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Concerns About Staffing Levels and
Patient Care in Acute Care Settings
Carol Diemert, RN, MSN
Minnesota Nurses Association
August 1, 2002
Causative Factors
Nursing shortage
Restructuring of health care delivery system
Increased demand for nursing services
(and health care in general)
Workplace issues, e.g., excessive
workloads, stressful job, increases in illness
and injury, low levels of morale and job
satisfaction
Focus on patient safety
Critical Public Health Issue
“I believe this [nursing shortage]
is the issue in health care for the
next 10 years. It will supercede
other issues, as more and more of
the public find themselves unable
to access care when they need it.”
-Daniel Sisto, President, Healthcare Association of New York State
“Shortage of Nurses Worsens: ‘Doorstep of a crisis’ reached as demand
outpaces supply.” Newsday, February 26, 2001
Fundamentally Different
RN Shortage
Steep demand growth will continue while
supply growth will slow and then decline
significantly after 2010
Two decades of decline in younger RNs
Less status perceived in nursing career
Years of dwindling RN graduations
Lower real and relative RN wages
Unremitting cost pressures
Economy-wide workforce shortages
RN Supply-Demand Relationship
Slow but steady growth in supply of
RNs, but peak & decline on horizon
Rapid and steep increase in demand
Diverging supply & demand curves
Shortage generally considered
“demand-driven” for now
Both supply and demand will fuel RN
shortage in the near future
U.S. RN Supply and Demand, 2000 - 2020
2,600,000
The Gap: 650,156
2,500,000
RN FTEs
2,400,000
2,300,000
The Demand
2,200,000
2,100,000
2,000,000
The Supply
1,900,000
1,800,000
1,700,000
2000
2005
2010
2012
2015
Years
2020
1.
Demand curve, American Health Care Association, February, 2001
2.
March, 2000 RN FTEs = 1.9 million, National Sample Survey of Registered
Nurses: Preliminary Findings, February, 2001
3.
2000 supply = 2020 supply, Buerhaus, et. al., “Implications of An Aging
Registered Nurse Workforce”, JAMA, June 14, 2000
Restructuring of the Health
Care Delivery System
The focus on cost containment driven largely by
managed care has included a marked and often
unsafe, decrease in the utilization of registered
nurses. American Nurses Association, 1999
The downsizing, structuring of jobs and
increased use of unlicensed assistive personnel
were dominant factors resulting in decreased
quality of care. Schindul-Rothschild, 1996. Where
Have All The Nurses Gone, AJN
Demand for Nursing Services
Estimated U.S. increases in demand for
nursing services, 1991 - 2020
54% increase projected for All
Settings



