Identifying and maintaining the appropriate number and mix of nursing staff is critical to the delivery of quality patient care. Numerous studies reveal an association between higher levels of experienced Registered nurses staffing land lower rates of adverse patient outcomes This paper focuses on the impact of nursing workload on patient satisfaction. We first present different concepts and models of nursing workload, then discuss the impact of workload on patients and on nursing staff, presenting various mechanisms of the relationship between nursing workload and patient satisfaction. Finally, it elaborate a human factors engineering approach on how work systems can be redesigned to decrease nursing workload or to minimize the unconstructive effect of a heavy nursing workload
INTRODUCTION
The link between workload and quality of care is often thought of in terms of adverse events. As mandated by State law, requires acute care hospitals to maintain minimum nurse-to-patient staffing ratios. Required ratios vary by unit, ranging from 1:1 in operating rooms to 1:6 on psychiatric units.( Rothberget al, 2005) The legislation also requires that hospitals maintain a patient acuity classification system to guide additional staffing when necessary, assign certain nursing functions only to licensed registered nurses, determine the competency of and provide appropriate orientation to nurses before assigning them to patient care, and keep records of staffing levels. To assist with compliance, the legislation made grants available to hospitals and provided funding to college and university nursing programs to increase the pipeline of new nurses. The legislation has increased nurse staffing levels and created more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in other states without mandated staffing ratios. (Vericourt, & Jennings, 2010). Despite initial concerns from opponents, the skill mix of nurses used by California hospitals has not declined since implementation of the mandated ratios
LITERATURE SEARCH
Several studies have shown the relationship between nurses’ working conditions, such as high workload, and job dissatisfaction and patient satisfaction. Job dissatisfaction of nurses can lead to reduced morale, absenteeism, turnover, and poor job performance, and probably interrupt patient care quality and organizational effectiveness. Researchers have found positive links exist between job satisfaction and job performance, and patient satisfaction and quality of care. Intense patient workloads for nurses has significantly led to poor patient outcomes and reduced job satisfaction. Yet the minority states need healthcare facilities to sustain minimum nurse-to-patient ratios, leaving nurses to care for a substantial number of patients at a time.
Association between heavy workloads and poor patient outcomes
According to numerous studies, heavier nursing workloads are linked with poor patient outcomes such as deaths, complications, and medical errors. For instance, the study by (Aiken et al 2002) found that every additional patient added to a nurse’s workload increased mortality within 30 days of admission by 7 %, and elevated the risk of an undetected medical complication causing preventable death or injury by the same magnitude. In another study by (Kane et al 2007)found that increased registered nurse (RN) staffing lead to reduced mortality on intensive care, medical, and surgical units; reduced hazard of hospital-acquired pneumonia, unplanned extubation, respiratory failure, cardiac arrest, and failure to rescue; and shorter lengths of stay for surgical (31 percent) and intensive care unit (ICU) patients (24 percent). On the same, other studies have confirmed that increased nurse staffing leads to improved patient results
Negative implications for nurses as well: the study by Aiken also found that every additional patient assigned to a nurse resulted to a 23-percent increase in the risk of nurse-reported “burnout” and a 15-percent increase in the risk of a nurse being dissatisfied with their job. Another study by (Sloane et al 2010)found that nurses in states without mandated minimum staffing ratios reported greater levels of burnout, job dissatisfaction, and turnover; these nurses also felt that patients received poorer quality care
Few states addressing minimum staffing levels through legislation: Despite the evidence cited above, only a few of states have established any form of legislation related to minimum nurse-to-patient ratios, with most having requirements that address only a specific unit or type of unit. Legislators are still reluctant to require hospitals and health systems to hire more nurses, predominantly with ongoing shortages in numerous regions.
THEORY FOR PROPOSED CHANGE
Minimum Staffing Ratios
The implemented standards should to specify minimum nurse-to-patient staffing ratios to be sustained always by different hospital units and departments. It may also be necessary if hospitals can achieve these needs through contracted staff to complement employed nurses.
