Staffing Guidelines in the Intensive Care Unit

Introduction

Problem Statement and Justification

The problem is that the healthcare system does not have strict staffing guidelines that can be implemented in the intensive care unit (ICU). Each state has different laws about nurse staffing based on the acuity of their patients and the availability of nurses; California and Massachusetts are the only ones that have a law right now regarding nurse staffing (American Nurses Association, 2015). The purpose of this paper is to identify a safe nurse-to-patient ratio that should be implemented at a federal level. For example, one would recommend a 1:1 nurse-to-patient ratio in the ICU to improve patient care. Currently the American Association of Critical Care Nurses (2018) does not have specific nurse-to-patient ratios, instead it defines appropriate staffing as an effective match between patients and family needs. Improving nurse staffing in the ICU can improve patient outcomes and increase nurse satisfaction. The evidence, proposed activities and implementation plan for the change proposal will be presented in this paper.

Rationale

This issue was selected because low nurse staffing affects patient outcomes including; increased falls, medication errors, increased length of stay and health-care related infections (Shang, Stone & Larson, 2015). Many studies have been conducted and found a relationship between nurse staffing and health-care associated infections (HAIs) and even death (Shang, Stone & Larson, 2015). Another reason this issue was chosen is due to the negative effect on nurse’s well-being. Low nurse staffing not only affects patient outcomes, but also affects the well-being of nurses. Shin, Park and Bae (2018) explained that low nurse staffing is linked to nurse burnout, job dissatisfaction, intent to leave and needle stick injuries.

Evidence

There is evidence that shows the impact of nurse staffing on patient outcomes and nurses satisfaction. According to Shang, Stone and Larson (2015), nurses play an important role in establishing a preserved environment for patients, both which are associated with infection control and prevention. Shang, Stone and Larson (2015) found that adequate nurse staffing was related to a decrease in some types of HAIs, such as urinary tract infections.

Shin, Park and Bae (2018) found that a safe nurse staffing level in health-care services, leads to a higher retention rate and overall job satisfaction (p. 273). Adequate nurse-to-patient ratios can have a positive impact on the patient’s healing process, nurses’ sense of accomplishment and reduce healthcare costs.

A third study discovered a connection between nurse staffing levels and a structure that measure patient outcomes. Driscoll et al. (2018) found that a higher level of nurse staffing was associated with a decrease in risk of in-hospital mortality. The study involved 175,755 patients admitted to the ICU and cardiothoracic unit (Driscoll et al., 2018). Results of the study indicates that these patients had a lower risk of in-hospital mortality rate by 12 percent. None of the three studies presented indicated a specific nurse-to-patient ratios, therefore further studies are needed.

Clinical Guidelines

There are some guidelines in place to support nurse staffing, but a federal law does not exist that mandates specific nurse-to-patient ratio. For example, the state of California has a mandated nurse-to-patient ratio, while Texas only has a nurse staffing committee (Shin, Park & Bae, 2015). This issue allows hospitals and stakeholders to measure nurse staffing or nursing care hours per patient volume. Congress has failed to pass a federal law that mandates specific nurse-patient ratios, which leads to regulation in certain states. The American Nurses Association (2015) indicates that California is the only state that has required minimum nurse to patient ratio at all times, while Massachusetts has a law that only pertains to the ICU requiring 1:1 or 1:2 depending on the acuity of the patient. These guidelines need to be changed to a regulation that mandates specific nurse-to-patient ratio in each unit.

Change Theory

The change theory that will guide the different stages of this change project is Roger’s Five Step Theory. The five stages to Rogers’s theory are as follow; knowledge about the issue even though there is lack of information about it, persuasion or interest in a change but more information is needed for a change, decision has been made and the advantages and disadvantages have been identified, implementation of a new idea or change to solve the issue and confirmation to continue with the source (Udod & Wagner, n.d). This theory was chosen because Roger believed that even if the change is unsuccessful, the change could be re-established at a later time (Udod & Wagner, n.d). In the event that the change proposal is unsuccessful, this theory supports the need to regenerate a proposal at a later time.

The change theory will assist in developing guidelines on the nurse-to-patient ratios to prevent negative nurse outcomes and to promote nurses health and well-being. The change in nurse-to-patient ratios will also decrease healthcare costs related to hospital-related infections, improve patient outcomes and satisfaction (Shang, Stone & Larson, 2015). Therefore, a change in nurse staffing is imperative and would be supported by Roger’s Five Step Theory.

