Keys to Appropriate Staffing

Nov 14, 2019

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We’re at a time now when leaders are beginning to embrace that we must accept zero harm to patients and the workforce as a core value. It has significant implications for ensuring that staffing is appropriate to ensure patient safety and optimal outcomes and enables our nursing profession to thrive, flourish, and find joy and meaning in our work.

Patricia McGaffigan

The widespread lack of appropriate staffing is an old and enduring problem in healthcare that requires new, sustainable ideas that can be scaled and replicated. AACN is leading the charge to “slay the dragon” of inappropriate staffing and is collaborating with leaders from the bedside to the c-suite. Among the groups to join AACN’s staffing coalition is the Institute for Healthcare Improvement (IHI). Since 1991, IHI has been an influential force in healthcare improvement in the United States and abroad. Patricia McGaffigan — a registered nurse (RN), certified professional in patient safety, and past AACN Certification Corporation chair— is vice president of safety programs for IHI and president of IHI’s Certification Board for Professionals in Patient Safety. She spoke to us recently about the current challenges and future plans for appropriate staffing

Appropriate staffing is an ongoing problem that impacts nurse, patient and family satisfaction and safety. How is IHI addressing this issue?

We know that appropriate staffing is essential for safe and quality care. The work IHI is doing to advance appropriate staffing is foundational to that. We ask, “How do we take improvement science and use that to address the challenges and opportunities of appropriate staffing and improve the circumstances.”

For example, appropriate staffing goes much deeper than putting more nurses into roles in nursing, because foundationally we need to understand what the challenges are and why those challenges are happening. Putting 10 more nurses on a unit in a healthcare system where safety cultures are poor, or where safe patient flow is obstructed, will not necessarily answer the challenges we have. It’s vital for us to take a systems approach to our thinking about whether staffing is appropriate overall, and includes the right mix of our vital team members, such as nursing assistants and other colleagues. I recently visited a system where nurse staffing was aligned with required ratios. However, nursing assistants had been cut back, and nurses were not able to work at the top of their license.

In environments where leaders have not yet embraced safety as a core value, it may also be challenging to deliver the best care possible. In organizations where cultures of safety are not paramount and central to the core vision and mission, we can add additional staff. However, we may not necessarily improve the safety and quality of care. One example of what’s essential for a culture of safety is ensuring that people feel comfortable raising questions and concerns without a fear of punishment.

Tell us more about IHI’s approach to identifying the deeper-seated problems.

What IHI is doing with respect to staffing is much broader than staffing in and of itself. We try to address situations with foundational perspectives to avoid our frequent tendency to take piecemeal approaches to solving. We think about a total systems approach to safe and quality care. We need to ask our nurses, “What does a great day look like for you? What matters to you in your day-to-day work? What challenges get in the way of that, and what ideas can we co-produce to optimize the work environment and your ability to deliver the best care possible? What can we do to make it easy for you to do the right thing, the best thing, for patients, families and colleagues?”

Staffing challenges endure because often we’re not asking the right questions.

Right. So much of what we do in healthcare is founded on what we’ve always done. What I love about IHI is that we encourage people to break the rules. We encourage people to remove some of those barriers that get in the way of making progress and that we can control, so patients, families and colleagues have the best experience possible.

IHI also focuses on ensuring that we have joy and meaning in our workforce. Workforce safety is vital. Yet healthcare has the highest rates of harm related to workforce injury and illness than other industries that we’d typically consider to be dangerous. There are more injuries in healthcare than traditionally defined dangerous professions, such as construction, coal mining and manufacturing. This includes musculoskeletal injuries, slips trips and falls, needlesticks and contact with hazardous substances and communicable diseases, as well as violence. We’re illuminating issues related to psychological harm and harm from inequities. We’re shining a light, so leaders and decision-makers understand that nurses, along with other members of the health care team, face risks at work every day. We must understand what those risks are and how to meaningfully address them. We want every colleague to leave work in the same condition that they started their day, or better.

We’re at a time now when leaders are beginning to embrace that we must accept zero harm to patients and the workforce as a core value. It has significant implications for ensuring that staffing is not only appropriate but also that our nurses will thrive and flourish. People should feel great about coming to work every day, knowing that the reason they chose this profession – to keep people safe and provide the highest quality of care – will truly be accomplished.

How do you recommend CNOs, nurse leaders and bedside nurses begin to innovate solutions for appropriate staffing and balanced scheduling?

Nurses at all levels – including CNOs, leaders, managers and nurses delivering direct patient care – can address and lead initiatives for appropriate staffing. One important way, yet almost always overlooked, is understanding the climate of the working environment. For example, in the safety world, we have surveys of patient safety culture. In lower-scoring domains, people are uncomfortable speaking up about their concerns. How do we get people to feel comfortable in their units and have the will, energy and passion to bring out their best, not only for themselves but for their colleagues? This work must begin with and be championed by leaders.

We need our executives, trustees and financial decision makers interfacing with the care team, patients and families in the environment in which care is being provided. They need to say, “What matters to you most? What are we learning about how and why things go well? What worries you about the next thing that could go wrong in your unit? I want to hear and understand this so, in my leadership or trustee role, I can ensure that this is front of mind as I consider how best to oversee this organization and partner with you to understand the day-to-day realities of what it takes to give the safest and best care possible.”

Describe an innovative staffing approach you’ve seen successfully implemented.

One example of a sustainable and meaningful innovation for staffing now and into the future is the ergonomics of scheduling. In the same way that we think about improving ergonomics in the design and use of healthcare technologies and devices, it’s important to consider the ergonomics of the human brain and body – circadian rhythms, cognition and fatigue-related issues. Is the cognitive burden excessive or manageable? These are all factors that must be considered in association with discussions about appropriate nurse staffing?

In the past, we’ve had scheduling systems that pushed the limits of human capabilities. An important example is that if a nurse works more than 12½ hours, they are two to three times more likely to make a medication error. Our colleagues are nothing less than stellar in their roles and commitment to safe and quality care. But we see evidence of the erosion of our brains and ability to process information. When I think about appropriate staffing, I think about these additional dimensions of what it means to provide the best care possible – including sensitivity to fatigue and fatigue management.

Why is it so important for organizations such as IHI, AACN and others to unite to address appropriate staffing?

We all have a vested interest in finding great solutions for innovative staffing. We’re operating in a very complex system that benefits from a more holistic approach to staffing. We need support from our colleagues, particularly at the leadership level, to have a collective voice that will be heard: Appropriate staffing must be a priority.

For so long we’ve looked at staffing and said that staff cost money. But we haven’t looked at the inherent value our nurses provide every day. We must transform those conversations into something and engage leadership at all levels. To fully embrace the concept of appropriate staffing requires us all to be at the table. And that’s why I love this coalition. We’ve got nurse leaders, healthcare financial managers, experts in quality and safety and nurses on the front lines of care.

What solutions and triumphs do you envision for the future of appropriate staffing and patient safety?

For the future of appropriate staffing I foresee a leveraging of the greatest partners in our system working collectively to improve the safety and the appropriateness of staffing. I'll give you one example. How many nurses spend time talking to their patient safety officer about staffing? How do we engage patient safety professionals in the conversation so we have the right parties at the table, for the right advocacy, perspective and depth of critical thinking that we need to understand and overcome the problem? We need to collect meaningful data that helps us document if we’re making a difference with enhancements to staffing. There is no better combination for understanding what matters to patients, families and the workforce than combining the perspectives of safety professionals and nursing professionals, and other members of our healthcare teams.