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New Nurse Staffing Measures Developed for Specialty Areas

Determining the optimal nurse staffing levels to avoid complications and improve patient outcomes has remained an elusive goal for many hospitals. Now, one of the industry’s chief quality improvement programs can generate staffing level correlations with patient outcomes in more clinical areas, including the emergency department and perioperative and perinatal services.

“Appropriate staffing levels and appropriate staffing composition are critical factors in patient safety and quality of care, and it’s important with patient assessment of satisfaction with the care provided,” said Nancy Dunton, PhD, FAAN, director of the National Database of Nursing Quality Indicators (NDNQI®) and research professor in the School of Nursing at the University of Kansas Medical Center, in Kansas City, Kan.

“Having concrete measures of staffing levels helps hospitals fine-tune performance, set quality improvement goals and monitor how they are doing,” she explained.

Approximately 2,000 hospitals currently participate in and report data to NDNQI, a quality improvement program of the American Nurses Association (ANA). They are able to review performance reports to determine how staffing shortages may be contributing to poor outcomes, such as falls or hospital-acquired infections, and then alter their staffing plans when the data signals a correlation.

In addition to quality improvement initiatives, hospitals may use the data for reporting requirements for The Joint Commission and Magnet Recognition Program; recruitment of nurses; budgeting, staffing plans and resource allocation to improve nursing work environments; or for research, added Janice Kelly, MS, RN-BC, Syntegrity business leader for the Association of periOperative Registered Nurses (AORN) in Denver.

The data includes a breakdown by the type of caregiver: RN, LPN, aide; the level of education and certification; and other nursing workforce characteristics.

For most units, hospitals report staffing data to NDNQI as nursing hours per patient day, which algebraically is the equivalent of a staffing ratio, Dunton explained.

“We don’t present them as patients per nurse, because there is more precision with nursing hours per patient day,” Dunton said. “Hours per patient day is an indicator of the workload of the nurse.”

However, in the emergency department, OR, and labor and delivery, patients are not there for days. ANA worked with the AORN, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) and the Emergency Nurses Association (ENA) in developing staffing measurers and outcomes for these units. They also included other nursing-like personnel and additional outcome measures.

For instance, in perinatal, NDNQI assigned a category for lactation consultants. In labor and delivery, hospitals will measure nursing care hours per case. NDNQI has added baby drops as an outcome measure.

“Perinatal nurse staffing is a critical component of improving patient outcomes,” said Debra Bingham, RN, DrPH, vice president of research, education and publications for the AWHONN. “AWHONN is interested in having accurate data on perinatal staffing in the United States to help identify staffing needs and ways units are being staffed, particularly related to breastfeeding.”

For instance, hospitals may see a correlation between the number of patients who are breastfeeding and staffing. Bingham said that more work needs to be done in the perinatal area, adding measures in other areas.

“This is an exciting first step,” Bingham said. “It’s quite interesting to us that there has been a limited amount of curiosity or data available in the area of perinatal staffing. The perinatal areas are very dynamic.”

For pre-op and post-op units, the measurement is nursing care hours per surgical case. In the OR, hospitals will measure nursing care minutes per surgical care minute. Additionally, NDNQI added surgical technologists and first assistants, differentiating between surgical and scrub RNs.

“Having that level of detail with comparison helps these areas understand how they are doing compared to others,” Dunton said.

The organization plans to add sponge count and use of pressure ulcer prevention techniques to outcome measures.

“As a profession, perioperative nurses have a responsibility to evaluate the quality and appropriateness of nursing practice,” Kelly said. “The data collection related to nursing care hours and the analysis of this data is necessary to evaluate the impact of the structure of nursing care indicated by the supply, the skill level and the education/certification of perioperative nursing staff on patient outcomes.”

In the emergency department, hospitals will report staffing by nursing care hours compared to the number of visits. NDNQI added categories for staffing with emergency medical technicians or paramedics. In the future, NDNQI plans to add assaults to the outcome measures in the ED.

“There are many variables that contribute to optimum patient outcomes,” said Deena Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, 2014 president of the ENA. “There is a relationship between the number of nursing care hours that can be collected in staffing level data in direct care and outcomes of care.”

NDNQI releases the data to hospitals and also at the system level to measure how their facilities are doing compared to others. It has released some data, not at the hospital level, to the Hospital Engagement Networks program. There is no public reporting.

Hospitals began collecting the new data in January, and Dunton expects NDNQI will issue reports in May for the first quarter.


For more information:
National Database of Nursing Quality Indicators (NDNQI®)
Preventing Never Events: Evidence-based Nurse Staffing
Better Nurse Staffing Shown to Reduce Readmission Penalties

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