Planning and evaluating evidence-based perinatal nurse staffing.

JOGNN CNE Continuing Nursing Education (CNE) Credit A total of 1.3 contact hours may be earned as CNE credit for reading “Planning and Evaluating Evidence-Based Perinatal Nurse Staffing” and for completing an online posttest and evaluation. AWHONN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AWHONN holds a California BRN number, California CNE Provider #CEP580. http://JournalsCNE.awhonn.org

Keywords perinatal nurse staffing calculating nurse staffing evaluating nurse staffing effectiveness and efficiency proposed nurse staffing frameworks Correspondence Debra Bingham, DrPH, RN, FAAN, Association of Women’s Health, Obstetric and Neonatal Nurses, 2000 L Street NW, Suite 740, Washington, DC 20036. [email protected] Debra Bingham, DrPH, RN, FAAN, is the Vice President of Nursing Research, Education and Practice, Association of Women’s Health, Obstetric and Neonatal Nurses, Washington, DC.

Catherine Ruhl, CNM, MS, is the Director of Women’s Health Programs, Association of Women’s Health, Obstetric and Neonatal Nurses, Washington, DC.

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Planning and Evaluating Evidence-Based Perinatal Nurse Staffing Debra Bingham and Catherine Ruhl

ABSTRACT Nurse staffing decisions are high-cost decisions. Having too few nurses may cause more mistakes or more episodes of missed care resulting in worse outcomes, increased pain, and additional suffering and health care costs. Having too many nurses increases health care costs. The Organizing Frameworks for Calculating Nurse Staffing and for Evaluating Nurse Staffing Decisions presented in this article build on the American Nurses’ Association’s principle-based staffing models and Donabedian’s framework for evaluating the quality of health care.

JOGNN, 00, 1-19; 2015. DOI: 10.1111/1552-6909.12544 Accepted August 2014

o simple formula exists to determine the number of registered nurses (RNs) and ancillary nursing staff needed to provide nursing care that meets the Institute of Medicine’s six aims for improvement: safety, effectiveness, patient centeredness, timeliness, efficiency, and equity (Institute of Medicine, 2001). Many dynamic factors affect the often minute-by-minute calculations that require adjustments in staffing decisions, and the wrong decisions can be costly. Several researchers have shown that inadequate RN staffing ratios are correlated with increased patient mortality and morbidity and more episodes of missed care that can lead to worse outcomes, including increased pain and suffering and health care costs (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Kalisch, Tschannen, & Lee, 2011; Needleman et al., 2011). Having too many nurses also increases health care costs.

N

Principle-Based Staffing

Neonatal Nurses’ (AWHONN; 2010) Guidelines for Professional Registered Nurse Staffing for Perinatal Units includes the ANA’s principle-based staffing framework and refers to the ANA’s work, asserting that “Classification of patients and clinical situations help determine the adequacy of staffing by establishing the nursing effort required for safe care” (p. 11) and that “Staffing needs in perinatal units are dynamic, consistent with the various types of patients and clinical situations encountered in a perinatal service” (p. 11). The purpose of this article is to detail important considerations about perinatal nurse staffing based on a review of relevant literature and input from perinatal nurse leaders across the United States. These considerations are organized into two proposed frameworks to aid in understanding the breadth and depth of factors pertinent to perinatal settings. Given the costs (in dollars spent and lives affected) associated with nurse staffing decisions, development and standardization of the methods used to determine and evaluate nurse staffing is needed.

The authors and planners for this activity report no conflict of interest or relevant financial relationships. The article includes no discussion of off-label drug or device use. No commercial support was received for this educational activity.

The American Nurses Association (ANA, 2005) proposed that nurse staffing decisions be based on the principle that nurse staffing patterns should not be based on payor type but instead should be based on achieving quality patient outcomes, meeting organizational goals, and ensuring appropriate quality of nurses’ work life. The ANA (1999, 2005) uses four categories to describe and organize the multiple variables affecting nurse staffing: the patient care unit (including patient factors and unit factors), the nursing staff, the organization, and evaluation of sufficient staffing. The Association of Women’s Health, Obstetric and

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C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses

Background The AWHONN perinatal staffing initiative was guided by recommendations from a task force of perinatal nurse experts representing nursing administration, research, practice and law. The AWHONN initiative was also informed by a national survey in which 884 members of AWHONN responded to the question, “Please give the staffing task force your input on what they should

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Planning and Evaluating Evidence-Based Perinatal Nurse Staffing

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Many dynamic factors affect the often minute-by-minute calculations that require adjustments in staffing decisions, and the wrong decisions can be costly.

consider in the development of recommendations for staffing of perinatal units” (Simpson, Lyndon, Wilson, & Ruhl, 2012, p. 475). The survey participants overwhelmingly stated that perinatal staffing guidelines needed to be updated and expressed concerns about having enough staff to provide safe care given the increase in complexity of the care they were providing and the increase in acuity of patients for whom they were providing care. They also reported concerns that inadequate staffing had a negative effect on nurse satisfaction and retention. The proposed Organizing Framework for Calculating Nurse Staffing (Figure 1) and the Organizing Framework for Evaluating Nurse Staffing Decisions (Figure 2) were conceived in 2012 as part of planning educational events offered by AWHONN (called leadership summits) about perinatal nurse staffing. The frameworks are being proposed to organize how the literature is reviewed and to respond to stated educational needs of nurses involved in all levels of achieving goals of effective and efficient staffing. AWHONN national headquarters staff reviewed, discussed, and reflected on summit and webinar participant feedback, discussion notes, and data obtained from the AWHONN Perinatal Staffing Data Collaborative when developing the proposed frameworks. The frameworks assist AWHONN staff in conceptualizing and organizing information obtained related to nurse staffing. Three categories were used to organize discussions and presentations at leadership summits in 2012 and 2013: Patient Factors, Nurse Factors, and System Factors. The proposed frameworks are shown in Figures 1 and 2. These frameworks are structures or approaches that AWHONN leaders are using to conceptualize and organize im-

