Shaping Workforce Dimensions: Balancing The Scales

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Di Twigg, Head of School of Nursing and Midwifery, Edith Cowan University delivered this presentation as part of the 2012 Assistants in Nursing Conference – A conference for organisations and managers looking to better understand and utilise the assistant in nursing role. For more information about the event, please visit the conference website: http://goo.gl/fvWjc

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Shaping Workforce Dimensions: Balancing The Scales

  1. 1. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalAssistants in Nursing ConferenceShaping Workforce Dimensions: Balancingthe ScalesProfessor Di TwiggEdith Cowan UniversityResearch Consultant Sir Charles Gairdner Hospital
  2. 2. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalA little bit about me35 years working in hospitals– 15 years in nursing administrationExecutive Director of Nursing 600 bed public teachinghospital SCGH (2nd busiest Hospital in Australia)– Designated a Magnet hospital in 2009Department of Health Chief Nurse (policy role ) for WA 6monthsHead of School, Nursing and Midwifery 3 years
  3. 3. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner Hospital
  4. 4. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalA little bit about me2004 sat on panel with Linda Aiken at a conference inSouth Australia– SCGH started the Magnet journey– I started the PhD journey– My passion - the importance of nurses to patientsafety and quality of care– PhD: Nurse staffing for patient safetyMy ah ha moment
  5. 5. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner Hospital
  6. 6. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalHow do we effectively utilise AINs in the acutesetting?
  7. 7. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalOutline:• What does the evidence suggest about skill mix?• How do AIN’s impact on the practiceenvironment?• What are the policy challenges?• How do we ethically manage future workforceneeds?• Where to from here (policy, practice and researchimplications)
  8. 8. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner Hospitalwww.nurstoon.com
  9. 9. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat does the evidence suggest about skill mix?:Aiken found a 10% increase in degree educated registerednurses was associated with:• 5% decrease in chance of patients dying within 30 days ofadmission• 5% decrease in failure to rescue(Aiken et al 2003)Significant patient outcomes were adversely affected by lowerregistered nurse staffing levels• Pneumonia, UTI, upper gastrointestinal bleed, length of stay,shock/cardiac arrest and failure to rescue• Failure to rescue = death from complication of pneumonia,shock or cardiac arrest, upper GI bleeding, sepsis or DVT.(Needleman et al 2002).
  10. 10. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat does the evidence suggest about skill mix?:• Hospitals with a higher proportion of registered nursescompared to non registered nurses were associated withlower rates of 30-day mortality. (Estabrooks et al., 2005)• A higher proportion of registered nurses in the staff mix(as compared to registered practical nurses) wasassociated with lower medication error rates and lowerwound infection rates (Hall, Doran, & Pink, 2004).• Higher percentages of registered nurse staff, higherpercentages of baccalaureate-prepared nurses, highernurse reported adequacy of staffing and resources wereassociated with lower 30-day mortality rates in medicalpatients(Tourangeau, Doran et al., 2006)•
  11. 11. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat does the evidence suggest about skill mix?:• Higher percentages of registered nurse staff, higherpercentages of baccalaureate-prepared nurses, higher nursereported adequacy of staffing and resources were associated withlower 30-day mortality rates in medical patients(Tourangeau, Doran et al., 2006)
  12. 12. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat does the evidence suggest about skill mix?:• Skill mix with higher proportion of RNs producedstatistically significant decreases in:• decubitus ulcers• gastrointenstinal bleeding• sepsis• shock• physiologic/metabolic derangement• pulmonary failure• failure to rescue• Falls(Duffield et al. 2007)
  13. 13. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat does the evidence suggest about skill mix?:Hospital 1 (skill mix 88.46%)16% increase in pneumoniaHospital 2 (skill mix 81.55%) Hospital 3 (skill mix84.05%)10% decrease pneumonia 4% decrease in medical pneumonia– 12% in surgical patients19% decrease in DVT 5% decrease ulcer/gastritis/UGIbleed– 20% in medical patients - 7% in medical patients17% decrease in surgical sepsis 2% decrease mortality medicalpatients27% decrease in shock/cardiac arrest– 34% in medical patients12% decrease in failure to rescue(Twigg et al., 2011)
  14. 14. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat does the evidence suggest about skill mix?:Several systematic reviews (Kane, Shamliyan, Mueller, Duval, &Wilt, 2007; Pearson et al., 2006; Stanton, 2004):• There was a 3 to 12% reduction in adverse outcomes withhigher registered nurse staffing levels• Higher registered nurse-to-patient ratios was associated witha reduction in mortality, failure to rescue and length of stay• The incidence of patient deaths decreased when thepercentage of nurses with Bachelor of Science in Nursingincreased.