Proposed Activities

Patient and Nurse Safety

A change in staffing guidelines can positively affect patient safety, due to adequate staffing as it can provide patients with the time that each one needs. Patients who received more time with direct care have less risk of falls, injuries and medication errors (Shang, Stone & Larson, 2015). The change in staffing guidelines can also affect nurse safety in a positive way. Adequate staffing can decrease the nurse’s stress and feeling of providing complete patient care. This can lead to a decrease in injuries such as needle sticks or missed care events. To create a change in staffing guidelines can also have a negative effect like not accepting patients if the hospital does not have the adequate number of staff or it can precipitate early hospital discharge.

Technology

The use of the electronic medical records (EMR) can support a change in staffing guidelines by improving the documentation and communication processes.  The use of tele-medicine or video monitoring can also be used in hospital in rural areas where physicians are not easily accessible. Telemedicine is described by Medicaid. Gov (n.d) as a cost effective alternative to the more traditional face-to-face way of providing medical care. These tools are added resources to nurses which can promote the delivery of patient care and improve patient outcomes. This would also decrease readmission rates so patients that are inpatient are in need of acute care.

Health Literacy Activities

Health literacy is an issue in the healthcare system that affects many patients from low socioeconomic status and low education to vulnerable population and minority groups. It is important for healthcare providers to ensure that each patient receives proper education about their disease process and self-management. Patient education can reduce disease exacerbation which in turns reduces the number of hospital visits, decreasing the healthcare costs (McHugh et al. (2017). Healthcare providers also need to be educated on issues like utilizing hospital resources to maximize patient care. Is important for healthcare providers to learn to delegate, especially when there is a patient that needs complete attention. Poor staffing can also influence the nurse’s ability to adequately handle patient education needs.

Administrative or Policy Changes

The current policy in most hospitals across the nation regarding nurse-to-patient ratio is based on the availability of staff and patients acuity. This policy needs to be change to a 1:1 nurse-to-patient ratio in the ICU. There are many reasons why this policy needs to be change; in order to improve work environment for nurses and decrease workload.

Administrative polices need to change to improve the work environment for nurses and decrease nurse-to-patient ratios. McHugh et al. (2017) explained that a more desirable work environment is connected to higher chances of patient survival. Outcomes are greater when nurses have a more acceptable workload and work in positive hospital work environment, leaders can be supportive of a good work environment by ensuring adequate nurse staffing. McHugh et al. (2017) also explained that failure to rescue (FTR) is a patient safety indicator used to assess the hospital’s ability to rescue patients who developed serious complications; there is evidence that patient care in hospitals with better nurse staffing have lower odds of FRT.

Population Health

The Affordable Care Act (ACA) was created in 2014 to promote equitable access to healthcare patient across the diverse populations and age groups. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy, childbirth, and mental health services (Healthcare.gov, n.d). ACA also offers preventive services like shots, screening tests, birth controls, patient education and counseling. Most plans under ACA offer behavioral health treatment like psychotherapy, counseling, inpatient services and substance abuse treatments. Coverage to the above services are not limited to those with low socioeconomic status, chronic or preexisting conditions, minority groups and immigrants. Preventative care can decrease healthcare costs by decreasing hospitalizations and unnecessary visits to the emergency room. Hospitals that save money with low hospitalization rates can increase their budget on nurse staffing.

Implementation Plan

 Implementation Factors

There are many factors that are likely to have a major effect on the implementation of a change in nursing staffing. Hospitals would most likely reject the change because of the financial impact that this change would have on the organization. Hiring and training additional staff to work in the ICU would require investment in time and money, but the investment is necessary, feasible and should be allowed by the organization.

Technological Considerations

Patient’s conditions can deteriorate rapidly, therefore hospital administrators need to have appropriate staffing to support patient needs. American Association for Critical Care Nurses (2018) explained that “adequate staffing requires flexible systems and tools, dynamic scheduling options, and influential, educated leaders accountable for the outcomes of staffing decisions”. For example, the use of EMR and telemedicine can provide options for high quality care. Having technologies like the above to diminish the demand on nurses and increase the ability of nurses’ work is imperative to impact patient outcomes.

Institutional Structures

The American Association of Critical Care Nurses (2018) identified that hospitals continue to operate in a similar way like traditional industries where the staff is view as an operating expense. However nurses are more than that, nurses are skilled and educated healthcare professionals, who currently are viewed as hourly laborers. Nurses should not be viewed as an expenses, instead they should be recognized as leaders to better outcomes, patient safety, and patient/family satisfaction (American Association of Critical Care Nurses, 2018). This way of thinking and transformation could support the need for financial contribution in staffing.

