Concern For Care Executive Summary

This project explores trends affecting patient care and the practice of registered nurses (RNs) within acute care hospitals in Minnesota.

In recent years, pressure has mounted within the acute care environment to balance cost and quality. Even more recently, employers have been confronted with increased consumer demand on the health care system. These factors have contributed to actions that have changed the skill mix of nursing personnel on hospital units. In many cases in the acute care setting, the number of licensed practical nurses (LPNs) and nursing assistants has increased while the number of RNs has decreased.

Purpose: Explore Practice Trends

The primary purpose of this project is to identify how such current trends affect registered nurses’ concerns for quality patient care and what impact those concerns may have on effective, safe professional nursing practice.

Data for this study was reported by RNs employed by facilities with bargaining units represented by the Minnesota Nurses Association (MNA).

Information was gathered using the following sources:

• 1,231 Concern for Safe Staffing and Concern for Practice Forms from the years 1995 to March, 1999.1
• 5 follow up focus groups and meetings
• 78 staff nurse interviews
• 18 and nursing administrator interviews

Four key issues related to patient care and professional nursing practice emerged from the data in this study:

1. Compromises in patient care result from inadequate staffing on nursing units.
2. Lack of supportive working environments for nurses affects the quality of care for patients.
3. Description and documentation of staffing variables is inadequate and limits determining appropriate staffing at the unit level.
4. Concern for maintaining professional nursing practice standards is heightened in situations where staffing is considered inadequate.

A Synopsis of Issues

Compromises in patient care result from inadequate staffing on nursing units

The amount and type of staff available per shift on a particular unit can dramatically decrease the amount of time RNs have available to provide essential care, according to MNA forms. Nurses documented short staffing situations in seventy two percent of the Concern for Safe Staffing reports analyzed. Registered nurses in this study regularly reported an inability to perform basic care such as feeding, bathing, and walking a patient and to assess and monitor patient status and outcomes. Because of time constraints, RN’s were frequently unable to give medications, administer treatments, and provide teaching or emotional support in a timely manner or at all.

Lack of supportive working environments for nurses affects the quality of care for patients

Nurses expressed extreme concern regarding their ability to provide safe care to patients under short staffing situations. An escalating level of frustration was reported by nurses as they struggle to maintain standards of professional nursing care within their work environments. Requirements in some work settings such as mandatory overtime and cross training have further increased job-related stress. Nurses regularly reported a decrease in both organizational and peer support. The visibility and availability of nurse managers at the unit level have diminished with hospital restructuring. The current work environments do not facilitate a sense of belonging to a group ("esprit de corps") or a feeling of basic respect and dignity.

Nurses perceive acute care environments are not always safe places for patients nor satisfying work settings for nurses. Where the care and healing relationship between the nurse and the patient as well as the mutual respect between nurse and organization is lacking, nurses believe patient care will ultimately be affected.

Description and documentation of staffing variables is inadequate and limits determining appropriate staffing at the unit level

Variables included to determine staffing within units of hospitals are neither comprehensive nor accurate, according to nurses. Registered nurses and nursing administrators participating in this study urged action to enhance the accuracy and predictability of staffing plans.

Two factors were repeatedly identified as creating extreme variability in staffing situations on nursing units; 1) Patient acuity levels, and 2) the total volume of patients on a unit (including admissions and discharges). Neither of these factors is adequately accounted for in "variable" staffing plans.

In addition to patient acuity and volume, registered nurses strongly recommended including nurse characteristics - type of nursing personnel available and the level of nursing care required - in helping to determine staffing levels.

According to the compiled data however, fifty-nine percent of nurses completing the "Concern for Safe Staffing" forms answered "no" to the question "Is staffing based on acuity?" In addition, continuous patient turnover (admissions and discharges) on some units creates severe staffing shortages due to the amount of nursing time often required in these changing situations.

Concern for maintaining professional nursing practice standards is heightened in situations where staffing is considered inadequate

Nurses consider some hospital-mandated procedures to be unsafe to patients and a risk to their licenses. Examples include the lack of policies governing the transcription of medical orders and the transportation of unstable patients from unit to unit within the hospital environment. These situations are often created by the inappropriate use of unlicensed personnel and short staffing.

Purpose: Examine Internal Procedures

A secondary purpose of this project is to identify a systematic process for continuous documenting and reporting of aggregated data within MNA on the issues of nursing practice and staffing.

Although the nurses in this study unanimously endorsed the use of some type of system to document and resolve staffing and practice issues within the work setting, the current MNA forms, Concern for Safe Staffing and Concern for Practice, are not effectively utilized by either the facilities or MNA. Fifty-seven percent of the nurses stated that no procedure for tracking these forms existed in their work settings. Of the nurses who acknowledged the existence of a procedure, sixty-five percent stated it was not effective in resolving staffing issues. Nurses regularly reported a feeling that little follow-up was done by either the facility or MNA after submitting a Concern for Safe Staffing form.

General Recommendations

1. Develop a single tool for collecting and analyzing data on practice and staffing.
   • Include mechanisms for explicitly connecting the issues of practice and staffing to patient care outcomes.
   • Expand the use of the tool from acute care settings to additional areas of nursing practice (particularly long-term care where similar practice and staffing issues exist).
   • Report the data at regular intervals not less than once a year.
2. Initiate the process of determining recommended staffing guidelines/principles which include both patient and nurse characteristics as well as structural features of the environment (ANA’s Nurse Staffing Principles (April 1999) outlines a format for establishing this process).
   • What are "core" requirements of a nurse on a particular unit?
   • Consider decisions regarding the need for additional staff be determined on a per shift basis at the unit level.
3. Address the concerns of nurses feeling more stress and minimal or non-existent support in the current work environment.
   • Determine effective strategies aimed at the "Care of the Caregiver" at both the individual and organizational levels.
4. Continue dialogue with institutions of higher education to explore strategies to increase recruitment into the profession and to expand the educational opportunities for practicing nurses.
   • Consider content related to labor relations and to quantifying/ qualifying nursing practice be explicitly included in nursing school curriculums and continuing education workshops.
5. Consider community level strategies regarding the issues of nursing practice and safe staffing.
   • Convene a statewide forum for the purpose of highlighting the relationship of nurse practice and staffing issues to the care of communities.
   • Explore the possibility of staffing quotas and how the regulatory/legislative process may facilitate resolving the issues of nursing practice and staffing.