SAFE STAFFING SAVES LIVES

INTERNATIONAL NURSES DAY 2006 SAFE STAFFING SAVES LIVES Information and Action Tool Kit

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SAFE STAFFING SAVES LIVES Table of Contents Introduction 5 Chapter 1 - Backgrounder on Safe Staffing 7 Chapter 2 - Why is Safe Staffing Important? 9 Chapter 3 - Opportunities 13 Chapter 4 - Obstacles 15 Chapter 5 - How Is It Done? 17 Chapter 6 - Role of National Nurses Associations 21 Chapter 7 - Recommendations 23 ANNEXES Annex 1: Nurse Staffing Assessment Tool 27 Annex 2: Safe Staffing: What Nurses Can Do 29 Annex 3: Sample Press Release 31 Annex 4: Did You Know? Facts of Safe Staffing 33 Annex 5: American Nurses Association Principles for Nurse Staffing 35 Annex 6: Estimating the Size and Mix of Nursing Teams 37 Annex 7: Position Statement: Occupational Health and Safety for Nurses 43 Annex 8: Position Statement: Patient Safety 47 Annex 9: Examples of Nurse-Patient Ratios 51 Annex 10: Sample Powerpoint Presentation 53 References 57 3

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Safe Staffing Saves Lives Introduction The concept of safe staffing emerged as a result of changes in the health care system worldwide. The provision of health care is seen by most countries as high priority. The degree of accountability for health care services and the concept of care provision are at the forefront of most political discussions. However, accountability becomes difficult when there is an inadequate supply of health care personnel such as nurses. In Africa, for example, the lack of nurses is a continuously debated issue in newspapers and magazines, but there is little resolution at the national level. The concept of safe staffing emerged as a result of changes in the health care system worldwide. During the past 20 years there have been major crises such as the AIDS pandemic, SARS, potential flu outbreaks, economic recessions leading to nursing shortages and escalating health care costs. There is now a greater understanding of the impact of nurse staffing on patient safety and morbidity and mortality. This tool kit is designed for use by professional nursing associations and nurses. It outlines the essential background information to support the argument for appropriate staffing levels. The annexes contain support material that include a nurse staffing assessment tool, a list of activities for nurses to improve safe staffing a fact sheet, a sample press release, a sample power point presentation and examples of nurse-patient ratios. The main document includes a backgrounder on safe staffing with relevant information that is essential to consider when discussing safe staffing issues. Evidence is provided that staffing levels have an impact on morbidity and mortality outcomes. The importance of skill mix and the clarification of roles are emphasized. The section entitled How Is It Done? describes legislation and frameworks and emphasizes the role of professional judgement in promoting strategies for safe staffing. In addition, important position statements are outlined to provide further background. Recommendations will guide nursing associations as they lobby for adjustments in work environments and adequate levels of nursing staff to provide safe care. Shortages and the shift of health personnel from countries with great need to those able to afford and sustain higher levels of professional workers have given rise to concerns about the health of the workforce. Issues such as healthy work environments, nurses health and appropriate staffing to maintain and sustain healthy populations have become progressively more important. There has been increased research demonstrating that the level of staffing has an impact on patient outcomes such as mortality. While this research is just beginning and is often undertaken within a Western context and focused on hospital care settings, it highlights a positive relationship between nurse staffing and overall patient care outcome. 5

There is no general consensus in the literature as to what safe staffing means. Because there are often economic constraints and a lack of access to higher education, some countries have used a variety of health personnel to provide care. There is no general consensus in the literature as to what safe staffing means and few definitions suit all international settings. However, authors do recognise that much of safe staffing is related to the care situation and elements include having an appropriate number of staff to meet the complexity of client needs in a range of settings. Nurses are a critical component of multidisciplinary teams and frequently provide care together with alternative care providers, such as family members. In examining the concept of safe staffing through an international lens, it is recognised that nurses work alongside various care providers. However, this does not exclude the importance of available professional staff. Because there are often economic constraints and a lack of access to higher education, some countries (e.g. India, Pakistan and China) have historically used a variety of health personnel to provide care. For example, lady health visitors, barefoot doctors and doulas are all categories of health workers that provide care in regions where there is little or no access to health professionals. In certain areas nurses work closely with lady health visitors (LHVs), a group of health workers who have existed in Pakistan since 1951. They are aligned with medicine and provide basic nursing care, maternal child health services and training of community workers (Upvall & Gonsalves 2002). LHVs are distinguished from nurses on the basis that they are health care providers who work in the community rather than the hospital (Upvall & Gonsalves 2002). In China, barefoot doctors played an important role in care provision. They were initiated in the 1960s during the Cultural Revolution. Thousands of peasants were given intense medical training in only a few months, after which they continued their farming work in the commune fields and provided basic health care. The programme was intended to expand the idea of health for the masses beyond infectious disease and provide sufficient health care services for the people of China. Although the programme collapsed in the 1980s and 1990s due to financial cutbacks, it was successful in reducing the incidence of diseases such as schistosomiasis. Countries still look to this model as a possible solution to the lack of personnel necessary to provide adequate care in rural health areas (Valentine 2005). Winslow (2005) recounts a recent example of alternative care provision using lay personnel in a remote American community. A member of the community, which was located 50 miles from the nearest hospital, received a mechanical heart (also known as a Left Ventricular Assist Device [LVAD]). Given the distance, there was need for a fully trained network able to respond quickly to emergency LVAD situations. As part of this initiative, the patient and his wife, their neighbours and emergency workers were given extensive instruction on how to provide back-up support in case of emergency. Career progression is an important factor in retaining health personnel. An important consideration in maximising the entire workforce potential is the creation of career progression (ladders) for workers involved in health care; thereby capitalising on the initial interest and experience of allied health personnel. This is important in recruitment of health workers and retention of a sufficient supply. 6

CHAPTER 1 Backgrounder on Safe Staffing Nursing care is considered essential to providing health care in a variety of settings. Authors began to realise that staffing went beyond numbers. It has been demonstrated that nursing care is essential to providing health care in a wide range of settings. As a result, much attention has been paid to levels of nurse staffing and variables necessary to provide safe and effective health care. For example, examining the appropriateness and availability of nursing staff. An important early definition of the term staffing is, the numbers and kinds of personnel required to provide patient care to patient or client (Giovannetti 1978, as cited in McGillis Hall 2005, p. 2). Authors have since realised that staffing goes beyond numbers and have included other variables that affect staffing and the provision of safe care, such as: workload, work environment, patient complexity, skill level of the nursing staff, mix of nursing staff, cost efficiency and effectiveness and linkage to patient and nurse outcomes. Authors have started to relate staffing levels to key indicators (e.g. mortality rates), thus introducing the element of patient safety. There are few definitions that merge the concept of safe with staffing. Interestingly, however, there are few definitions that merge the concept of safe with staffing. The American Federation of Teachers (1995) states: Safe staffing means that an appropriate number of staff, with a suitable mix of skill levels, is available at all times to ensure that patient care needs are met and that hazardfree working conditions are maintained. The North Carolina Nurses Association (NCNA 2005) more recently stated: Safe staffing reflects the maintenance of quality patient care, nurses work lives and organisational outcomes. Safe staffing practices incorporate the complexity of nursing activities and intensities; varying levels of nurse preparation, competency and experience; development of health care personnel; support of nursing management at the operational and executive levels; contextual and technological environment of the facility; available support services; and the provision of whistleblower protection. 7

