safely care for – it's not just math. The rigid, one size fits all approach proposed by the ballot initiative failed to acknowledge the complexities of staffing and undermined nurses' professional autonomy and decision-making in determining staffing on their units," she said. "The robust debate spurred by the ballot question helped to educate consumers about the importance of nurse staffing and its impact on quality patient care. We know hospital and nursing leaders across the state are ready to work together to identify a constructive path forward to develop shared solutions and accountability to ensure staffing levels meet the needs of patient populations, and align with nurses' experience and associated resources. Only when that happens, can victory be declared."