Financial Trends That Affect the Availability of Human Resource and Project Funding

It is important to have a collaboration between hospital administrators and nursing staff to achieve appropriate staffing, which can contribute to increased hospital financial viability and decreased patient costs. The American Association of Critical Care Nurses (2018) explained the importance of organizations to test new staffing models and embrace changes. The new staffing model should allow nurses to document and collaborate with the multidisciplinary team in order to identify solutions to care delivery challenges.

Hospital or Governmental Policy Constraints

Adequate nurse staffing can prevent adverse patient events and reduce hospital admissions. In order to ensure adequate nurse staffing, the American Nurse Association (ANA) continues to work with law makers and the current administration to support safe nurse staffing (2018). So far state hospital associations, ANA-affiliated state nurses associations and other executives have agreed in a balanced state-level staffing legislation that can benefit patients, nurses and hospitals. A balanced approach like the above can promote the development and implementation of valid, reliable, and individualized staffing plans to ensure patient safety (American Nurse Association, 2018). Specific guidelines that support a 1:1 nurse-to-patient ratio in the ICU instead of depending on staffing availability would be a balanced approach.

Regulatory Requirements

According to the American Nurses Association (2018) seven states have already achieved safe staffing legislation using the Registered Nurses Safe Staffing Act’s committee approach, starting with Oregon in 2002, Texas in 2009, Illinois in 2007, Connecticut in 2008, Ohio in 2008, Washington in 2008, and Nevada in 2009. The legislation was enacted to ensure that nurses are not bound to work without proper training in units where they are not adequately trained or experienced, and to allow the secretary of Health and Human Services to enforce civil monetary penalties for each known violation (American Nurses Association, 2018). The Magnet recognition program is used by the American Nurses Credentialing Center to recognize hospitals for their quality improvement and a structured means to engage staff in decision-making (n.d).  Magnet recognition contributes to increased staff satisfaction, patient satisfaction and a positive financial impact.

Patient Diversity

Different ethnic backgrounds, culture and religious beliefs can have an impact and should be considered when deciding nurse guidelines. Hospitals and with large population of immigrants need to have adequate staff to accommodate patient’s needs; for example, they should have interpreters and bilingual nurses available. Populations with low socioeconomic status or low education also require additional resources to manage their diseases. Nurses may need to spend more time with the patient/family for education and training. Nurses may also need to advocate for the patient and reach out to the community and other resources that the patient may need. Hospital administrators should consider the diversity of their staff. For example, in depth training and education on how to promote self-management on vulnerable population and minority groups would be essential investment.

It would also be important for hospital administrators to promote diverse staffing with ethnic backgrounds, languages and skills to appeal to diverse populations and to ensure that they can receive cultural competent care.

In conclusion, there are many factors to consider when implementing the change proposal for nurse guidelines. Roger’s Five Step Theory recommendations to bypass the obstacles for the change proposal is to first identify the issue which is to improve nurse staffing of ICUs through setting specific nurse-patient ratios. The second recommendation is to be persuasive and insist that a change is necessary to improve patient outcomes. Recommendation three is to make the decision that a change is necessary, evaluating the advantage and disadvantage of the change proposal. The fourth recommendation is to implement the change, and the last recommendation is to continue with the plan if gets turned down. If the change proposal gets turn down by administrators, the proposal should be presented again at a later time with new evidence to show that the change is necessary.

Evaluation Plan

The evaluation plan would be use to analyze if the implementation of a 1:1 nurse-to-patient ratio can reduce patient and staff injuries and improve patient care. The first step would be to use the In-patient Quality Indicator (IQI) and Patient Safety Indicators (PSI) to collect data on patient mortality rates caused by lack of care. The second step would be to obtain a staff survey using the Hospital Survey on Patient Safety Culture to assess staff experience and knowledge about safety.  The survey should include the staff experience and satisfaction with the hospital environment, quality of care and need for improvement. The third step to evaluate the change proposal would be a financial report of the organization. The financial stability of the organization needs to be considered when evaluating an increased in nurse staffing.