Nurse Factors

System Factors

portant aspects of perinatal nurse staffing. They offer ways to think about perinatal nurse staffing in a broad and comprehensive manner related to structure, process, and outcomes. These frameworks have not been research tested but are offered as a way to organize the literature review and as a basis for building informed models for staffing that will be validated by research. The categories of factors in the AWHONN proposed frameworks are consistent with Donabedian’s (1988) framework of assessing the quality of health care by evaluating structures, processes, and outcomes. The components of the Donabedian framework have been accepted among quality improvement experts as components that need to be considered when working to improve health care. These staffing frameworks are also consistent with the three-level model (conceptual, theoretical, and empirical) of Wilson and Blegen (2010). The conceptual level of the Wilson and Blegen model is based on Donebedian’s structure, process, and outcomes categories; the theoretical level equates structure with organization, process with nursing care, and outcomes as patient outcomes. The empirical level of this model proposes proxy variables to measure structure (hospital ownership, teaching status, number of licensed beds), process (productive hours of care and skill mix), and outcomes (cesareans, instrumentassisted births, neonatal intensive care unit admissions, newborn injury). In another article in this series, Simpson demonstrates that the Wilson and Blegen model is a practical model for determining and assessing nurse staffing (Simpson, 2015). More research is needed to identify whether the proxy variables proposed by Wilson and Blegen are the most sensitive and critical measurements to support evidence-based nurse staffing decisions and evaluation of these decisions. These frameworks are proposed for use by researchers and administrators when making perinatal nurse staffing budgetary decisions and when evaluating perinatal nurse staffing. Administrators may also want to consider measuring and

Patient Factors

Nursing FTEs Needed

Figure 1. Organizing Framework for Calculating Nurse Staffing.

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Bingham, D., and Ruhl, C.


Actual Nurse Staffing

Actual System Factors

Patient Outcomes

Efficiency & Effectiveness of Nursing Care

Figure 2. Organizing Framework for Evaluating Nurse Staffing Efficiency and Effectiveness.

tracking more system, process, and outcome variables than those proposed by Wilson and Blegen. Goetz, Janney, and Ramsey found that when a comprehensive, data-driven approach was used by nursing leaders hospital-wide to determine staffing, and when they benchmarked their staffing decisions with similar types of hospital units, they were able to identify errors in assumptions regarding staffing variations, save more than $10 million during a 4-year period, and report improvements on select patient outcomes (2011).

are based on what the actual staffing was (budgeted full-time equivalents [FTEs] compared to actual FTEs). The evaluation of effectiveness and efficiency is utilized to determine how well the planned staffing matched with the reality of what occurred and how those decisions affected patient outcomes and budgets.

Subcomponents of the three major categories of factors in the staffing frameworks and examples of factors to be considered for each are outlined in Table 1. To view and print a full color version of Table 1, see the online version of this article at http://jognn.awhonn.org. For the purposes of the framework, efficient and effective staffing is defined as staffing that meets the six Institute of Medicine (2001) aims for health care improvement. Namely, that the nursing care was safe, effective, patient centered, timely, efficient, and equitable. The definition of measuring effectiveness and efficiency of nurse staffing also incorporates the Institute for Healthcare Improvement’s Triple Aim approach to determine whether the nursing care provided improved the patient experience of care, including quality and satisfaction; improved the health of populations; and reduced the percapita cost of health care (Institute for Healthcare Improvement, 2014).

Perinatal staffing determinations and evaluation is important for the range of perinatal patient populations (women, fetuses, and newborns) and applies to the different types of specialized nursing care provided by women’s health and perinatal nurses in multiple types of care settings. This care includes triage and evaluation of a pregnant woman presenting for unscheduled evaluation and care, scheduled outpatient procedures and evaluations, antepartum care, intrapartum care, intraoperative care, postanesthesia care, highrisk newborn care, and postpartum mother/infant couplet care for women with and without major medical illnesses and/or surgical birth. An underlying premise of AWHONN’s perinatal nurse staffing guidelines (2010) is that the nurse staffing levels provided for the care of these women should be consistent with the levels of nurse staffing in other similar types of hospital units; for example, in the main emergency department, intensive care units, operating rooms, postanesthesia care units, or medical/surgical floors. Other underlying premises are that nurse staffing decisions should be based on the best evidence, data driven, flexible, supportive of the ability of nurses to provide emotional and spiritual support, and tailored to the needs of the women and newborns under their care.

The framework for calculating nurse staffing is used to plan, and the framework for determining effectiveness and efficiency is used to evaluate. For example, the nurse factors subcategory data utilized to determine the plan and budget for how many staff need to be on duty are based on projections. The nurse factors data used to evaluate effectiveness and efficiency of nurse staffing

It is beyond the scope of this article to address all of the subcomponents as they apply to each of the perinatal care areas and patient populations. Instead, we provide examples of how these frameworks and select subcomponents for calculating staffing FTEs and evaluating nurse staffing can be used to determine and evaluate perinatal nurse staffing.

Description of the AWHONN’s Organizing Frameworks

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Skill Mix

Patient Day

Patient Day and Total Nursing Hours per

Registered Nurse (RN) Nursing Hours per

Nurse Factors Subcomponents

r r

r

r r

Unit assistants

Nurse aides

Scrub techs

On-unit ancillary or support staff

Licensed practical nurses (LPNs)

Agency or travelers

Float staff

Regular staff

RNs

r r r r

time efficiently and care is not too fragmented

(Continued)

Evaluate whether the RN and other nursing staff are spending their

Number of ancillary or support staff hours

Number of LPN hours

Number of RN hours based on RN type

Stone, 2014).

Vacancy rates Vacation time allotted

these changes affect team performance (Bartel, Beaulieu, Phibbs, &

Illness rates

Track and report overuse of unplanned absences due to illness since

year).

r

Hospital committee involvement Mortality and morbidity reviews

a patient assignment (this will vary based on the number of births per

Quality improvement activities

Identify the number of times the charge nurse does and does not have

related activities and achieve work-life balance.

r

to ensure that nurses have time for direct and in-direct patient care

Orientation, including orientation to technology Drills

indirect or nonproductive RN and Total Nursing Hours per Patient Day

Track and evaluate the actual number of direct or productive and

Continuing education

r

Examples of Nurse Factors to Consider when Evaluating Nurse Staffing

Indirect RN or Total Nursing Care Hours

Direct RN or Total Nursing Care Hours

Equivalents (FTEs)

Examples of Nurse Factors to Consider when Calculating Full-Time

Table 1: Components of the AWHONN Perinatal Nurse Staffing Organizing Frameworks

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Nursing Model of Care

Staffing Model


Table 1: Continued

r

r

r

r

staff and patients.

occurring in the nursery or in the mother’s room

occurring a break room or at the patient bedside, baths

The location of where the nursing care occurred, e.g., handoffs

Mechanisms for RNs to report inappropriate staffing

Charge nurse responsibilities: do they take patient assignments?