41% increase projected for Short Term
Hospitals
66% increase projected for Nursing Homes
270% increase projected for Home Health
Agencies
Source: American Health Care Association, February, 2001
Demand for Patient Services
Increases per 1000 Minnesota health plan
members, 1995 - 1999:
38% increase in outpatient surgeries
19% increase in preventative care visits
11% increase in inpatient hospital
admissions
5% increase in office visits
Pharmaceutical costs and greater service
volumes are driving healthcare spending
Source: Minnesota Council of Health Plans
Workplace Issues
2001 ANA Staffing Survey
75% of RNs feel quality of nursing care declined
over past 2 years at their facilities
54% of RNs would not recommend the nursing
profession to their children or friends
40% of RNs would not feel comfortable having a
family member or someone close to them
cared for in the facility in which they work
American Nurses Association, February 6, 2001
Workplace Issues
2001 ANA Staffing Survey con’t
78% of RNs indicated they are skipping meals
and breaks to care for patients
58% of RNs stated they are pressured to work
voluntary overtime
52% of RNs stated they suffer from increased
stress-related illness
American Nurses Association, February 6, 2001
Workplace Issues
RN Illnesses & Injuries
Hospitals report more non-fatal workplace
injuries than any other private sector industry
according to the Bureau of Labor Statistics.
90 percent of intensive care unit nurses have
symptoms of post-traumatic stress disorder.
The disorder is more common among ICU
nurses than in any other segment of the
population studied – including Israeli
soldiers, Vietnam War veterans, rescue
workers and medical students.
“Not Enough Nurses”, Virginian Pilot ( Norfolk, VA) Jan. 14, 2001
Workplace Issues
They came, they saw, they went
“Dr. Georges C. Benjamin, secretary of
Maryland's Department of Health and
Mental Hygiene, summed up the
shortage this way: ‘They're not coming
in; they're not staying in; and while
they're here, they're not happy.’’’
San Francisco Chronicle, “Nationwide Shortage of Nurses
Forecast Over Next 20 Years”, February 14, 2001
Focus on Patient Safety
Institute of Medicine
November, 1999, To Err is Human:
Building a Safer Health System – A call
for action to make care safer
March 20, 2001, Crossing the Quality
Chasm – A call for action to improve the
American health care delivery system
Focus on Patient Safety con’t.
Studies on Nursing
1994, Nursing Care Report Card for Acute
Care, ANA, in which 10 specific quality
indicators of nursing were defined and
developed
1996, Shindal-Rothschild (et al) – Nurses
reported factors of downsizing, restructuring,
and increased use of unlicensed assistive
personnel as dominant factors resulting in
decreased quality of care
Focus on Patient Safety con’t.
Studies on Nursing
1998, Kovner and Gergen – Reported
an inverse relationship between nurse
staffing and adverse patient events
2000, Aiken and Patricia – Reported
that the higher the job satisfaction
scores for nurses, the higher the quality
of care
Focus on Patient Safety con’t.
Studies on Nursing
2002, Needleman, Buerhaus et al –
Reported that a higher proportion of
hours of nursing care provided by
registered nurses per day are
associated with better care for
hospitalized patients
Concern for Care: Trends in Nursing
Practice Concerns in Minnesota
Minnesota Nurses Association
Made possible by a grant from
American Nurses Association
Purpose
To explore RNs’ concerns for
effective, safe professional nursing
practice in acute care facilities.
To identify a potential system for
handling data on the issues of
nursing practice and staffing.
Background
Changes in nursing as a career choice
Valuing of “caring” work
Restructuring of the health care system
Changing demography
Summary of Methods
Quantitative Methods
Concern for Safe Staffing and Concern for
Practice Forms available from 1/95 - 3/99
(1321 forms)
 Categorized into 6 most repetitive, salient
concerns ( Figure 1)
 Established inter-rater reliability
 Compiled and summarized the data using
the program ACCESS

Summary of Methods con’t.
Qualitative Methods
2 focus group meetings
 3 regular meetings in facilities
 78 staff nurse interviews
 18 nursing administrator interviews
 Reviewed notes from meetings and
interviews - content analysis used to
identify themes

Study Outcomes
Compromises in patient care result from
inadequate staffing. (Figure 1)
Lack of supportive working environments
for nurses affects the quality of care.
Description and documentation of staffing
variables is inadequate.
Concern for practice standards is
heightened where staffing is considered
inadequate.
Study Outcomes con’t.
Compromises in patient care result from
inadequate staffing. (Figure 1)





Inability to perform basic care - 52%
Inability to do basic assessment and monitoring 70%
Inability to give medications on time or at all 22%
Lack of time to provide emotional support or
teaching - 14.5%
Concerns regarding personal safely and health
and licensure - 15%
Study Outcomes con’t.
Lack of supportive working environments
for nurses affects the quality of care
Effective communication, feeling of
belonging, and sense of respect/dignity
decreased
 Nurse managers less visible and available
 Mandatory overtime, cross training, chronic
sick time, and seniority increase stress

Study Outcomes con’t.
Description and documentation of staffing
variables is inadequate.
Acuity not regularly considered - 59%
(Figure 1)
 Admissions/discharges not often included in
volume of patients
 Type of nursing staff mix available should be
considered
 Structure and environment of the unit should
be considered

Study Outcomes con’t.
Concern for practice standards is heightened
where staffing is considered inadequate.



