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Policy MemorandumTo: Dr. Howard ZuckerFrom: Robert Tulman, Chinsia Francis-Hill, Ronda Malabe-StagiasRE: Nursing Staff Shortage in New YorkDATE: 12/3/2015Executive SummaryHealthcare facilities across New York are currently battling the epidemic of nurse understaffing. The negative health outcomes and financial implications of this issue are evident, with little being done to correct the issue. With a vacancy rate of 7.5%, this matter is already reaching crisis mode. The negative healthcare outcomes are evident, as over hundreds of thousands of patients die each year from complications associated with preventable harm due to understaffing. Facilities are susceptible to malpractice suits and the inability to serve their community. More importantly, due to the extraneous workload placed on nurses in New York, clinicians who once looked to make a difference in their community are now running from the profession. Understaffing in healthcare facilities is creating long-term repercussions that will continue to increase the gap between nurses available and nurses needed. The policies that we have proposed look to combat this extremely complicated issue. Our strategy is to attack the underlying causes of understaffing in an effort to disrupt the current cycle within this profession.Overview of the Problem: Nurse Understaffing in NY By nature, the Healthcare industry is subject to problems due to the ever-changing health needs of the population that clinicians serve. While healthcare facilities may not be able to combat or predict some biological factors, many administrative issues can be fixed through policy reform. In New York State, understaffing of nurses in hospitals is an issue that is inherent of today’s healthcare system. This administrative issue is the cause of an increased rate of patient mortality as well as the decline of the facilities financial health. Multiple studies have directly linked high patient to nurse ratios to patient’s readmission and mortality (Robbins). In New York City alone, nurses typically have a caseload of seven to nine patients. The suggested maximum is four (Robbins). In the past decade, nursing staff shortages have seen a dramatic increase (Aiken 1987-1988). It is clear that nursing staff policy must be addressed before this problem worsens even further.How Dangerous is This Issue?The problem of nurse understaffing can be considered almost as dangerous as the diseases and injuries that these nurses combat. Currently the vacancy rate for New York nurses is at the extreme high of 7.5% (Gillibrand). This high rate of vacancy increases the workload for nurses working in acute hospital settings. Overwhelming patient caseloads lead to poorer quality of care, which puts patients at risk. A study published in the Journal of the American Medical Association showed that the likelihood of dying within 30 days of admittance increased by 7% per additional patient assigned to a nurse (Aiken 1991). In 2013 hospital errors became the third leading cause of death in the U.S. (Fischer). A study found in the Journal of Patient Safety stated that over 400,000 deaths were labeled as premature and associated with preventable harm (James 123). The number of lives at risk by understaffing is overwhelming, but this is by no means the only negative outcome.The Financial Impact of Nurse UnderstaffingWhen looking at this issue at a glance, it would seem as if the understaffing is caused by a restriction in funds. The idea that hospitals may be able to conserve revenue by over extending nurses is extremely out of date. There is far more money lost due to staffing shortages than money saved. Diederich Healthcare, a leading medical malpractice agency released a report on what they have observed thus far in 2015. The statistics show that in New York, over 300 million dollars have been paid out for malpractice suits (Gowner, sec. 2). While this does include private practice physicians as well, the data shows that 46% of the claims were paid out to inpatient (hospital) patients. Aside from malpractice, other expenses arise from nursing shortages. When looking at understaffed facilities, a study found that it is actually more cost effective to higher per diem or supplemental help than it is to pay multiple nurses’ overtime (Xue 135). A common theme in the studies we reviewed was that understaffing itself was a reason why many nurses quit their positions. The cost associated with the replacement of nurses due to an increased turnover rate is significantly higher than the cost of hiring due to normal growth. A study published in The Journal of Nursing Administration showed that on average, healthcare facilities spend $300,000 annually for every 1% increase in the turnover of nurses (Jones 11). The study also observed that preventing nursing turnover increased job satisfaction and productivity for the employees (Jones 17).Causes of the IssueThere is a direct correlation between job dissatisfaction among nurses and staff size of the nursing team. The reason this problem must be addressed is because a cycle has been created that will continue to cripple hospitals and other urgent care facilities. Understaffing causes job