Nurses primarily manage women in labor

Mother nurse only and nursery nurse only

(Continued)

model of care to reduce the number of hand-offs among the nursing

Triage-labor-birth nurses Mother/baby couplet care nurses

nursing time and improve quality and safety, e.g., adjust the nursing

Triage-labor-birth-recovery postpartum nurses

Evaluate and revise the nursing model of care to reduce wasted

antepartum, postpartum, and high-risk nursery units

Triage-labor-birth-recovery nurses

Characteristics of the nursing model utilized

Requirements for minimal number of nurse staff on unit

Size of nursing staff pool

Number of part-time staff available to add additional shifts

Measure and track census and acuity at least every 4 hours in the

room and postanesthesia care area

Number of staff available to work overtime

obstetric emergency department, labor and delivery, operating

Number of areas staff are crossed trained in

Measure and track census and acuity at least every 2 hours in the

Number of staff cross trained

How quickly on-call staff can arrive at the hospital

measurements

Include women, fetuses, and newborns in the census and acuity

On-call system

(Needleman et al., 2011). At a minimum

Evaluate and revise staffing frequently to capture unit turbulence

patient, nurse, and system factors.

Track whether the nurse staffing increased or decreased based on

24-hour cycle

r

r


(including determination of necessary staff and skill mix) throughout a

Method and frequency of assessing and responding to staffing needs

units and other hospital units

Integration of the perinatal nursing staff among the various perinatal

Equivalents (FTEs)

Examples of Nurse Factors to Consider when Calculating Full-Time


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Professional Team Members’ Staffing Patterns

System Factors Subcomponents

Characteristics of the Nursing Staff


Table 1: Continued

Do you have a deep respect for the needs of others? Do you communicate a helping, trusting attitude towards others? Do you give full consideration to situational factors?

evidence-based practice analysis Experience

Fluency level in languages spoken by patient population

r

Interns or residents

Medical Students

Expertise of non-nurse clinicians

workers, dieticians/nutritionist

Number and hours of non-physician and non-RN staff, e.g., social

Number and hours of in-house coverage by nurse practitioners

(Continued)

of non-RN professional staff.

hospitalists

births and patient population characteristics to compare the number

Measure and benchmark with other hospitals with similar volumes of

Staffing

Number and hours of in-house coverage by physicians or

r

Examples of System Factors to Consider when Evaluating Nurse

perinatal expertise and a master’s degree.

There is a perinatal nurse educator or clinical nurse specialist with

providing evidence-based nursing care.

order to adequately support the team and facilitate that nurses are

Nursing leaders and supervisors have expertise in perinatal nursing in

at all times.

Number and hours of in-house coverage by midwives

Number and availability of non-RN professional team members

Equivalents (FTEs)

r

r

decisions are made and that adequately skilled nursing staff on-duty

Measure whether staffing plans ensure equity in how nurse staffing

patients.

r

Type of experience, e.g., worked in hospitals with high-, medium-, or low volumes

knowledge base, skills, and experience to care for specific types of

Years in nursing total

Evaluate whether the nurses on the team have the adequate

answer questions such as

Competence, including competence in performing an

r

Caring Attributes Scale (Watson, 2009). The scale asks the nurse to

Nursing certification

Years in perinatal/neonatal

validated tool such as The Nyberg Caring Assessment Scale or CAS

Evaluate the caring attitudes and behaviors of nurses by using a

non-BSN

r


Education, e.g., Bachelor of Science in Nursing (BSN) versus

The caring attitudes and behaviors of the nurse

Examples of System Factors to Consider when Calculating Full-Time

r

r

r r

r r

Equivalents (FTEs)

Examples of Nurse Factors to consider when Calculating Full-Time



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Availability of Equipment

Systems

Characteristics of the Medical Records

Teamwork


Table 1: Continued

r

r

r

Characteristics of the medical records systems:

r

equipment. (Continued)

Determine how to reduce wasted nursing time to search for needed

accessible.

r

there is enough equipment and whether the equipment is readily

Perform time and motion studies of nursing staff to determine whether

Eliminate charting that is non-essential.

Streamline charting to eliminate redundant charting.

amount of unnecessary time RNs spend charting.

Perform time and redundancy studies to determine how to reduce the

training.

teamwork and communication patterns, e.g., debriefs, drills, team

Identify and track ways in which the team has worked to improve

independent contributions of care.

Ensure that all members of the team are respected for their

communication and track how these complaints are resolved.

Systems are in place to ensure equipment is easy to obtain.

r

r r

r

r

r

maintained.

Systems are in place to ensure equipment is clean and properly

hospital, e.g., blood bank, laboratory

elements are available to NICU staff and other areas of the

various perinatal units, e.g., antepartum and intrapartum data

Documentation of key information flows smoothly among the

system

Hospital electronic records interface with the fetal heart monitoring

the system

such that systems do not require extra steps to enter data into

Documentation systems are geared to the perinatal population

records as needed

Clinicians can readily access antepartum records and other

Limited number of redundancies in what nurses need to chart

Limited amount of down-time of electronic systems

The amount and type of team building and communication training

Frequency of team huddles

Responsiveness of colleagues to nursing staff concerns

staff

r r r

Measure the number and type of staff complaints about inter-team

Staffing

The ways the non-RN professional team members interact with the RN

Equivalents (FTEs)

r


Examples of System Factors to consider when Calculating Full-Time



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Administrative Support

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Leadership Support

Practice and Quality Improvement Initiatives

Number and Type of Evidence-Based

r

r r

r r

r

r r

r

r r

r

quality improvement project.

perform evidence-based practice evaluations and design/lead a

RNs have access to mentoring and education on how to formally

RNs have time to explore clinical concerns and questions.