  15. 15. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner Hospital
  16. 16. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalHow do AIN’s impact on the practice environment?:Professional nursing practice is likely to be supported by:1.Clinical care philosophy of quality, safety,interdisciplinary collaboration, continuity of care, andprofessional accountability2. Recognition of nurses’ contributions to clinical carequality and patient outcomes3. Executive-level nursing leadership4. Nurses’ participation in (decentralised) clinical decisionmaking and organisation of clinical care systems
  17. 17. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalHow do AIN’s impact on the practice environment?:5. Career opportunities for nurses6. Support for nurses’ professional development7. Collaborative relationships within the health careteam(American Association of Colleges of Nursing, 2002)
  18. 18. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalHow do AIN’s impact on the practice environment?:Aiken, L.H.; Cimiotti, J.P; Sloane, D.M.; Smith H.L.; Flynn, L; Neff, D.F. (2011)• 665 hospitals in 4 large states in US• 1,262,120 general, orthopaedic, and vascular surgerypatients,• Random sample of 39,038 hospital staff nursesThe effect of decreasing workloads by 1 patient/nurse ondeaths and failure-to-rescue (FTR)• is virtually nil in hospitals with poor work environments• decreases the odds by 4% on both deaths and FTR inaverage environments,• decreases the odds by 9% and 10%, respectively thebest environments.
  19. 19. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalHow do AIN’s impact on the practice environment?:The effect of 10% more Bachelors Nursing Degree nursesdecreases the odds on death and FTR outcomes in all hospitals,regardless of their work environment, by roughly 4%.Aiken et al concluded:• The positive effect of increasing percentages of BachelorsNursing Degree nurses is consistent across all hospitals• Lowering the patient-to-nurse ratios: markedly improves patient outcomes in hospitals with goodwork environments slightly improves them in hospitals with averageenvironments has no effect in hospitals with poor environments
  20. 20. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalHow do AIN’s impact on the practice environment?:High nursing absenteeism coupled with a high patient loadwas associated with:• higher use of restraint• greater numbers of incident reports (Unruh, Joseph andStrickland 2007)• For Hospitals that ran above 100% occupancy for muchof the year, every 0.1% increase in the patient-to-nurse ratiothere was a 28% increase in the adverse event rate.(Weissman et al)
  21. 21. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalIn summary:Nurses play an important role in providing acontinuous surveillance system enabling the earlydetection and prompt intervention when patients’conditions deteriorate ( Aiken 2002).The ability of nurses to initiate actions that minimiseadverse events and negative outcomes for patients isdirectly linked to skill mix, educational preparationand the practice environmentSo what are the policy challenges and what is therole of the AIN?
  22. 22. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat are the policy challenges?:Nurses: even though we ‘can’t live without them’ wedon’t have enough of them!The global nursing shortage is a challenge for healthcare systems aroundthe word and solutions are critical to prevent escalating adverse healthoutcomes (ICN 2006)The World Health Organisation (2006) estimated a shortage of almost 4.3million doctors, midwives, nurses and support workers globallyUS predicts a deficit in Registered Nurses (RNs) in the United States,relative to projected demand, will begin in 2015 and continue to worsenwith projected shortages of 285,000 RNs by 2020 and 500,000 RNs by2025. (Buerhaus 2008)
  23. 23. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat are the policy challenges?:In Australia:Health Workforce Australia report (2012) identified projectedshortages of 20,079 nurses in 2016 increasing to 109,490 in 2025.If Australia aimed for medium self sufficiency of the nursing workforcewith less reliance on migration, the shortage in 2025 would increaseto 129,818 nurses.However.....if retention was improved by sustaining exit rates at 2% of the totalnursing workforce the shortage would fall to 25,000 in 2025This equals a reduction of over 100,000 nurse shortages(Health Workforce Australia, 2012).
  24. 24. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat are the Policy Responses?:• Calls for greater workforce flexibility and skill mixchanges• Substitution of more highly skilled workers withassistant type roles• Promotion of new models of care that maximisethe use of less skilled workers to assist in patientcare• Workforce and workplace reform to boostproductivity, flexibility and retention• Training
  25. 25. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhat are the Policy Challenges?:Australia and the western world is facing significantnursing shortages that are predicted to worsen overthe coming decadeThe policy response to the nursing workforceshortages to date have been inadequate.Strategies relying on substitution with less skilledworkers is in direct contrast to the evidence.How do we balance the scales?