Evidence 

The evidence for the steps of evaluation plan includes two articles from the Agency for Healthcare Research and Quality (AHRQ).  The first article is on the use of  the Hospital Survey on Patient Safety Culture, which indicates that “There is a growing recognition that organizational change to improve patient safety, including fall prevention, requires a general culture of safety among its staff” (Agency for Healthcare Research and Quality, 2013, p. 1). Article two supports the need for further evaluation of the quality indicators suggesting that “evaluation effort will be best amplify by a continuous communication loop between the users of these measures, researchers interested in improving these measures, and policy makers with influence over the resources aimed at data collection and patient safety measurement” (McDonald et al., 2002, p. 1).  Both articles are supportive on the use of quality indicators to provide hospitals with understanding of the issue and opportunity for improvement.

Indicators  

Some of the measurable data that will measure success, both in implementing the change itself and in ensuring quality outcomes for diverse patients include; decrease fall rates, decrease death rates and decrease medication errors. Other measurable data that can ensure success within the nursing staff would include; increase staff satisfaction, and increase retention rates. The measurable data can be used to ensure that the change proposal has been successful or if further change in necessary.

 Processes  

There are processes to use for gathering feedback from relevant nurses and patients on what is and is not working in order to support continuous improvement. In order to obtain feedback, hospital administrators should gather feedback from the nurses on the ICU about whether the implementation of the new staffing guidelines has been successful. Nurses are the front line of patient care, any change on a nursing unit should be evaluated directly by the nurses. It would also be important to obtain feedback from patients and their families to ensure that the change is having a positive impact on patient care. Hospital administrators should encourage feedback from nurses and patients and should make rearrangement as needed.

References

• Agency for Healthcare Research and Quality. (2013). Preventing falls in hospitals. Retrieved from: https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool1a.html
• American Association of Critical Care Nurses. (2018). AACCN guiding principles for appropriate staffing. Retrieved from: https://www.aacn.org/policy-and-advocacy/guiding-principles-for-staffing
• American Nurses Association. (2015). Nurse staffing. Retrieved from: https://www.nursingworld.org/practice-policy/advocacy/state/nurse-staffing/
• American Nurses Association. (2018). Safe staffing. Retrieved from: https://ana.aristotle.com/SitePages/safestaffing.aspx
• American Nurses Credentialing Center. (n.d) Magnet recognition program. Retrieved from: https://www.nursingworld.org/organizational-programs/magnet/why-become-magnet/benefits/
• Driscoll, A., Grant, M.J., Carroll, D., Dalton, S., Deaton, C., Jones, I., Lehwardt, D., McKee, G., Munyombwe, T., & Astin, F. (2018). The effect of nurse-to-patient ratios on nurse-sensitive patient outcomes in acute specialist units: A systematic review and meta-analysis. European Journal of Cardiovascular Nursing, 17(1), 6-22. https://doi.org/10.1177/1474515117721561
• Healthcare.gov. (n.d). Essential health benefits. Retrieved from: https://www.healthcare.gov/glossary/essential-health-benefits/
• Medicaid.gov. (n.d). Telemedicine. Retrieved from: https://www.medicaid.gov/medicaid/benefits/telemed/index.html
• McDonald, K. M., Romano, P. S., Geppert, J., Davies, S. M., Duncan, B. W., Shojania, K. G & Hansen, A. (2002). Measures of patient safety based on hospital administrative data-the patient safety indicators. Agency for Healthcare Research and Quality. ISBN-10: 1-58763-121-0
• McHugh, M. D., Rochman, M. F., Sloane, D. M., Berg, R. A., Mancini, M. E., Nadkarni, V. M., Merchant R. M. & Aiken, L. H. (2017). Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Medical Care, 54(1), 74-80 doi: 10.1097/MLR.0000000000000456
• Shin, S., Park, J-H. & Bae, S-H. (2018). Nurse staffing and nurse outcomes: A systematic review and meta-analysis. Nursing Outlook, 66(3), 273-282. https://doi.org/10.1016/j.outlook.2017.12.002
• Shang, J., Stone, P. & Larson, E. (2015). Studies on nurse staffing and health care-associated infection: Methodologic challenges and potential solutions. American Journal of Infection Control, 43(6), 581-588. https://doi.org/10.1016/j.ajic.2015.03.029
• Udod, S. & Wagner, J. (n.d) 9. Common change theories and application to different nursing situations. Pressbooks. Retrieved from: https://leadershipandinfluencingchangeinnursing.pressbooks.com/chapter/chapter-9-common-change-theories-and-application-to-different-nursing-situations/