(Continued)

readjusted.

in relevant research studies.

Determine whether these processes are adequate or need to be

Identify the processes for evaluating mentor and mentee experiences.

recognized. Track the type and amount of training they receive.

List the ways mentors and preceptors are shown they are valued and

for which nurses receive financial support.

RNs are able to consult with nursing research experts and participate

r

r

Measure the number of educational meetings or conferences nurses

together to share and discuss their findings.

involvement and time budgeted to support nurses’ ability to gather

Identify the number and types of systems available for rewarding staff

RNs are provided adequate mentoring and time to grow professionally.

huddles to adjust staffing based on patient, nurse, and system factors.

Requirements for nursing leaders to attend organizational staffing

quickly and in a productive manner.

Systems in place to easily communicate concerns and resolve issues

Nursing leadership has expertise in the area of perinatal nursing care.

r

r

initiatives, and research.

Systems facilitate data gathering.

participating in safety, evidence-based practice, quality improvement

collection and analysis.

Identify the number of nursing hours budgeted to for leading and

Nurses are provided adequate support staff to facilitate data

Nurses are allowed adequate time to gather data and analyze data.

materials for doing the job are readily available.

Track time, motion, and flow in order to assess whether the right

amount of nursing time spent ensuring adequate communication.

person with the right skill set is doing the right job and whether the

r

Staffing Measure the percent of patients who need translation services and the

education material accessible.

r

r


additional staff during busy times, prepare documents, keep patient

Nursing staff have clerical support as needed, e.g., to call in

language line support via telephone

Availability of translation services, either a face to face translator or

Equivalents (FTEs)


Translation Services


Table 1: Continued



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General Organization Characteristics


Table 1: Continued


r r

r r

r

Acceptable rates of job demands

Desirable work schedules

Opportunity and support for care coordination

Support for ethical decision making

Work-related staff illness and injury rates

Level of RN satisfaction

Compliance with local, state, federal regulations

Human Resources and benefits packages

Regular evaluation of nurse staffing issues from a system perspective:

Leaders focus on patient-safety priorities

that they value the work and contributions of the team

Organization leaders invest in team development and demonstrates

Support for professional growth of nurses

collaboratives (system-, state-, and national level)

Active leadership in multi-organizational quality improvement

accountable care organization

Leaders strive to be a high reliability organization and/or an

Support and value for learning throughout the organization

Leaders promote a just culture

r

acknowledged and valued.

(Continued)

Measure how the independent and collaborative practice of nurses is

survey and strive to improve the work environment.

Track how organization leaders respond to the results of the safety

the Safety Attitudes Questionnaire (Profit et al., 2012).

r

Safety and quality context Team training available

based using assessment tools validated for the perinatal setting, e.g.,

Connection of the hospital with medical and nursing schools

Periodically assess the safety attitudes context for the perinatal unit

(Lake, 2002).

r

(PES-NWI) that has been endorsed by the National Quality Forum

For profit or nonprofit hospital Hospital location, e.g., rural, urban, critical access

such as the Practice Environment Scale of the Nursing Work Index

Independent hospital or part of a hospital system

Measure the overall work environment of nurses using a validated tool

State designation level for neonatal care

Volume of annual births

Staffing

r

Equivalents (FTEs)

r r r r r r r r r r r





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Patient Volume

Patient Factors Subcomponents

Unit Geography


Table 1: Continued

r

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r r r

r

r

post-anesthesia care area.

Transfers Discharges

Rapidity of triage, admissions of women and newborns, transfers, and discharges

Newborn length of stay

Postpartum length of stay

Intrapartum length of stay

Antepartum length of stay

Outpatient length of stay (triage)

Other types of measures of patient volume

Admissions

Turbulence

those discharged home)

(Continued)

Number of women triaged and evaluated (those admitted and Number of outpatient procedures, e.g., versions

r

antepartum, postpartum, high-risk nursery units. Measure amount of unit turbulence

Number of patients cared for in non-obstetric areas

for evaluation before disposition

Number of patients typically triaged and evaluated and length of stay

Women schedule for a procedure that may need to be admitted

Women scheduled for cesarean birth

r

emergency department, labor and delivery, operating room and

Number of anticipated admissions

Measure and track census at least every 4 hours in the

Measure and track census at least every 2 hours in the obstetric

Current volume of admitted infants Women scheduled for an induction of labor

Include women, fetuses, and newborns in the census count.

Current volume of admitted women

Measure patient volume

and include fetuses and newborns in census count)

Current volume of patients admitted (measure census every 2–4 hours

Staffing

r

Examples of Patient Factors to Consider when Evaluating Nurse

and evaluated.

Measure the effect of the unit geography on staffing is acknowledged

Staffing

Equivalents (FTEs)

Location of the physician and midwife on-call rooms

nurses and physicians or a collective lounge

Location of the lounge and whether there is a separate lounge for

unit, and the postpartum/well-baby nursery

department, the labor and delivery area, the neonatal intensive care

Amount of physical separation of the obstetric emergency

Number and location of the nursing station(s)

r


Examples of Patient Factors to Consider when Calculating Full-Time

r

r

r r

Equivalents (FTEs)




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Patient Characteristics

Patient Acuity


Table 1: Continued

High-intensity educational needs, e.g., high-risk maternal or neonatal

r

r r r

r r

Co-morbidities (TWO or more moderate- or high-risk conditions)

r

characteristics. (Continued)

Identify when staffing was and was not adjusted based on patient

interpreter.

Social support including family presence

interpreters were used, and how long it took the nurses to obtain an

Age, e.g., adolescents have special developmental needs

Track percent of patient population who need interpreters, how often

High intensity social, emotional or mental health issues

r

number of teenagers cared for in a given shift.

Newborns are nonverbal

to meet the unique needs of each patient they are cared for, e.g.,

Track the frequency that nurses tailored the education they provided

intensive nursing care.

Track the number of patients with characteristics that require more

frequency staffing is adjusted based on acuity.