Hospital-mandated procedures may be unsafe for
patients and a risk for nurses
Increase in part-time nurses because of increased
demands and requirements of practice
Language minimizing the professional judgment of
the nurse may affect practice standards
Figure 1 - Summary
Reason for concern
28 Not oriented to unit
52 Not trained or experienced in area assigned
74 Given an assignment which posed a serious threat to my health
or safety
704 Case load assignment is excessive and interferes with delivery of
adequate patient care
285 Transferred, discharged, or admitted new patient(s) to unit without
adequate staff
Not given adequate staff for acuity (check appropriate descriptions)
37 Staffed with inappropriate number of temporary pool personnel
44 Staffed with inappropriate number of unlicensed personnel
883 Short staffed
92 Not provided with unit clerk
Figure 1 - Summary con’t.
Staffing information on shift of
objection
Is staffing based on acuity?
314 Yes
442 No
Did staff provided match acuity?
31 Yes
66 No
Figure 1 - Summary con’t.
Needed staff to provide patient care
434 Short 1 RN
190 Short 2 RNs
61 Short 3 RNs
106 Short 1 LPN
17 Short 2 LPNs
2 Short 3 LPNs
136 Short 1 Ancillary
25 Short 2 Ancillary
5 Short 3 Ancillary
Figure 1 - Summary con’t.
Float/casual/temporary staff used:
513 Yes
494 No
Maximum staffing but acuity high:
39 Yes
6 No
Acuity:
837 High
178 Average
2 Low
Figure 1 - Summary con’t.
Compromises in patient care resulting
from lack of staff?
651 (52%) Basic hygiene, feeding, ADLs not done on time
or at all.
856 (70%) Assessment, observation, not done as scheduled
jeopardizing patient safety.
268 (22%) Medications, orders, not done on time or at all.
53 (4.3%) Special procedures, treatments, tests not done on
time or at all.
180 (14.5%) Emotional support or teaching not done.
188 (15%) Nurse safety or license at risk, no breaks.
Figure 2 - Interview Guide Data
Position with bargaining unit:
49 Chair 11 Rep 15 Member
In your work environment, do you use the
Concern for Safe Staffing form?
49 Yes
5 No
3 Have own form
 Concern for Practice form?
6 Yes
15 No
10 Never heard of it

Approximate number of forms completed in one year
span of time:
26 Less than 10
53 10 to 50
11 More than 50
Figure 2 - Interview Guide Data
con’t.
Does your workplace have a formal procedure for
responding to the concerns expressed through
the use of these forms?
20 Yes
29 No
2 "Sort of"
Do you think the procedure in your workplace is
effective?
6 Yes
22 No
6 Sometimes
Is your perception that your workplace is
currently experiencing a shortage of nurses?
39 Yes
10 No
Conclusions (Secondary Purpose)
Use of Concern for Practice and Concern for
Safe Staffing forms is episodic rather than
systematic.
Data not regularly compiled or reported.
Practice and staffing issues are often
interrelated, but are not systematically
connected.
57% of respondents stated no follow-up
procedure in their facility.
65% of respondents stated existing procedure
not effective.
Sample Management Response
Example of Management Response
to Concern for Safe Staffing
refer to page 23 of report
 includes:

