ANA continues attack on staffing redesign

Preliminary results of an American Nursing Association (ANA) study indicate staffing mixes containing a high ratio of unlicensed assistive personnel (UAP) to RNs hurt patient clinical outcomes.

The survey, Implementing Nursing’s Report Card: A Study of RN Staffing, Length of Stay, and Patient Outcomes found staffing mixes containing a high RN ratio were related to shorter lengths of stay per acuity-adjusted day, and fewer RNs in the skill mix were related to an increase in nosocomial infections, such as pressure ulcers, pneumonia, postoperative infections, and urinary tract infections. In addition, nursing intensity weights by DRG were found to be significantly related to differences in nurse staffing ratios.

The Washington, DC-based ANA commissioned the study to measure nursing’s affect on selected patient outcomes and to assess the feasibility of capturing the information necessary to develop specific staffing and outcome measures for hospitals.

The preliminary findings come from data collected in California, Massachusetts, and New York. Next, the ANA wants to extend the project to other parts of the country. The ANA will use the project to provide a framework for educating consumers and policy-makers about nursing’s contributions to care. The ANA has been battling increased use of UAPs in various care models, such as those advocated in patient-focused care redesign.

"We wanted to see what, if any, data were being collected by hospitals. We knew that many report card projects are collecting administrative outcomes, such as how long a patient waits for an office visit or how long the phone call is. But we wanted to encourage hospitals and networks to begin to collect data in the areas of nursing care-sensitive activities, especially related to clinical outcomes of patients. Our focus is the patient and how he [or she] is affected by nursing — that patient’s clinical outcomes," says Sarah Stanley, RN, MS, director of nursing practice with the ANA. Stanley has been director of the report card project since its launch in November 1994 as part of the group’s Nursing’s Quality Initiative.

The first step was to identify measurable quality indicators of nursing structure, process, and outcomes for acute care settings. Three types of quality indicators were categorized:

Patient-focused. How patients and their conditions are affected by their interactions with nursing staff.

Process of care. How care is delivered. This includes how nurses perceive and discharge their roles and the nature, amount, and quality of care provided.

Structure of care. Measures of staffing patterns expected to affect quality and quantity of care. This includes ratio of RNs to patients, number of care hours provided to patients and safety rate with which nurses are deployed.

From the following 10 indicators, the committee selected the first seven as seeming to show the strongest link to patient care:

• mix of RNs, LPNs/LVNs, and unlicensed staff;

• ratio of nursing staff to patients;

• nursing staff satisfaction and turnover;

• nosocomial infections;

• decubitus ulcers;

• patient injury rate;

• patient satisfaction;

• RN education and qualifications;

• use of agency nurses;

• medication errors.