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CHAPTER 2 Why is Safe Staffing Important? The Patient Safety Movement The patient safety movement is important because it focuses on a variety of care indicators. The evidence to support adequate staffing is beginning to accumulate. The patient safety movement is important because it focuses on a variety of care indicators. It is a broad area that was legitimised by documenting adverse events resulting from the care typically given in hospital settings. Adverse events such as falls, drug errors and inappropriate surgeries were documented as factors that increased the morbidity and mortality of patients. In the Canadian Adverse Events Study, Baker et al. (2004) found an incidence rate of 7.5% for adverse events. This suggests that of almost 2.5 million annual hospital admissions in Canada similar to the ones in this study, about 185,000 are associated with an adverse event, of which 70,000 are preventable. Equally alarming statistics were found in a project commissioned by the Institute of Medicine. In their review, Kohn, Corrigan and Donaldson (2000) showed that health care systems have problems arising from inadequate processes, inadequate human resource support and systems that do not promote safe practices. The authors note that experts estimate 98,000 people per year die from medical errors occurring in hospitals; this is more than die from motor vehicle accidents, breast cancer or AIDS. Recommendations are proposed at national, state and local levels to reduce medical errors and improve patient safety and centre around: Leadership and knowledge for patient safety; Error reporting systems; Protection for nurses reporting adverse events and staffing issues; Setting performance standards and expectations for patient safety; and Creating safety systems in health care organisations. In order to accomplish the above, there has to be adequate staffing. A number of research articles have described a direct relationship between safe staffing and patient outcomes (e.g. mortality and morbidity). The evidence to support adequate staffing is beginning to accumulate for various conditions and settings. Although this research is from a Western perspective and focused on hospitalbased care, it does provide good background to support decisions that encourage adequate staffing. As early as 1998, Blegen, Goode, and Reed studied the effect of nurse staffing on patient mortality and morbidity. They found that a higher registered nurse (RN) skill mix corresponded to a lower incidence of medication errors and pressure ulcers and higher patient satisfaction. An additional study that year examined nurse staffing levels and patient outcomes and found that medication administration errors were reduced with a higher proportion of RNs in the staff mix (Blegen & Vaughn 1998). 9

Kovner and Gergen (1998) found a relationship between full-time-equivalent (FTE) RNs per patient day and urinary tract infections, pneumonia, thrombosis and pulmonary compromise after major surgery. In a study of over 68,000 acute myocardial infarction patients, RN hours per patient day were found to be inversely related to mortality (Schultz, van Servellen, Chang, McNeese-Smith & Waxenberg 1998). In their study comparing the quality of care given to AIDS patients, Aiken, Sloane, Lake, Sochalski and Weber (1999) found that an additional nurse per patient day was associated with a 50% decrease in 30-day mortality. An increase of 0.25 nurses per patient day was associated with a 20% reduction in 30-day mortality. The risk of postoperative and pulmonary complications was found to increase if a nurse cared for more than two ICU esophagectomy patients at night (Amaravadi, Dimick, Pronovost & Lipsett 2000). 10 Authors have found an inverse relationship between mortality and RNs per patient day. Kovner (2001) examined the impact of staffing and the organisation of work on patient outcomes and health care workers. Research on staffing was found to be discipline-specific (i.e. nursing). Most authors have found an inverse relationship between mortality and RNs per patient day, RNs as a percentage of all nursing staff, and RNs per hospital. Some authors reported an inverse relationship between RNs per patient day and adverse events. In an observational cohort study conducted by Dimick, Swoboda, Pronovost and Lipsett (2001), an association was found between fewer nurses at night and an increased risk for specific postoperative pulmonary complications. Lower fall rates and higher patient satisfaction levels with pain management were observed when there were increased RN hours worked per patient (Sovie & Jawad 2001). In an influential study by Aiken, Clarke, Sloane, Sochalski and Silber (2002), data from 10,184 staff nurses and 232,342 surgery patients was collected and analysed. The authors found that each additional patient per nurse with a four-patient caseload was associated with a 7% increase in the likelihood of dying within 30 days of admission, and a 7% increase in the odds of failure to rescue. In Canada, a retrospective study by Tourangeau, Giovannetti, Tu and Wood (2002) investigated 30-day mortality rates for hospitalised patients. Data was gathered on 46,941 patients diagnosed with acute myocardial infarction, stroke, pneumonia, or septicemia who had been discharged from 75 acute care hospitals in Ontario, Canada. Findings support a relationship between lower 30-day mortality and a richer RN skill mix, and more years of experience on the clinical unit. A cross-sectional analysis by Needleman, Buerhaus, Mattke, Stewart and Zelevinsky (2002) examined the relation between the amount of care provided by hospital nurses and patient outcomes. Data, including that from 5 million medical patients and 1.1 million surgical patients, was analysed. The authors found a higher proportion of hours of care per day by RNs and a greater number of hours of care by RNs per day were associated with a shorter length of stay; lower rates of urinary tract infections, upper gastrointestinal bleeding, pneumonia, shock and cardiac arrest; and reduced cases of failure to rescue. Pneumonia and bedsores are well documented results of immobility. A study conducted by Cho, Ketefian, Barkauskas and Smith (2003) found that an increase of one hour worked by RNs per patient day was associated with an 8.9% decrease in the odds of pneumonia, and a 10% increase in RN proportion was associated with a 9.5% decrease in the odds of pneumonia. Bostick (2004) found an increase in RN staff time may reduce the prevalence of pressure ulcers.

A systematic review conducted in another study confirmed that adequate staffing is associated with lower inpatient mortality and shorter hospitals stays (Lang, Hodge, Olson, Romano & Kravitz 2004). Person et al. (2004) assessed the association of nurse staffing with in-hospital mortality for patients with acute myocardial infarction. They found that patients treated in environments with higher RN staffing were less likely to die inhospital. The literature demonstrates that there is a relationship between nurse staffing levels and patient outcomes. Lankshear, Sheldon and Maynard (2005) reviewed 22 studies that confirmed adequate staffing and skill mix were associated with improved patient outcomes. Finally, a literature summary by the Canadian Federation of Nurses Union (CFNU 2005) notes strong empirical evidence demonstrating the link between inadequate nurse staffing and a range of adverse patient outcomes, including: pressure ulcers; urinary tract infections; pneumonia; postoperative wound infections; medication errors; pulmonary compromise; thrombosis; pain management; upper gastrointestinal bleeding; falls, shock and cardiac arrest; failure to resuscitate; and readmission. Patient satisfaction, on the other hand, decreased with reduced nurse staffing. It also shows a reduction in adverse events when nurse staffing levels are adequate for the level of patient care required. To conclude, the literature demonstrates that there is a relationship between nurse staffing levels and patient outcomes. However, further research in a variety of international settings is important to support adequate staffing. This research is being encouraged by the International Council of Nurses (ICN) through its International and Regional Workforce Forums. The Role of Competition Hospitals in the United States of America (USA) publish precise Organisations with an adequate number of nurses and physicians are using the size of their staff to increase their competitive edge against other hospitals. details about indicators of quality in individual facilities. Organisations with an adequate number of nurses and physicians are using the size of their staff to increase their competitive edge against other hospitals. The attractive work environments of these organisations, sometimes referred to as magnet hospitals, allow them to recruit and retain staff. These hospitals share characteristics such as strong leadership, nursing representation on policy committees, a participative management style, ongoing quality improvement, good interdisciplinary relationships, and opportunity for development (Lash & Munroe 2005). This concept of competitiveness is mainly in the private sector and may not be relevant to countries with alternative health care systems such as Canada, Japan, Germany, China and Holland. While there may be private sector provision in these countries, there is not the same focus on competition across organisations. 11

Occupational Health: The Health of Nurses It is recognised that having adequate staff is important because it affects the health of nurses. It is recognised that having adequate staff is important because it affects the health of nurses. During a time of shortage, the government of Canada has become so concerned about the health of nurses that it commissioned a national study on the nursing population, which will be published in 2007. According to Baumann et al. (2001), safe staffing is essential for the demands of contemporary work environments. These environments include increased work pressure and stress resulting from concerns about job security, workplace safety, support from managers and colleagues, control over practice, scheduling, leadership and inadequate staffing. Nursing is associated with other occupations (e.g. policing and fire fighting) where there is uncertainty, high risk and a potentially dangerous environment. As with nursing, stress, burnout and issues of recruitment and retention are well documented in these professions. In terms of trying to recruit or retain staff, studies have shown there is a relationship between staffing levels and job satisfaction (Aiken, Clarke & Sloane 2002; Aiken, Clarke, Sloane, Sochalski & Silber 2002). A United Kingdom (UK) study by Sheward, Hunt, Hagen, Macleod and Ball (2005) found that high patient-to-nurse ratios were associated with increased risk of emotional exhaustion and dissatisfaction with current job. Nurses who continuously work overtime or work without adequate backup are prone to greater absenteeism and poorer health. Professional Liability Nurses often feel compromised in patient care situations when there is not adequate staff. In countries where there is a history of legal suits, professional liability is a constant concern. The Oxford English Dictionary (1989) defines the term liable as: There have been cases of individual nurses who have been found liable in the provision of care. 12 The condition of being liable or answerable by law or equity; the condition of being liable or subject to something, apt or likely to do something; that for which one is liable; an attribute or trait which sets one at a disadvantage; hence, a burdensome or disadvantageous person or thing, a handicap. There have been cases of individual nurses who have been found liable in the provision of care. The issue of liability focuses on aspects of care that include the individual as well as the team. Therefore, regardless of the situation (i.e. the context in which errors occur), the nurse is liable. Safe staffing is thus a critical element for nurses because it impacts their ability to carry out appropriate care. Liability increases in a clinical context where there is inappropriate infrastructure and staffing. In many health care environments, the lack of personnel may be an issue of supply (i.e. the country is not producing enough health care workers to support the system). An alternative situation occurs when workers are migrating at a faster rate than the country is producing new nurses. This critical dilemma is highlighted in a World Health Organization (WHO) synthesis report (Awases et al. 2004), which presents the findings of a study on the migration of health care workers out of several African countries. Because many health care workers are migrating, the nurses who are left are faced with very low staffing levels which hinder their ability to provide safe care.