Track the methods used to evaluate staffing decisions and the

Measure the perinatal population specific patient acuity.

the mother and the infant)

Language barriers and need for translation

r

r

r r

Readmission rates within 1–2 weeks of discharge (track separately for

gestational age and large for gestational age infants

e.g., fewer than 2500 grams, 2500 grams or more, small for

Number and percent of high-risk nursery admissions based on weight,

term, full-term, late-term, and postterm

gestational age, e.g., very-low-birth-weight, late preterm infants, early

Communication barriers

Cultural diversity

conditions with a mother who has low literacy

Fetal, infant, or maternal demise

Life-threatening urgent need

High risk

Moderate risk

Low risk

Scheduled admissions and procedures

r r r r r r r

Staffing

Equivalents (FTEs)

Number and percent of high-risk nursery admissions based on


Examples of Patient Factors to consider when Calculating Full-Time



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Patient Outcomes

Caring


Table 1: Continued

Not applicable

by the nursing staff. Patients felt cared for.

r

r

r

r

r

r

Nursing Care Quality Measures (AWHONN, 2013, 2014).

national measures such as AWHONN’s Women’s Health and Perinatal

Measurement and evaluation of evidence-based nursing care using

the National Quality Forum’s Healthy Term Newborn Measure

metrics, e.g., the five Joint Commission perinatal care core measures,

Measurement of patient outcomes using nationally recognized quality

Kilpatrick, Main, & DʼAlton, 2014; Kilpatrick et al., 2014).

administration of 4 or more units of blood (Callaghan, Grobman,

of admissions to intensive care unit (ICU), ICU length of stay,

Measurement of severe maternal mortality and morbidity, e.g., number

Safety in Women’s Healthcare, 2014; Kilpatrick et al., 2014)

identify, record, and communicate lessons learned (Council on Patient

Perinatal mortality and morbidity tracking system with peer review to

McCann, & Strickler, 2014).

Implement and track the number of “caring moments” (Tonges,

Caring Model (AWHONN, 2014).

Quality Measures that are based on the Duffy and Hoskins Quality

Utilize the AWHONN’s Women’s Health and Perinatal Nursing Care

2013).

Caring Science Institute & International Caritas Consortium,

Valued their personal beliefs and faith, allowing for hope (Watson

Created a caring environment that helped them heal; and

Developed a helpful and trusting relationship with them;

Met their basic human needs;

Delivered their care with loving-kindness;

following elements:

Score that asks patients to rank their care givers from 1–7 on the

cared for by using a validated tool such as the Watson Caritas Patient

Measure aspects of nursing care that determine whether patients felt

Staffing

r

Equivalents (FTEs) Patients’ emotional and spiritual needs were identified and attended to


Examples of Patient Factors to consider when Calculating Full-Time



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Nurse Factors Based on the review of the literature and feedback from the summit participants, five proposed subcomponents of the nurse factors (see Table 1) are RN nursing hours per patient day and total nursing hours per patient day, skill mix, staffing model, nursing model of care, and characteristics of the nursing staff.

RN Nursing Hours per Patient Day and Total Nursing Hours per Patient Day Staffing FTE calculations are affected by the number of RN and non-RN nursing hours per patient day and total amount of nonproductive or nondirect patient care hours. Examples of common nondirect patient care hours are those hours nurses spend gathering data for quality improvement, coordinating and participating in educational events such as drills, orientation, sick leave, vacation, and ineffective work flow. Hospital units can more accurately plan by determining what their typical monthly or annual amounts of nonproductive hours have been. In addition, working to reduce unexpected absenteeism, such as elimination of overuse of sick time, is one way to reduce staffing costs without reducing the number of budgeted FTEs, because covering sick time usually costs more per hour by paying time and a half per hour versus a regular hourly wage or paying contract nurses who typically make more money per hour than regular staff.

Skill Mix In addition to the high hourly costs of using a contract nurse or regular staff working overtime to cover nonscheduled nurse time off the unit, these replacement nurses may also have a negative effect on patient outcomes. Researchers have shown that hiring more contract RNs increases length of stay (Bartel, Beaulieu, Phibbs, & Stone, 2014). Bartel et al.’s (2014) study was not designed to measure the accumulative effect of several months of permanent staffing changes, and the authors acknowledged the “possibility that productivity effects of temporary staffing changes could be larger or smaller in units with more frequent permanent staffing disruptions (e.g., high turnover)” (p. 247). They hypothesized that these differences in outcomes are largely due to disruptions in the overall team performance. Research results indicated that ancillary staff or assistive personnel staffing should also be considered when evaluating the effect of nurse staffing on patient outcomes since nurses’ perception of staffing adequacy was shown to be correlated with


Nurses need to be provided with adequate time and training to more effectively and efficiently work to improve quality and safety.

actual assistive personnel staffing at the unit level (Kalisch, Gosselin, & Choi, 2012).

Nursing Model of Care The nursing model of care affects the efficiency of the team and the number of quality and safety risks the woman and newborn are exposed to. For example, the more occurrences of intrahospital handoffs, the higher the risk of inadequately communicating critical information among team members (Ong, Biomed, & Coiera, 2011). For example, a nurse working on the labor and delivery unit who is transferring a mother and infant to a postpartum unit where the mother has a different nurse than her infant will need to report to both nurses. Providing reports twice to two different nurses makes it more likely that critical information will not be communicated during this critical handoff report. In addition, the more time a nurse spends trying to connect with the appropriate nurse and giving report, the less time she or he has available for direct patient care. Small amounts of time spent performing redundant tasks (e.g., giving report more than once) add up over time. Also, Block et al. (2013) found that improving intershift and post-shift handoffs among the interdisciplinary team improved the overall safety climate on the unit and reduced burnout among labor and delivery nurses.

System Factors Examples of subcomponents of the system factors are professional team members’ staffing patterns, teamwork, characteristics of the medical records systems, availability of equipment, translation services, administrative support, number and type of evidence-based practice and quality improvement initiatives, leadership support, general organizational characteristics, and unit geography (ANA, 2005) (Table 1).