dissatisfaction and job dissatisfaction leads to turnover and increased understaffing. While some may argue that job dissatisfaction is prevalent in all professions, a study showed that job dissatisfaction among nurses is 4 times greater than the average U.S worker (Aiken 1987). People may attribute this to stress associated with patient care in general, and the same study proved that job dissatisfaction is higher among nurses than any other healthcare profession. When identifying the cause of this statistic, the study conducted by Linda Aiken measured that job dissatisfaction for a nurse rose by 23% per additional patient added to their caseload. In a study conducted by the Vickie Milazzo Institute, out of over 3,300 nurses surveyed, an alarming 89% said that they are not working efficiently due to understaffing (Fischer). This level of discontent among nurses is creating a larger gap in the workforce.This gap will only continue to grow due to other variables as well. One of the earliest causes of nurse understaffing can be linked to the limitations of clinical training. Senator Kristen Gillibrand has been following nursing staff shortages very closely. When trying to identify the cause, she reached out to the University of Staten Island for their opinion on the issue. The University stated that out of 400 applicants, only 125 were accepted. When asked why, a University official stated that while some of the applicants were just under qualified, a main reason for the low acceptance rate was that clinical classrooms could only educate a limited number of students. What is alarming about this information is that a large number of current nurses will soon be leaving the profession. Senator Kirsten Gillibrand’s team has found that 19% of nurses in New York are over 55 years old. This means that a large part of the already thin workforce will be entering retirement soon. Due to restrictions in clinical education, a large number of these nurses may not be able to be replaced if policy reform is not looked into. The nurses that constantly help our sick and advocate for our safety are now in need of help themselves. The frustration for these nurses is unbearable. While the nurses affected by understaffing may be clinically sound, they are still unable to save as many lives due to variables out of their control. Nurse understaffing is not an issue only seen in New York. Many other states have not only faced this challenge, but have also taken steps to combat this problem. My team has reviewed scholarly research articles; policy analysis data and industry expert testimony in order create a layout of a few policy options that may help mitigate this problem. Policy 1: Mandatory Staffing Law 1:4 Nurse to Patient RatioA common theme in our research was the recommendation of a 1 to 4 nurse to patient ratio. This ratio provides the best patient outcomes and also helps to increase job satisfaction. California currently has the strictest nurse to patient ratio laws. The success observed in California is a reason why New York should look to mirror this policy.By implementing a policy on required nurse to patient ratios, hospitals are unable to force their nursing staff to take on a dangerous amount of patients. A report stated that in California the turnover rate of nurses has decreased because of increased job satisfaction (Kaissi). The report also shows that patient safety has improved as well (Kaissi) Another positive result from the policy is that the improved job satisfaction has lead to advocacy by nurses in persuading others to join the profession (Kaissi). Overall, this policy can not only help patients stay safe, but can also help correct one of the system’s flaws that contribute to repeating staffing shortages.Policy 2- Reserve funds for Supplemental Nurses:Healthcare facilities should have a network of per diem and temporary nurses in order to help in times of increased patient presence. Understaffing in healthcare facilities is extremely evident during times of increased patient admittance. While hospitals may be able to predict to some degree what their busy seasons may be, many times an increased influx of patients is due to an unforeseen event or illness. Hospitals must allocate funds in a proactive as opposed to reactive manor. We noted a study conducted by the Journal of Nursing Care Quality. This study looked into the cost outcomes of supplemental nurse staffing through outside vendors. In regards to supplemental staffing, healthcare managers had “concerns raised about quality of care and cost issues”(Xue 130). What the study proved is that the use of supplemental nurse staffing is more cost effective than paying staff nurses overtime hours (Xue 135). The study showed that nurses earned an average of $29 per hour plus $44 for overtime hours. The cost of supplemental nursing per hour usually costs $51 per hour. The reason why the supplemental nursing is more cost effective is because the overtime hours are usually paid for an extended period of time and for catching up on patient notes. When nurses are not treating, the hospital is not receiving any compensation. Prior research has also dispelled the myth that supplemental nursing staff may have less education and are less