CHAPTER 3 Opportunities Hospitals with safe staffing levels can realise considerable financial savings. According to the California Nurses Association (CNA n.d.), hospitals with safe staffing levels can realise considerable financial savings. Inadequate staffing results in additional costs incurred through high RN turnover rates and the need to hire temporary RN staff. The longterm investment in full-time staff yields cost savings in both recruitment and retention (Baumann & Blythe 2003a; Baumann & Blythe 2003b). Safe staffing has repeatedly been shown to contribute to better patient outcomes, which ultimately manifest in reduced health costs for individuals, families and communities and increased tax revenues as patients return to the active workforce. Skill Mix: Clarification of Roles It is important to establish the guidelines for certain health roles and determine their effective mix. Safe or adequate nurse staffing is influenced by other health care providers. Health care delivery includes a variety of roles and positions. It is important to establish the guidelines for certain roles and determine their effective mix, which will vary from country to country. There are a small number of existing models and frameworks to guide appropriate staff mix, but one size does not fit all. Regardless, determining the right staff mix is important. Errors in nursing staff mix can lead to clinical errors, which may result in adverse patient and organisational outcomes (Canadian Nurses Association 2003). Further collaboration is needed at the local and national levels to increase understanding of the contributions of various health professionals and volunteers. An interesting collaboration is currently underway in Canada to develop a joint evaluation framework for staff mix decision-making in relation to RNs, licensed practical nurses (LPNs) and registered psychiatric nurses (Canadian Nurses Association 2003). The Canadian Nurses Association (2005) has published a resource highlighting important issues concerning nursing staff mix decision-making and patient safety with a focus on RNs and LPNs. Supports for staff mix decision-making are included. The document addresses policy directions for staff mix research; decision-making frameworks and tools; legislated staffing ratios; and challenges in making appropriate staff mix decisions. 13

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CHAPTER 4 Obstacles Supply and Demand In terms of supply and demand, the basic issue is to have adequate nursing supply to meet the health needs of the population. While there is debate concerning the number of nurses required in any one country, there is no doubt that countries with an ample supply of health professionals have better health indicators. The overall supply of nurses has recently been impacted by shortages in the more industrialised nations. The overall distribution of nurses has recently been impacted by shortages in the more industrialised nations which recruit nurses from abroad. Locally, retention of the nursing supply is influenced by adequate economic compensation, healthy work environments and strong educational institutions. When there is an insufficient nursing supply, a nursing shortage occurs. In developed countries, nursing shortages occur due to inadequate supply and poor local recruitment and retention rates resulting from insufficient planning, unattractive career opportunities or early retirements (Buchan, Parkin & Sochalski 2003). What are the most efficient and effective ways to resolve nursing shortages? International recruitment is not an adequate solution. Buchan, Parkin and Sochalski (2003) propose a framework of policy responses to nursing shortages: Increase new supply from pre-registration/training; Improve retention of current staff; Improve utilisation of nurses skills and mix with other staff; Encourage return of nurses currently not practicing; and Examine scope for ethical international recruitment. Other means of increasing supply of nurses include lobbying governments. Other means of increasing supply include lobbying governments to adequately subsidise the educational system to meet internal demand and improving working environments to recruit and retain nurses in challenging work conditions. Any policy framework has to include interventions at all levels. National and local policies have to be created in order to assure a system-wide approach to sufficient human resources. The demand of a population for health care varies around the world. The demand of a population for health care varies around the world. In some countries devastated by disease, the supply of nurses is severely compromised by migration and overwhelming health requirements. The local supply of nurses can be impacted by migration. In the last four decades, the number of international migrants has more than doubled (192 million per year). Nurses are increasingly part of the migratory stream that circles the globe. Foreign-educated health professionals now make up 25% of the medical and nurse workforces of Australia, Canada, the UK and the USA. 15

The distribution of nurses has expanded with the introduction of a global labour market and the war for talent or scarce skills. Recruiting nurses from abroad, however, does not address the original recruitment/retention issues that cause shortages in the destination countries (Kingma 2006). There is, however, great regional variation across and within countries for nurses and each country has to have a variety of strategies to address local shortages. Financial Constraints Safe staffing may not receive adequate attention. Health care systems are expensive. Many interests compete for health dollars and countries vary in their investment in health issues. By and large, the overwhelming costs include pharmaceuticals, technology and physician services. The remaining dollars go to institutions and community care in which nursing care and safe staffing are embedded. Because the context of safe staffing is seated within a wide spectrum of cost concerns, it may not receive adequate attention unless it is paired with patient safety. According to Spetz (2005), the main reason hospitals in the USA do not reach optimum nurse staffing levels is because they are not paid according to the quality of care they provide. Hospitals receive little benefit to increase their quality of care, but the expense of doing so can result in high expenditures. As a result, even though greater nurse staffing can benefit patient care, the costs associated with having more nursing staff outweigh the gains for hospitals. However, cost drivers such as absenteeism, turnover of staff and greater mobility and mortality have to be considered an overall, ongoing cost to the system and to society. Lack of Effective Workload Measurement Tools Existing tools are unable to capture more than 40% of nursing work. Workload measuremen t tools are not a complete solution to determine safe staffing. For many years nursing has struggled to quantify the work of nurses. Research in this area has mainly been done in acute care settings in large teaching hospitals. There is agreement that the existing tools, which are now commercialised, are unable to capture more than 40% of the nursing work in some settings. While the tools have been helpful in identifying tasks of nurses, most have not been able to capture the cognitive/intellectual aspects of the role. Important functions such as coordination, facilitation and decision-making have not been adequately described or quantified. Thus, while workload measurement tools have been used in safe staffing debate, they are by no means a complete solution to determine safe staffing. A recent ICN (2004) document has summarised the issues in the effort to measure the work of nurses. There is no doubt that issues such as working in multidisciplinary health care teams and the evolving issue of patient and family contributions further blur the discussion of who does what. Having said that, the importance of having professional nursing as a major component of care has been well documented (Baumann, Deber, Silverman & Mallette 1998). 16

CHAPTER 5 How Is It Done? Safe staffing initiatives can be encouraged in a variety of ways. Legislation Some countries have been able to enact legislation to improve safe staffing for nurses. In the USA, for example, the American Nurses Association (ANA) has proposed safe staffing legislation for nurses (The ANA Talks 2001). The need for such legislation arose as a result of the nursing shortage in the USA and the ensuing consequences (e.g. overtime and compromised patient care and safety). The legislation, which was introduced in the House of Representatives in December 2003, includes: Whistleblower protection for nurses who report unsafe conditions; Collection and public reporting of nursing-sensitive quality data (e.g. staffing levels required for safe quality care); and The need for better tools to calculate appropriate staffing level and staffing mix. Legislated nurseto-patient ratios have been implemented in the American state of California and in Victoria, Australia. Authors have attempted to quantify the number of staff required for the range of patient problems, but this calculation is considered complex. Another approach to ensuring safe staffing for nursing is the legislation of safe staffing ratios (ICN n.d.). While staffing ratios have been recommended in Belgium using a minimum data set (ICN 2004), legislated nurse-to-patient ratios have only been implemented in the American state of California and the Australian state of Victoria (see Annex 9). However, at least 14 other US states are considering similar legislation (CFNU 2005). The ratios are the maximum number of patients that may be assigned to an RN during one shift and vary according to acute care units (CNA 2003). The specific ratios in California are based on Assembly Bill 394 and incorporate the ANA s Principles for Nurse Staffing (ANA, 1999). The bill was initiated to manage the patient-care crisis, address the nursing shortage, protect patient safety and improve the nursing situation in California (CNA 2003). Authors have attempted to quantify the number of staff required for the range of patient problems, but this calculation is considered complex. Hurst (2002) suggests other approaches for estimating the size and mix of nursing teams (see Annex 6). He reviews an algorithm that is based on professional judgement, a formula to calculate the number of nurses per shift, the nurse per occupied bed method, the acuity quality method, the time-task/activity method and the regression analyses method. All these methods require considerable data and documentation and may be difficult in environments that are already compromised in terms of adequate staffing. Hurst reviews the strengths and weaknesses of each approach. There has been some interesting work that discusses the pros and cons of using safe staffing ratios. 17