Characteristics of the Medical Records Systems The introduction of electronic medical records has not reduced the burden of charting on nursing staff; in fact, some researchers have demonstrated an increase in the number of hours nurses spend charting (Furukawa, Raghu, & Shao, 2010). There may be an increased

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burden on nurses if the electronic medical records system does not adequately meet the needs of the perinatal populations (Ivory, 2015). For example, electronic charting systems must seamlessly connect the outpatient records with the inpatient units so that nurses can easily find information on the maternal and fetal tests that were performed during the antepartum period. Potential advantages have been identified with the use of electronic medical records. For example, electronic medical records systems could reduce redundancies in what nurses are charting and more readily transfer critical information to enhance the nurses’ ability to adjust their treatment plan and care for patients. In addition, electronic medical records systems have been recognized as a tool for collecting patient data and nurse staffing data that is used to track and evaluate nurse staffing decisions (Crist-Grundman & Mulrooney, 2011).

Availability of Necessary Equipment Nurses are responsible for ensuring patient care equipment is available when needed because it is nurses who typically administer the hospitalbased patient treatments or facilitate/supervise the treatments other members of the team perform. Hospital administrators may decrease nurses’ productivity if they buy an inadequate amount of equipment, do not replace outdated or malfunctioning equipment, or do not develop adequate support systems to ensure that needed equipment is clean, maintained, and readily dispatched to the unit when the patient requires treatment.

Leadership Support Leaders need to consider the costs of not adequately staffing a unit. For example, researchers have found that patient mortality and complications were more likely in hospitals where nurses reported increased psychological demands, such as not enough time to accomplish work, system delays, frequent disruptions, unfavorable work schedules (e.g., long shifts, lack of time away, insufficient work breaks, mandatory overtime), and/or high physical demands (e.g., high physical exertion, extreme lifting or lowering, frequent awkward posture) (Trinkoff et al., 2011). Lower RNto-patient ratios have also been shown to increase burnout and job dissatisfaction (Aiken et al., 2002).

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It is costly to hire and orient new staff to labor and delivery because nurses on orientation are not able to practice independently and orientation takes many weeks, even if the new hire is an experienced nurse (Scheich & Bingham, 2015). Hospital leaders who reported incorporating onboarding processes as part of their comprehensive staffing strategy showed improvements in retention rates and reported an overall costs savings of $10 million over a 4-year time period (Goetz, Janney, & Ramsey, 2011).

General Organizational Characteristics The Practice Environment Scale of the Nursing Work Index (PES-NWI) is a widely used tool that has been endorsed by the National Quality Forum (number 0206) for the purpose of assessing and comparing the overall work environment of nurses (Lake, 2002). The index score is determined based on the survey responses of a sample of registered nurses who work at a particular hospital. The survey includes five subscales: nurse participation in hospital affairs; nurse manager ability, leadership, and support of nurses; staffing and resource adequacy; nursing foundations for quality of care; and collegial nurse–physician relations. Subsequently researchers have shown that “nurses reporting quality as excellent was significantly different between hospitals with good, mixed, and poor practice environments as measured by the PES-NWI” and found that “nurses in Magnet hospitals had a statistically significant higher median proportion of nurses reporting excellent quality” (McHugh & Stimpfel, 2012, p. 7). A more comprehensive measure of the teamwork climate that has been studied in labor and delivery units is the safety attitudes questionnaire (Sexton et al., 2006). It is critical that leaders work to improve the organizational safety climate, including improving how the team communicates with each other. In a recently published study, investigators showed that 34% of physicians, 40% of midwives, and 56% of registered nurses who are members of professional organizations and who responded to a national survey reported that patients were put at risk due to lack of listening or responsiveness from other team members (Lyndon et al., 2014). The researchers also found that 37% of physicians, 25% of midwives, and 43% of nurses reported having unresolved issues that affected patient care and described feelings of resignation regarding their ability to protect patients from harm (Lyndon et al., 2014).


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Number and Type of Evidence-Based Practice and Quality Improvement Initiatives In the past few years, the number of national and state perinatal quality improvement initiatives has increased. The data collection burden for these perinatal initiatives may add to the workload of nursing staff, especially if these data are obtained from chart audits rather than administrative data sets. Nurses need to be provided with adequate time and training to more effectively and efficiently work to improve quality and safety. Computer charting systems also need to be configured to more efficiently gather data and generate standardized staffing data reports.

Patient Factors The proposed subcomponents of the patient factors are patient volume, patient acuity, patient characteristics, caring, and patient outcomes.

Patient Volume Measures of patient volume on perinatal units must be adjusted such that turbulence or unit churn (number of admissions and discharges during a given shift) is measured because unit churn has been shown to lead to worse patient outcomes (Needleman et al., 2011). Researchers who compared nurse staffing hours per patient day calculations based on midnight census to the inverse of the length of stay (1/LOS) and the Admission/Discharge/Transfer (ADT) Work Intensity Index found that if the hospital leaders only use the midnight census to determine nurse staffing, the actual workload of the nurses is underappreciated, particularly in units where patients have shorter lengths of stay (Hughes, Bobay, Jolly, & Suby, 2013). The recognition that admitting, discharging, and transferring a patient increases the workload of the nurse is of particular relevance to perinatal areas. For a dynamic area like labor and delivery, the census needs to be counted and staffing adjusted more frequently than every 24 hours. The volume of patients presenting for emergency triage and evaluation needs to be captured in a manner that is similar to how patient volume is counted in the main emergency department. Namely, patient volume needs to be counted based on the number of patients evaluated and their lengths of stay in the triage and emergency evaluation area prior to being admitted or sent back home. Unlike staff in the main hospital emergency department, the


perinatal nurse caring for each pregnant woman is actually caring for two or more (in the case of multiple gestations) patients: the woman and the fetus. The mother and her fetus must be recognized as contributing to the workload, because both are evaluated and are part of the triage nurse’s responsibility. For a mother/baby unit, relying on a midnight census is not adequate, and leaders should consider evaluating the census more frequently. Leaders who attended the staffing summits recommended that the census be evaluated at least every 4 hours, and the number of women currently in labor as well as the number of anticipated discharges needs to be considered when making staffing decisions. In addition, the complexity of well-infant care is often underappreciated; these infants are patients who require total care and are unable to speak up and explain what they need. In addition, even with a low-risk population where the majority of infants born are healthy, the infants need to be cared for by a nurse with specialized skills, the expertise to recognize abnormalities, and the knowledge to respond to these findings in a timely and efficient manner. The need for nurses who are specially trained in the care and evaluation of newborns is particularly important because in many hospitals in the United States pediatricians are not on duty 24 hours per day and only come to the hospital once per day (usually in the mornings) to perform newborn infant examinations. This means that the nurse’s examination is the only one a newborn infant will have during the critical first few hours of life and often for more than 12 hours of the first day of life. Thus, part of the mother/baby census must include a count of the number of infants being cared for by nursing staff with the appropriate expertise.