qualified (National Association of Travel Healthcare Organizations). Because outside vendors have no restrictions when setting prices, New York Hospitals must model a policy based on the rates charged in the study. Having a separate source of emergency funds for the hiring of temporary and supplemental staff can help balance the nurse to patient ratio while remaining cost effective.Policy 3- Support through Telehealth:As healthcare technology improves, healthcare policy must adapt in order to utilize new tools. Telemedicine is the idea that trained nurses and clinicians can observe, blood levels, vital signs and other necessary bedside information from a center located outside of the facility. The Telehealth center is able to review this information in real time so input and warnings can be given to staff located at the facility. A policy should be established that requires healthcare facilities with high patient to nurse ratios to utilize Telehealth facilities.Since nurse understaffing effects patients being observed by overwhelmed nurses, we looked at data concerning one of the most prevalent bedside illnesses; Sepsis. Sepsis is an infection due to a lowered immune system after an acute injury. Every year it is estimated that 28 to 50 percent of the patients diagnosed with Sepsis, will die (National Institute of General Medical Sciences). When looking at the Telehealth model, it not only improves patient outcomes but also makes the bedside nursing team more efficient and less stressed (Varma). Since the Telehealth center is solely observing bedside patients, they are able to observe one patient while a nurse is attending to another. As opposed to a nurse responding to an immediate case of Sepsis, the Telehealth center can identify which patients are at risk and prevent Sepsis before it occurs.This is just one example of how a Telehealth policy can help alleviate the stress placed on understaffed nursing teams. Reducing the stress would not only improve patient outcomes but could also increase job satisfaction among nurses. As we have seen in previous research, job dissatisfaction contributes to nurse understaffing and hopefully this policy could end that cycle.Policy 4- Nurse Staffing CommitteesThe issue of nurse understaffing implies that by simply increasing the number of nurses, the issues associated should fix themselves. This theory however does not take into consideration the communication that is necessary between nursing teams and administrative staff. As we have seen, nurse understaffing and its affect on job satisfaction is a leading contributor to nurse turnover. A policy of mandatory Nurse Staffing Committees as seen in states like Nevada, Ohio, Connecticut Washington, Illinois, Oregon and Texas can help increase job satisfaction by giving nurses the proper platform to express their concerns. In the states mentioned above, half of the committee must be comprised of nursing administration and the other half by actual staff nurses (Devandry 470). This allows for transparency between upper management and the nurse’s that provide the treatment. This committee can help establish staffing guidelines that are approved by the nurses themselves. While it is clear that high patient to nurse ratios lead to poorer patient outcomes, how to address these problems is harder task. Nurse Staffing Committees would allow nurses to give specific input into what patients and shifts need the most staffing (Glazer). This would help reduce the pressure and stress placed on nurses by giving them support where they feel it is the most necessary. Policy RecommendationsIn order to address this issue, we feel that two of our policy options presented above must be implemented in order to end the cycle of nurse understaffing. Policy option 1 and 4 not only address short-term repercussions of understaffing, but also can potentially break the cycle of job dissatisfaction causing long term nurse vacancy. After reviewing feedback by experts within the field, we believe that policy option 2 may not be cost effective over time. We also chose to move away from policy option 3, Telehealth, because it does not address the long-term causes of nurse understaffing.Policy option 1 calls for the implementation of new staffing ratio legislation. The ratio of patients to nurses is almost 9 or 10 to one proving that this is not only a safety issue for the people of the country wanting to get admission into hospitals, but also creates a huge task for the nurses who are suffering due to the excess amount of work pressure. CITATION Yas15 \l 1033 (Yasmin, 2015) This is one of the primary reasons that we decided to choose mandatory nurse to patient policy option.The staffing laws that are in place for 14 cities in the US along with New York is the 42CFR 482.23(b) which states the following:The hospitals need to have a staffing committee which create plans for staffing that is in line with the necessities of the population.There needs to be a specific ratios mentioned in the laws for ensuring the correct amount of patients as compared to the number of nurses working in the organization.Facilities are required to disclose staffing levels to all the (public or regulatory) bodies that regulate and ensure the