Pros: Studies indicate that a higher nurse-to-patient ratio plays an important role in the outcomes for patient care (Dimick, Swoboda, Pronovost & Lipsett 2001; Sasichay- Akkadechanunt, Scalzi & Jawad 2003); Improvement in the quality of care delivered to patients (CFNU 2005); Improved recruitment and retention of nurses (CFNU 2005; CNA 2003); Improvement in the well-being of nurses, higher morale, decline in workplace injuries, increased job satisfaction and reduced stress (CFNU 2005); Increased ability to provide services to the public (CFNU 2005); Increased confidence in the public health system (CFNU 2005); Decreased dependence on nursing agencies (CFNU 2005); and Lack of provisions for enforcement in voluntary staffing plans (CFNU 2005). Cons: Studies have found little clinical evidence to support the introduction of minimum nurse-to-patient ratios for acute care hospitals (Bolton et al. 2001; Lang, Hodge, Olson, Romano and Kravitz 2004); Consistent staffing ratios are costly and any legislation needs to be accompanied by financial agreements to adequately subsidise it; Do not accurately reflect the needs of patients or the complexity of care required (CFNU 2005); Only serve as a blunt measure for staffing requirements; Do not generally account for changes in the patient acuity level, layout of nursing unit, presence of ancillary personnel, non RN care providers, or presence of technology (CFNU 2005); May not address endemic workplace issues and is not relevant in many international contexts. One study found that patient-tonurse ratios of 4:1 are costeffective and associated with lower patient mortality. How should safe staffing ratios be determined? One study demonstrated the cost-effectiveness of patient-to-nurse staffing ratios ranging from 8:1 to 4:1. The authors found that while eight patients per nurse was the least expensive ratio, it was associated with higher patient mortality. They concluded that as a patient safety intervention, patient-to-nurse ratios of 4:1 are reasonably costeffective (Rothberg, Abraham, Lindenauer & Rose 2005). However, ratios depend on many factors, such as patient acuity and the care that is required. Cost considerations may vary depending on the perspective of the payer, e.g. hospital, health system or society. Professional Judgement Instead of legislating safe staffing ratios, some authors suggest that organisations should identify their own definition of safe staffing. 18 Instead of legislating safe staffing ratios, some authors suggest that organisations should identify their own definition of safe staffing based on variables such as acuity of patients, number of ratios and staff mix. The ANA also supports professional judgement in determining safe staffing, as demonstrated in their safe staffing legislation which culminated in the Quality Nursing Care Act of 2004. This Act is based on the ANA s Principles for Nurse Staffing which advocate that safe staffing systems require the input of direct-care RNs together with considering the

number of patients, experience of nurses on the unit, severity of patients conditions and availability of support systems and resources (ANA 1999; Artz 2005; Donnellan 2003; Safe Staffing Initiatives 2004). This approach would allow for consideration of the variety of caregivers that might be available in different settings. Professional Frameworks Nurses may find themselves without an adequate in country framework to support the demand for adequate staffing. Individual nurses may find themselves without an adequate in country framework to support the demand for adequate staffing. Organisations such as the ICN do provide frameworks for the provision of care (ICN 2004). These documents encourage healthy work environments and adequate numbers of nurses to provide care (ICN 2000). In an ideal situation, there may be regulatory frameworks, professional practice guidelines and best practice guidelines at the local level; all of which reinforce the importance of nursing care and the necessity of adequate environmental and staff support (Pan American Health Organization 2004; WHO 2002). In the absence of such supports, nurses have to rely on external documentation to strengthen their arguments for safer staffing. The web sites of various organisations contain a wealth of information in a variety of languages. 19

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CHAPTER 6 Role of National Nurses Associations Research National nurses associations (NNAs) are influential in setting local, national and international research agendas. They identify priority areas of concern and gaps in information. They network with educational and research institutions, thus serving as a valuable source of data or expertise and sometimes leading the research effort. Nursing associations are credible social partners, good candidates for grants that finance data collection and situation analysis. Policy-making Proactive nurse leaders are knowledgeable of the field realities and experts in problem solving. Health sector stakeholders and nurses look to NNAs for guidance and effective strategies to address the critical nursing shortage experienced in many health care systems worldwide. NNAs have introduced accreditation processes for health care organisations with safe staffing as a criterion. Their policy-making has generated a new function for the NNA, which is now taking on an expanded role in the health sector. NNA representatives tend to be active board members of the national regulatory body. In some cases, the NNA may function as the national regulatory body for nurses and nursing. In this capacity, they develop frameworks that support patient safety, which should include safe staffing and establish mechanisms to monitor and enforce safe staffing policies. Valuable data on capacity in and outflows can be gathered from the register if this is a live register. Advocacy NNAs play a key role in the advocacy for healthy working environments and safe staffing practices. NNAs play a key role in the advocacy for healthy working environments and safe staffing practices. This can be at a national level or in a special interest/specialty group capacity. For example, Adkinson (2004) discusses the position statement of the Society of Pediatric Nurses (SPN) on safe staffing. They advocate for adequate staffing levels on paediatric units. Their recommendations are based on studies that demonstrate increased patient morbidity and mortality rates when adequate staffing is not available. The NCNA (2005) also has a position paper on safe staffing. They support endeavours to promote safe staffing for nurses and endorse the RN Safe Staffing Act and the ANA s Principles for Nurse Staffing (see Annex 5). They stress the need for safe staffing outcomes to be clearly defined under patient care, nursing work life and organisational categories. 21

Representation NNAs have a responsibility to represent and defend their members whether in court or the regulatory body. In an environment where litigation is increasing, nurses find themselves legally and sometimes financially accountable for adverse events generated by faulty health systems (e.g. short staffing), rather than the malpractice or error of any one individual. NNAs have a responsibility to represent and defend their members whether in court or the regulatory body. Some associations have been able to introduce whistleblower legislation legal protection of personnel who denounce unsafe practices when internal attempts to correct problems within the workplace have failed thus providing assistance before a crisis occurs. Negotiation In terms of the critical nursing shortages, human resources planning is frequently cited as one of the first measures needed to redress the situation. NNAs have a critical role to play in speaking for nurses and nursing, negotiating an adequate supply of nurses entering active practice (e.g. student positions, subsidies and scholarships) and pushing for working conditions that retain competent nurses within the health sector (e.g. safe staffing). NNAs worldwide are involved either directly or indirectly in negotiating nurses work life. Collective agreements supporting safe staffing levels are legally binding instruments that lead to manageable workloads as well as patient safety. Negotiation takes place not only in a labour context but also within parliament. As mentioned, provincial and state legislation have introduced measures to ensure safe staffing. This, however, would not have been possible without the ongoing and effective negotiation of the NNAs concerned. Safe staffing clearly demands a multi-prong approach, with NNAs mobilising their resources as well as all their networks. 22