Patient Acuity Acuity is another patient factor that needs to guide staffing decisions. Staffing ratios based on acuity need to be adjusted frequently and in a timely manner. Staffing plans need to be flexible enough to meet the acuity of a given patient population throughout their entire hospitalization. In 1983 the cesarean birth rate in the United States was 16.5%; in 2012 the cesarean birth rate was 32.8% (Martin, Hamilton, Osterman, Curtin, & Mathews, 2013). This represents nearly a 100% increase during a 30-year period. Yet approximately 60% of this increase has occurred since 1996. This rapid increase in overall perinatal

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in-patient population acuity affects the number of nurses needed to provide safe care for women who have had major surgery and are in need of more pain medications, intravenous infusions, antibiotics, breastfeeding support, and frequent assessments due to their increased risk of complications. In addition, in just a 10-year period (1998– 1999 compared to 2008–2009) there has been an increase in patient acuity among women who are hospitalized when giving birth. Specifically, researchers found a 183% increase in the number of women who received blood transfusions, a 75% increase in severe complications during delivery hospitalizations, and 114% increase during postpartum hospitalizations (Callaghan, Creanga, & Kuklina, 2012). No data show that perinatal RN staffing ratios have been adjusted to meet the increased acuity of the perinatal population. Also, data are lacking to determine whether the increase in perinatal morbidity might have been avoided had more RNs been working in labor and delivery and postpartum during this time period. These data do indicate that careful and thoughtful attention to RN staffing ratios based on patient acuity must be attended to and adjustments in staffing must be made to meet these documented changes in perinatal acuity. Situations occur in which perinatal acuity can easily be underappreciated. For example, in the situation of a fetal or infant death or high-risk newborns, if a nursing supervisor determines postpartum staffing solely on census and medical needs, then workload is underestimated. One less infant in the census and a stable postpartum woman does not adequately account for the staffing needs of this unit because the woman and her family needs intensive bereavement nursing care and education. In addition, associated paperwork and postmortem care that the nurse must complete are time-consuming. If a stable healthy woman gives birth in a neonatal intensive care unit (NICU), the postpartum nurse needs to support the woman to breastfeed and ensure that she gets to and from the NICU to see her infant even though the nurse is not personally responsible for providing nursing care to this infant. Even if the NICU is in a different hospital, the nurse will need time to prepare the woman for referral and transfer to another hospital or for early discharge and will need to provide additional nursing care support and education until she is transferred or discharged due to the woman’s increased needs because she did not give birth to a healthy newborn.

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It is often assumed that nurses who work in perinatal units are working in positive environments where happy events are the norm. The dramatic rise in the number of women with severe negative outcomes during childbirth has now increased the number of nurses exposed to traumatic events, and the effect of this documented increase in perinatal acuity on perinatal nurses is not well understood. However, Beck and Gable (2012) showed that 35% of the 464 labor and delivery nurse members of AWHONN who responded to a national survey reported moderate to severe levels of secondary traumatic stress. The traumatic stress was severe enough for some of them to report that they were considering no longer being a labor and delivery nurse.

Patient Outcomes Patient outcomes are the standard by which leaders need to evaluate the effectiveness and efficiency of nurse staffing. Researchers have shown that there is a relationship between the number of registered nurses caring for patients and adverse patient outcomes such as failure to rescue or rates of mortality (Aiken et al., 2002; Needleman et al., 2011). Kalisch et al. (2011) found that missed nursing care events also correlate with nurse staffing ratios. Missed nursing care events may be a more sensitive measurement than adverse outcomes, because not all missed nursing care will lead to a measurable difference in patient morbidity and mortality. McHugh and Stimpfel (2012) identified a simple and reliable method of ranking overall quality of nursing care as a complement to other more detailed measures of patient care quality and outcomes. They asked nurses to rank the quality of nursing care as excellent, good, fair, or poor by responding to the question: “How would you describe the quality of nursing care delivered to patients in your unit?” They found that the selfreported perceptions of nursing care quality at 396 hospitals in four different states corresponded with the hospital’s rates of mortality, failure to rescue, and patient satisfaction. They hypothesized that asking nurses about the quality of the nursing care on their unit makes sense because nurses are at the bedside of patients from admission to discharge. The Women’s Health and Perinatal Nursing Care Quality Measures Panel released the first set of draft measures in 2013 to obtain public comments (AWHONN, 2013). These draft measure specifications have been refined based on


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the public comments in preparation for measurement testing (AWHONN, 2014).

Caring It is critical for nurses, administrators, and public policy leaders to recognize that caring and relationships are at the core of high- quality nursing care and health care quality. Nurses have long recognized the importance of caring in relationship to health and healing, and much of the science around measuring caring is being led by nurses. In 2011, Nelson summarized some of the science in this field of inquiry, including measuring biochemical markers of stress, such as cortisol levels, as a means of measuring how caring affects patients and care givers. Other health care leaders also recognized and asserted that caring is the essence of health care: “‘person-centeredness’ is not an element of an agenda for improvement; it is a precondition of improvement” (Berwick, 2014, p. xi). Unfortunately, results from a cross-sectional survey of 2917 of nurses who work in the United Kingdom indicated that 86% of the nurses surveyed reported that due to lack of time they missed performing one or more care activities during their last shift on duty; the most frequent care left undone was comforting or talking with patients (Ball, Murrells, Rafferty, Morrow, & Griffiths, 2014). Measuring how much a nurse cared or measuring the caring behaviors among health care workers may seem too challenging to pursue. However, the Watson Caritas Patient Score is a simple tool that can be used to ask patients to rank their care givers from 1 to 7 on the following elements: delivered their care with loving-kindness; met their basic human needs; developed a helpful and trusting relationship with them; created a caring environment that helped them heal; and valued their personal beliefs and faith, allowing for hope (Watson Caring Science Institute & International Caritas Consortium, 2013). In addition, AWHONN’s Women’s Health and Perinatal Nursing Care Quality Measures are based on the Duffy and Hoskins quality caring model (AWHONN, 2013). Health care systems have published the results of quality improvement initiatives designed to measure and increase the caring behaviors of staff that work in in-patient and outpatient settings. For example, the University of North Carolina Hospitals (UNCH) used the Swanson caring theory as the foundation for forming their culture of care (Tonges, McCann, & Strickler, 2014). The Swanson caring theory includes five


