Staffing formulas and guidelines have been driven by the need to ensure all patient populations receive the highest level of safe, quality care. However, nurse-related staffing formulas and guidelines assume that all nurses practice with the same level of vigilance and expertise. They also assume that all nurses exhibit the same level of critical thinking and clinical judgment and are able to access vital resources in a timely fashion when a patient's condition deteriorates or his or her safety and well-being are at risk.
Several professional nurse practice models acknowledge the importance of appropriate nurse staffing as it relates to patient safety and care outcomes.1-3 They do so, however, within a complex framework of interrelated and dynamic nursing and patient variables, not the least of which include nurse characteristics, such as nursing practice, role development, competencies, shared learning, and mentoring, and patient characteristics, such as level of stability, participation in decision making, and vulnerability.
The dangers of the numbers game
One group of researchers extensively reviewed studies addressing staff mix as defined by qualified and unqualified nurses—nurses with different qualifications and varying levels of experience—and methods used to assign nursing staff to various types of specialty units.4 Although 6,202 possible studies were generated from the search, only 486 were relevant. After applying inclusion criteria that considered study design, methodology, sample size, and risk of bias, only 15 out of the remaining 486 were accepted for review. With respect to findings and conclusions, the researchers found no eligible studies on nurse staffing levels; educational interventions; or grade mix, including qualifications, experience, and competencies. As a result, they recommended the need for more rigorously designed studies.
In obstetrics, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) has championed the development of guidelines to ensure effective and efficient perinatal nurse staffing based on stages of labor, level of risk, and interventions.5 AWHONN recognizes and acknowledges the importance of professional judgment and critical thinking to staffing guidelines. Unfortunately, it appears that these essential elements have been overlooked or minimized in the “numbers game,” which promotes the belief that by increasing staffing numbers, without prior consideration to the level of clinical judgment and critical thinking skills of each nurse in the staffing mix, the potential for adverse events/outcomes will be decreased solely on the basis of limiting the number of patients cared for at any given time.
Although past studies have recognized an association between adequate nurse staffing and quality of care, patient safety, and mortality, such a one-dimensional perspective is much too simplistic and dangerously flawed given the challenges associated with patient needs and healthcare delivery systems in today's complex and multifaceted environments.6-11
Bigger picture thinking
It's imperative for nurse leaders, especially directors, managers, and educators, to partner with their staff to evaluate each nurse's competency level relative to critical thinking and clinical judgment skills. This information can then be used as the basis for constructing adequate, safe staffing while continuing to provide educational opportunities, including mentoring. It can also be used to encourage periodic self-evaluations and peer review to advance practice and expedite proficiency in deficit areas or areas in need of attention.
There are a number of reliable and valid critical appraisal tools available, such as the Watson-Glaser Critical Thinking Appraisal tool and the Performance Based Development System assessment.12,13 These assessment tools can be used in conjunction with exemplars to assess and track a nurse's advancement from novice to expert.1 As part of practice expectations, nurse leaders and educators should require staff to submit such exemplars as part of ongoing competency assessments and yearly evaluations. In addition, nursing leadership should reward more expert nurses—who are stepping up to the plate to mentor their colleagues—with creative and meaningful incentive programs while challenging them to advance their own professional practice through career advancement opportunities.
Last, but not least, patient safety and quality care aren't just about nursing practice and nurse staffing. Consider the following: What if each patient had one nurse throughout his or her entire hospitalization, but the nurse was unable to access resources needed to prevent an adverse event or act in a timely fashion? This situation has nothing to do with staffing numbers, or clinical judgment or expertise, but everything to do with having adequate resources available and supports in place.
A model for safe patient care that represents the bigger picture is crucial. It must consider the availability, accessibility, and appropriate utilization of other healthcare providers and resources, particularly physicians, including anesthesiologists, pharmacists, and lab technicians, as well as ancillary personnel, such as unit secretaries/coordinators, unlicensed assistive personnel, surgical technicians, and equipment and resource materials managers. The model must also consider the availability and immediate accessibility of “must have” onsite equipment; supplies; and technologies, including telemetry, electronic documentation, and an integrated electronic medical record system.
Each professional group and ancillary support team involved in the delivery of healthcare services must be responsible for determining their own staffing needs based on their respective care models for practice, including respectful collaboration, and identifying resources they must have onsite to keep patients safe and prevent adverse outcomes. In addition, all hospitals and outpatient facilities must be committed to comprehensive and thorough systems integration, with departmental accountability, ongoing monitoring for purposes of sustainability, and, when indicated, the flexibility to make timely course corrections based on the emerging needs of the population served and healthcare resources available.
The work of the Institute of Medicine, Institute for Healthcare Improvement, Centers for Medicare and Medicaid Services, Robert Wood Johnson Foundation, and others is clearly focused on patient safety and preventable adverse outcomes. Mandates have been forthcoming and expectations set with serious consequences for noncompliance. The Accountable Care Organization model is also gaining momentum, with a focus of care that includes a collaborative and collegial partnership among all providers in which care coordination, prevention, and the implementation of best practices are stressed.
Safe staffing = safe care
The intent isn't to deny the value of developing a workflow model for nurse staffing that considers the dynamic nature and acuity of a specialty population, but rather to stress the importance of not doing so in isolation. All healthcare disciplines, not just nursing, and all organizations in the business of delivering healthcare, be they inpatient or outpatient facilities, equally share the burden of developing a comprehensive, integrated model of care that includes safe staffing, a population-based focus mindful of culture and access issues, and the provision of necessities available at the point of care.
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