CHAPTER 7 Recommendations Health care environments vary, but the need for adequate staff is shared. Inadequate staffing in some settings has reached crisis proportions. The emphasis on safe staffing has highlighted many issues involved in patient care. The evidence is mounting to support the demand for adequate nursing staff to provide comprehensive care. Health care environments vary, but the need for adequate staff is shared. This need goes beyond the minimum required for potential substandard care and reflects the necessity of adequate staff to provide optimum care. Outlined below is a guide to increase the support for safe staffing. The recommendations are aimed at professional associations. 1. Determine the extent of the problem; 2. Define what safe staffing is in the context of patient requirements; 3. Collect any relevant data; 4. Use an assessment tool to further refine the issues; 5. Prepare a communication plan that influences decision-making; 6. Use the tool kit to provide background data to support safe staffing initiatives; 7. Participate in health human resource planning and policy development at the governmental level; 8. Support impact assessment studies so that the consequences of potential or actual changes in policy are known in terms of staff working conditions and work life as well as patient safety; 9. Lobby employers to provide healthy work environments and appropriate staffing; 10. Educate the public about the importance of nursing services; and 11. Work on local initiatives that promote healthy work environments for nurses. 23

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TOOL KIT FOR SAFE STAFFING SAVES LIVES 25

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Annex 1 Nurse Staffing Assessment Tool Employers Work Environment/Organisation Does the work environment/organisation provide adequate equipment for staff to provide sufficient patient care? Does the work environment/organisation have an appropriate physical plant in that staff can carry out their work in a functional facility? Are there work environment/organisation policies that address safe staffing? Is their enforcement monitored? Are the policies reviewed regularly and revised as required? Are grievance procedures in place? Is there clear and influential nursing leadership at the highest levels of decisionmaking playing a full and proactive role in corporate and strategic planning? Do nurses receive adequate compensation for their work? Do the working conditions allow for optimal nurse recruitment and retention? Nurse Does the nursing staff contain a mix of adequate personnel? Is patient complexity considered when determining nurses workload? Are regular nurse workload evaluations conducted including an assessment of the impact of such duties as education and supervisory duties? Are nurses involved in staffing decisions? Do nurses monitor their personal health? Government Do government policies address an adequate supply of nurses available to meet the health needs of the patient populations? Is there a health human resource policy framework? Is there a mix of regulated health personnel and do they practice together? Are retention and immigration policies in place to ensure nursing shortages do not occur? Is government involved in the financing and stewardship of the health care system? Does the government provide a regulatory framework for ensuring safe nurse staffing practices? Does the government conduct a policy impact assessment before introducing changes to legislation that will impact on workforce demand? Do nurses receive adequate compensation for their work? 27

National Nurses Association (NNA) Are accreditation processes for health care organisations with safe staffing as a criterion supported by the NNA? Does the NNA advocate for and promote healthy work environments for nurses? Is the NNA involved in educating health sector stakeholders, including employers, about safe staffing practices for nurses? Does the NNA encourage and provide professional development for nurses? Are alliances sought with patient organisations or other professional groups to ensure a focused response to workload issues? Does the NNA contribute to the formulation of the research agenda and capacity and capability assessment of the nursing workforce? Educational Institution Do educational institutions play a full part in ensuring curricula equip nurses with the necessary competencies to assess, plan, implement and evaluate care in a manner that generates workload and acuity information as a by-product? Do educational institutions offer flexible access to education to support recruitment and retention initiatives? Are educators part of the discussion about local supply and the overall policy dialogue? Regulatory Body Do regulatory bodies regularly review scopes of practice and competencies required to deliver contemporary nursing care? Is data from the register routinely used to inform workforce planning decisions and to assess the success of initiatives designed to recruit or retain staff? Does the regulatory body routinely analyse trends from complaints and the outcome of health and conduct referrals to inform employers and the government of emerging workforce issues? Do regulators meet on a regular basis with sectors such as education, health and labour? 28

Annex 2 Safe Staffing: What Nurses Can Do Lobby for safe staffing levels and healthy working environments in your workplace, your community and at a national level. Use e-mails, letter writing or visit government offices to educate government officials, senior hospital and community administrators and other decision-makers and organisations that affect nursing practice. Recommend safe ratios given local and institutional contexts. Negotiate safe staffing in collective bargaining agreements. Demonstrate why safe staffing is important for your patients safety and what type of care you can provide when staffed appropriately. Ensure that nursing has a voice in your country by participating in local and national resource planning, management and development. Use the tool kit to provide background data to support safe staffing initiatives. Ensure that data is routinely used to inform workforce planning decisions and to assess the success of initiatives designed to recruit or retain staff. Develop and disseminate a position statement, a fact sheet and a press release on safe staffing levels and patient safety (see sample). Use your NNA newsletter or journal and send to the local and national press agencies to communicate to a wide audience. Define the scope of action of nursing and health team members. Determine specific and shared competencies of each. Lobby for regular review of scopes of practice and competencies needed to deliver optimum nursing care. Get support from non-nurses. Form partnerships with other health professionals. Organise patient and public safety events and provide public education on safe staffing levels. Make a presentation at your religious centre, women s group or community group on how safe staffing affects everyone. Inform patient and consumer groups of the importance of safe staffing levels and adequate nurse/patient ratios. Buy advertising space in your local paper to educate the public about the importance of safe RN staffing. It will get the attention of the public, local government and the hospital administration. Disseminate brochures and posters and organise media events, such as radio or television interviews. Support research and collect data for best practice. Disseminate cost-effective research on RN staffing levels. Undertake workforce and patient safety impact assessment studies when health sector-related policies are planned or established. Present awards to health care facilities that implement safe staffing. 29

Advocate for flexible access to nursing education and improvement of curricula to ensure nurses have the necessary competencies to assess, plan, implement and evaluate care. Support capacity building of managers in the area of human resources planning, management and development. Disseminate the safe staffing tool kit via the NNA web site, teleconferences and workshops. Share it with other interested organisations. Web and/or e-mail alerts can be sent to notify targeted audiences about the tool kit s availability on the web sites. 30

Annex 3 Press Information Communiqué de presse Comunicado de prensa SAMPLE PRESS RELEASE Safe Staffing in Health Care Saves Lives and Money Nursing worldwide calls for legislators and policy makers to address the need for sufficient and suitable human resources in health care settings Geneva, 12 May 2006 - Inadequate staffing in health care settings is reaching crisis proportions in all regions. Evidence indicates that this is resulting in a critical increase in length of hospital stays, patient morbidity and mortality and preventable adverse events. One study found that raising a nurse s workload from four surgical patients to six resulted in a 14% increase in likelihood of a patient within that nurse s care dying within 30 days of admission. 1 The reality is that many nurses are challenged with much greater patient workloads on a daily basis. On the occasion of International Nurses Day, nurses everywhere are calling for a policy framework to ensure serious attention is given to comprehensive health human resource planning and an adequate nurse-topatient staffing ratio in all healthcare settings. There is no doubt. Numbers of health care workers make a difference. The evidence is in: an adequate nursing supply is essential to the health outcomes of nations. Improved nurse staffing (in numbers and skill-mix) is associated with lower inpatient mortality rates and shorter hospital stays saving both lives and money, stated Hiroko Minami, President of the International Council of Nurses (ICN). Safe staffing leads to lower incidences of medication errors, postintervention urinary tract infections, upper gastrointestinal bleeding, falls, pneumonia and shock. The global nursing shortage experienced today clearly threatens reaching the Millennium Development Goals. High patient-to-nurse ratios not only have a negative impact on patient outcomes but also affect the nurses who are at higher risk of emotional exhaustion, stress, job dissatisfaction and burnout. Nurses who continuously work overtime or work 1 Aiken L, Clarke S, Sloane D, Sochalski J & Silber J (2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction, JAMA. 288: 1987-1993

without adequate backup are prone to greater absenteeism and poorer health, thus weakening health system responses to communities health needs. Health care environments vary worldwide, but the need for adequate staff is shared. This need goes beyond the minimum required for potential sub standard care. Nurses, their nursing associations and health sector stakeholders are being challenged to determine safe staffing levels in the context of patient requirements, collect relevant clinical and workforce data, disseminate and demonstrate the importance of safe staffing, form alliances to support safe staffing policies, undertake impact assessment studies, and prepare a communication plan that effectively influences decision-making. To help nurses, hospital administrators, government and the public in general to understand this complex and critical subject, ICN has prepared a toolkit on safe staffing, Safe Staffing Saves Lives, which is available on the ICN website www.icn.ch. Editor s note The International Council of Nurses (ICN) is a federation of 129 national nurses' associations representing the millions of nurses worldwide. Operated by nurses for nurses since 1899, ICN is the international voice of nursing and works to ensure quality care for all and sound health policies globally. For further information contact Linda Carrier-Walker Tel: +41 22 908 0100 Fax: +41 22 908 0101 Email: carrwalk@icn.ch ICN Website: www.icn.ch 32