Unit-specific staffing minimums are significant since minimum ratios differ by specialty and department; Additional staffing can be done when patient acuity is high. The legislation requires hospitals to sustain and utilize a classification system to measure patient acuity, and to add registered nurses if accepted by the system. The system should take into account intensity of patient illness, need for specialized equipment and technology, patient self-care abilities, and the extent of practice of the nursing staff. (Baumann et al, 2001). Unlicensed staff should be regulated where Hospitals shouldn’t assign unlicensed staff to perform nursing operations and invasive procedures. Registered nurses must perform these tasks. Consequently, it’s important to assess the competency of nurses and provide significant orienting before getting the mandate to perform in any clinical. Conversely, registered nurses need to be accommodated in areas of shortages since the legislation allows these institutions to meet the State mandate with a lower nursing skill mix. In addition, staffing records should be maintained in hospitals as a condition for licensure to enhance compliance.
Hospitals need to be supported to meet the requirements in accordance to the legislation. For instance, the federal government offered 3 years of funding to help in hiring additional nurses and to bolster nursing education programs at colleges and universities. Hospitals need to be supported in hiring staff. Hospitals should apply for grant money to help them hire more registered nurses. (Kuehn , 2007). Consequently, Support for nursing education is a very significant approach. Community colleges and universities receive State funding to increase the capacity of their nursing programs. Through these funds, more nursing instructors may be hired and to provided with additional supervised clinical experiences.
IMPLEMENTATION OF PROPOSED CHANGE, EVALUATION AND DISSEMINATION
First, drafting legislation should be done with help of various organizations around the states that are responsible for staffing and meeting various healthcare needs. It’s necessary to collaborate with different stakeholders across the state to verify how the legislation could be shaped to minimize opposition. While initial drafts include actual staffing ratios, the implementation processes need to be overseen by various health departments around the country that will manage the process to establish the ratios and communicate them to hospitals.
Drafting the legislation will be followed by Conducting staffing ratio study, it’s important to work with researchers so as to evaluate appropriate staffing ratios. The comprehensive study evaluates staffing systems in all health facilities in the country and conduct surveys with nursing directors all over the state. ((Kuehn , 2007). Conversely, it is important to work in hand with the stakeholders and researchers and acquire various ideas about relevant levels of staffing
Final ratios need to be Determined and broadcasted depending on the need of various regions and hospitals basing on the finding by various researchers and other contributing stakeholders. The state should formally communicate the ratios to hospitals through the State hospital association and to nurses via nursing professional organizations. In addition, the popular and health care media strongly covered the development process and the announcement of the final ratios. Funding should be increased to improve nursing supply(.( Rothberget al, 2005)
Required resources and skills
Staffing
Various departments of Health Services need to amplify the number of staff in order to accommodate the additional requirements needs that have been brought about by the legislation as noted earlier, nurse staffing levels at various health facilities need to be increased to cater for the need that have emerged, with the level of increase varying by hospital.
Costs
The federal government needs to prepare for incurring costs related to the staff added at the Department of Health Services, educational institutions with nursing programs, with the aim of elevating the levels of the nursing supply
Three general models that can sufficient nurse staffing have been used at the state level around the country. The first is approach is to reflect on the needs of the patient population and match the skills and experience of the staff. Secondly it’s important for legislators to mandate specific nurse to patient ratios in legislation or directive. And thirdly standards should be set for facilities to disclose staffing levels to the public and /or a regulatory body(Shekelle, 2013)..
METHODS TO EVALUATE THE EFFECTIVENESS Of The PROPOSED SOLUTION AND VARIABLES TO BE ASSESSED WHEN EVALUATING PROJECT OUTCOMES,
The legislation has increased staffing levels and created more reasonable workloads for nurses in California hospitals, leading to fewer patient deaths and higher levels of job satisfaction than in other states without mandated staffing ratios (Unruh, 2008). in spite of initial concerns from opponents, the skill mix of nurses used by California hospitals has not declined since implementation of the mandated ratios. Higher staffing levels; Nurse hours per patient day (adjusted for severity of illness) in California hospitals grew from 6.03 in 2003 (before implementation of the mandate) to 7.11 in 2008. The 2008 level is approximately a half hour more than in comparable hospitals in four states without mandatory minimum ratios (Florida, New York, Pennsylvania, and Texas)
The legislation has improved levels of staffing and made reasonable workloads for nurse’s hospitals, leading to reduced patient deaths and increased standards of job satisfaction. Moderate the evidence consists of pre- and post-implementation comparisons of nurse staffing levels in California hospitals, along with post-implementation comparisons of key nursing-related metrics in California to several other large states without mandated ratios; metrics include patients per shift, 30-day mortality rates, levels of job satisfaction and burnout, and nurse skill mix (Tevington, 2011).