effective running of the system. CITATION ANA15 \l 1033 (ANA, 2015)In New York State these laws and rules laid down did not help change the scenario of Nurse staffing in the US. We hope to create a law that incorporates stricter penalties for non-compliance. The “Safe Staffing for Quality Care" act will ensure that the Nurse ratios are taken into consideration for acute as well as regular situations. The nurses will not be over-assigned cases beyond the stipulated numbers and there will be no averaging with the number of cases one is supposed to handle for e.g. RN’s in Nursing homes will be divided in shifts of 45 minutes which will be distributes equally thought all the shifts. CITATION Car15 \l 1033 (Carmel, 2015)We feel that this is the best option that the federal system can take towards helping patients and nurses in New York State. It is one of the most transparent methods of reviewing patient ratios and regulating them so that there is adequate staffing. Hopefully, harsher penalties for healthcare facilities operating outside of these ratios will help correct the long-term damage already inflicted by nursing staff shortages.Job dissatisfaction was a large component of nurse understaffing because it served as a catalyst to early retirement. Throughout our research, we have seen the ineffectiveness of current legislation and have called for reform. Policy option 4 looks to create mandatory nurse-staffing committees in order to increase communication and advocacy for nurse working in the facilities.The states that have mandated nurse-staffing committees are Nevada, Ohio, Connecticut, Washington, Illinois, Oregon, and Texas (Devandry et al., 2009). The public disclosure mandate is currently in affect in five states; New York, New Jersey, Rhode Island, Vermont, and Illinois. The public disclosure mandate simply makes current ratios available to the public. This of course helps the public chose which hospitals they would prefer to be admitted to, but does little to stop the trend of understaffing.Because the half of the committee is made up of healthcare administrators and the other half consists of nurses who work within the facility, it serves as an effective platform to express concerns. Although nurses are equally represented, the recommendations made in the committee must ultimately be approved by the administration in order to be implemented. Even though nurses on theses committees technically have less authority, the fact that they represent a large number of the staff is very influential.ConclusionUnfortunately, the issue of nurse understaffing will eventually affect all of New York City residents. While we cannot control how or when we get ill, we can control the manor in which we are cared for. While New York State has addressed understaffing with rhetoric, it is time to follow up with action. Ultimately, we hope this presentation helps you and your staff thinks about significant damaged caused to patients as well as nurses due to this issue. We thank you for your time Dr. Zucker, and we hope to collaborate in the future to address this matter. Works CitedAiken, Clarke, et al. “Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction.” Journal of the American Medical Association 208 (October 2002) 1981- 1993.Devandry, Suzanne N., and Jennifer Cooper. "Mandating Nurse Staffing in Pennsylvania: More Than a Numbers Game." The Journal of Nursing Administration 39.11 (November 2009) 470- 478. Web page. 29 September 2015.Fischer, Kristen. “Nurses: Overworked and Understaffed on the Front Lines.” 7 July. 2014. Web page. 4 September 2015. Gillibrand, Kirsten. “New York’s Nursing Shortage.” The Huffington Post 25 May.2011. Web page. 4 September 2015.Glazer, Greer. "Legislative: Executive Summary of the Report of the Ruckelshaus Center Nurse Staffing Steering Committee." The Online Journal of Issues in Nursing 15.1 (October 2009). Web page. 29 September 2015.Gower, Jeremy. “2015 Medical Malpractice Payout Analysis.” 9 Mar. 2015 Web page. 4 Sept. 2015.James, John. “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care.” Journal of Patient Safety 9 (September 2013) 122-128.Jones, Cheryl. “Revisiting Nurse Turnover Costs.” The Journal of Nursing Administration 38 (2008) 11-18.Kaissi, Amer. “Nurse-To-Patient Ratios: The Science And The Controversy”. Healthcare Hacks. 16 February 2010. Web page. 28 September 2015.Robbins, Alexandra. “We Need More Nurses.” The New York Times 28 May 2015. Web page. 4 Sept. 2015. "Sepsis Fact Sheet." National Institute of General Medical Sciences. 1 August 2014. Web page. 1 October 2015."Use Of Supplemental Nurses Is Cost-Effective Strategy To Address Hospital Short- Term Staffing Needs." National Association of Travel Healthcare Organizations. 12 March 2014. Web page. 29 September 2015.Varma, Manu. "Telehealth in Command: Real-Time Decision Support Takes on New Powers." Health Management Technology. 22 August 2014. Web page. 29 September 2015Xue, Ying, et al. "Cost Outcomes of Supplemental Nurse Staffing in a Large Medical Center." Journal of Nursing Care Quality (December 2014): 130-137.Yasmin, B. SAFE STAFFING. New York: New York State Nurses Association. 2015 ................
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