Annex 4 Did you know? Facts of Safe Staffing Safe staffing means that an appropriate number of staff, with a suitable mix of skill levels, is available at all times to ensure that patient care needs are met and that hazard-free working conditions are maintained. In the US, 98,000 people per year die from medical errors occurring in hospitals (more than die from motor vehicle accidents, breast cancer, or AIDS) - unsafe staffing and heavy workloads being major contributing factors. A richer registered nurse skill mix leads to lower patient morbidity and mortality, reduced incidences of adverse events, shorter hospital lengths of stay, and higher patient satisfaction. Nurses in these work environments report greater job satisfaction, less stress and cases of burnout. Absenteeism and turnover rates are reduced, thus having a positive impact on the continuity and quality of care. In a unit providing care given to AIDS patients, the addition of one nurse per patient day was associated with a 50% decrease in 30-day mortality. Research found that fewer nurses at night was linked to an increased risk for specific postoperative pulmonary complications, higher fall rates and lower patient satisfaction levels with pain management. In a surgical unit, researchers found that each additional patient per nurse with a four-patient caseload was associated with a 7% increase in the likelihood of dying within 30 days of admission, and a 7% increase in the odds of failure to rescue. A cross-sectional analysis of medical and surgical patients found that a higher proportion of hours of care per day by RNs and a greater number of hours of care by RNs per day were associated with a shorter length of stay; lower rates of urinary tract infections, upper gastrointestinal bleeding, pneumonia, shock and cardiac arrest; and reduced cases of failure to rescue. Safe staffing is cost-effective for individuals, health systems and society. Organisations with an adequate number of nurses and physicians are using the size of their staff to increase their competitive edge against other hospitals. In periods of critical nursing shortages, safe staffing is a powerful incentive for nurses to remain in or return to active practice, thus an effective recruitment and retention strategy. Liability increases in a clinical context where there is inappropriate infrastructure and staffing. Health human resource policy frameworks are essential to guide decisions about nurse staffing.

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Annex 5 American Nurses Association Principles for Nurses Staffing Matrix for Staffing Decision-Making Items Patients Intensity of unit and care Context Expertise Elements/Definitions Patient characteristics and number of patients for whom care is being provided. Individual patient intensity; across-the-unit intensity (taking into account the heterogeneity of settings); variability of care; admissions, discharges and transfers; volume. Architecture (geographic dispersion of patients, size and layout of individual patient rooms, arrangement of entire patient care units and so forth); technology (beepers, cellular phones, computers); same unit or cluster of patients. Learning curve for individuals and groups of nurses; staff consistency, continuity and cohesion; cross-training; control of practice; involvement in quality improvement activities; professional expectation; preparation and experience. Principles for Nurse Staffing The nine principles below were identified by an expert panel for nurse staffing and adopted by the ANA Board of Directors on November 24, 1998: Patient Care Unit Related 1. Appropriate staffing levels for a patient care unit reflect analysis of individual and aggregate patient needs. 2. There is a critical need to either retire or seriously question the usefulness of the concept of nursing hours per patient day. 3. Unit functions necessary to support delivery of quality patient care must also be considered in determining staffing levels. Staff Related 4. The specific needs of various patient populations should determine the appropriate clinical competencies required of the nurse practising in that area. 35

5. Registered nurses must have nursing management support and representation at both the operational level and the executive level. 6. Clinical support from experienced RNs should be readily available to those RNs with less proficiency. Institution/Organisation Related 7. Organisational policy should reflect an organisational climate that values registered nurses and other employees as strategic assets and exhibit a true commitment to filling budgeted positions in a timely manner. 8. All institutions should have documented competencies for nursing staff, including agency or supplemental and travelling RNs, for those activities that they have been authorised to perform. 9. Organisational policies should recognise the myriad needs of both patients and nursing staff. 36

Annex 6 Selecting and Applying Methods for Estimating the Size and Mix of Nursing Teams Adapted from Summary: Systematic review of the literature commissioned by the Department of Health, April 2002, by Dr Keith Hurst, Senior Lecturer, Nuffield Institute for Health, Leeds University. Introduction The aims of this report are to help you make sense of the complex and uncertain world of nursing workforce planning and to make better decisions about cost-effective numbers and mixes of nurses. Consequently, five commonly used workforce planning methods are reviewed and described. Considerable effort has gone into explaining the strengths and weaknesses of these five nursing workforce planning systems briefly described here: 1. Professional judgement approach. 2. Nurses per occupied bed method. 3. Acuity-quality method. 4. Timed-task/activity approaches. 5. Regression-based systems. Explanations and exercises for the five commonly used methods for estimating or evaluating the size and mix of your nursing teams go from simple to complex. The exact steps required to calculate the size and mix of nursing teams using each method can be found in the full report by Dr Hurst. Please see the website address at the end of this summary. The Professional Judgement Method This technique simply helps you to convert your duty rotas into whole time equivalents (WTEs). This method, as the algorithm below shows, is simple to use and is an excellent starting point before you tackle the more sophisticated methods that come later. You ll find this method invaluable for quickly adjusting your nursing establishments following policy or practice changes such as hand-over or break-time amendments. In the following example from a 15 bed surgical ward, a decision is made to roster three nurses for the morning and afternoon shifts, and two nurses for the night shift. A 30 minute morning to afternoon shift hand-over period, and a 15 minute afternoon to night shift hand-over is included because it is part of the usual work pattern. You can substitute local times and your preferred number of staff for different contexts. 37

Table 1: Seven day ward - Professional Judgement Staffing Formula Step 1. Calculate the number of working hours needed: Early shift: 0700 to 1430 = 7.5 hrs x 3 nurses x 7 157.5 hrs days Late shift: 1400 to 2130 = 7.5 hrs x 3 nurses x 7 157.5 hrs days Night shift 2115 to 0715 = 10 hrs x 2 nurses x 7 140 hrs days Total = 455 hrs However, these hours assume that nurses are never sick or take holidays, etc. A timeout adjustment to cover leave of all kinds, therefore, is necessary. The 22% allowance used in the formula below was obtained from a time-out study of 300+ general wards in the UK. However, if you wish then you can substitute a local figure (obtainable from your personnel department). Step 2. Adding the time-out allowance. 455 hrs x 1.22 (time-out) = 555.1hrs/37.5hrs (1 WTE) = 14.8 WTE s A staffing pattern of three nurses for the morning, three nurses for the afternoon/evening and two nurses at night, therefore, requires almost 15 full-time nurses for this small surgical ward. Strengths quick, simple and inexpensive to use; can be applied to any speciality, no matter how many hours a day the service operates; results are easy to update; little adjustment is needed for other care groups; the effects of adjusting nurse staffing on the quality of care and job satisfaction can be measured by one of several nursing quality and nurses job satisfaction surveys. This method acts as an excellent springboard to more sophisticated methods and it is often used to check the results from other methods, a kind of belt and braces approach to operational management. Similar results from two or more methods (known as triangulation) gives you confidence about your decisions. Weaknesses the relationship between staffing levels and nursing quality is hard to explain (i.e. how do we know if 25.5 WTE nurses is enough to maintain an acceptable standard of care, or to ensure equitable workloads, job satisfaction and therefore, a desire to stay in the job?); 38