The effectiveness of the mandated nurse patient ratios can be evaluated by examining the extend of workloads to nurses. Since the implementation workload for nurses has reduced extensive reduction in workload .After implementation of the mandated ratios, nurses in California had, on average, 4.1 patients per shift, compared to 5.4 patients in both New Jersey and Pennsylvania, which do not have mandatory minimum ratios. This difference was reflected across various types of units, including medical-surgical (4.8 in California versus 6.8 in New Jersey and 6.5 in Pennsylvania), pediatric (3.6 versus 4.6/4.4), ICU (2.1 versus 2.5/2.3), telemetry (4.5 versus 5.9/5.7), oncology (4.6 versus 6.3/5.7), and psychiatric (5.7 versus 7.0/7.9), and labor/delivery (2.4 versus 2.6/2.8 (Vericourt, & Jennings, 2010).
Consequently, another approach that can be used in determining the level of patient outcomes in terms of deaths. 2006 comparison of outcomes in California, Pennsylvania, and New Jersey hospitals found that 30-day mortality rates were 10 to 13 percent lower in California than in the other 2 states. California hospitals also had a significantly lower incidence of failure-to-rescue cases. In the aforementioned 2006 survey, a smaller percentage of California nurses reported that heavy workloads caused them to miss a change in a patient condition (33 versus 41/37 percent (Rothberg et al 2005). Effectiveness of the approach can also be viewed in terms of level of burnout, level of satisfaction and retention. The aforementioned 2006 survey found that California nurses reported less burnout (29 versus 34/36 percent) and less job dissatisfaction (20 versus 26/29 percent) than their counterparts in New Jersey and Pennsylvania. Two-thirds of California nurses agreed that they are more likely to remain in their jobs as a result of the legislation. Finally it may be viewed by observing the skill mix. (Stantor, 2004). The nursing skill mix in California hospitals did not fall after implementation of the mandate, as many critics had feared. In fact, it increased to a similar degree as in other states
Variable to be observed
Due to the reduced workload and good working condition the perception and attitude of workers that had initially deteriorated has now improved. They have improved attitude and morale towards their work. On the other hand, looking at the attitudes of patient it has really improved due to the better outcomes in hospital (Carayon& Gurses, 2006). Finally, the rate of nursing staff turnover, the legislation has led to reduced level of burn out, increased the capacity of satisfaction and retention
SUMMARIZE YOUR STRATEGY FOR DISSEMINATING THE RESULTS OF THE PROJECT TO KEY STAKEHOLDERS AND TO THE GREATER NURSING COMMUNITY.
Dissemination the results requires developing the tools essential to educate project participants and to evaluate project outcomes surveys, questionnaires, teaching materials, PowerPoint slides among others gives room for recurrent feedback to clinicians, and have higher face authority for clinicians than outcome measures. Also, there are few applicable resulting measures, and an extensive sample is needed to make available a truer estimate of performance. Therefore, clinician response is few and far between and time and again challenged owing to inadequate risk adjustment. Health professionals are supposed balance scientific thoroughness with probability when deciding whether to measure a course of action or effect(Thungjaroenkul et al 2007).
The implementation process can be undertaken using the following approach. Firstly, engage by involving the concerned stakeholders by providing relevant information such as an estimate of the number of deaths attributable to the outcome targeted. Secondly, it’s important to educate by providing evidence sustaining the intervention in the variety of concise summaries and slide presentations. This is then followed by executing the intervention by walking the process, talking to reluctant clinicians, and pilot testing the intervention before broader implementation. Finally it’s important to evaluate progress in improving patient safety by measuring performance and/or the impact on the outcome(Carayon & Gurses, 2006).
Sustaining This Innovation
Push for legislation instead of other forms of policies
Legislation mandating minimum staffing ratios is required to ensure long-term sustainability, since such legislation will be more complex to adjust than general hospital policies or professional association recommendations.