Comprehensive, equitable, evidence-based methods for determining and evaluating perinatal RN staffing should include data that account for system factors, nurse factors, and patient factors.

interrelated components that were integrated into the culture at the UNCH hospital system where the staff support patients in maintaining belief and show compassion that is “embodied in knowing and being with combined with the competence demonstrated in doing for and enabling” (Tonges et al., 2014, p. 326). They operationalized the caring culture by implementing what they titled “caring moments” that they defined as 3 minutes of uninterrupted time when staff sit down near a patient and listen to the patient, show recognition of the feelings the patient expressed, establish a personal connection, and express concern. Implementing this approach increased the unit-level patient satisfaction scores from the 15th percentile to the 65th percentile despite the fact that the staff were expected to have caring moments with only one of the patients they were assigned to care for on a given shift.

Conclusion The complexity of determining and evaluating perinatal nurse staffing is a contributing factor in why there are still no evidence-based, standardized perinatal nurse staffing decision making and evaluation tools available even after more than a half-century of maternity nurses’ caring for the majority of birthing women and infants in hospital settings in the United States. Indeed, the long list of variables that are known to affect staffing decisions and patient outcomes outlined in Table 1 underscores the complexity of nurse staffing decision making. Despite the complex nature of these decisions, every day, every shift, in every hospital where perinatal nurses are working, staffing decisions are being made that affect nurses, patient outcomes, and health care costs. Acknowledging that staffing decisions are complex decisions affected by multiple factors is not sufficient. More effort is needed to determine how many nurses are required and then to evaluate the effect of actual nurse staffing on patient outcomes. These proposed perinatal nurse staffing organizing frameworks and the literature reviewed herein identify components for consideration when researching, planning, or evaluating perinatal nurse staffing. Many nurse leaders who attended the

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AWHONN summits described their frustration with the current nonperinatal staffing tools and nonperinatal-specific benchmarking metrics they are held accountable to. Given the current rise in maternal morbidity and mortality, efforts are needed to improve perinatal nurse staffing with perinatal-specific tools. At minimum leaders need opportunities to benchmark and share with each other the type of perinatal nurse staffing decisions they are making and the type of data they are using to evaluate these decisions. Yet benchmarking systems require consistency in the data definitions and data collected.

sures specifications. Washington, DC: Author. Retrieved from http://www.awhonn.org/awhonn/content.do;jsessionid=1CE7DC 74ADCD43B7CCB5E69C18AA4E8E?name=02_Practice Resources/02_perinatalqualitymeasures.htm Association of Women’s Health, Obstetric and Neonatal Nurses. (2014). Women’s health and perinatal nursing care quality refined draft measures.

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Staffing data that go beyond tracking nursing costs and the numbers of nursing FTEs are also needed. More complex data such as data on how nurse staffing affects the safety and quality climate of the unit, patient outcomes such as length of stay, readmission rates, mortality and morbidity, rates of surgical births, missed nursing care, nurse burn-out, nurse turn over, teamwork, and nurse caring must also be collected and reported. Public health leaders, regulatory agencies, hospital boards, and health care insurers must support the efforts of nursing leaders and hospital administrators to identify more effective and efficient ways to reduce health care costs and improve patient outcomes that move beyond the often knee-jerk and short-sighted solution of simply cutting FTEs. Maternal health leaders who are working to decrease disparities in our maternal and infant outcomes can also use data on nurse staffing to assess possible disparities in hospital staffing and outcomes. Women who give birth in the United States need leaders who advocate for and promote the adoption of more comprehensive, equitable, evidence-based methods for determining and evaluating perinatal RN staffing that include data that account for system factors, nurse factors, and patient factors.

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Certificates of completion will be issued on receipt of the completed evaluation form, application and processing fees. Note: Accredited status does not imply endorsement by AWHONN or the American Nurses Credentialing Center of any commercial products displayed or discussed in conjunction with this activity.

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Predicting nurse staffing needs for a labor and birth unit in a large-volume perinatal service.

The RAFAELA system: a workforce planning tool for nurse staffing and human resource management.

Nurse staffing matters: now what?

The role of health care technology in support of perinatal nurse staffing.

ICU workforce: revisiting nurse staffing.

Evaluating nursing hours per patient day as a nurse staffing measure.

Analysis and control of nurse staffing.

Chief Nurse responds to safe staffing concerns.

Analysis of nurse staffing and patient outcomes using comprehensive nurse staffing characteristics in acute care nursing units.

NICE to address safe emergency nurse staffing.

The impact of nurse staffing on readmissions.

Innovations in staffing: the resource nurse.

Pre-implementation studies of a workforce planning tool for nurse staffing and human resource management in university hospitals.

Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses' perceptions of nurse staffing.

Nurse staffing, medical staffing and mortality in Intensive Care: An observational study.

Wage, work environment, and staffing: effects on nurse outcomes.

Nurse staffing and education in Europe: if not now, when?

Comparing the nurse staffing in Korean and U.S. nursing homes.

physician assistant staffing and critical care mortality.

Nurse Staffing Levels and Patient-Reported Missed Nursing Care.

Nurse specialist in family planning.

Manpower planning for nurse personnel.

Relationship between nurse staffing levels and nurse outcomes in community hospitals, Thailand.

Unequal staffing: A snapshot of nurse staffing in critical care units in New South Wales, Australia.