less flexible when patient numbers and especially patient dependency mix change (i.e. the ward will often be over- or understaffed); too subjective (i.e. should professionals themselves be determining their own staffing levels without an independent check?); calculations get awkward when unusual shifts are worked such as long days. However, computer spreadsheets ease the burden. Nurses per Occupied Bed Method Average nurses per occupied bed (NPOB) is another popular and simple method of determining or evaluating the number and mix of ward staff. Strengths can also be used to verify professional judgement method findings; most useful if your ward bed complement changes and you need to modify the nursing establishment; keep-it-simple method of demand-side workforce planning is honoured; formulas for the main specialities are unique because they are derived from data collected only in same-speciality wards; makes determining establishments and generating the ward s grade mix easy since formulas are broken down by nursing grade; the data are easily built into a computerised spreadsheet. Weaknesses assumes that base staffing was rationally determined; no guarantee that the averages from other sources come from wards that deliver an acceptable standard of care; insensitive to patient dependency changes (i.e. the formulas recommend the same number of nurses for patient populations that are predominantly low dependency as it does for high dependency inpatients); formulas are costly to update; routinely collected data, such as bed occupancies used in staffing formulas, are more error-prone than those that are deliberately and systematically collected because empirical data are usually confirmed in some way; contains hidden structures and processes that need to be made explicit; data may be drawn from wards that are geographically different to your wards; insensitive to consideration of learner nurses contributions, or alternatively their demand on qualified staffs time. Acuity-Quality Method A third way of estimating or evaluating the size and mix of ward nursing teams is the dependency-activity-quality method. This staffing method overcomes most of the weaknesses highlighted in the professional judgement and the NPOB methods. It is useful for wards where patient numbers and mix fluctuate. Consequently, medical and surgical admission unit managers find the acuity-quality method invaluable. Formulas are not only sensitive to the number and mix of inpatients but also have a floor below which nursing care standards shouldn t fall. Formulas are, therefore, more complex to 39

construct and apply. Analysis usually requires computer spreadsheets especially when what-if? questions are asked such as what to do if the ward has a sudden influx of highdependency patients. Strengths changing ward variables, especially patient numbers and dependency mixes, is easily accommodated by the acuity-quality algorithm; you can turn the acuity-quality method around and adjust your ward s occupancy and patient dependency mix to suit the available nursing resources; once a computer is set up, it is possible to calculate staffing numbers for individual shifts; nursing benchmarks and performance indicators (such as nursing cost per occupied bed) are a natural spin-off from the acuity-quality method. Weaknesses the acuity-quality method is complex; the daily direct care minutes for each dependency category have to be accepted unless local nursing activity values can be obtained; the sense of ownership that is engendered by using local information may be lost when external data are used; collapsing patient numbers and related nursing activity data into dependency groups ignores individual patient characteristics; nursing activity, used to obtain the amount of nursing time required, sometimes fails to measure the psychological component of patient care. However, most of the alternative methods are even less sensitive to these issues; in some situations can recommend nursing establishments insufficient to provide at least one qualified nurse per shift because the formula is workload as well as occupancy based; patient populations less than 12 (especially if the patients are low dependency) create the so-called small ward problem; adds to ward nurses workload because additional patient information is required; obtaining up-to-date data can be expensive, e.g. representative, nursing activity and nursing quality data require two independent non-participant nurse observers spending several days in the ward; the grade mix configurations may not suit your ward s context, e.g. it may not be local policy to employ Level 3 or 4 health care assistants. Reconfiguring the grade mix according to local policy, and adjusting the acuity-quality algorithm at the same time, takes considerable fieldwork and skill; lends itself less well to forecasting the number of staff than some of the following methods. Timed-task/Activity Method This method of estimating or evaluating the size and mix of nursing teams arose mainly from a belief that acuity-quality staffing methods, for example, were inferior staffing predictors. The type and frequency of nursing interventions required by patients are felt to be a better predictor than patient dependency. If nurses are comfortable with constructing patient care plans then the timed task/ activity method simply requires 40

nursing minutes to be added to each intervention in the plan thereby generating the number of nursing hours needed. This method will suit wards in which care plans are systematically constructed, and for wards where patients nursing needs can be confidently predicted; notably those that admit from waiting lists. In practice, each patient s daily direct nursing care needs are recorded either manually or electronically on a locally developed checklist of nursing interventions. The number of nursing interventions from which to chose varies from system to system. Because each intervention is paired with a locally agreed completion time, the patient s care plan and nursing time requirement is systematically built. The value attached to each intervention is generally the amount of time needed to carry out the care for one patient over a 24 hour period. As with the acuity-quality method, a ward overhead is added to cater for the indirect care and other aspects of nurses time. Similarly, breaks and time-out have to be considered and ideally, the method should be computerised. Strengths generates results that can be easily corroborated by other methods; easily computerised so that the method becomes part of a nursing information system; adopting the system in other care settings is possible without destroying its integrity. Weaknesses the most expensive of all the methods described; time consuming; reducing nursing care to a work-study type list horrifies some nurses. Regression Analysis Method Broadly, regression methods predict the required number of nurses for a given level of activity. The predictor is called the independent variable and the outcome or level of staff is known as the dependent variable. Although the statistical analysis is challenging, once completed, all we need to know is the independent variable value to predict the number of staff (dependent variable). For example, one study developed a nurse-staffing model from an analysis of ward establishments and bed occupancies. Regression analysis showed that the number of nurses (dependent variable) increased as bed occupancy (independent variable) rose thus allowing staffing estimations. Other independent variables in the literature include the number of theatre sessions and day surgery cases. In short, once the base data are collected and analysed then the calculations are as straightforward as the NPOB method. Strengths useful for situations where predictions are possible, such as the number of planned admissions; helps managers to forecast and prepare for extra demands; tends to be a cheaper method because data are easier to collect and can be aggregated from similar wards; 41

especially useful to managers with limited resources, and who cannot afford to carry out full dependency-activity-quality or a timed-task/activity study; outcomes tend to be corroborated with independent evidence; staffing formulas are judged valid, reliable and also more usable than the detailed and expensive acuity-quality and timed-task/activity methods; ease of use staffing recommendations are relatively easily tested for accuracy by checking how well nursing time is used following enactment of staffing recommendations drawn from regression models. Weaknesses need knowledge and skills of a statistician to help you design and implement fieldwork that collects the most appropriate data for regression analysis; transferring staffing formulas derived from regression coefficients from one setting to another isn t encouraged owing to unique variables (such as ward layout). However, validity and reliability tests help to check if transplanting is safe; some independent variables are qualitative while others are deemed subjective such as the ward manager s perceptions of ideal staffing; sometimes, nominal data have to be assigned to variables, but this model is usually based on interval or ratio data; wards providing data for regression analysis are assumed to operate efficiently and effectively, i.e. wards supplying establishment and bed occupancy data have had staffing varied according to patient demand; including data from wards with excess absenteeism or poor quality care can distort and invalidate results; unsafe to predict staffing levels outside the regression model s observed range, i.e. if your data came from wards with no more than 25 beds then extrapolating to wards with e.g. 30 occupied beds can lead to errors because we can t be sure that linear relationships between independent and dependent variables exist beyond 25 beds; imposing regression statistical techniques has alienated some nurses owing to a lack of ownership and understanding. For more information: The full report by Dr Hurst is available on-line at http://www.nuffield.leeds.ac.uk/downloads/nursing_teams_summary_published.pdf 42

Annex 7 Occupational Health and Safety for Nurses ICN Position: ICN deplores the lack of appropriate national occupational health and safety legislation covering nurses in their place of employment, the often inadequate mechanisms for workers participation in the monitoring/elimination of professional hazards, and the insufficient resources allocated to ensure optimal occupational health and safety services and labour inspection. ICN promotes the development and application of international policies or instruments that will safeguard the nurses' right to a safe work environment, including continuing education, immunisation and protective clothing/equipment. ICN reconfirms its mandate to encourage research in this area and to circulate relevant information on a regular basis to member associations. ICN strongly supports the various ILO Conventions relating to occupational health and safety and believes that national nurses' associations should: Urge their respective governments to ensure that all health agencies fall within the provision of occupational health and safety legislation. This can be done through lobbying, individual and/or collective political action. Initiate and/or support research in their countries into the safety and suitability of the work environment of nurses as well as risk behaviours, attitudes, procedures and activities. Sensitise nursing personnel, employers and the public to occupational hazards in the health sector, including violence or abuse. Raise nurses awareness of their rights (as workers) to a safe environment and of their obligations to protect their safety and promote the safety of others. Convince governments and employers to adopt and implement all necessary measures to safeguard the health and well-being of nurses at risk in the course of their work, including vaccination when appropriate. Urge governments/employers to ensure the access of nursing personnel to protective measures (e.g. clothing) and equipment at no extra cost to staff;

Occupational Health and Safety for Nurses, page 2 Encourage nurses to undergo vaccinations relevant to their health and safety in the workplace. Cooperate with the competent authorities to ensure the accuracy of the List of Occupational Diseases and periodically evaluate its relevance to nursing personnel. Support nurses' claims for compensation in relation to occupational disease and/or injury. Obtain and disseminate information on the incidence of work-related accidents, injuries and illnesses of nurses. Cooperate with other organisations supporting the worker s right to a safe work environment. Recognise the important relationships between workers and their families in the development of culturally appropriate occupational health and safety policies and treatment plans. Support nurses freedom from being intimidated in their role of patient advocate. Call for adequate monitoring systems at all levels that will ensure appropriate implementation of policies. Disseminate information on the introduction of new hazards in the workplace. Disseminate information on non-compliance by employers of occupational health and safety legislation, including reporting mechanisms for such violations. Background: ICN recognises the major role occupational health and safety plays in health promotion. Furthermore, ICN acknowledges the growing expertise nurses have gained in the area of occupational health and safety and the costeffectiveness of the services provided for workers.