  26. 26. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalBalancing the scales:RN AINRNsENsAINsThe balance changesas patient needschange
  27. 27. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalHow do we ethically manage future workforce needs?High % of our problems have a single right answer i.e.Either/or problem solving orientationPolarity Management – The genius of the BOTH/ANDHave 2 or more right answers that areinterdependentBoth combined out perform either aloneA well managed polarity capitalises on the inherenttensions between two poles to get the benefits ofboth upsides and the synergies between them
  28. 28. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalBetter patient outcomesImproved patient satisfactionStaff retentionSustainable health caresystemIncreased access to healthcareHealthcare too expensiveReduced access to healthcareExcessive and wastefuldemandsPoor health outcomesReduced patient satisfactionStaff turnover+_Quality/safety AffordabilityANDA Polarity MapAchieving a sustainable high quality healthcare systemManaging is GETTING THE BEST OF BOTHFailing is GETTING THE WORST OF BOTH
  29. 29. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalOther Polarities:Extending scope of practice AND workforce shortagesWorkforce redesign AND service redesignPatient needs AND workforce needsShared competencies AND professional identity
  30. 30. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalWhere to from here (policy, practice and research):• Policy developments need to support ethicalmanagement of a scarce resource (nurses)• Focus on retention – reduces Australian shortage to25,000 in 2025• Develop an understanding of when it isappropriate/safe to use AIN’sSafe patient care AND management nurseworkload• Further research on workforce requirements forparticular patient groups
  31. 31. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalKey messages:1. Skill mix is an important determinate of safe, highquality patient care2. Workforce policy requires more sophistication tobalance the scales3. Nurse retention (including workload management) isa ‘game changer’ – we need to think differentlyabout how we manage a scarce resource.
  32. 32. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalReferences:Aiken, L.H., Clarke, S.P., Sloane, D.M., & Silber, J.H. (2003). Education levels of hospital nursesand surgical patient mortality. Journal of Americal Medical Association, 290(12), 1617-1623.Aiken, L. H., Clarke, S. P., Sloane, D. M., Lake, E. T., & Cheney, T. (2008). Effects of hospital careenvironment on patient mortality and nurse outcomes. Journal of Nursing Administration,38(5), 223-229.Aiken, L. H., Cimiotti, J. P., Sloane, D M. Smith, H. L., Flynn, L.D, Neff, D. F. (2011) Effects ofNurse Staffing and Nurse Education on Patient Deaths in Hospitals With Different Nurse WorkEnvironments Medical Care DOI Number 10.1097/MLR.0b013e3182330b6eAmerican Association of Colleges of Nursing. Hallmarks of the professional nursing practiceenvironment. Journal of Professional Nursing. 2002;18(5):295-304. DOI:10.1053/jpnu.2002.129231Buerhaus, P. 2008. Current and future state of the US nursing workforce. Journal of AmericanMedical Association, 300, 2422-2424.Duffield, C., M. Roche, et al. (2007). Glueing it together: Nurses, their work environment andpatient safety. Broadway, University of Technology, Sydney.
  33. 33. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalReferences:Health Workforce Australia 2012. Health Workforce 2025 - Doctors, Nurses and Midwives - Volume 1.Adelaide: Health Workforce Australia.International Council of Nurses 2006. The Global Nursing Shortage: Priority Areas for Intervention.Geneva.Kane, R.L., Shamliyan, T., Mueller, C., Duval, S., & Wilt, T. (2007). Nursing staffing and quality ofpatient care. Evidence report/technology assessment no 151: Agency for Healthcare Researchand Quality.Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., & Zelevinsky, K. (2002). Nurse-staffing levelsand the quality of care in hospitals. The New England Journal of Medicine, 346(22), 1715-1722.Pearson, A., O’Brien-Pallas, L.L., Thomson, D., Doucette, E., Tucker, D., Wiechula, R., et al. (2006).Systematic review of evidence on the impact of nursing workload and staffing on establishinghealthy work environments. Journal of Evidence Based Healthcare, 4, 337-384.Stanton, M.W. (2004). Hospital nurse staffing and quality of care (No. 04-0029): Agency for healthcareresearch and quality.Twigg, D., Duffield, C., Thompson, P. L., & Rapley, P. (2010). The impact of nurses on patientmorbidity and mortality - the need for a policy change in response to the nursing shortage.Australian Health Review, 34, 312-316.
  34. 34. School of Nursing & MidwiferyCentre for Nursing Research, Sir Charles Gairdner HospitalReferences:Twigg, D., Duffield, C., Bremner, A., Rapley, P., & Finn, J. (in press). Impact of skill mixvariations on patient outcomes following implementation of nursing hours per patient daystaffing: A retrospective study. Journal of Advanced Nursing.World Health Organisation. 2006. Working together for health. The world health report 2006[Online]. Geneva: World Health Organisation. [Accessed January 24 January 2009].

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