actions taken
 effects on patient care
 follow-up by nurse manager
 conclusion

Sample Management Response
con’t.
Procedure for Follow-up
to Concern for Safe Staffing Forms
SAMPLE HOSPITAL SAFE STAFFING CONCERN LOG
DATES / TOTAL
DATE/
SHIFT
PATIENT
CARE AREA
ISSUE
ACTION TAKEN
THAT SHIFT
MANAGER
FOLLOW-UP
Sample Log
SAMPLE HOSPITAL SUMMARY - SAFE STAFFING CONCERN LOG
Total Received
By Unit:
2E
3W
3E
ICU
4W/4E
2W
E.D.
SARS
PACU
5E
1st
Quarter
2nd
Quarter
3rd
Quarter
4th
Quarter
Total
19
0
0
3
1
6
1
7
1
0
0
30
0
0
0
1
0
0
22
0
0
7
8
0
0
1
3
0
0
4
0
0
0
11
0
0
2
2
3
0
0
0
0
4
68
0
0
6
7
9
1
33
1
0
11
Follow-up Since Study
at Minnesota Nurses Association
Implemented, tracked and reported new
Concern for Safe Staffing forms
2. Operationalized the patient flow policy
contained in contract agreements between
MNA and several metro hospitals following
nurses strike June 2001
3. Passed the mandatory overtime bill
(MS181.275) in 2002 legislature
1.
Follow-up Since Study
at Minnesota Nurses Association con’t
4.
Promoted the ANA programs:


Nursing-Sensitive Quality
Indicators for Acute Care
Magnet Nursing Service
Recognition
Concern for Safe Staffing Form
The revised Concern for Safe Staffing
form is attached
Contract Language/Collective
Bargaining Agreements
All units will review staffing grids which
cannot be changed downward unless
evaluated by a team. Staffing grids will
be based on acuity, experience level of
RN staff, composition of skills/roles
available, unit admissions, discharges,
and transfers.
In the Twin Cities agreements, MNA
won the right for RNs to close a unit
to new patients when too few staff are
available to care for more patients.
This landmark innovation to deal with
excessive workloads could set a new
direction in collective bargaining.
American Journal of Nursing, August 2001
In the area of health and safety, there
is growing interest among frontline
nurses to protect themselves and their
livelihood from work-related injury and
illness. This concern is likely to intensify
and become a dominant issue at the
bargaining table.
American Journal of Nursing, August 2001
Mandatory Overtime Bill
What does the new law accomplish?
The new law clearly states that a hospital is
prohibited from “taking any action against a nurse
solely on the ground that the nurse fails to accept
an assignment of additional consecutive hours at
the facility in excess of a normal work period, if the
nurse declines to work additional hours because
doing so may, in the nurse’s judgment, jeopardize
patient safety.” MS 181.275 Subd. 2
Mandatory Overtime Bill con’t
The focus of the law is on the nurse being able to
exercise his/her own judgment to decline the work
if the nurse believes working the additional hours
would jeopardize patient safety. The law clearly
recognizes that the nurse, not the employer, must
make this judgment call.
Nursing Sensitive
Quality Indicators
What is NDNQI?
The National Database of Nursing Quality
Indicators (NDNQI) is a project of the American
Nurses Association’s (ANA) Safety & Quality
Initiative, which addresses the issues of patient
safety and quality of care arising from changes
in health care delivery.
What kind of information is in NDNQI?
NDNQI will contain information on nursing staff
mix and nursing hours, as well as indicators that
describe the structure, process, and outcomes of
care. The following seven quality indicators form
the core of NDNQI:
Patient Injury Rate (Falls)
Maintenance of Skin Integrity (Pressure ulcers)
Patient Satisfaction (Overall care, nursing care,
patient education, and pain management)
Nursing Staff Satisfaction
Skill Mix of RNs, LPNs/LVNs, and Unlicensed Staff
Total Nursing Care Hours Provided per Patient Day
Nosocomial Infections
Magnet Recognition Program
AAN Study 1983
41 hospitals
Attracted and retained qualified nurses
(magnet concept)
Promotion of quality patient care
through excellence in nursing services
Magnet Recognition Program
Purpose
Recognize excellence in:
Management philosophy and practices
of nursing services
Adherence to standards for improving
the quality of patient care
Leadership of the Chief Nurse Executive
in supporting professional practice and
continued competence
Attention to cultural and ethnic diversity
in patient, family and staff