Occupational Health and Safety for Nurses, page 3 ICN supports the expanding role of the occupational health nurse in meeting workers primary health care needs, and demands fair remuneration and adequate career structures that support professional development. The work environment of the nurse is frequently unsafe as a result of: Environmental contamination by waste products resulting from human and industrial activity. Risks (e.g. chemical, biological, physical, noise, radiation, repetitive work). Medical technology lack of maintenance, insufficient training in the use of technology. Inadequate access to protective clothing and safe equipment. The disturbance of everyday life patterns associated with shift work. The increasing demands made upon the emotional, social, psychological and spiritual resources of the nurse working in complex political, social, cultural, economic and clinical settings. Incidents of violence, including sexual harassment. Poor ergonomics (engineering and design of medical related equipment, materials and facilities). Inadequate allocation of resources, e.g. human, financial. Isolation. Patient care benefits from a safe work environment for health personnel. ICN notes that most governments fail to collect current accurate information on the incidence of accidents, injuries and illness of nursing personnel as the basis for sound policy formulation. The lack of relevant data is a matter of great concern. In certain countries, there is no occupational health and safety legislation. In others, the means to monitor its implementation and the machinery to discipline the offending employers is ineffective or non-existent. Yet other countries have adopted legislation that excludes hospitals and other health agencies. 45

Occupational Health and Safety for Nurses, page 4 Convention 149 of the International Labour Organization (ILO) concerning Employment and Conditions of Work and Life of Nursing Personnel 1) calls on member states to improve existing laws and regulations on occupational health and safety by adapting them to the special nature of nursing work and of the environment in which it is carried out. Section IX of the accompanying Recommendation (157) 1 further develops the measures considered necessary to guarantee the health and safety of nurses in the workplace. Adopted in 1987 Reviewed and updated in 2000 Related ICN Positions: Reducing environmental and lifestylerelated health hazards Nurses and the Natural Environment Tobacco use and Health The International Council of Nurses is a federation of more than 120 national nurses' associations representing the millions of nurses worldwide. Operated by nurses for nurses, ICN is the international voice of nursing and works to ensure quality care for all and sound health policies globally. 1) International Labour Organization, Convention 149 and Recommendation 157 concerning the Employment and Conditions of Work and Life of Nursing Personnel, Geneva, ILO, 1977. 46

Annex 8 Patient Safety ICN Position: Patient safety is fundamental to quality health and nursing care. ICN believes that the enhancement of patient safety involves a wide range of actions in the recruitment, training and retention of health care professionals, performance improvement, environmental safety and risk management, including infection control, safe use of medicines, equipment safety, safe clinical practice, safe environment of care, and accumulating an integrated body of scientific knowledge focused on patient safety and the infrastructure to support its development. Nurses address patient safety in all aspects of care. This includes informing patients and others about risk and risk reduction, advocating for patient safety and reporting adverse events. Early identification of risk is key to preventing patient injuries, and depends on maintaining a culture of trust, honesty, integrity and open communication among patients and providers in the health care system. ICN strongly supports a systemwide approach, based on a philosophy of transparency and reporting - not on blaming and shaming the individual care provider and incorporating measures that address human and system factors in adverse events. ICN is deeply concerned about the serious threat to the safety of patients and quality of health care resulting from insufficient numbers of appropriately trained human resources. The current global nursing shortage represents such a threat. ICN believes nurses and national nurses associations have a responsibility to: Inform patients and families of potential risks. Report adverse events to the appropriate authorities promptly. Take an active role in assessing the safety and quality of care. Improve communication with patients and other healthcare professionals. Lobby for adequate staffing levels. Support measures that improve patient safety. Promote rigorous infection control programmes. Lobby for standardised treatment policies and protocols that minimise errors. Liaise with the professional bodies representing pharmacists, physicians and others to improve packaging and labelling of medications. Collaborate with national reporting systems to record, analyse and learn from adverse events.

Patient Safety, page 2 Develop mechanisms, for example through accreditation, to recognise the characteristics of health care providers that offer a benchmark for excellence in patient safety. Background: While health care interventions are intended to benefit the public, there is an element of risk that errors and adverse events will occur due to the complex combination of processes, technologies and human factors related to health care. An adverse event can be defined as harm or injury caused by the management of a patient s disease or condition by health care professionals rather than by the underlying disease or condition itself. 1 [1] Common threats to patient safety include medication errors, hospital acquired infections, exposure to high doses of radiation and use of counterfeit medicines. Although human errors play a role in serious adverse events, there are usually inherent system factors, which if addressed properly would have prevented the errors. There is growing evidence that inadequate institutional staffing levels are correlated with increase in adverse events such as patient falls, bed sores, medication errors, nosocomial infections and readmission rates that can lead to longer hospital stays and increased hospital mortality rates. 2 [2] Staff shortages and poor performance of personnel because of low motivation or insufficient technical skills are also important determinants of patient safety. Poor quality health care causes substantial number of adverse events with serious financial impact on health care expenditures. 1 Thomas EJ & Brennan BMJ (2000), Incidence and types of preventable adverse events in elderly patients: population based review of medical records. 18 March 2000. p.9. 2 Aiken lh et al. (2002). Hospital Nurse Staffing and Patient Mortality, Nurse Burnout and Job Dissatisfaction. JAMA (2002); 288: 1987-1993. 48

Patient Safety, page 3 Adopted in 2002 Related ICN Position Statements: Protection of the title nurse Nursing regulation Scope of nursing practice Assistive or supportive nursing personnel ICN Publications: Patient Safety, WHPA, Fact Sheet (2001). The International Council of Nurses is a federation of more than 120 national nurses' associations representing the millions of nurses worldwide. Operated by nurses for nurses, ICN is the international voice of nursing and works to ensure quality care for all and sound health policies globally. 49

Annex 9 Examples of Nurse-Patient Ratios US State of California s Nurse-Patient Ratios Intensive/Critical Care 1:2 Neo-Natal Intensive Care 1:2 Operating Room 1:1 Post-Anesthesia Recovery 1:1 Labor and Delivery 1:2 Antepartum 1:4 Postpartum Couplets 1:4 Postpartum Women Only 1:6 Paediatrics 1:4 Emergency Room 1:4 ICU Patient in the ER 1:2 Trauma Patient in the ER 1:1 Step Down Initial 1:4 Step Down in 2008 1:3 Telemetry Initial 1:5 Telemetry in 2008 1:4 Medical/Surgical Initial 1:6 Medical/Surgical in 2005 1:5 Other Specialty Care Initial 1:5 Other Specialty Care in 2008 1:4 Psychiatric 1:6 Source: California Nurses Association. (n.d). Ratio basics. Retrieved November 2, 2005, from http://www.calnurse.org/files.calnurse.org/assets/finratrn7103.pdf Victoria, Australia s Nurse-Patient Ratios Type of Unit Hospital Category a.m. Shift p.m. Shift General Medical/Surgical Level 1 1:4 + in charge 1:4 + in charge Ward Level 3 1:5 + in charge 1:6 + in charge Ante/Postnatal All Levels 1:5 + in charge 1:6 + in charge Operating Theatre 3 nurses per theatre (1 scrub, 1 scout and 1 anaesthetic nurse) This may vary up and down depending on pre-determined factors Post Anaesthetic Care Unit/Recovery Room All shifts 1:1 for unconscious patient Source: Canadian Federation of Nurses Union. (2005). Enhancement of patient safety through formal nurse-patient ratios: A discussion paper. Retrieved November 2, 2005, from http://www.nursesunions.ca/en/docs/2005-10-03-nurse-patient-ratio-en.pdf 51

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