ANA Principles for Nurse Staffing

ANA Principles for Nurse Staffing
Ohio Nurses Association Convention
11 October 2013
Katherine A. Kany, MSN, BS, RN
Assistant Director/AFT Healthcare
The Most Amazing Feats of
Daring; All done without a
safety net!
Appropriate Nurse Staffing
“Appropriate nurse staffing is a match of
registered nurse expertise with the needs of
the recipient of nursing care services in the
context of the practice setting and situation.
The provision of appropriate nurse staffing is
necessary to reach safe, quality outcomes; it is
achieved by dynamic, multifaceted
decision-making processes that must take into
account a wide range of variables.”
(ANA, 2012)
How do we determine appropriate
nurse staffing and what are the
variables that need to be factored
into that determination?
Pathway to the Principles:
Conception and Gestation
Recognition of the problem.
Identification of subject matter experts.
Review and annotation of the literature.
Convening of the expert panel.
Deliberations and discussion of the state
of the science.
• Consideration of nurse: patient ratios.
• Identification of the structure, process
and outcome variables comprising the
I. Patient Care Unit
• Appropriate staffing levels for a patient
care unit reflect analysis of individual and
aggregate patient needs.
• There is a critical need to either retire or
seriously question the usefulness of the
concept of nursing hours per patient day
• Unit functions necessary to support
delivery of quality patient care must also
be considered in determining staffing
II. Staff Related
• The specific needs of various patient
populations should determine the
appropriate clinical competencies
required of the nurse practicing in that
• Registered nurses must have nursing
management support and representation
at both the operational level and the
executive level.
• Clinical support from experienced RNs
should be readily available to those RNs
with less proficiency.
III. Institution/Organization
• Organizational policy should reflect an
organizational climate that values registered
nurses and other employees as strategic assets
and exhibit a true commitment to filling
budgeted positions in a timely manner.
• All institutions should have documented
competencies for nursing staff, including
agency or supplemental and traveling RNs, for
those activities that they have been authorized
to perform.
• Organizational policies should recognize the
myriad needs of both patients and nursing
ANA Principles for Nurse
Staffing, 2nd Edition (2012)
• Principles Related to
• Principles Related to
and Other Staff
• Principles Related to
Workplace Culture
• Principles Related to
• Principles Related to
the Healthcare
Registered Nurses
Organization and
the Practice
Staffing Evaluation
PNS Policy Statements
• Nurse staffing patterns and the level of
care provided should not depend on the
type of payor.
• Evaluation of any staffing system should
include quality of worklife outcomes, as
well as patient outcomes.
• Staffing should be based on achieving
quality of patient care indices, meeting
organizational outcomes and ensuring
that the quality of the nurse's worklife is
What Does This Do for
the Problems We Face?
Framework for
Appropriate Nurse Staffing
Weaving the PNS into
a Valuable Framework
Legislative language.
Contract language.
Assessing staffing systems.
Information with which to educate
policymakers and the public.
PNS as a Legislative
Staffing systems must:
• Be created with input from direct-care RNs.
• Be based on the number of patients and
level and intensity of care to be provided,
with consideration given to admissions,
discharges and transfers that nurses must
handle each shift.
• Reflect the level of preparation and
experience of those providing care.
Legislative Framework
• Account for architecture and geography of
the environment and available technology.
• Reflect staffing levels recommended by
specialty nursing organizations.
• Provide that a RN not be assigned to work
on a particular unit without first having
established the ability to provide
professional care in such a unit.
Federal Staffing Bills
• H.R.1821 -- Registered Nurse Safe Staffing Act of
2013 (Capps/CA) Requires staffing plans to identify
appropriate number of registered nurses provide direct
patient care in each unit that: (1) address the unique
characteristics of the patients and hospital units; and
(2) result in the delivery of safe, quality patient care
consistent with specified requirements.
• H.R.1907 -- Nurse Staffing Standards for Patient
Safety and Quality Care Act of 2013
(Schakowsky/IL) Minimum direct care registered
nurse-to-patient ratio by unit + adjustments above.
HHS to develop a national acuity tool to establish
nurse staffing requirements above minimum ratios.
• S.739 -- National Nursing Shortage Reform and
Patient Advocacy Act (Boxer/ CA)-same provisions
as H.R. 1907.
Using the PNS to Evaluate
• Does the staffing plan account for the
myriad patient needs?
• Does the staffing plan factor the nurse
staff characteristics?
• Does the staffing plan consider the
practice environment?
• Does the staffing plan reflect the
PNS Used in Contract
• Hawaii Nurses Association (patient
acuity system)
• Michigan Nurses Association (nursingsensitive outcomes data review)
• Ohio Nurses Association …
Educating the Public
and the Policy Makers
Using the PNS as a framework, nurses can
explain the complexity of staffing decisionmaking:
• Distinguishing the abilities of nurses from a
range of perspectives (expertise, fatigue,
orientation to unit).
• Quantifying the level of illness and requisite
care needs of each patient.
• Clarifying the continuum of care.
• Highlighting the need for autonomy.
• Measuring the sufficiency of staffing.
Are Ratios Necessary;
Are Ratios Enough?
• What everyone forgets about California;
ratios are the fallback staffing method.
• A nurse is not a nurse; a patient is not a
• Technology and implications for the care
process; care can protracted rather than
shortened with some of the HER
• Safety nets versus ceilings; what we miss
when we rush to use ratios.
How Can You Use the
Lobbying efforts
Contract proposals
Organizing tool
Setting the standard for all staffing
deliberations at the facility, state and
federal level
• Contract committee resource or policy
• Patient classification system assessment
• Other ??
• American Nurses Association (ANA).(1999).
Principles for nurse staffing.Washington,DC:Author.
• American Nurses Association (ANA).(2012).
Principles for nurse staffing(2nd ed.) Silver Spring,
• Needleman, J., Buerhaus, P., Pankratz, V., Leibson,
C., Stevens, S., & Harris, M. (2011) Nurse staffing
and inpatient mortality. New England Journal of
Medicine, 364(11), 1037-1045.
• Weston, M., Brewer, K., & Peterson, C. (2012).
ANA Principles: The framework for nurse staffing to
positively impact outcomes.

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