Need for ongoing reporting
Implementing Legislation alone does not ensure compliance over time. As a result, hospitals should be required to report staffing ratios on an ongoing basis so as to create accountability and allow for monitoring and oversight (Carayon , et al. 2005). And finally Support nursing education: Financial support for education can help ensure a steady stream of new nurses into the workforce, which helps hospitals meet the staffing requirements
CONCLUSIONS
There are several significant effects of high nursing workload. Research shows that a heavy nursing workload has an adverse effect to patient satisfaction .Furthermore; it negatively influences nursing job satisfaction and in the long run contributes to high turnover and the nursing shortage. In totaling to the higher patient acuity, work system factors and expectations also sums up to the nurses’ workload: nurses are expected to perform nonprofessional tasks such as delivering and retrieving food trays; housekeeping duties; transporting patients; and ordering, coordinating, or performing ancillary service (Spetz,2008). Heavy nursing workload increases burnout and job dissatisfaction, which in turn contributes to high nurse turnover. Nursing workload is influenced by levels of staffing and the conditions of patients by the design of the nurses’ work system. The predicament of poor patient service delivery among others can stem from insufficient staffing and extreme workload creating a hard work environment. Some of the domino outcomes of difficult work environment are: unyielding time constraints, insufficient communication, and scarce supervision of support staff and traumatic work environment that can result in poor job performance and employee distress.
Reference
Vericourt, F. & Jennings, O. B. (2010). Nurse-to-patient ratios in hospital staffing: A Queuing perspective. Management Science.
Tevington, P. (2011). Mandatory nurse-patient ratios.Medsurg Nursing, 20(5), 265-268.
Rothberg, M.B., Abraham, I., Lindenauer, P.K. & Rose, D. N. (2005). Improving nurse-to-patient ratios as a cost-effective safety intervention. Medical Care, 43(8), 785-791.
Carayon, P. &Gurses, A. P. (2006).Nursing workload and patient safety – A human factors engineering perspective. Patients Safety and Quality: An Evidence-Based Handbook for Nurses. Applied Ergonomics, 37(4), 525-535
Aiken, L.H., et a(2010) l. Implications of the California nurse staffing mandate for other states. Health Serv Res. 2010;45(4):904-21.
Aiken, L. H, , et al(2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA.288(16):1987-93.
Baumann, A, et a(2001)l. Healthcare restructuring: the impact of job change. Can J Nurs Leadersh.;14:14–20
Kane R. L, et al. (2007) The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. ;45(12):1195-204.
Kuehn, B.M.(2007). No end in sight to nursing shortage: bottleneck at nursing schools a key factor. JAMA. 298, 1623–5.
Shekelle, P.G. (2013). Nurse-patient ratios as a patient safety strategy: A systematic review. Annals of Internal Medicine, 158, 404-409.
Stantor, M. W. (2004). Hospital nurse staffing and quality care. Research in Action, 14. Retrieved from www.ahrq.gov/research/findings/factsheets/services/nursestaffing/index.html
Thungjaroenkul, P., Cummings, G. G. & Embleton, A. (2007). The impact of nurse staffing on hospital costs and the patient length of stay: A systematic Review. Nursing Economics, 25(5), 255-265’
Carayon, P. & Gurses, A. P. (2006). Nursing workload and patient safety – A human factors engineering perspective. Patients Safety and Quality: An Evidence-Based Handbook for Nurses. Applied Ergonomics, 37(4), 525-535.
Spetz, J. (2008). Nurse satisfaction and the implementation of minimum nurse staffing regulations. Policy, Politics & Nursing Practice, 20(10), 71-77.
Rothberg, M.B., Abraham, I., Lindenauer, P.K. & Rose, D. N. (2005). Improving nurse-to-patient ratios as a cost-effective safety intervention. Medical Care, 43(8), 785-791.
Vericourt, F. & Jennings, O. B. (2010). Nurse-to-patient ratios in hospital staffing: A Queuing perspective. Management Science.
Unruh, L. (2008). Nurse staffing and patient, nurse, and financial outcomes. American Journal of Nursing, 108(1), 62-71.
